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EVALUATION OF THE U.S. DEPARTMENT OF DEFENSE PERSIAN 15
GULF COMPREHENSIVE CLINICAL EVALUATION PROGRAM
provided in a later section of this report (see Epidemiological Research Relevant
to the CCEP).
SPECIFIC MEDICAL DIAGNOSES
In addition to the committee's general review of symptoms and diagnoses,
it has reviewed five disease categories in more detail. Three of these disease
categories are the most prevalent in the CCEP population: psychiatric
conditions; musculoskeletal conditions; and signs, symptoms, and ill-def~ned
conditions. In addition, infectious diseases have been reviewed because of the
possibility that troops deployed to the Persian Gulf may have acquired diseases
that are unusual outside that region. Finally, the last category includes three
conditions that have been reviewed because of their poorly defined nature:
chronic fatigue syndrome, fibromyalgia, and multiple chemical sensitivity.
Psychiatric Conditions
Three major issues that are relevant to psychiatric conditions will be
discussed: (1) the prevalence and impact of psychiatric conditions among CCEP
patients, (2) the standardization of psychiatric evaluations in the CCEP, and (3)
the recognition of psychosocial stressors in the CCEP population, including
relevant epidemiological research.
Prevalence and Impact of Psychiatric Conditions Among CCEP Patients
Of the primary diagnoses in the CCEP population, 19% are psychiatric
conditions (DoD, l995d). A primary or secondary diagnosis of a psychiatric
condition has been made in 37 % of CCEP patients. According to the DoD, the
prevalence of psychiatric diagnoses in the CCEP population may be "somewhat
higher than that found for other groups of health seeking individuals in which
structured psychiatric interviews were used" (DoD, l995d). The most common
psychiatric conditions in the CCEP population are major and minor depression
(diagnosed in 3% and 8% of all CCEP patients, respectively), PTSD (5%),
adjustment disorder (4%), and mild anxiety syndromes (2%) (DoD, l995d). In
addition, personality disorders appear to be common in the CCEP populations;
however, use of the section of the Structured Clinical Interview for DSM III-R
(Diagnostic and Statistical Manual of Mental Disorders, 3rd edition, revised)
that is used to diagnose these disorders is not currently mandated by the DoD
(Engel, 1995~.
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Many aspects of military service in wartime can cause significant physical
and psychological stress. Physicians have observed that in many previous wars,
including the Vietnam War, wartime stressors can lead to the development of
higher rates of psychiatric illnesses than are observed in the general population.
PTSD and major depression are prevalent problems in veterans. As might be
expected from experiences in previous conflicts, many of the patients who have
been evaluated in the CCEP have been diagnosed with psychological problems,
as well as with other medical problems.
Patients need to understand that these are real diseases that cause real
symptoms and that these diagnoses are made with objective criteria and are not
merely "labels" that were applied because physical abnormalities were not
found. The CCEP patients, as well as their primary care physicians, also need
to understand the prevalence of and the concomitant morbidity that result from
psychiatric disorders in the general population (major depression, for example).
Finally, the CCEP patients need to be aware that effective treatments that
actually ameliorate symptoms exist for many of these disorders.
In addition to the IOM committee on the CCEP, several other review
groups have examined the health concerns of Persian Gulf veterans. Three
major reviews have recognized the potential impact of psychological stress in
this population, including rapid deployment, primitive living conditions in the
desert, the threat of chemical and biological warfare agents, and actual combat
exposure (Defense Science Board, 1994; NIH, 1994; IOM, l995b).
The committee concludes that many of the psychiatric diseases in the CCEP
population have both physical and psychological symptoms and manifestations.
In its future reports, the DoD is encouraged to emphasize that psychosocial
stressors can produce physical and psychological effects that are as real and
potentially devastating as physical, chemical, or biological stressors. The DoD
should also emphasize that thorough efforts to diagnose psychiatric conditions
in the CCEP population may lead to appropriate, successful treatments.
