Psychiatric diagnoses in Gulf War veterans with fatiguing ... - Impact

Psychiatric diagnoses in Gulf War veterans with fatiguing ... - Impact

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Psychiatry Research 89 1999 3948

Psychiatric diagnoses in Gulf War veterans with

fatiguing illness

Gudrun Lange a, , Lana Tiersky a , John DeLuca c , Arnold Peckerman a ,

Claudia Pollet a , Theresa Policastro a , Jennifer Scharer a ,

John E. Ottenweller a , Nancy Fiedler b , Benjamin H. Natelson a

a Center for Enironmental Hazards Research, VA Medical Center, East Orange, NJ, USA

b Enironmental and Occupational Health Sciences Institute, Robert Wood Johnson Medical School, Piscataway, NJ, USA

c Kessler Medical Rehabilitation Research and Education Corporation, West Orange, NJ, USA

Received 25 August 1998; received in revised form 9 March 1999; accepted 30 August 1999


The purpose of this study was to determine whether Gulf War Illness Ž GWI.

can be explained by the presence of

psychiatric disorders as assessed by DSM-III-R. To reduce the heterogeneity amongst Persian Gulf War veterans

with GWI Ž PGV-F ., only those were studied who presented with severe fatigue as a major complaint and also

fulfilled clinical case definitions for Chronic Fatigue Syndrome, Idiopathic Chronic Fatigue, andor Multiple

Chemical Sensitivity. A total of 95 Registry PGVs were examined; 53 presented with GWI and 42 did not report any

post-war health problems Ž PGV-H .. All subjects were assessed for the presence of DSM-III-R Axis I psychiatric

disorders. Compared to PGV-Hs, 49% of PGV-Fs had similar post-war psychiatric profiles: either no, or only one,

psychiatric disorder was diagnosed. Psychiatric profiles of the remaining 51% of PGV-Fs were significantly different

from PGV-Hs in that most of these veterans suffered from multiple post-war psychiatric diagnoses. The presence of

psychiatric disorders as assessed by DSM-III-R criteria cannot explain symptoms of Gulf War Illness among all

Persian Gulf veterans with severe fatiguing illness. 1999 Elsevier Science Ireland Ltd. All rights reserved.

Keywords: Gulf War Illness; Chronic Fatigue Syndrome; Multiple Chemical Sensitivity

Corresponding author. UMDNJ, New Jersey Medical School, Dept Psychiatry, MSB-E 561, 185 South Orange Avenue, Newark,

NJ 07103, USA. Tel.: 1-973-972-0512; fax: 1-973-972-8305.

E-mail address: Ž G. Lange.

0165-178199$ - see front matter 1999 Elsevier Science Ireland Ltd. All rights reserved.

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PII: S 0 1 6 5 - 1 7 8 1 9 9 0 0 0 9 5 - 5


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G. Lange et al. Psychiatry Research 89 1999 3948

1. Introduction

Following the Persian Gulf War, many veterans

returned home with medical and psychiatric complaints

including chronic fatigue, rash, headache,

arthralgiasmyalgias, gastrointestinal complaints,

impotence, sleep problems, difficulties concentrating,

memory loss, irritability, nervousness,

tenseness, depressed mood and other emotional

changes ŽPersian Gulf Veterans Coordinating

Board, 1995; Sutker et al., 1995a,b; Amato et al.,

1997; Haley et al., 1997; Iowa Persian Gulf Study

Group, 1997 .. In order to address these health

concerns, the Department of Veterans Affairs


created a Gulf War Registry. As of 28

February 1997, 52 313 Persian Gulf veterans

Ž PGVs. had enrolled in this Registry ŽGray et al.,

1998 .. The majority of veterans enrolling in the

Registry had medical complaints many of which

had no known cause and remain unexplained.

This collection of unexplained symptoms has come

to be labeled ‘Gulf War-related Illness’ ŽGWI;

Haley et al., 1997 ..

The cause of GWI is yet unknown. Ideas range

from its being somatic manifestations of wartime

stress-related psychiatric illnesses, such as Posttraumatic

Stress Disorder ŽPTSD; Sutker et al.,

1993, 1995a ., to its being due to exposure to low

doses of organophosphate nerve gases ŽJamal et

al., 1996; Haley et al., 1997 .. Data supporting a

psychiatric etiology for GWI in deployed symptomatic

PGVs include high prevalence rates of psychiatric

disorders Ž Haley et al., 1997 ., the association

of high rates of somatic complaints consistent

with GWI with such psychiatric disorders

Ž Sutker et al., 1994a,b ., and particularly, a high

rate of PTSD ŽSutker et al., 1993, 1995b; Baker et

al., 1997 .. Additionally, Baker et al. Ž 1997.


found that Gulf War veterans diagnosed with

PTSD had especially high rates of multiple symptom

complaints. In contrast, reports of neurological

abnormalities, such as raised thermal and

vibratory thresholds, generally impaired audio

vestibular function, and increased mean somatosensory

and brain stem auditory evoked potential

latencies in PGVs, support an organic

etiology Ž Jamal et al., 1996; Haley et al., 1997 ..

