Posttraumatic stress symptomatology is associated with unexplained illness attributed to Persian Gulf War military service

Self-reported gastrointestinal disorders among veterans with gulf war illness with and without posttraumatic stress disorder

BACKGROUND

Gulf War Illness (GWI) is a chronic, multi-symptom disorder affecting 25%-32% of Gulf War veterans. Veterans with GWI disproportionately suffer from gastrointestinal (GI) disorders. Given the increasing evidence supporting a gut-brain axis, we explore the relationship between post-traumatic stress disorder (PTSD), GWI, and self-reported GI disorders among GW veterans.

METHODS

Veterans from the Gulf War Era Cohort and Biorepository responded to a mail-based survey (N = 1058). They were stratified by GWI (Centers for Disease Control definition) and PTSD status. This yielded three groups: GWI-, GWI+/PTSD-, and GWI+/PTSD+. Multivariable logistic regression adjusting for demographic and military characteristics examined associations between GWI/PTSD groups and GI disorders. Results were expressed as adjusted odds ratios (aOR) with 95% confidence intervals (95% CI).

KEY RESULTS

The most frequently reported GI disorders were irritable bowel syndrome (IBS), gastroesophageal reflux disease (GERD), and colon polyps (CP). The GWI+/PTSD+ group had a higher odds of these disorders than the GWI+/PTSD- group (aOR_IBS  = 3.12, 95% CI: 1.93-5.05; aOR_GERD  = 2.04, 95% CI: 1.44-2.90; aOR_CP  = 1.85, 95% CI: 1.23-2.80), which had a higher odds of these disorders than the GWI- group (aOR_IBS  = 4.38, 95% CI: 1.55-12.36; aOR_GERD  = 2.51 95% CI: 1.63-3.87; aOR_CP  = 2.57, 95% CI: 1.53-4.32).

CONCLUSIONS & INFERENCES

GW veterans with GWI and PTSD have significantly higher odds of specific self-reported GI disorders than the other groups. Given the known bidirectional influences of the gut and brain, these veterans may benefit from a holistic healthcare approach that considers biopsychosocial contributors to the assessment and management of disease.

Assessment of Post-traumatic Stress Disorder Among Objective Esophageal Motility and Reflux Phenotypes in Symptomatic Veterans

Prior research suggests post-traumatic stress disorder (PTSD) is associated with the development of esophageal symptoms. We aimed to evaluate the prevalence of PTSD in veterans with esophageal symptoms, and assess for differences in objective esophageal motility and reflux classifications. Consecutive veterans reporting esophageal symptoms (e.g., dysphagia and reflux) underwent clinical evaluation with standard reflux and motility testing. Relevant demographic, mental health, and clinical esophageal information was gathered. Patients were classified into "PTSD" and "Non-PTSD" groups based on the documentation of a clinician-confirmed diagnosis of PTSD in the medical chart. Of the 273 consecutive veterans (89% men, mean age: 62 years) that met inclusion criteria for the study, 34% had a clinician-confirmed diagnosis of PTSD. Differences existed between PTSD and non-PTSD groups on smoking, bipolar disorder, depression, ADHD, and opiate use. However, no differences existed in objectively determined motility or reflux phenotypes. While PTSD was highly prevalent among our sample of symptomatic veterans, the presence of PTSD was not associated with differences in motility classifications and reflux phenotypes. These findings are consistent with recent research in psychogastroenterology, which suggests psychological processes are important to consider across esophageal classifications.

Post-traumatic stress impact on health outcomes in Gulf War Illness

BACKGROUND

Gulf War Illness (GWI) is a chronic, multi-symptomatic disorder affecting an estimated 25-32% of the returning military veterans of the 1990-1991 Persian Gulf War. GWI presents with a wide range of symptoms including fatigue, muscle pain, cognitive problems, insomnia, rashes and gastrointestinal issues and continues to be a poorly understood illness. This heterogeneity of GWI symptom presentation complicates diagnosis as well as the identification of effective treatments. Defining subgroups of the illness may help alleviate these complications. Our aim is to determine if GWI can be divided into distinct subgroups based on PTSD symptom presentation.

METHODS

Veterans diagnosed with GWI (n = 47) and healthy sedentary veteran controls (n = 52) were recruited through the Miami Affairs (VA) Medical Health Center. Symptoms were assessed via the RAND short form health survey (36), the multidimensional fatigue inventory, and the Davidson trauma scale. Hierarchal regression modeling was performed on measures of health and fatigue with PTSD symptoms as a covariate. This was followed by univariate analyses conducted with two separate GWI groups based on a cut-point of 70 for their total Davidson Trauma Scale value and performing heteroscedastic t-tests across all measures.

RESULTS

Overall analyses returned two symptom-based subgroups differing significantly across all health and trauma symptoms. These subgroups supported PTSD symptomatology as a means to subgroup veterans. Hierarchical models showed that GWI and levels of PTSD symptoms both impact measures of physical, social, and emotional consequences of poor health (ΔR2 = 0.055-0.316). However, GWI appeared to contribute more to fatigue measures. Cut-point analysis retained worse health outcomes across all measures for GWI with PTSD symptoms compared to those without PTSD symptoms, and healthy controls. Significant differences were observed in mental and emotional measures.

CONCLUSIONS

Therefore, this research supports the idea that comorbid GWI and PTSD symptoms lead to worse health outcomes, while demonstrating how GWI and PTSD symptoms may uniquely contribute to clinical presentation.

The Influence of Posttraumatic Stress Disorder on Health Functioning in Active-Duty Military Service Members

Researchers have suggested that posttraumatic stress disorder (PTSD) is associated with significant healthcare burden and utilization of medical services. The purpose of this study was to examine the impact of PTSD symptoms on health functioning among active-duty military personnel. Participants in the study were 366 treatment-seeking service members who had returned from deployment and were participating in a larger PTSD treatment study. Assessments included measures of PTSD symptom severity, combat experiences, life stress, health functioning, alcohol use, and depression. We hypothesized that at baseline, PTSD severity and its symptom clusters would be significantly associated with poorer physical and mental health functioning. We conducted separate hierarchical multiple regressions to examine the predictive contribution the hypothesized factors would have on the variance in physical and mental health scores. Consistent with previous literature, we found that PTSD severity was significantly associated with poorer mental health functioning, B = -0.25, SE = 0.08, β = -0.15, t(342) = -3.07, R² = .37, p = .002; however, contrary to our hypotheses, PTSD severity was not associated with poorer physical health functioning. Further, the hyperarousal symptom cluster was significantly associated with poorer physical health functioning, B = -0.83, SE = 0.26, β = -0.18, t(340) = -3.16, R² = .11, p = .002, but not mental health functioning. Limitations of our study included the use of self-report measures only and lack of objective measures. Future directions for study include examination of how health functioning perceptions change over a longer duration of PTSD symptoms and after treatment.

