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Gulf War Syndrome

Gulf War syndrome

Definition

Gulf War syndrome describes a wide spectrum of illnesses and symptoms ranging from asthma to sexual dysfunction that have been reported by U.S. and U.S. allied soldiers who served in the Persian Gulf War in 199091.

Description

Between 1994 and 1999, 145 federally funded research studies on Gulf War-related illnesses were undertaken at a cost of over $133 million. Despite this investment, and the data collected from over 100,000 veterans who have registered with the Department of Defense and/or Veterans Administration as having Gulf War-related illnesses, there is still much debate over the cause and nature of Gulf War Syndrome. Veterans who have the illness experience a wide range of debilitating symptoms that elude a single diagnosis. They are tired, have trouble breathing, have headaches, sleep poorly, are forgetful, and cannot concentrate. Similar experiences among Gulf War veterans have been reported in the United Kingdom and Canada.

Causes & symptoms

There is much current debate over a possible causative agent for Gulf War Syndrome other than the stress of warfare. Intensive efforts by the Veterans Administration and other public and private institutions have investigated a wide range of potential factors. These include chemical and biological weapons, the immunizations and preventive treatments used to protect against them, smoke from oil well fires, exposure to depleted uranium, and diseases endemic to the Arabian peninsula. So far investigators have not approached a consensus. They even disagree on the likelihood that a specific agent is responsible, as a combination of these risk factors may have negative health consequences. There is, however, a likelihood that sarin and/or cyclosarin (nerve gases) were released during the destruction of Iraqi munitions at Kharnisiyah, Iraq, and that these chemicals might be linked to the syndrome.

In October 1999, the U.S. Pentagon released a report that hypothesized that an experimental drug known as pyriostigmine bromide, or PB, might be linked to the physical symptoms manifested in Gulf War Syndrome. The experimental drug was given to U.S. and Canadian troops during the war to protect soldiers against the effects of the chemical nerve agent soman.

Statistical analysis shows that the following symptoms are about twice as likely to appear in Gulf War veterans than in their non-combat peers: depression , post-traumatic stress disorder (PTSD), chronic fatigue , cognitive dysfunction (diminished ability to calculate, order thoughts, evaluate, learn, and remember), bronchitis , asthma, fibromyalgia , alcohol abuse, anxiety , and sexual dysfunction. PTSD is the modern equivalent of shell shock (term used in World War I) and battle fatigue (World War II). It encompasses most of the psychological symptoms of war veterans, not excluding nightmares, panic at sudden loud noises, and inability to adjust to peacetime living.

Chronic fatigue syndrome has a specific medical definition that attempts to separate common fatigue from a more disabling illness in hope of finding a specific cause. Fibromyalgia is another newly defined syndrome, and as such it has arbitrarily rigid defining characteristics. These include a certain duration of illness, a specified minimum number of joint and muscle pains located in designated areas of the body, sleep disturbances, and other associated symptoms and signs. One study comparing unexplained symptoms in Gulf War veterans with symptoms in control subjects found that over half the veterans with unexplained muscle pain met the criteria for fibromyalgia, and a significant portion of the veterans with unexplained fatigue met the criteria for chronic fatigue syndrome.

As of 2001, amyotrophic lateral sclerosis (ALS), which is also known as Lou Gehrig's disease , has been added to the list of illnesses that occur more frequently in veterans of the Gulf War. Gulf War veterans are twice as likely as other veterans to develop ALS, which is a disease that causes wasting of muscle tissue and kills its victims within three to five years. About 40 Gulf War veterans have been diagnosed with ALS; most have already died.

Researchers have identified three distinct syndromes and several variations in Gulf War veterans. Type one patients suffer primarily from impaired thinking. Type two patients have a greater degree of confusion and ataxia (loss of coordination). Type three patients are the most affected by joint pains, muscle pains, and extremity paresthesias (unnatural sensations like burning or tingling in the arms and legs). In each of the three types, researchers found different but measurable impairments on objective testing of neurological function. The functioning of the nervous system is much more complex and subtle than other body systems. Measuring it requires an equally complex effort. The tests used in this study carefully measured and compared localized nerve performance at several different tasks against the same values in normal subjects. Brain wave response to noise and touch, eye muscle response to spinning, and caloric testing (stimulation of the ear with warm and cold water, which causes vertigo) were clearly different between the normal and the test subjects. The researchers concluded that there was "a generalized injury to the nervous system." Another research group concluded their study by stating that there was "a spectrum of neurologic injury involving the central, peripheral, and autonomic nervous systems."

