Effects of the Persian Gulf War on U.S. Veterans

Introduction

Approximately 697,000 U.S. veterans served in the Persian Gulf War, and more than 263,000 have since sought medical care at the Department of Veterans Affairs (National Gulf War Resource Center, Inc., http://www.ngwrc.org/*, 2002). Over 185,000 have filed claims with the Veterans Administration for service-related medical disabilities, including significant physical and psychological distress that they attribute to their participation in the operation. Perhaps the most unusual consequence of serving in the Persian Gulf is Gulf War Illness. This fact sheet focuses on what is known about Gulf War Illness and briefly summarizes the psychological and physical effects that Gulf War veterans experience.

What is Gulf War Illness?

Gulf War Illness is difficult to define, but clinicians and researchers often describe it as a combination of physical and psychological symptoms that some military personnel develop as a result of being involved in the Gulf War (GW). Generally, studies have found no evidence of a single, unique illness related to GW services (Joseph, 1997). In spite of great efforts, researchers continue to struggle with classifying the symptoms experienced by GW veterans. In an effort to clarify the concept of Gulf War Illness for veterans, physicians, and mental health professionals and to help guide treatment, the Centers for Disease Control (CDC) created a nomenclature for classifying the illness. This classification consists of three distinct symptom types:

• fatigue
• mood and cognition problems (e.g., feeling depressed, having difficulty remembering or concentrating, feeling moody, feeling anxious, having trouble finding words, having difficulty sleeping)
• musculoskeletal problems (e.g., joint pain, joint stiffness, and muscle pain) (Fukuda et al., 1998). Within these categories, symptoms can vary in type and severity.

Most veterans who report being affected by some aspects of their service in the Gulf War describe a combination of physical complaints and psychological distress.

What are the risk factors for Gulf War Illness?

Although it is not clear what factors cause the physical and psychological symptoms described above, there is some evidence to suggest that certain conditions might increase one's risk of developing Gulf War Illness. These risk factors include exposure to the following: extremes of heat and cold, blowing dust, smoke from oil-well fires, petroleum fuels and their combustion products, pyridostigmine bromide (administered as pretreatment for potential poison-gas exposure), anthrax and botulinum toxoid vaccines, depleted uranium (used in certain artillery shells), infectious diseases, chemical warfare agents (such as sarin gas), pesticides, and pervasive psychological and physiological stress (Institute of Medicine, 1995 as cited in Landrigan, 1997).

Researchers have explored different hypotheses to explain the physical and psychological reactions to toxic exposure, but current scientific research does not consistently support any single explanation. Some researchers argue based on evidence that psychiatric symptoms resulting from combat stress do not describe the full extent of Gulf War Illness (Lange et al., 1999; Wolfe, Erickson, Sharkansky, King, & King, 1999; Wolfe, Proctor, Davis, Borgos, & Friedman, 1998). These researchers argue that toxic exposure provides additional explanation for Gulf War Illness symptoms. However, the Presidential Advisory Committee on Gulf War Veterans' Illness (1996) argues that the only well-documented explanation for Gulf War Illness is that the psychological and physiological symptoms result from combat stress. If this is true, then this combination of stressors could occur in a separate setting, which calls into question whether Gulf War Illness is truly unique to participation in the Gulf War.

In spite of continued controversy about the definition and etiology of Gulf War Illness, researchers and clinicians agree that the physical and psychological symptoms characteristic of the illness are valid and need further research so that appropriate assessment and treatment options can be provided. In fact, President George W. Bush recently appointed another committee on Gulf War Illness to advise the government on the direction of future research regarding this debilitating condition.

What should I do if I think I have Gulf War Illness?

Reading this fact sheet is a good first step; it is important to learn what you can about Gulf War Illness. Other good sources of information include the links listed below. In terms of treatment, there is not one specific treatment designed to address all of the symptoms related to Gulf War Illness. Because symptoms can involve a combination of physical and psychological difficulties, it is important to involve both a primary care physician and a mental health professional. These individuals can collaborate to accurately assess the nature of your difficulties and recommend treatment. The following link is a good resource for additional information about benefits provided by the Veterans Administration for Gulf War veterans: http://www.va.gov/gulfwar/*.

Numerous mental health treatments may be used to treat the psychological symptoms of Gulf War Illness. Treatments for depression, anxiety, and PTSD are particularly relevant as symptoms of these disorders are quite common in Gulf War Illness. Also see our treatment section for more information.

What psychological difficulties are common among Gulf War veterans?

As with most combat experiences, there are numerous psychological difficulties related to participation in the Gulf War. Depressed mood, anxiety, and related psychological symptoms (e.g., sleep difficulties, concentration problems) are quite common among GW veterans, and deployed GW veterans have more symptoms of depression, anxiety, and alcohol abuse than non-deployed GW veterans (Iowa Persian Gulf Study Group, 1997). Neuropsychological testing has also revealed evidence of subtle impairments in cognitive function and mood state (White et al., 2001).

Across combat situations, posttraumatic stress disorder (PTSD) is one of the most common stress reactions that military personnel experience. PTSD is defined as the reaction to a severe stressor resulting in intense fear, horror, and/or helplessness. The three symptom clusters of PTSD include re-experiencing (e.g., intrusive, upsetting memories), emotional numbing and/or behavioral avoidance, and hyperarousal (e.g., difficulty sleeping, irritability).