The committee is particularly concerned about the CCEP patients who have
developed or who are at risk of developing major depression or PTSD. These
people need to be identified and provided with some form of preventive
intervention. Some people can develop depression or PTSD as long as 5 years
after a traumatic event, and they may also develop related delayed-onset
problems such as substance abuse. In addition, there may be Persian Gulf
veterans who currently have symptoms of depression or PTSD who have not
sought medical care, and some form of outreach is needed to identify them and
notify them that help is available through the CCEP. Some Persian Gulf
veterans who have these conditions may be experiencing physical symptoms that
could have psychological underpinnings. Both depression and PTSD could be
underlying mechanisms for some sleep disorders, for example. There appears
to be an unexpectedly high prevalence of sleep disorders in the CCEP
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populations, which, in turn, could be contributing to other symptoms (Matthews,
1995).
Standardization of Psychiatric Evaluations in the CCEP
Psychiatric evaluations are mandated for all patients in Phase II of the
CCEP. These include the Structured Clinical Interview for DSM III-R and the
Clinician Administered PTSD Scale in addition to a clinical evaluation by a
psychiatrist. With the use of such validated instruments, the psychiatric
evaluations can be performed more systematically across the many hospitals in
the country.
Nonetheless, there are difficulties in some patients in differentiating
psychopathology versus illness behavior versus difficulties in adjustment to
activities of daily living; that is, there is variability in the threshold of
psychiatric diagnosis. This is complicated in patients who are strongly attached
to a sickness role. As a result, there is likely to be variability in the CCEP
psychiatric diagnoses despite strong efforts to standardize procedures. For
instance, the proportion of patients who receive a primary diagnosis of a
psychiatric disease varies considerably from site to site. For example, the rates
of serious psychiatric diseases are particularly high at the Walter Reed Army
Medical Center. In addition to the mandated tests, Walter Reed staff always
include the Minnesota Multiphasic Personality Inventory and a social worker's
evaluation in the psychiatric exam (Roy, 1995~.
The committee recommends that the DoD consider methods of improving
the standardization of the psychiatric evaluations in the CCEP. The DoD should
consider establishing detailed guidelines for the psychiatric evaluations and
should attempt to obtain greater standardization of these evaluations among the
various hospitals across the country. These guidelines could provide suggested
procedures for the use of selected self-report instruments for the assessment of
the most commonly diagnosed disorders, as well as procedures for more in-
depth structured clinical interviews when indicated. Validated self-report
instruments are available to assist primary care physicians in screening patients
for common psychiatric conditions (Spitzer et al., 1995~. It would be especially
important to document the onset and course of symptoms and to investigate their
possible link with psychosocial stressors associated with mobilization and return
home, as well as with service-related exposures in the Persian Gulf region. This
assessment would require an additional set of questions to supplement the
questionnaire currently used in Phase I of the CCEP. The thorough assessment
of psychosocial stressors is essential information for treatment planning for
patients with complex, chronic symptoms.
Standardization of the neuropsychological evaluations is a related concern.
The neuropsychological methods vary from pencil and paper testing at some
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sites to computer-administered testing at other sites. This could lead to
diagnostic variability from site to site. At some sites, it appears that patients
receive only a computerized test battery without an individualized clinical
evaluation. At these sites, it is unknown how cutoff scores for judging whether
the patient's performance is abnormal were determined. It is also unknown how
premorbid abilities are assessed. In addition, explicit criteria would be helpful
for determining which patients would benefit from a neuropsychological
evaluation. One method of achieving a better consensus, suggested by RMC
physicians, is to convene a meeting attended by one psychiatrist and one
neuropsychologist from each center to attempt to standardize their methods.
In addition to the standardization of psychiatric evaluations in the CCEP,
the classification and coding of these diseases should also be standardized. In
general, the ICD-9 coding of the diagnoses in the CCEP appears to be
appropriate, but the categorization of some psychiatric and neurological
conditions is confusing. Migraine and other severe headaches are categorized
under the nervous system, tension headaches are categorized under psychological
conditions, and still a third group of headaches is categorized under the group
signs, symptoms and ill-defined conditions (DoD, l995c). The classification of
different types of headaches into these three separate categories may be
consistent with ICD-9 coding rules, but the DoD should also report a special
tabulation that combines all headaches into one group. This is particularly
important, since 39% of the CCEP patients complain of headache symptoms
(DoD, l995d).