Diagnosis

Until there is a clear definition of the disease, diagnosis is primarily an exercise in identifying those Gulf War veterans who have an undefined illness in an effort to learn more about them and their symptoms. Both the Department of Defense (DoD) and the Veterans Administration (VA) currently have programs devoted to this problem. Both the DoD's Comprehensive Clinical Evaluation Program and the VA's Persian Gulf Registry provide free, in-depth medical evaluations to Gulf War veterans and their families. In addition to providing individual veterans with critical medical care, these organizations use the cumulative data from these programs to advance research on Gulf War syndrome itself.

Treatment

Specific treatment awaits specific diagnosis and identification of a causative agent. Meanwhile, veterans can benefit from the wide variety of supportive and nonspecific approaches to this and similar problems. The key to working successfully with people living their lives with Gulf War syndrome is long-term, ongoing care, whether it be hypnotherapy, acupuncture, homeopathy, nutrition , vitamin/mineral therapy, or bodywork.

Allopathic treatment

There are many drugs available for symptomatic relief. Psychological counseling by those specializing in this area can be immensely beneficial, even life-saving, for those contemplating suicide. Veterans' benefits are available for those who are impaired by their symptoms.

Expected results

The outlook for war veterans is unclear, but will hopefully improve as more information is gathered about the illness. Gradual return to a functioning life may take many years of work and much help. However, even in the absence of an identifiable and curable cause, recovery is possible.

Resources

BOOKS

Isselbacher, Kurt, et al., ed. Harrison's Principles of Internal Medicine. New York: McGraw-Hill, 1998.

"Posttraumatic Stress Disorder." Treatments of Psychiatric Disorders. 3rd ed. Ed. Glen O. Garbbard. Washington, DC: American Psychiatric Press Inc., 2001.

PERIODICALS

Bourdette, Dennis N., et al. "Symptom Factor Analysis, Clinical Findings, and Functional Status in a Population-Based Control Study of Gulf War Unexplained Illness." Journal of Occupational and Environmental Medicine 43 (December 2001): 10261040.

Haley, R. W., et al. "Evaluation of Neurologic Function in Gulf War Veterans. A Blinded Case-Control Study." Journal of the American Medical Association. 277 (January 15, 1997): 223230.

Knoke, James D., and Gregory C. Gray. "Hospitalizations for Unexplained Illnesses Among U.S. Veterans of the Persian Gulf War." Emerging Infectious Diseases 4 (April-June 1998): 211219.

McDiarmid, Melissa, et al. "Surveillance of Depleted Uranium-Exposed Gulf War Veterans: Health Effects Observed in an Enlarged 'Friendly Fire' Cohort." Journal of Occupational and Environmental Medicine 43 (December 2001): 9911000.

"Self-Reported Illness and Health Status Among Gulf War Veterans. A Population-Based Study. The Iowa Persian Gulf Study Group." Journal of the American Medical Association 277 (January 15, 1997): 238245.

Spencer, Peter S., et al. "Self-Reported Exposures and Their Association With Unexplained Illness in a Population-Based Case-Control Study of Gulf War Veterans." Journal of Occupational and Environmental Medicine 43 (December 2001): 10411056.

Szegedy-Maszak, Marianne. "A Gulf War Legacy." U.S. News & World Report (December 24, 2001): 50.

ORGANIZATIONS

Office of the Special Assistant for Gulf War Illnesses. 5111 Leesburg Pike, Suite 901, Falls Church, Virginia, 22041. 703-578-8518. brostker@gwillness.osd.mil. <http://www.gulflink.osd.mil>.

The American Legion. Gulf War Veteran Issues. <http://www.legion.org/veterans/vt_gulfvet_info.htm>.

Veterans Administration. Persian Gulf Medical Information Helpline. 400 South 18th Street, St. Louis, Missouri 63103-2271. (800) 749-8387.

Veterans Administration. Persian Gulf Registry. 800-PGW-VETS (800-749-8387). <http://www.va.gov>.

Gulf War News. Office of the Special Assistant for Gulf War Illnesses, 5113 Leesburg Pike, Suite 901, Falls Church, Virginia 22041. (703) 578-8518. edipaolo@gwillness.osd.mil.