Gulf War syndrome – has it gone away?

‘Gulf War syndrome’ was a phrase coined after the 1991 Gulf War. This article looks at the variety of hypotheses that have been put forward about the origins of the concept and the studies attempting to characterise the health manifestations of Gulf service and the lasting effects on veterans. It also serves to bring readers up to date with research on the present deployment in Iraq. Finally, consideration is given to how Gulf War syndrome compares with the rich historical literature of post-conflict medical syndromes and how sociological factors may interact with symptom attribution in veterans.

Posttraumatic stress disorder and somatic complaints: Contrasting Vietnam and OIF/OEF Veterans' experiences

OBJECTIVE

To replicate and expand upon the relationship of somatic symptoms and posttraumatic stress disorder (PTSD) by comparing symptoms among service eras in US Veterans.

METHOD

Data were collected from 226 Vietnam and 132 Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) Veterans who were referred to a Veterans Affairs (VA) hospital PTSD outpatient clinic between 2005 and 2013. Veterans were administered self-report inventories and a clinical interview to measure somatic symptoms and PTSD severity. A subset of Veterans (n=185) screening positive for PTSD were administered the Clinician Administered PTSD Scale (CAPS) to measure PTSD severity. Multiple moderated linear regressions were used to examine the influence of service era on the relationship between somatic and PTSD symptoms.

RESULTS

There were no significant differences between service eras in pain severity, pain interference, and total somatic symptoms reported. Vietnam Veterans were more likely to report limb/join pain (p<.05), fainting (p<.01), and shortness of breath (p<.001), whereas OIF/OEF Veterans were more likely to complain of headaches (p<.001). A significant interaction effect occurred between service era and dizziness (p<.05) and chest pain (p<.01), with OIF/OEF Veterans reporting higher levels of these symptoms significantly more likely than Vietnam Veterans to also experience more severe PTSD.

CONCLUSION

Findings are consistent with previous research demonstrating the relationship of somatic symptoms and PTSD across service eras but provide additional data concerning similarities and differences of somatic symptoms between eras. Potential explanations for observed service era differences in somatic symptoms are discussed.

Patterns of somatic distress among conflict-affected persons in the Republic of Georgia

BACKGROUND

There are substantial risk factors for somatic distress (SD) among civilian populations affected by armed conflict in low and middle income countries. However, the evidence is very limited. Our aim was to examine patterns of SD among conflict-affected persons in the Republic of Georgia, which has over 200,000 internally displaced persons (IDPs) from the wars over separatists regions in the 1990s and with Russia in 2008.

METHODS

A cross-sectional household survey was conducted with 3600 randomly selected IDPs and former IDPs (returnees). SD was measured using the Patient Health Questionnaire (PHQ-15). Post-traumatic stress disorder (PTSD), depression, anxiety, and disability were measured using the Trauma Screening Questionnaire, Patient Health Questionnaire 9, Generalised Anxiety Disorder 7, and WHO Disability Assessment Schedule 2.0, respectively. Descriptive, tetrachoric and multivariate regression analyses were used.

RESULTS

Forty-two percent of respondents (29% men; 48% women) were recorded as at risk of SD (PHQ-15 score >5). In tetrachoric analysis, SD scores were highly correlated with depression (r = 0.60; p < 0.001), PTSD (r = 0.54; p < 0.001), and anxiety (r = 0.49; p < 0.001). Factors significantly associated with SD in the multivariate regression analysis were depression, PTSD, anxiety, individual trauma event exposure, cumulative trauma exposure, female gender, older age, bad household economic status, and being a returnee compared to an IDP. SD was also associated with increased levels of functional disability (b = 6.73; p < 0.001).

CONCLUSIONS

The high levels of SD among IDPs and returnees in Georgia indicate significant suffering. The findings have implications for both mental and physical health services in Georgia.

Replication of a cognitive behavioral therapy for chronic pain group protocol by therapists in training

According to the American Psychological Association (Division 12), there is strong, long-standing research support for cognitive behavioral therapy (CBT) to treat chronic pain. Furthermore, meta-analytic comparisons have shown CBT to be highly efficacious. However, not all researchers agree with this conclusion. The purpose of the current pilot study was to determine whether a CBT outpatient, group-based treatment facilitated by junior therapists benefited veterans who suffer from mixed idiopathic, chronic, noncancer pain, thus replicating results from effective CBT programs from the past. A sample of 46 veterans aged 33 to 81 years with chronic, noncancer pain who participated in an outpatient CBT pain group therapy protocol at a Midwestern Veterans Affairs Medical Center between November 3, 2009, and September 2, 2010 was evaluated. All participants completed a pre- and postintervention assessment. Paired-samples t tests were conducted to evaluate the impact of the program on veterans' scores on assessment measures. No significant difference was found between the pre- and posttest primary outcome measures of pain intensity. A significant difference was established between the pre- and posttest secondary outcome measure of catastrophizing. However, there were no other significant differences found among the remaining pre- and posttest secondary outcome measures of pain interference, disability, and psychological distress. Training junior therapists on how to use CBT protocols may be enhanced by paying greater attention to what mechanisms are responsible for the desired outcomes among veterans with chronic pain.

Lasting personality pathology following exposure to catastrophic trauma in adults: systematic review

BACKGROUND

By definition, personality disorders (PDs) are evident in late childhood and adolescence, but evidence for personality pathology occurring after adolescence is unclear.

AIM

We aimed to review extant literature on personality change following exposure to catastrophic trauma in adults in order to identify the prevalence and clinical features of any long-term personality pathology.

METHOD

Relevant studies were identified by searching three bibliographic databases (MEDLINE, EMBASE and PsychINFO) from inception to November 2011 using terms related to personality and trauma.

RESULTS

No prospective studies that investigated long-term personality change following exposure to trauma in adults were found. Two retrospective studies reported the prevalence of enduring personality change of 2.6% and 6% (weighted prevalence 4.6%, 95% confidence interval 3.4-6.3%), and one study reported 20% increase in adult-onset antisocial behaviour following exposure to trauma. Findings from cross-sectional studies that examined the prevalence of PDs in people exposed to catastrophic trauma reported that Cluster C and Cluster A were the most common with avoidant, paranoid and obsessive-compulsive PDs among those most frequently reported.

CONCLUSION

A minority of adults who are exposed to severe trauma appear to go on to develop significant personality pathology. The observed personality disturbance is multifarious and more extensive than the prototype described in ICD-10.

Interrelationship of PTSD, perceived health, and treatment satisfaction

Purpose

– The residential therapeutic community (TC) treatment modality has been shown to effectively reduce drug use and improve psychiatric/medical health among clients who are often disproportionately impacted by medical conditions and have a co-occurring psychiatric disorder such as Posttraumatic Stress Disorder (PTSD). Yet not much is known regarding how clients’ health may impact their treatment satisfaction. Using path analysis, the interrelationship between PTSD, perceived health, and treatment satisfaction was examined. The paper aims to discuss these issues.