If psychiatric and neuropsychological diagnoses are made inconsistently or
are not coded uniformly, the DoD will not be able to provide accurate and
reliable summary data based on the combination of information from many
patients. The DoD now has experience with more than 10,000 patients;
therefore, the more frequent types of chart errors, omissions, or inconsistencies
should be apparent by now. More explicit written instructions could be added
to the CCEP guidelines to help prevent the most frequent problems found in the
medical record-keeping and coding. These comments about inconsistencies are
mainly aimed at the quality control necessary for accurate reporting of summary
data rather than at the quality of the medical care itself.
Recognition of Psychosocial Stressors in the CCEP Population
A brief overview of the psychological stressors faced by the troops who
were deployed to the Persian Gulf appears in two section in the DoD report on
10,020 CCEP patients: Potential Health Risks Associated with Persian Gulf
Deployment, and Individual and Group Response to Environmental Hazards as
a Factor Contributing to Health Consequences Among CCEP Participants (DoD,
l995d). In future reports, the DoD should consider expanding this description
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EVALUATION OF THE U.S. DEPARTMENT OF DEFENSE PERSON 19
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to provide a more thorough, in-depth discussion of the psychological stressors
that were present during the Persian Gulf War. For example, although there
were few American casualties, thousands of Iraqi soldiers were killed.
Witnessing large numbers of dead Iraqi soldiers or involvement in their burial
has been associated with the development of significant psychological distress
(Sutker et al., 1994a,b).
The DoD and the DVA have recognized the need for epidemiological
research on the psychological stressors of the Gulf War and on the prevalence
of psychiatric outcomes among Persian Gulf veterans. This need was
summarized in a recent document that outlines their current research strategy
(PGVCB, 1995a). The justification by the DoD and the DVA for this type of
research is as follows (PGVCB, 1995a):
Psychiatric morbidity among U.S. troops deployed to the Persian
Gulf area was predicted even though the war was of short duration,
resulted in a relatively low number of casualties, and positive support for
the war prevailed at home. Persian Gulf veterans were exposed to many
psychophysiological stressors besides direct combat, such as sudden
mobilization for military service (especially among members of resene
and National Guard units), exposure to dramatic oil well fires, the
constant threat of chemical and biological warfare agents, and fear of
combat in general. A wide range of somatic and psychological responses
could be expected from individuals deployed to the Persian Gulf area
from stress associated with deployment (Wolfe et al., 19931....
A variety of symptoms have been reported by Persian Gulf veterans.
Some symptoms may be related to post-traumatic stress disorder (PTSD).
Published findings(Sutker etal., 1993; Sutkeret all, 1994a,b; and Wolfe
et al., 1993) suggest an increased prevalence of PTSD and other
psychiatric diagnoses, such as depression, in some Persian Gulf War
veterans. Although the prevalence of these disorders was found to be
lower than that found among Vietnam veterans, it is evident that stressors
during the Persian Gulf conflict were sufficient to cause significant
psychiatric morbidity. Because of the low level of combat experienced
by many troops in the Persian Gulf conflict, the presence of psychiatric
problems among some returnees suggests the importance of stress other
than actual combat as a precipitating factor.
Currently, the DoD and the DVA are funding several research projects
relevant to psychiatric conditions in Persian Gulf veterans (PGVCB, 1995a).
These include four DoD and six DVA projects, which will acquire self-reported
data on exposures to psychophysiological stressors among Persian Gulf veterans.
These projects will also collect questionnaire data, which will allow the
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development of prevalence estimates of psychological symptoms and diagnoses
(PGVCB, 1995a).
It is possible that the DoD will be able to use the results of these
epidemiologic studies on psychiatric conditions to revise the CCEP, that is, to
revise the standardized questionnaires or to add or delete targeted lab tests or
specialty consultations. In addition, the CCEP clinicians may be able to utilize
these results in the counseling and treatment of their patients. These results may
also be useful for the DoD in its planning to minimize the effects of
psychosocial stressors in future deployments through the use of preventive
medicine interventions. For instance, a better understanding of the
psychological symptoms in the CCEP, coupled with more information on the
deployment circumstances associated with patients with these problems, might
suggest hypotheses for further research on prospective interventions.