OTHER

Joseph, Stephen C., and the Comprehensive Clinical Evaluation Program (CCEP). "A Comprehensive Clinical Evalutation of 20,000 Persian Gulf War Vetrans." Military Medicine 162 (March 1997). [cited October 2002]. <http://www.defenselink.mil/pubs/foi/clinic.pdf>.

Paula Ford-Martin

Rebecca J. Frey, PhD

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Gulf War Syndrome

Gulf War Syndrome

Definition

Gulf War syndrome describes a wide spectrum of illnesses and symptoms ranging from asthma to sexual dysfunction that have been reported by U.S. and U.S. allied soldiers who served in the Persian Gulf War in 19901991.

Description

Between 1994 and 1999, 145 federally funded research studies on Gulf War-related illnesses were undertaken at a cost of over $133 million. Despite this investment and the data collected from over 100,000 veterans who have registered with the Department of Defense (DOD) and/or Veterans Administration (VA) as having Gulf War-related illnesses, there is still much debate over the origin and nature of Gulf War syndrome. As of early 2001, the DOD has failed to establish a definite cause for the disorder. Veterans who have the illness experience a wide range of debilitating symptoms that elude a single diagnosis. Common symptoms include fatigue, trouble breathing, headaches, disturbed sleep, memory loss, and lack of concentration. Similar experiences among Gulf War veterans have been reported in the United Kingdom and Canada.

Causes and symptoms

There is much current debate over a possible causative agent for Gulf War syndrome other than the stress of warfare. Intensive efforts by the Veterans Administration and other public and private institutions have investigated a wide range of potential factors. These include chemical and biological weapons, the immunizations and preventive treatments used to protect against them, smoke from oil well fires, exposure to depleted uranium, and diseases endemic to the Arabian peninsula. So far investigators have not approached a consensus. In its final report released in December 2000, the Presidential Special Oversight Board for Department of Defense Investigations of Gulf War Chemical and Biological Incidents cited combat stress as a possible causative factor, but called for further research. There is also a likelihood that U.S. and allied forces were exposed to low levels of sarin and/or cyclosarin (nerve gases) released during the destruction of Iraqi munitions at Kharnisiyah, Iraq, and that these chemicals might be linked to the syndrome. In July 1997, the VA informed approximately 100,000 U.S. servicemen of their possible exposure to the nerve agents.

In October 1999, the U.S. Pentagon released a report that hypothesized that an experimental drug known as pyriostigmine bromide (PB) might be linked to the physical symptoms manifested in Gulf War Syndrome. The experimental drug was given to U.S. and Canadian troops during the war to protect soldiers against the effects of the chemical nerve agent soman. It has also been suggested that botulinum toxoid and anthrax vaccinations administered to soldiers during the conflict may be responsible for some manifestations of the syndrome.

Some studies have shown that Gulf War veterans have a higher incidence of positive tests for Mycoplasma fermentans, a bacteria, in their bloodstream. However, other clinical studies have not found a link between the bacterial infection and Gulf War-related illnesses.

Statistical analysis tells us that the following symptoms are about twice as likely to appear in Gulf War veterans than in their non-combat peers: depression, posttraumatic stress disorder (PTSD), chronic fatigue, cognitive dysfunction (diminished ability to calculate, order thoughts, evaluate, learn, and remember), bronchitis, asthma, fibromyalgia, alcohol abuse, anxiety, and sexual discomfort. PTSD is the modern equivalent of shell shock (World War I) and battle fatigue (World War II). It encompasses most of the psychological symptoms of war veterans, including nightmares, panic at sudden loud noises, and inability to adjust to peacetime living. Chronic fatigue syndrome has a specific medical definition that attempts to separate common fatigue from a more disabling illness in hope of finding a specific cause. Fibromyalgia is another newly defined syndrome, and as such it has arbitrarily rigid defining characteristics. These include a certain duration of illness, a specified minimum number of joint and muscle pain located in designated areas of the body, sleep disturbances, and other associated symptoms and signs.