Design/methodology/approach

– A survey including the Posttraumatic Stress Disorder Checklist-Specific (PCL-S), a perceived health rating, and a Treatment Satisfaction Scale was collected from 303 clients at three comparable long-term residential TC treatment programs in New York City.

Findings

– Findings indicated that clients with PTSD rated their health significantly worse than those without PTSD. Although no direct relationship between PTSD and treatment satisfaction was found, there was a significant positive correlation between perceived health and treatment satisfaction.

Research limitations/implications

– Findings likely constitute a regional sample thus generalizability is limited.

Practical implications

– Simultaneously addressing addiction, PTSD, and medical issues can improve clients’ treatment satisfaction, consequently increasing treatment retention and producing greater positive post-treatment outcomes.

Originality/value

– Few if any studies have examined the extent to which PTSD and perceived health impact treatment satisfaction within residential substance abuse treatment programs.

Multiple physical symptoms in a military population: a cross-sectional study

BACKGROUND

Medically unexplained symptoms have been reported among both civilians and military personnel exposed to combat. A large number of military personnel deployed to the Gulf War in 1991 reported non-specific symptoms. These symptoms did not constitute a clearly defined syndrome. Post-traumatic stress disorder (PTSD) and to a lesser degree exposure to combat are associated with physical symptoms.

METHODS

This is a cross-sectional study of representative samples of Sri Lanka Navy Special Forces and regular forces deployed in combat areas continuously during a 1-year period. Multiple physical symptoms were elicited using a checklist of 53 symptoms. Cases were defined as individuals with ten or more symptoms. Symptoms of common mental disorder were identified using the General Health Questionnaire 12 (GHQ-12). PTSD was diagnosed using the 17-item National Centre for PTSD checklist civilian version.

RESULTS

Prevalence of multiple physical symptoms was 10.4% (95% CI 8.11-12.75). Prevalence was significantly less in the Special Forces (5.79%) than in the regular forces (13.35%). The mean number of symptoms reported by those who met the criteria for PTSD was 12.19 (SD 10.58), GHQ caseness 7.87 (SD 7.57) and those without these conditions 2.84 (SD 3.63). After adjusting for socio-demographic and service variables, 'thought I might be killed' , 'coming under small arms fire' , and 'coming under mortar, missile and artillery fire' remained significant. Multiple physical symptoms were associated with functional impairment and poor perceived general health.

CONCLUSIONS

Prevalence of multiple physical symptoms was significantly lower in the Special Forces despite high exposure to potentially traumatic events. More multiple physical symptoms were reported by personnel with PTSD and common mental disorders. Multiple physical symptoms were associated with functional impairment.

Someone to watch over me: exposure to war events and trust in the armed forces in Israel as factors in war-related stress

This study examined the role of trust in the national armed and security forces in Israel as a potential protective factor in post-war stress symptoms, alongside other known correlates such as exposure to war events, sense of danger, and demographics. A cluster sample of 870 residents of the town of Kiryat-Shemona in Israel participated in this correlational study. The town was under heavy bombing during the second Lebanon war, and data collection took place about a year after the end of the war. Our results suggest that while sense of danger and exposure to war events are the strongest correlates of stress related symptoms, trust in the armed forces was negatively correlated with stress, even after controlling for demographics; therefore supporting our hypothesis. Theoretical, methodological and practical implications are discussed in light of our findings.

Visual event-related potentials as markers of hyperarousal in Gulf War illness: evidence against a stress-related etiology

An exaggerated response to emotional stimuli is among the many symptoms widely reported by veterans of the 1991 Persian Gulf War. These symptomologies have been attributed to damage and dysfunction associated with deployment-related exposures. We collected event-related potential data from 22 veterans meeting Haley criteria for Gulf War (GW) Syndromes 1-3 and from 8 matched GW veteran controls, who were deployed but not symptomatic, while they performed a visual three-condition oddball task where images authenticated to be associated with the 1991 Persian Gulf War were the distractor stimuli. Hyperarousal reported by ill veterans was significantly greater than that by control veterans, but this was not paralleled by higher amplitude P3a in their ERP responses to GW-related distractor stimuli. Whereas previous studies of PTSD patients have shown higher amplitude P3b responses to target stimuli that are placed amid trauma-related nontarget stimuli, ill veterans in this study showed P3b amplitudes to target stimuli - placed amid GW-related nontarget stimuli - that were significantly lower than those of the control group. Hyperarousal scores reliably predicted P3b, but not P3a, amplitudes. Although many factors may contribute to P3b amplitude differences - most notably depression and poor sleep quality, symptoms that are prevalent in the GW syndrome groups - our findings in context of previous studies on this population are consistent with the contention that dysfunction in cholinergic and dopaminergic neurotransmitter systems, and in white matter and basal ganglia may be contributing to impairments in GW veterans.

An assessment of survey measures used across key epidemiologic studies of United States Gulf War I Era veterans

Over the past two decades, 12 large epidemiologic studies and 2 registries have focused on U.S. veterans of the 1990-1991 Gulf War Era. We conducted a review of these studies' research tools to identify existing gaps and overlaps of efforts to date, and to advance development of the next generation of Gulf War Era survey tools. Overall, we found that many of the studies used similar instruments. Questions regarding exposures were more similar across studies than other domains, while neurocognitive and psychological tools were the most variable. Many studies focused on self-reported survey results, with a range of validation practices. However, physical exams, biomedical assessments, and specimen storage were not common. This review suggests that while research may be able to pool data from past surveys, future surveys need to consider how their design can yield data comparable with previous surveys. Additionally, data that incorporate recent technologies in specimen and genetic analyses would greatly enhance such survey data. When combined with existing data on deployment-related exposures and post-deployment health conditions, longitudinal follow-up of existing studies within this collaborative framework could represent an important step toward improving the health of veterans.

The grapes of war. Somatoform pain disorder and history of early war traumatization in older people

Persistent pain is not a normal part of aging. Nevertheless, many older patients have long-lasting, more or less medically unexplained pain symptoms and, consequently, are often severely disabled, incur high health care costs, and have high comorbidity rates. Moreover, the effects of early traumatization, especially due to wars, and even below the level of posttraumatic stress disorder (PTSD) are apparent. However, the developmental and neurobiological underpinnings of somatoform pain disorder, especially in pain-prone elderly patients, and its correlations with a history of war traumatization even decades after the incident remain unclear. Furthermore, a management strategy for this disorder tailored to older people and their special needs is lacking. Adequate therapeutic regimens such as adjusted psychotherapeutic procedures for elderly patients can only be promoted through a better understanding of the neurobiological and biographical underpinnings of this still controversial disorder.