Researchers have found that rates of PTSD are generally lower among Gulf War veterans than among military personnel from prior wars (Wolfe & Proctor, 1996), perhaps due to lower levels of exposure to combat. For example, the Iowa Persian Gulf Study Group (1997) found only a 2% rate of PTSD among a large sample of GW veterans. Wolfe and colleagues (1993) found a slightly higher rate of 4-9% among army personnel within 5 days of return from deployment. Other studies have found higher rates of PTSD among GW veterans with the following risk factors: female gender, exposure to a highly stressful event during deployment (e.g., body recovery and identification as well as lack of experience with the stressor), and precombat abuse history. Moreover, one study found that rates of PTSD in GW veterans increased significantly over time, with a rate of 3% (3% for men, 8% for women) immediately upon return from the war and a rate of 8% (7% for men, 16% for women) at follow-up 18 to 24 months later (Wolfe, Erickson, Sharkansky, King, & King, 1999). (The number of men in this study was significantly larger than the number of women, which explains why the overall rate is so much lower than the women's rate alone.)

What physical ailments are common among Gulf War veterans?

A significant number of GW veterans have reported unexplained physical symptoms arising during or after their services in the GW (Storzback et al., 2000). Some of these symptoms include memory and attention losses, chronic fatigue, muscle and joint pain, gastrointestinal distress, and skin rash (Persian Gulf Veterans Coordinating Board, 1995). The evidence for impairments in cognitive function and mood state leads to the possible explanation of central nervous system damage, especially because concentration difficulties remain significant even after researchers have controlled for mental health conditions (Lange et al., 2001; White et al., 2001).

Some clinicians use language such as "medically unexplained fatiguing illness" or "multiple nonspecific symptoms" to attempt to categorize the physical symptoms of Gulf War Illness. Others believe the combination of several of these symptoms is consistent with diagnoses of fibromyalgia and chronic fatigue syndrome, two conditions that appear to be empirically associated with Gulf War Illness. A large percentage of GW veterans experience physical complaints, and many veterans fear that the military's use of biological agents is the cause of these symptoms. Some research has begun to identify chemical agents and other substances as possible explanations for the physical and psychological symptoms of Gulf War Illness.

Sources

Fukuda, K., Nisenbaum, R., Stewart, G., Thompson, W. W., Robin, L., Washko, R. M., et al. (1998). Chronic multisymptom illness affecting Air Force veterans of the Gulf War. JAMA, 280, 981-988.

Institute of Medicine. (1995). Health consequences of service during the Persian Gulf War: Initial findings and recommendations for immediate action. Washington, DC: National Academy Press.

The Iowa Persian Gulf Study Group. (1997). Self-reported illness and health status among Persian Gulf War veterans: A population-based study. JAMA, 277, 231-237.

Joseph, S. C. (1997). A comprehensive clinical evaluation of 20,000 Persian Gulf War veterans. Military Medicine, 162, 149-155.

Landrigan, P. J. (1997). Illness in Gulf War veterans: Causes and consequences. JAMA, 277, 259-261.

Lange, G., Tiersky, L. A., DeLuca, J., Peckerman, A., Pollet, C., Policastro, T., et al. (1999). Psychiatric diagnoses in Gulf War veterans with fatiguing illness. Psychiatry Research, 89, 39-48.

Lange, G., Tiersky, L. A., DeLuca, J., Scharer, J., Policastro, T., Fiedler, N., et al. (2001). Cognitive functioning in Gulf War Illness. Journal of Clinical and Experimental Neuropsychology, 23, 240-249.

Persian Gulf Veterans Coordinating Board. (1995). Unexplained illnesses among Desert Storm veterans: A search for causes, treatment, and cooperation. Archives of Internal Medicine, 155, 262-268.

Presidential Advisory Committee on Gulf War veterans' illness: Final report. (1996). Washington, DC: US Government Printing Office.

Storzbach, D., Campbell, K. A., Binder, L. M., McCauley, L., Anger, W. K., Rohlman, D. S., et al. (2000). Psychological differences between veterans with and without Gulf War unexplained symptoms. Psychosomatic Medicine, 62, 726-735.

White, R. F., Proctor, S. P., Heeren, T., Wolfe, J., Krengel, M., Vasterling, J., et al. (2001). Neuropsychological function in Gulf War veterans: Relationships to self-reported toxicant exposures. American Journal of Industrial Medicine, 40, 42-54.

Wolfe, J., Brown, P. J., & Kelley, J. M. (1993). Reassessing war stress: Exposure and the Persian Gulf War. Journal of Social Issues, 49, 15-31.

Wolfe, J., Erickson, D. J., Sharkansky, E. J., King, D. W., & King, L. A. (1999). Course and predictors of posttraumatic stress disorder among Gulf War veterans: A prospective analysis. Journal of Consulting and Clinical Psychology, 67, 520-528.

Wolfe, J., & Proctor, S. P. (1996). The Persian Gulf War: New findings on traumatic exposure and stress. PTSD Research Quarterly, 7, 1-7.

Wolfe, J., Proctor, S. P., Davis, J. D., Borgos, M. S., & Friedman, M. J. (1998). Health symptoms reported by Persian Gulf War veterans two years after return. American Journal of Industrial Medicine, 33, 104-113.