Researchers have identified three distinct syndromes and several variations in Gulf War veterans. Type one patients suffer primarily from impaired thinking. Type two patients have a greater degree of confusion and ataxia (loss of coordination). Type three patients were the most affected by joint pains, muscle pains, and extremity paresthesias (unnatural sensations like burning or tingling in the arms and legs). In each of the three types, researchers found different but measurable impairments on objective testing of neurological function. The business of the nervous system is much more complex and subtle than other body functions. Measuring it requires equally complex effort. The tests used in this study carefully measured and compared localized nerve performance at several different tasks against the same values in normal subjects. Brain wave response to noise and touch, eye muscle response to spinning, and caloric testing (stimulation of the ear with warm and cold water, which causes vertigo) were clearly different between the normal and the test subjects. The researchers concluded that there was "a generalized injury to the nervous system." Another research group concluded their study by stating that there was "a spectrum of neurologic injury involving the central, peripheral, and autonomic nervous systems."

Diagnosis

Until there is a clear definition of the disease, diagnosis is primarily an exercise in identifying those Gulf War veterans who have undefined illness in an effort to learn more about them and their symptoms. Both the Department of Defense and the Veterans Administration currently have programs devoted to this problem. Both the DOD's Comprehensive Clinical Evaluation Program and the VA's Persian Gulf Registry provide free, in-depth medical evaluations to Gulf War veterans and their families. In addition to providing individual veterans with critical medical care, these organizations use the cumulative data from these programs to advance research on Gulf War Syndrome itself.

Treatment

Specific treatment awaits specific diagnosis and identification of a causative agent. Meanwhile, veterans can benefit from the wide variety of supportive and non-specific approaches to this and similar problems. There are many drugs available for symptomatic relief. Psychological counseling by those specializing in this area can be immensely beneficial, even life-saving for those contemplating suicide. Veterans' benefits are available for those who are impaired by their symptoms.

Alternative treatment

The symptoms can be worked with using many modalities of alternative health care. The key to working successfully with people living their lives with Gulf War syndrome is long-term, ongoing care, whether it be hypnotherapy, acupuncture, homeopathy, nutrition, vitamin/mineral therapy, or bodywork.

Experimental treatment with antibiotics is advocated by some healthcare professionals who believe that Gulf War illness is related to a Mycoplasma fermentans bacterial infection. However, a conclusive link has not been clinically proven.

Prognosis

The outlook for Persian Gulf War veterans is unclear, but will hopefully improve as more information is gathered about the illness. Gradual return to a functioning life may take many years of work and much help. It is important to note that even in the absence of an identifiable and curable cause, recovery is possible.

KEY TERMS

Ataxia Lack of coordination.

Caloric testing Flushing warm and cold water into the ear stimulates the labyrinth and causes vertigo and nystagmus if all the nerve pathways are intact.

Endemic Always there.

Paresthesia An altered sensation often described as burning, tingling, or pin pricks.

Syndrome Common features of a disease or features that appear together often enough to suggest they may represent a single, as yet unknown, disease entity. When a syndrome is first identified, an attempt is made to define it as strictly as possible, even to the exclusion of some cases, in order to separate out a pure enough sample to study. This process is most likely to identify a cause, a positive method of diagnosis, and a treatment. Later on, less typical cases can be considered.

Resources

BOOKS

Wheelwright, Jeff. The Irritable Heart. New York: W.W. Norton & Co., 2001.

ORGANIZATIONS

The American Legion. Gulf War Veteran Issues. http://www.legion.org/gulftoc.htm.

Office of the Special Assistant for Gulf War Illnesses. 5113 Leesburg Pike, Suite 901, Falls Church, VA, 22041. (703) 578-8518. http://www.gulflink.osd.mil.

U.S. Department of Defense. Comprehensive Clinical Evaluation Program (CCEP). (800) 796-9699.

Veterans Administration. Persian Gulf Medical Information Helpline. 400 South 18th Street, St. Louis, Missouri 63103-2271. (800)749-8387.

Veterans Administration. Persian Gulf Registry. (800)PGW-VETS (800) 749-8387. http://www.va.gov.

OTHER

Office of the Special Assistant for Gulf War Illnesses. Fourth Annual Report: Office of the Special Assistant for Gulf War Illnesses. Falls Church, VA: Office of the Special Assistant for Gulf War Illnesses, 2000. http://www.gulflink.osd.mil/library/annual/4thannual_report_jan01.htm.

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Gulf War Syndrome

GULF WAR SYNDROME

Gulf War syndrome, or Gulf War illness, refers to a group of poorly understood symptomatic illnesses afflicting veterans of the 19901991 Persian Gulf War. The most characteristic symptoms are fatigue, musculoskeletal complaints, and psychiatric complaints of emotional distress, anxiety, and cognitive problems. To date, no specific underlying physical abnormalities have been identified, which links Gulf War illness to other medically unexplained syndromes such as chronic fatigue syndrome and multiple chemical sensitivity. In fact, substantial proportions of ill Gulf War veterans have complaints consistent with these other conditions.