Cognitive disorders in mice: cytokine signaling pathways as therapeutic targets

Surplus accumulation of regulatory T cells (Tregs) is known to be at the bottom of many morbid conditions, among them being neuropsychiatric diseases. In particular, Tregs may inhibit Th1 cells, including brain autoimmune lymphocytes, controlling the local microglial response and brain tissue homeostasis. The present study was undertaken in an attempt to suggest a novel approach for the treatment of maladaptation to mental stress associated with excessive Treg accumulation. Recently it was shown that alkylating drugs (ADs), such as melphalan and cyclophosphamide (Cy) in the dose 100-fold lower than cytostatic one are capable to disturb signal transduction by IL-2R. In this study we demonstrated that IL-2R is not a unique receptor, which may be blocked with ADs. Similar effect has been shown for two other surface receptors: TNFR and Fas. Molecular mechanisms of the receptor blockage were investigated on the model of TNF signaling. Study of NF-κB activity in nuclear extracts showed that alkylating agents act at the level of surface receptor or of the receptor platform. It was also shown that ADs administration in ultralow doses results in selective elimination of Tregs. In this study we used a new laboratory model of Treg accumulation in mice. Such Treg accumulation was associated with cognitive and behavioral abnormalities, which may be prevented by Cy administration.

The relationship between Gulf War illness, brain N-acetylaspartate, and post-traumatic stress disorder

A previous study (Haley RW, Marshall WW, McDonald GG, Daugherty MA, Petty F, Fleckenstein JL: Brain abnormalities in Gulf War syndrome: evaluation with 1H MR spectroscopy. Radiology 2000; 215: 807-817) suggested that individuals with Gulf War Illness (GWI) had reduced quantities of the neuronal marker N-acetylaspartate (NAA) in the basal ganglia and pons. This study aimed to determine whether NAA is reduced in these regions and to investigate correlations with other possible causes of GWI, such as psychological response to stress in a large cohort of Gulf War veterans. Individuals underwent tests to determine their physical and psychological health and to identify veterans with (n=81) and without (n=97) GWI. When concentrations of NAA and ratios of NAA to creatine- and choline-containing metabolites were measured in the basal ganglia and pons, no significant differences were found between veterans with or without GWI, suggesting that GWI is not associated with reduced NAA in these regions. Veterans with GWI had significantly higher rates of post-traumatic stress disorder, supporting the idea that GWI symptoms are stress related.

Posttraumatic stress disorder, poor physical health and substance use behaviors in a national trauma-exposed sample

Both experiencing a traumatic event and PTSD are related to physical health problems (e.g., Schnurr and Jankowski, 1999) and health-risk behavior (e.g., Stewart, 1996). Using structural equation modeling analyses, we examined the interrelationships among number of distinct traumatic event exposures, PTSD diagnosis, physical health, and substance use behavior using epidemiological data from the National Comorbidity Survey Replication (NCS-R; Kessler et al., 2004). Results provide some evidence that PTSD mediates the relationship between: (a) number of distinct traumatic event exposures and poor physical health defined by clusters of difficulties with gastrointestinal, musculoskeletal, and/or cardiovascular health, and (b) number of distinct traumatic event exposures and substance use behaviors. However, substance use behaviors did not significantly mediate the relationship between PTSD and poor physical health.

Somatic distress among Kosovar civilian war survivors: relationship to trauma exposure and the mediating role of experiential avoidance

PURPOSE

The current study examined the prevalence and correlates of somatic distress (SD) in the aftermath of war, and the role of a process hypothesized to contribute to posttraumatic stress: experiential avoidance.

METHODS

Civilian war survivors (n = 163) from Kosovo were assessed in structured interviews, reporting on average more than ten types of traumatic war exposure.

RESULTS

One in eight (12.9%) of the participants meet criteria for SD, which was associated with greater psychological distress, experiential avoidance, and lower quality of life after accounting for the effects of war-related variables, demographic variables, as well as posttraumatic stress disorder and major depressive episode. Experiential avoidance partially mediated the association between SD and psychological distress and quality of life.

CONCLUSIONS

The results indicate that SD is prevalent among war-exposed civilians and that experiential avoidance may be a significant factor in understanding and treating traumatized people who are experiencing SD.

The psychological burden of an initially unexplained illness: patients with sternocostoclavicular hyperostosis before and after delayed diagnosis

BACKGROUND

Sternocostoclavicular hyperostosis (SCCH) is a rare, debilitating, chronic inflammatory disorder of the anterior chest wall due to a chronic sterile osteomyelitis of unknown origin. SCCH is largely underdiagnosed and often misdiagnosed. In individual cases it can remain unrecognized for years. The purpose of this study is twofold. Firstly, to evaluate the psychological condition of SCCH patients, both in the sometimes quite extended pre-diagnostic period between first manifestations and confirmed diagnosis of the disease, and in the current situation. Secondly, to investigate the relationships between the pre-diagnostic and the current psychological conditions of confirmed SCCH patients.

METHODS

Structured interviews were held with 52 confirmed SCCH patients. Questionnaires were included to assess posttraumatic stress symptoms, social support, aspects of pain, illness perceptions, self-reported health status, and quality of life.

RESULTS

SCCH patients reported stronger posttraumatic stress symptoms, more unfavorable illness perceptions, lower health status, and poorer quality of life than healthy individuals and patients with other diseases or traumatic experiences. Psychological distress in the pre-diagnostic period was associated with unfavorable conditions in the current situation.

CONCLUSION

SCCH is an illness with serious psychological consequences. Psychological monitoring of patients with unexplained complaints is recommended as long as a diagnosis has not been reached.

Impaired response inhibition in ill Gulf War veterans

Poor performance on tasks requiring response inhibition has been observed among chronically ill veterans of the 1991 Persian Gulf War. Semantic difficulties have also been reported. We collected event-related potential (ERP) and behavioral data from 25 Gulf War veterans who complained of cognitive difficulties and from 23 matched controls, who were deployed but not symptomatic, while they performed a GO-NOGO task that required both a semantic decision and inhibitory processing. A significantly greater false-alarm rate among the ill veterans was accompanied in the ERP data by significantly reduced amplitude in the NOGO P3, consistent with previous ERP studies of other patient groups that have shown poor inhibitory response performance. This supports the contention that the ill veterans' deficit lies more in inhibiting than in detecting task-related differences in the stimuli.

Association between posttraumatic stress disorder and primary care provider-diagnosed disease among Iraq and Afghanistan veterans

OBJECTIVE

To determine if a diagnosis of posttraumatic stress disorder (PTSD) was associated with primary care provider-diagnosed physical disease in the first 5 years post deployment.

