Gulf War Syndrome

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Gulf War Syndrome

• Exposing the Myths
• or

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Outline

• History
• Definition
• Etiologies
• Beliefs
• Facts
• Conclusions

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History of Gulf War Syndrome

• Tens of thousands of U.S., British, Canadian, and
  Australian soldiers experienced sudden onset of
  unexplained symptoms during or following
  deployment to Persian Gulf in 1990-91
• Initially attributed to post-traumatic stress
  disorder
• Psychiatric interviews did not support PTSD as
  etiology, prompting further investigation

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What is Gulf War Syndrome?

• No specific definition
• No identifiable marker
• Constellation of symptoms
• Common complaints fatigue, joint pain, muscle
  pain, headache, cognitive problems, rash
• Heterogeneity of symptoms group of syndromes
• Complicated by similarity to other conditions
• Chronic fatigue syndrome, fibromyalgia, multiple
  chemical sensitivity

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Possible Etiologies of GWS

• Psychiatric PTSD
• Infectious
• Leishmaniasis, Sand Fly Fever, Mycoplasma
• Toxic exposure
• Pyridostigmine bromide, sand, pesticides,
  nerve/mustard chemical weapons, depleted uranium,
  petroleum-based fuels, smoke from burning oil
  wells, vaccinations

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Toxic Exposures

• Increased acute respiratory symptoms seen due to
  sand exposure
• Smoke, pesticides, and long-term effects of
  exposure to chemical warfare agents have unknown
  relationship to GWS
• Depleted uranium exposure not appreciably higher
  than background
• Less radioactive, toxic due to chemical properties

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Toxic Exposures

• Pyridostigmine bromide
• Taken prophylactically for nerve agents
• Can cause neurologic symptoms at high doses
• Vaccines anthrax
• Half of British soldiers refused vaccine prior to
  2nd Gulf War

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Toxic Exposures

• Sarin nerve agent
• Declassified information from CIA demonstrated
  widespread, low-level exposure
• GWS patients found to have decreased activity of
  paraoxonase, an enzyme that breaks down
  organophosphates
• Autonomic nervous dysfunction
• Animal studies show low-level exposure of Sarin
  leads to damage to deep grey matter (basal
  ganglia)
• N-acetylaspartate levels decreased in basal
  ganglia and pons of GWS patients

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Toxic Exposures

• Difficult to study because no reliable metric
  exists to quantify exposure
• Self-reporting exposure results in over-reporting

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Beliefs and Functional Status

• Increased impairment reported with
• Belief that symptoms caused by anthrax
• Requirement of medical treatment
• Disability or worsening impairment
• Decreased impairment reported with
• Belief that symptoms caused by stress
• Amelioration of symptoms with medication
• Symptoms improvement
• Treatment requiring a specialist

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Beliefs and Functional Status

• Presence of mental health symptoms (PTSD,
  depression) predicted increased frequency and
  severity of somatic symptoms
• Model of Illness
• Four axes seriousness, locus of control,
  controllability, changeability
• Severe symptoms and poor function associated with
  high level of seriousness and external locus of
  control

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GWS What we do know

• Information based predominantly on registries
  available to Gulf War Veterans
• Evaluation involved screening exam, medical
  record review, questionnaires, and surveys
• Twenty studies of registry info from 1995-2002
• Sample size ranged from 41-18,000
• Over 130,000 veterans examined as of 2003
• Presence of GWS always self-reported
• Confounded by self-selection bias, recall bias,
  and media reports
• Army, Reserve, National Guard, older, and female
  personnel more likely to report
• Most common risk factor was deployment to Persian
  Gulf during or before the war

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GWS What we do know

• Gulf War veterans have increased rate of
  hospitalizations and injuries
• Pre-existing conditions, increased risk taking
  behavior, stress, alcohol, PTSD
• Gulf War veterans have higher rates of alcohol-,
  drug-, and stress-related disorders
• Strongest predictor was pre-war status
• No relationship to combat (except with EtOH)

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GWS What we do know

• Female Gulf War veterans found to be at increased
  risk for ectopic pregnancies and spontaneous
  abortions as compared to nondeployed peers
• No increased rate of birth defects

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GWS What we do know

• Amyotrophic lateral sclerosis (ALS)
• 18 increased risk for ALS development as
  compared with nondeployed peers
• No increased risk for SLE or fibromyalgia
• Nerve agent exposure
• Subclinical exposure in March 1991 near
  Khamisiyah, Iraq
• Relative risk of 1.23 for development of
  dysrhythmias

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Conclusions

• No unique constellation of signs or symptoms has
  been identified
• Symptoms overlap with other multi-symptom
  conditions
• No specific, etiologic exposure is evident
• One Study There is probably a causal link
  between deployment to the Persian Gulf theater of
  operation and the development of the poorly
  defined multi-symptom illness known as GWS.

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Conclusions

• Gulf War veterans have increased rates of
  injuries, mental health disease, and
  multi-symptom conditions
• Very similar to veterans from previous conflicts
• Relationship between GWS, ALS, nerve agent
  exposure, and dysrhythmias merits further study

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Outline

• History
• Definition
• Etiologies
• Beliefs
• Facts
• Conclusions

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References

• Hunt S., Richardson R., Engel C., Atkins D., and
  M. McFall. Gulf War Veterans Illnesses A Pilot
  Study of the Relationship of Illness Beliefs to
  Symptom Severity and Functional Health Status. J
  Occup Environ Med. 2004 46818-827.
• Gronseth G. Gulf War Syndrome A Toxic Exposure?
  A Systematic Review. Neurol Clin. 2005
  25523-540.
• Gray G., Gackstetter G., Kang H., Graham J., and
  K. Scott. After More than 10 Years of Gulf War
  Veteran Medical Evaluations, What Have We
  Learned? Amer J of Preven Med. 2004
  26(5)443-452
• Haley R. Gulf War Syndrome Narrowing the
  Possibilities. Neurology. 2003 2272-273
• Kerr C. Anthrax Vaccine Gets Cold Shoulder from
  Troops. Canadian Med Assoc Journal. 2003
  168(10).
• Young H., Simmens S., Kang H., Mahan C., and P.
  Levine. Factor Analysis of Fatiguing Syndrome in
  Gulf War Era Veterans Implications for Etiology
  and Pathogenesis. J Occup Environ Med. 2003
  451268-1273