Musculoskeletal Conditions
Musculoskeletal conditions account for 17% of the primary diagnoses in the
CCEP population. A primary or secondary diagnosis of a musculoskeletal
condition has been made in 45% of the CCEP patients. Of these conditions,
51 % are included in three categories: joint pain, osteoarthritis, and
backache/lumbago (DoD, l995d).
These musculoskeletal conditions could be related to the physical demands
of military service. Occupational and recreational overuse injuries frequently
occur as a consequence of the physical activities associated with military training
and operations (DoD, l995d). It is fortunate that most of these musculoskeletal
conditions do not appear to cause serious impairment. Of the patients who had
a musculoskeletal condition as their primary diagnosis, 82% stated that in the
previous 90 days they had not missed even 1 day of work because of illness
(DoD, 1995c).
The draft and final DoD reports on 10,020 CCEP patients do not provide
adequate details for the IOM committee to make a thorough evaluation of the
diagnostic categorization of musculoskeletal conditions (DoD, l995c,d). All
three of the categories of musculoskeletal conditions mentioned joint pain,
osteoarthritis, and backache/lumbago are broad and vague; therefore, some
explicit examples of the actual diseases categorized under musculoskeletal
conditions would be helpful. More explanation about the diagnostic aspects of
these musculoskeletal conditions would be useful, for example, information on
singlejoint involvement versus multijoint conditions or articular versus non-
articular conditions. In addition, details on disease severity and disease activity
would be useful.
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The DoD and DVA apparently are not currently performing any
epidemiological investigations that are focused on musculoskeletal conditions
among Persian Gulf veterans (PGVCB, 1995a). The DoD and DVA are
performing several general health surveys among Persian Gulf veterans in which
musculoskeletal conditions may be a minor consideration. The IOM committee
believes that the DoD and the DVA should consider placing more emphasis on
research on musculoskeletal conditions, since these are the most prevalent
disorders among the CCEP populations. A variety of instruments are available
for use in epidemiological research on musculoskeletal conditions.
Musculoskeletal conditions represent a significant cause of morbidity among
military personnel in general, that could be prevented if risk factors could be
identified (DoD, l995d).
Signs, Symptoms, and Ill-Defined Conditions
The ICD-9 category of signs, symptoms, and ill-defined conditions (SSIDC)
Is extremely heterogeneous. It encompasses generalized symptoms such as
fatigue and malaise, nonspecific abnormal laboratory results (i.e., an elevated
sedimentation rate), and signs and symptoms that prove to be transient (i.e., a
history of a skin rash). In general, no significant objective anatomical,
pathological, or biochemical abnormalities are detectable in this category. Since
many specific conditions that are not otherwise classified in ICD-9 are
categorized as SSIDC, coding a diagnosis as SSIDC may reflect limitations in
the ICD-9 criteria, as much as a physician's inability to explain the condition.
SSIDC is the primary diagnosis for 17% of CCEP patients, and 41% of
CCEP patients have a primary diagnosis or a secondary diagnosis of SSIDC
(DoD, 1995d). This group does not have homogeneous symptoms, and some
of the patients in this group have well-recognized diseases, such as dyslexia or
sleep apnea, which are not classified elsewhere in ICD-9. Therefore, it should
not be concluded that the 17% of the CCEP patients whose primary diagnosis is
SSIDC have a "mystery illness." Rather, the committee recommends that in
future reports the DoD attempt to clarify the types of disorders that are included
in the category of SSIDC. Individuals with these signs, symptoms, and ill-
defined conditions should be evaluated in a rigorous manner, just as individuals
with any other symptoms are evaluated.
Infectious Diseases
An overview of the infectious diseases that occurred during the Persian Gulf
War was recently published (Hyams et al., 1995~. The most frequently reported
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infectious causes of acute morbidity were generally mild cases of acute diarrhea
and upper respiratory infections, neither of which would be likely to lead to
long-term sequelae. There were unexpectedly low rates of arthropod-borne
infections, for example, sandily fever. These very low rates were due to low
insect populations in the winter months. A total of 226 noncombat deaths,
primarily from accidental injuries, were reported during the Persian Gulf War.
No deaths due to infectious diseases were reported (Helmkamp, 1994; Hyams
et al., 19951.