METHODS

An examination of medical records of 4416 veterans of Operations Enduring Freedom and Iraqi Freedom (OEF/OIF) was conducted. Participants were veterans who served between September 11, 2001 and December 31, 2007, without prior combat exposure, and who utilized primary care services within the VA Healthcare Network of Upstate New York. Primary care provider-diagnosed International Statistical Classification of Diseases and Related Health Problems, Revision 9 (ICD-9) physical diseases were examined.

RESULTS

Adjusting for demographic characteristics and clinical factors (e.g., age, gender, depression, and substance use), PTSD was significantly associated with an almost two-fold increase of developing nervous system (odds ratio [OR], 1.98), musculoskeletal disease (OR, 1.84), and signs and ill-defined conditions of disease (OR, 1.78). A diagnosis of PTSD was significantly associated with increased odds of developing circulatory (OR, 1.29), hypertensive (OR, 1.38), and digestive system disease (OR, 1.34). Survival analyses showed that veterans with PTSD experienced early onset disease compared with veterans without PTSD; hypertensive (hazard ratio [HR], 1.56; 95% confidence interval [CI], 1.19-2.04), circulatory, (HR, 1.36; 95% CI, 1.11-1.67), digestive (HR, 1.24; 95% CI, 1.08-1.43), nervous (HR, 1.81; 95% CI, 1.59-2.06), musculoskeletal disease (HR, 1.49; 95% CI, 1.32-1.67), and signs and ill-defined disease (HR, 1.70; 95% CI, 1.51-1.92).

CONCLUSIONS

PTSD is associated with increased prevalence and onset of physical disease among OEF/OIF veterans within the early years post military service. Rising rates of PTSD may foreshadow an increase in lifespan morbidity and healthcare utilization in the coming years among OEF/OIF veterans.

Framing written emotional expression from a religious perspective: effects on depressive symptoms

OBJECTIVE

Previous research has found an inverse association between exposure to emotional trauma and well-being. More recently, studies on written emotional expression found that repeated expression of a traumatic experience is beneficial to physical health. However, possible mechanisms through which written emotional expression may work to influence health are still under investigation. Recent research on psychological stress has also found associations among religion, meaning, and health. This study evaluated the effects of taking a religious perspective while engaged in written emotional expression.

METHOD

Participants included 215 college students, who were assigned randomly to one of three experimental groups. One was given conventional written emotional expression instructions for writing about a traumatic experience; another was instructed to write about the trauma from a religious/spiritual perspective; a control group wrote about a trivial topic.

RESULTS

Compared with control participants, those in the trauma-religion condition experienced significantly greater reductions in depressive symptoms at 1-month follow-up. Conventional trauma writing had no effect on dependent measures.

CONCLUSION

These findings encourage further investigation of religion as a factor that may augment the health-promoting effects of written emotional expression.

Pituitary response to metyrapone in Gulf War veterans: relationship to deployment, PTSD and unexplained health symptoms

OBJECTIVE

Gulf War deployment has been associated with a distinct neuroendocrine profile characterized by low 24h basal ACTH levels and enhanced cortisol and ACTH suppression to low-dose dexamethasone. The metyrapone stimulation test was performed to further characterize hypothalamic-pituitary activity in Gulf War veterans (GWV) and its relationship to unexplained medical symptoms and post-traumatic stress disorder (PTSD).

METHOD

Eleven GWV without PTSD, 18 GWV with PTSD and 15 healthy subjects not exposed to the Gulf War theater (non-exposed) underwent the metyrapone stimulation test, which inhibits cortisol synthesis, impairs cortisol-mediated negative feedback inhibition and in turn increases levels of ACTH and 11-deoxycortisol, a cortisol precursor. These hormones were measured at baseline (7:00 a.m.) and at intervals (from 8:00 a.m. to 4:00 p.m.) following the administration of metyrapone 750mg orally at 7:05 a.m. and at 10:05 a.m.

RESULTS

There were group differences in the ACTH response despite similar cortisol and 11-deoxycortisol responses to metyrapone. GWV without PTSD had a significantly attenuated ACTH response compared to non-exposed subjects; GWV with PTSD had a significantly higher ACTH response than GWV without PTSD but did not differ from non-exposed subjects. Among GWV, unexplained medical health symptoms (e.g., neurological, musculoskeletal, cardiac, and pulmonary symptoms) and PTSD symptoms were significantly positively associated with the ACTH response to metyrapone.

CONCLUSION

Gulf War deployment is associated with a substantially lower ACTH response to metyrapone. In contrast, unexplained health symptoms and PTSD in Gulf War veterans are associated with relatively greater hypothalamic-pituitary activity which may reflect increased CRF activity and is evident only in consideration of deployment effects. This pattern of differences suggests either that Gulf War deployment and its associated exposures results in enduring changes in pituitary function or that reduced hypothalamic-pituitary activity protects against the development of PTSD and other deployment-related health problems.

The physical and mental health of Australian Vietnam veterans 3 decades after the war and its relation to military service, combat, and post-traumatic stress disorder

The long-term health consequences of war service remain unclear, despite burgeoning scientific interest. A longitudinal cohort study of a random sample of Australian Vietnam veterans was designed to assess veterans' postwar physical and mental health 36 years after the war (2005-2006) and to examine its relation to Army service, combat, and post-traumatic stress disorder (PTSD) assessed 14 years previously (1990-1993). Prevalences in veterans (n = 450) were compared with those in the Australian general population. Veterans' Army service and data from the first assessments were evaluated using multivariate logistic regression prediction modeling. Veterans' general health and some health risk factors were poorer and medical consultation rates were higher than Australian population expectations. Of 67 long-term conditions, the prevalences of 47 were higher and the prevalences of 4 were lower when compared with population expectations. Half of all veterans took some form of medication for mental well-being. The prevalence of psychiatric diagnoses exceeded Australian population expectations. Military and war service characteristics and age were the most frequent predictors of physical health endpoints, while PTSD was most strongly associated with psychiatric diagnoses. Draftees had better physical health than regular enlistees but no better mental health. Army service and war-related PTSD are associated with risk of illness in later life among Australian Vietnam veterans.

Gulf War syndrome: an emerging threat or a piece of history?

‘Gulf War syndrome’ is a phrase coined after the 1991 Gulf War to group together disparate, unexplained health symptoms in Gulf veterans. This paper examines the many hypotheses that have been put forward about the origins of the concept and gives an overview of the studies that have attempted to explain the lasting health effects associated with Gulf service. Our review finds that although in the UK there has not yet been evidence of a new Gulf War syndrome as a result of the current conflicts in Iraq and Afghanistan, there is a rise in post-conflict psychiatric disorders now being reported in the USA. We postulate that after conflicts military personnel will always face some form of post-conflict syndrome and the nature of the threats experienced is likely to dictate the form the syndrome might take. We also postulate that media reporting is likely to have influenced and to continue unhelpfully to influence the health of service personnel.