Medically unexplained symptoms have been common in soldiers who have returned from previous deployments. The symptoms among Gulf War veterans are somewhat different from those noted after previous conflicts, however. Further, complaints of contemporary soldiers who were not deployed to the Persian Gulf are similar in character, though the symptoms occur at substantially greater rates, and with greater severity, among those deployed to the Gulf.

Specific causes for Gulf War illness are unknown. The presence of similar complaints in those not deployed to the Gulf suggests that a unique Gulf War exposure is not the sole cause. While individuals with complaints report higher rates of exposure to various toxins in the Gulf, including pesticides, anti-nerve gas pills, immunizations, and exploding missiles, these associations are not regarded as definitive at this time, with recall and information bias being very problematic. Because of this uncertainty, prevention efforts have been nonspecific and aimed at a reduction of various stressors and an improvement in risk communication with at-risk soldiers. Further research is ongoing.

Howard M. Kipen

(see also: Multiple Chemical Sensitivities; War )

Bibliography

Fukuda, K.; Nisenbaum, R.; Stewart, G.; Thompson, W. W.; Robin, L.; and Washko, R. M. et al. (1998). "Chronic Multisymptom Illness Affecting Air Force Veterans of Gulf War." Journal of the American Medical Association 280(11):981988.

Fulco, C. E.; Liverman, C. T.; and Sox, H. C., eds. (2000). Gulf War and Health, Vol. 1: Depleted Uranium, Sarin, Pyridostigmine Bromide, Vaccines. Committee on Health Effects Associated with Exposures During the Gulf War. Division of Health Promotion and Disease Prevention. Institute of Medicine.

Hodgson, M. J., and Kipen, H. M. (1999). "Gulf War Illnesses: Causation and Treatment." Journal of Occupational and Environmental Medicine 41(6):443452.

Hyams, K. C.; Wignall, F. S.; and Roswell, R. (1996). "War Syndromes and Their Evaluations: From the U.S. Civil War to the Persian Gulf War." Annals of Internal Medicine 125(5):398405.

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Gulf War syndrome

Gulf War syndrome, popular name for a variety of ailments experienced by veterans after the Persian Gulf War. Symptoms reported include nausea, cramps, rashes, short-term memory loss, fatigue, difficulty in breathing, headaches, joint and muscle pain, and birth defects. Ailments have been reported by American, Canadian, Australian, and British veterans alike; in some cases spouses of veterans have reported similar symptoms.

The mysterious syndrome has sparked debate between veteran's groups, congressional investigators, and the military over questions of accountability, treatment, and compensation. Hypothesized causes have included parasites, biological and chemical warfare agents, prophylactic vaccines and medications given against biological and chemical warfare agents, fumes from oil well fires, and stress. In 1994 an advisory panel organized by the National Institutes of Health reported that the syndrome represented many illnesses and many causes; they deemed biological and chemical warfare agents unlikely as causes. Causes for the illnesses in many subsets of patients have been identified, e.g., some 30 veterans had leishmaniasis, a parasitic disease spread by sand flies, but in many instances the cause has not been identified.

In 1999 researchers said that brain scans of some sick veterans revealed signs of damage caused by exposure to toxic chemicals, and a study in 2004 suggested that some veterans may have been sensitive enough to otherwise low levels of poison gases to cause symptons associated with the syndrome. A committee appointed by Congress said in 2008 that evidence suggested that acetyl cholinesterase inhibitors, which include the nerve gas sarin, an anti-nerve-gas agent, and pesticides used against sand flies, and a genetic sensitivity to such chemicals may be the cause of the syndrome. Some medical historians have pointed out that syndromes of undiagnosable diseases have occurred after other wars, including World Wars I and II and the American Civil War.

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Gulf War syndrome

Gulf War syndrome (gulf wor) n. a variety of symptoms, mainly neurological (including chronic fatigue, dizziness, amnesia, digestive upsets, and muscle wasting), that have been attributed to exposure of armed forces personnel to chemicals (e.g. insecticides) used during the Gulf War (1991) or possibly to the effects of vaccines and tablets given to protect personnel against the anticipated threat of chemical and biological warfare during the conflict.

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