The DoD report on 10,020 CCEP patients summarized the types and
prevalence of infectious diseases as follows (DoD, l995d):
The threat to deployed military personnel posed by infectious
diseases was recognized and preparations were made from the earliest
stages of Operation Desert Shield. Specific infectious diseases
observed in U.S. troops during Operations Desert Shield/Storm
conformed with expected disease threats. Data suggest that overall
exposure to recognized pathogens was quite low. Furthermore, it
suggests that no route of infection, other than ingestion of locally-
produced food, was common. The reported incidence of infectious
diseases observed during the Operations is relevant to evaluation of
current health complaints of Gulf War veterans....
The low incidence of leishmaniasis during and immediately after
Operations Desert Shield/Storm, the absence of other sandfly-borne
diseases in our troops, and the low prevalence of objective findings
pointing to leishmania disease among 10,000 CCEP patients, all
indicate that viscerotropic leishmaniasis plays no significant role in the
current complaints of Gulf War veterans.
The CCEP itself has identified a wide variety of infectious
diagnoses. Of these, by far the largest group has been fungal infections
of the skin due to fungi common in the United States. Virtually all of
the remaining infections have represented common illnesses, such as
sinusitis, diarrheas, and a few cases of viral hepatitis, not specific to
the Persian Gulf region. The overwhelming majority of these
diagnoses represent incidental diagnoses which would not explain
persistent systemic complaints.
The IOM committee concludes that infectious diseases are not a frequent
cause of serious illness in the CCEP population. Only 3% of the CCEP
population has a primary diagnosis of an infectious disease. A primary or
secondary diagnosis of an infectious disease has been made in 9% of the CCEP
population (DoD, l995d). Of the 278 patients who have a primary diagnosis of
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an infectious disease, 81% stated that in the previous 90 days they had not
missed even one day of work because of illness (DoD, l995c).
A variety of organ systems have been affected by infectious diseases in the
CCEP population, without any observable patterns. The majority of these
diseases have been minor or asymptomatic, or they were diseases that were
diagnosed before the patient enrolled in CCEP (Gasser, 19951. To date, very
few CCEP patients have demonstrated the classical objective physical and
laboratory abnormalities that would indicate a chronic infectious process, such
as documented fever, leukocytosis, lymphadenopathy, hepatomegaly, or
splenomegaly (Gasser, 1995; Hyams et al., 1995; PGVCB, l995b).
The IOM committee concludes that on the basis of the current evidence, it
is unlikely that a significant proportion of Persian Gulf veterans are afflicted
with some previously unknown pathogen that is evading the current diagnostic
efforts.
Chronic Fatigue Syndrome, Fibromyalgia,
and Multiple Chemical Sensitivity
The IOM committee's review of the CCEP protocol suggests that data on
chronic fatigue syndrome (CFS), f~bromyalgia (FM), and multiple chemical
sensitivity (MCS) may have been collected by various diagnostic methods. For
this reason, it is not possible to estimate the prevalence of these conditions from
the CCEP data.
In the clinical evaluations, the IOM committee believes that data should be
collected by using established diagnostic criteria for CFS and FM. A widely
accepted set of diagnostic criteria does not exist for MCS. Consequently, the
medical evaluation in CCEP cannot be expected to diagnose the clinical
syndrome of MCS. If more is to be learned about the relationship between these
disorders (CFS, FM, and MCS) and Persian Gulf service, they should be
included among the epidemiological research studies that are ongoing or planned
for the future.
The symptoms of some of the CCEP patients are similar to or overlap the
nonspecific symptoms that previous authors (Holmes et al., 1988; Wolfe et al.,
1990) have described for CFS or FM, as shown in Table 7 of the DoD report
on 10,020 patients (DoD, l995d). These nonspecific symptoms include fatigue,
joint and muscle pain, headache, sleep disturbance, and depressed mood.
Because of the thorough, systematic workup mandated in the CCEP, many
disorders that could contribute to sleep disturbance and fatigue have been
diagnosed. These have included obstructive sleep apnea, gastroesophageal
reflux, hyperthyroidism, chronic sinusitis, and PTSD. For example, 5 % of the
first 10,020 CCEP patients were diagnosed with PTSD (DoD, l995d). These
Representative terms from entire chapter:
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