Diurnal cortisol patterns and stress reactivity in child Holocaust survivors reaching old age

OBJECTIVES

Late-life implications of early traumatic stress for the adreno-cortical system were examined in a sample of 133 child survivors of the Holocaust, who were subjected to Nazi persecution during infancy.

METHOD

In a non-convenience sample of child survivors, born between 1935 and 1944, basal circadian cortisol release and cortisol reactivity to a stressor were assessed.

RESULTS

Age, parental loss during the Holocaust, current depression, post-traumatic stress disorder (PTSD) and physical illness were not associated with differences in basal diurnal cortisol levels. Neuro-endocrine effects, however, were found in stress reactivity through elevated cortisol levels in male respondents in the youngest age group (born 1941-1945), and in male respondents suffering from PTSD-related functional impairment.

CONCLUSION

The youngest survivors of Nazi persecution show late-life effects of traumatic stress during early childhood, evidenced by the early onset of differential neuroendocrine pathways to stress-regulating strategies.

Impact on health care workers employed in high-risk areas during the Toronto SARS outbreak

BACKGROUND

A number of publications focusing on health care workers (HCWs) during a severe acute respiratory syndrome (SARS) outbreak have suggested that HCWs experienced psychological distress, particularly increased levels of posttraumatic stress symptomatology (PTSS). Factors contributing to increased distress in HCWs working in high-risk areas treating patients with SARS have not been fully elucidated. The goal of this study was to quantify the psychological effects of working in a high-risk unit during the SARS outbreak.

METHODS

HCWs in a Toronto hospital who worked in high-risk areas completed a questionnaire regarding their attitude toward the SARS crisis along with the Impact of Event Scale-Revised, which screens for PTSS. The comparison group consisted of clinical units that had no contact with patients infected with SARS.

RESULTS

Factors that were identified to cause distress in the 248 respondent HCWs were the following: (a) perception of risk to themselves, (b) impact of the SARS crisis on their work life, (c) depressive affect, and (d) working in a high-risk unit. In addition, HCWs who cared for only one SARS patient in comparison to those caring for multiple SARS patients experienced more PTSS.

CONCLUSIONS

As expected, HCWs who were working in high-risk units experienced greater distress. Contrary to expectations, HCWs who experienced greater contact with SARS patients while working in the high-risk units were less distressed. This suggests that HCW experience in treating patients infected with SARS may be a mediating factor that could be amenable to intervention in future outbreaks.

Trauma, PTSD, and physical health: an epidemiological study of Australian Vietnam veterans

OBJECTIVE

This study aimed to examine the relative contributions to physical health of combat trauma exposure and posttraumatic stress disorder (PTSD), which have both been implicated separately in poorer physical health but whose unconfounded effects have not been teased out.

METHODS

Data from an epidemiological study of Australian Vietnam veterans, which used personal interviews and standardized physical and psychiatric health assessments, provided the means to assess the independent and joint effects of psychological trauma exposure and PTSD on a wide range of self-reported measures of physical health. Trauma exposure was measured by published scales of combat exposure and peritraumatic dissociation. Logistic regression modeling was used to assess the relative importance of trauma exposure and PTSD to health while controlling for a set of potential confounders including standardized psychiatric diagnoses.

RESULTS

Greater health service usage and more recent health actions were associated more strongly with PTSD, which was also associated with a range of illness conditions coded by the World Health Organization International Classification of Diseases, 9th Edition (asthma, eczema, arthritis, back and other musculoskeletal disorders, and hypertension) both before and after controlling for potential confounders. In contrast, combat exposure and peritraumatic dissociation were more weakly associated with a limited number of unconfounded physical health outcomes.

CONCLUSIONS

This study provided evidence that PTSD, rather than combat exposure and peritraumatic dissociation, is associated with a pattern of physical health outcomes that is consistent with altered inflammatory responsiveness.

Twenty-four hour plasma cortisol and adrenocorticotropic hormone in Gulf War veterans: relationships to posttraumatic stress disorder and health symptoms

BACKGROUND

We aim to characterize the baseline functioning of the hypothalamic-pituitary-adrenal (HPA) axis in Gulf War veterans (GWV) and examine the extent to which posttraumatic stress disorder (PTSD) and unexplained health symptoms-which commonly co-occur-have similar or different biological correlates.

METHODS

Thirty-one GWV, 20 with current PTSD and 11 without current or lifetime PTSD, and 16 healthy nondeployed subjects not exposed to the Gulf War theater underwent medical and psychiatric examination followed by blood sampling every half-hour over 24 hours for the measurement of cortisol and adrenocorticotropic hormone (ACTH).

RESULTS

Gulf War veterans without PTSD or another psychiatric disorder had significantly lower 24-hour plasma ACTH levels, a significantly higher cortisol:ACTH ratio, and no difference in cortisol levels compared to nondeployed subjects and to GWV with PTSD, controlling for body mass index (BMI). Among GWV, health symptoms (mood and cognitive symptoms) were positively associated with, and hyperarousal symptoms were negatively associated with, the cortisol:ACTH ratio. Additionally, the self-reported acute effects of pesticides and of pyridostigmine bromide during deployment were associated with lower ACTH levels, controlling for BMI and PTSD.

CONCLUSIONS

The data provide evidence of HPA axis dysregulation in Gulf War veterans, which may be related to Gulf War deployment exposures. Despite the overlap of chronic unexplained health symptoms and PTSD in GWV, these symptom constellations appear to be biologically distinct.

Gulf War Illness: lessons from medically unexplained symptoms

Service in the Persian Gulf in 1991 is associated with increased reporting of symptoms and distress in a proportion of those who served there. Yet despite clear evidence of an increase in symptom burden and a decrease in well being, exhaustive clinical and laboratory based scientific research has failed to document many reproducible biomedical abnormalities in this group. Likewise, there has been no evidence of an increase in disease related mortality. Formal psychiatric disorders are twice as common in Gulf War veterans, as might be expected in the aftermath of any conflict, but this too is insufficient to explain the ill-health observed. Many service personnel who returned unwell believe that they have Gulf War Syndrome, and that their ill-health is due to exposures that they encountered in theatre. Research on multiple exposures to date has not generated a plausible aetiological mechanism for veterans' ill-health. Even if medical research has failed to provide a satisfactory explanation, it remains the case that many of those affected continue to be unwell and disabled some 15 years after returning from combat. For this reason, it is time that more attention is given to developing effective interventions to relieve their ill-health and distress. In this review we discuss the importance of the wider social context, individual illness beliefs and attributions and go on to outline a model of continuing ill-health in Gulf veterans. The review concludes with some suggestions for future research priorities, in particular the need for further qualitative studies to further our understanding of the illness, in order that better treatments may be developed.

Post-disaster physical symptoms of firefighters and police officers: role of types of exposure and post-traumatic stress symptoms

OBJECTIVES

To examine the relationships between exposure to the air disaster in Amsterdam and multiple physical symptoms among firefighters and police officers, and to explore the role of post-traumatic stress symptoms (PTSS) herein.

DESIGN

Historic cohort study.

METHODS

On average 8.5 years post-disaster, exposed professional firefighters (N=334) and police officers (N=834) and their nonexposed colleagues (N=194 and N=634, respectively) completed questionnaires on disaster exposure and current symptoms. Logistic regression with adjustment for background characteristics was used to compare exposed and nonexposed workers. PTSS were added to these models, as was the interaction between exposure and PTSS, to explore potential mediating and modifying effects, respectively.

RESULTS

Exposed workers reported multiple physical symptoms significantly more often. Multiple physical symptoms seemed to have particularly affected the exposed firefighters who rescued people, and the exposed police officers who supported injured victims and workers, who were involved in the identification of or search for victims and human remains, who witnessed the immediate disaster scene or had a close one affected by the disaster. These exposure effects were essentially independent of PTSS, and no significant interactions between exposure and PTSS were found.

CONCLUSIONS

In conclusion, the excess in post-disaster multiple physical symptoms in exposed workers could not be attributed to PTSS.

Somatoform-spectrum diagnoses among medically evacuated "Operation Enduring Freedom" and "Operation Iraqi Freedom" personnel

Ten percent of military medical evacuees from military operations in Iraq and Afghanistan are psychiatric referrals. Three percent of these psychiatric patients had somatoform-spectrum disorders (SSDs). Potential reasons for this low rate include lower stigma for other types of psychiatric presentations and the possibilities that SSD patients have not yet emerged in clinical settings or are managed in deployment environments. SSD patients, compared with other veterans, are more likely to be enlisted-rank, younger, and an ethnic minority. They are more likely to have non-combat deployment stressors and past psychiatric histories than combat-specific stressors and family problems at home.

Enhanced cortisol suppression to dexamethasone associated with Gulf War deployment

OBJECTIVE

To examine whether PTSD or post-deployment health symptoms in veterans of the first Gulf War (Operation Desert Shield/Storm) are associated with enhanced suppression of the pituitary-adrenal axis to low-dose dexamethasone (DEX).

METHOD

Plasma cortisol and lymphocyte glucocorticoid receptor (GR) number were measured at 08:00 h on two consecutive days, before and after administration of 0.5mg of DEX at 23:00 h in 42 male Gulf War veterans (14 without psychiatric illness, 16 with PTSD only, and 12 with both PTSD and MDD) and 12 healthy male veterans not deployed to the Gulf War or another war zone.

RESULTS

In the absence of group differences in basal cortisol levels or GR number, Gulf War veterans without psychiatric illness and Gulf War veterans with PTSD only had significantly greater cortisol suppression to DEX than non-deployed veterans and Gulf War veterans with both PTSD and MDD. Gulf War deployment was associated with significantly greater cortisol suppression to DEX controlling for weight, smoking status, PTSD, and MDD; PTSD was not associated with response to DEX. Among Gulf War veterans musculoskeletal symptoms were significantly associated with cortisol suppression and those who reported taking anti-nerve gas pills (i.e., pyridostigmine bromide) during the war had significantly greater DEX-induced cortisol suppression than those who did not.

CONCLUSIONS

The data demonstrate that alterations in neuroendocrine function are associated with deployment to the Gulf War and post-deployment musculoskeletal symptoms, but not PTSD. Additional studies are needed to examine the relationship of enhanced glucocorticoid responsivity to deployment exposures and chronic unexplained medical symptoms in Gulf War veterans.

Millennium Cohort: enrollment begins a 21-year contribution to understanding the impact of military service

OBJECTIVE

In response to health concerns of military members about deployment and other service-related exposures, the Department of Defense (DoD) initiated the largest prospective study ever undertaken in the U.S. military.

STUDY DESIGN AND SETTING

The Millennium Cohort uses a phased enrollment strategy to eventually include more than 100,000 U.S. service members who will be followed up through the year 2022, even after leaving military service. Subjects will be linked to DoD and Veterans Affairs databases and surveyed every 3 years to obtain objective and self-reported data on exposures and health outcomes.

RESULTS

The first enrollment phase was completed in July 2003 and resulted in 77,047 consenting participants, well representative of both active-duty and Reserve/Guard forces. This report documents the baseline characteristics of these Cohort members, describes traditional, postal, and Web-based enrollment methods; and describes the unique challenges of enrolling, retaining, and following such a large Cohort.

CONCLUSION

The Millennium Cohort was successfully launched and is becoming especially relevant, given current deployment and exposure concerns. The Cohort is representative of the U.S. military and promises to provide new insight into the long-term effects of military occupations on health for years to come.

The effects of prior combat experience on the expression of somatic and affective symptoms in deploying soldiers

OBJECTIVE

Deployment to a combat zone is undoubtedly an extremely stressful experience. It was hypothesized that, when faced with an impending wartime deployment, soldiers with prior combat experience would report minimal emotional problems accompanied by high rates of somatic complaints compared with combat-naive soldiers.

METHODS

Self-reports of posttraumatic stress disorder (PTSD) and affective and somatic complaints were collected from 2068 U.S. soldiers just prior to combat deployment during Operation Iraqi Freedom.

RESULTS

Although the percentage of soldiers scoring positive for PTSD was nearly identical for the experienced and inexperienced groups, scores on the Affective and Somatic scales differed as a function of prior combat history. Previous combat experience was associated with lower affective and greater somatic complaints relative to combat-naive soldiers.

CONCLUSIONS

Consistent with theories of stress reaction, repression, and somatic amplification, combat-experienced soldiers reported limited affective complaints but greater somatic complaints relative to soldiers without combat experience.

Chronic widespread pain and psychiatric disorders in veterans of the first gulf war

More than 10% of the 700,000 American troops who served during the first Gulf War (GW) are receiving treatment for a constellation of diffuse and frequently poorly defined medical and psychiatric symptoms that have been designated the GW syndrome by both clinicians and the popular media. The current clinical consensus is that the symptoms reported in GW veterans are the sequela of combat and other stressful events that have been identified in the veterans of other wars and armed conflicts. Chronic diffuse pain is one constellation of symptoms commonly reported in GW veterans. Research has confirmed a close bimodal relationship between chronic pain and psychiatric symptoms. Investigators are now exploring the efficacy of treatment approaches that address the close relationship between chronic pain and mental illness in this challenging patient population.

Posttraumatic stress disorder screening status is associated with increased VA medical and surgical utilization in women

BACKGROUND

Women with posttraumatic stress disorder (PTSD) report poor health, but associations with health care utilization are understudied.

OBJECTIVE

To determine associations between medical/surgical utilization and PTSD in female Veterans Affairs (VA) patients.

DESIGN

Prospective comparison of utilization rates between women screening positive or negative for PTSD on a mailed survey.

SUBJECTS

Women receiving care at an urban VA medical center between October 1996 and January 2000.

MEASUREMENTS

Survey responses, including a validated screen for PTSD (PCL-C), and VA utilization data through September 2002.

RESULTS

Two thousand five hundred and seventy-eight (2,578) women (78% of those eligible) completed the PCL-C; 858 (33%) of them screened positive for PTSD (PTSD+). In unadjusted models, PTSD+ women had higher rates of medical/surgical hospitalizations and surgical inpatient procedures. Among women ages 35 to 49, mean days hospitalized/100 patients/year was 43.4 (95% CI 26 to 61) for PTSD+ women versus 17.0 (16 to 18) for PTSD negative (PTSD-) women. More PTSD+ women underwent surgical procedures (P<.001). Mean annual outpatient visits were significantly higher among PTSD+ women, including: emergency department (ED) (1.1 [1.0 to 1.2] vs 0.6 [0.5 to 0.6]), primary care (3.2 [3.0 to 3.4] vs 2.2 [2.1 to 2.3]), medical/surgical subspecialists (2.1 [1.9 to 2.3] vs 1.5 [1.4 to 1.6]), ancillary services (4.1 [3.7 to 4.5] vs 2.4 [2.2 to 2.6]), and diagnostic tests (5.6 [5.1 to 6.1] vs 3.7 [3.4 to 4.0]). In multivariate models adjusted for demographics, smoking, service access, and medical comorbidities, PTSD+ women had greater likelihood of medical/surgical hospitalization (OR=1.37 [1.04 to 1.79]) and of being among the top quartile of patients for visits to the ED, primary care, ancillary services, and diagnostic testing.

CONCLUSIONS

Female veterans who screen PTSD+ receive more VA medical/surgical services. Appropriateness of that care deserves further study.

Physical and mental health costs of traumatic war experiences among Civil War veterans

BACKGROUND

Hundreds of thousands of soldiers face exposure to combat during wars across the globe. The health effects of traumatic war experiences have not been adequately assessed across the lifetime of these veterans.

OBJECTIVE

To identify the role of traumatic war experiences in predicting postwar nervous and physical disease and mortality using archival data from military and medical records of veterans from the Civil War.

DESIGN

An archival examination of military and medical records of Civil War veterans was conducted. Degree of trauma experienced (prisoner-of-war experience, percentage of company killed, being wounded, and early age at enlistment), signs of lifetime physician-diagnosed disease, and age at death were recorded.

SETTING AND PARTICIPANTS

The US Pension Board surgeons conducted standardized medical examinations of Civil War veterans over their postwar lifetimes. Military records of 17,700 Civil War veterans were matched to postwar medical records.

MAIN OUTCOME MEASURES

Signs of physician-diagnosed disease, including cardiac, gastrointestinal, and nervous disease; number of unique ailments within each disease; and mortality.

RESULTS

Military trauma was related to signs of disease and mortality. A greater percentage of company killed was associated with signs of postwar cardiac and gastrointestinal disease (incidence risk ratio [IRR], 1.34; P < .02), comorbid nervous and physical disease (IRR, 1.51; P < .005), and more unique ailments within each disease (IRR, 1.14; P < .005). Younger soldiers (<18 years), compared with older enlistees (>30 years), showed a higher mortality risk (hazard ratio, 1.52), signs of comorbid nervous and physical disease (IRR, 1.93), and more unique ailments within each disease (IRR, 1.32) (P < .005 for all), controlling for time lived and other covariates.

CONCLUSIONS

Greater exposure to death of military comrades and younger exposure to war trauma were associated with increased signs of physician-diagnosed cardiac, gastrointestinal, and nervous disease and more unique disease ailments across the life of Civil War veterans. Physiological mechanisms by which trauma might result in disease are discussed.

A new view on hypocortisolism

Low cortisol levels have been observed in patients with different stress-related disorders such as chronic fatigue syndrome, fibromyalgia, and post-traumatic stress disorder. Data suggest that these disorders are characterized by a symptom triad of enhanced stress sensitivity, pain, and fatigue. This overview will present data on the development, mechanisms and consequences of hypocortisolism on different bodily systems. We propose that the phenomenon of hypocortisolism may occur after a prolonged period of hyperactivity of the hypothalamic-pituitary-adrenal axis due to chronic stress as illustrated in an animal model. Further evidence suggests that despite symptoms such as pain, fatigue and high stress sensitivity, hypocortisolism may also have beneficial effects on the organism. This assumption will be underlined by some studies suggesting protective effects of hypocortisolism for the individual.

Biopsychosocial issues in irritable bowel syndrome

Irritable bowel syndrome is a biopsychosocial disorder that results from dysregulation of central and enteric nervous system function. It manifests as dysmotility and/or visceral hypersensitivity, and is modified by psychosocial processes. The interaction of the biopsychosocial factors determines the experience of the illness. An understanding of the biopsychosocial model of illness requires a shift from concepts traditionally taught in Western medical schools (biomedical reductionism and dualism) to that of multicausality, where biologic and psychologic factors interact to determine the disease and its experience or illness.

Resolving Disputes About Toxicological Risks During Military Conflict

In the last 15 years, the US and UK have fought two major wars in the Persian Gulf region. Controversy has arisen over the nature and causes of health problems among military veterans of these two wars. Toxic exposures have been hypothesised to cause the majority of the long-term health problems experienced by veterans of the 1991 Gulf War. The assessment of these toxic exposures and the resolution of controversy about their health effects provide a unique case study for understanding how toxicological disputes are settled in the US. Neither clinical examination of ill war veterans nor scientific research studies have been sufficient to answer contentious questions about toxic exposures. Numerous expert review panels have also been unable to resolve these controversies except for the US National Academy of Sciences Institute of Medicine (IOM). The IOM has conducted exhaustive and independent investigations based on peer-reviewed scientific literature related to potential health risks during the two Gulf Wars. In four recent studies, IOM committees identified a wide range of previously documented illnesses associated with common occupational and environmental exposures after considering thousands of relevant publications; however, they did not identify a new medical syndrome or a specific toxic exposure that caused widespread health problems among Gulf War veterans. These IOM studies have, therefore, added little to our basic knowledge of environmental hazards because most of the health effects were well known. Nevertheless, this expert review process, which is on-going, has been generally acceptable to a wide range of competing interests because the findings of the IOM have been perceived as scientifically credible and independent, and because none of the postulated toxicological risks have been completely ruled-out as possible causes of ill health among veterans.