One major problem limiting advances in

knowledge about the cause of GWI is the heterogeneity

inherent in the patient pool ŽSutker et al.,

1993, 1995a; Haley et al., 1997 .. Data from groups

studying symptomatic PGVs suggest that many

cases of GWI would fulfill published case definitions

for fatiguing illness ŽHyams et al., 1996;

Amato et al., 1997; Fukuda et al., 1998 ..

In the present study we described and compared

the psychiatric profiles of healthy Registry

PGVs to only those veterans who reported fatigue

as a major symptom and fulfilled case definitions

for either chronic fatigue syndrome ŽCFS; Fukuda

et al., 1994 ., idiopathic chronic fatigue ŽICF;

Fukuda et al., 1994 ., andor multiple chemical

sensitivity Ž MCS; Cullen, 1987 .. The purpose of

this strategy was to reduce heterogeneity associated

with GWI by focusing primarily on those

PGVs whose GWI centers on complaints of severe

fatigue. By comparing the psychiatric profiles

of a homogeneous group of veterans with GWI to

that of healthy PGVs, it will be possible to determine

whether psychiatric disorders as assessed

by DSM-III-R criteria can explain GWI in PGVs.

If GWI were some variant of a diagnosable psychiatric

disorder stemming from the stress of deployment

and combat, then one would expect to

find DSM-III-R psychiatric diagnoses to covary

with GWI. Not finding this result would not eliminate

the possibility that stress could produce the

somatic symptoms of GWI, but alternative explanations

would also have to be considered.

2. Methods

2.1. Subjects

The subjects were Gulf War veterans either in

good health or reporting new onset and substantial

problems with fatigue after returning home.

Veterans were identified either from the computer

database of the DVA NJ Health Care System

or from the DVA Gulf War Registry limited

to 10 states east of the Mississippi Ži.e. PA, NC,

OH, MA, NJ, VA, MD, NY, IL and CT .. For

characteristics of Registry participants, see Gray

et al. Ž 1998 ..

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G. Lange et al. Psychiatry Research 89 1999 3948 41

2.2. Procedures

Veterans completed an initial mailed health

questionnaire to determine if the severity of their

symptoms was consistent with case definitions of

CFS, ICF andor MCS to ascertain if they were

in good health Ž PGV-F and PGV-H, respectively ..

Based on the published CFS case definition

Ž Fukuda et al., 1994 ., veterans were excluded for

the following reasons: medical illness, alcohol

abusedependence within the 2 years prior to

completing the questionnaire, or the presence of

any of the following lifetime psychiatric diagnoses:

mania, schizophrenia or eating disorders.

Also excluded were veterans over the age of 57 to

eliminate those with a higher likelihood of covert

medical illness, and veterans with a self-reported

history of loss of consciousness for longer than 30

min, because fatigue is a common sequella after

head injury.

In total, 147 PGVs 47 PGV-H and 100

PGV-F participated in the center’s activities,

came to the center, and signed informed consent.

All PGVs received an intensive history and physical

examination performed by an internist expert

in diagnosing the above conditions and had appropriate

rule-out blood tests done. The physician

then determined if the PGV-F fulfilled case criteria

for CFS, ICF andor MCS according to specific

diagnostic protocols Ž Pollet et al., 1998 .. In

order to obtain information about exposure to

substances during service in the Gulf, the following

selected items from the Devens questionnaire

Ž Wolfe et al., 1996 ., a health and exposure

to substances survey, were administered: Ž. 1 Do

you think that you got sick due to your time spent

in the Persian Gulf War? Ž. 2 While serving in the

Gulf, did you take anti-nerve gas pills? Ž. 3 While

in the Gulf, were you ever on ‘formal alert’ for

chemical attack Že.g. had to put on full suit, boots,

gloves and mask .? Ž 4.

Are there any specific substances

that you were exposed to in the Gulf


To assess Axis I psychiatric status conforming

to DSM-III R criteria, trained personnel administered

a computerized standardized diagnostic interview

Ž Q-DIS-III-R; Marcus et al., 1990 .. When

an Axis I condition was diagnosed, the examiner

determined whether the disorder was one of those

leading to exclusion. If this was not the case, a

time criterion was established based on whether

the disorder had only been present after returning

from the Gulf Ž post-war ., whether it was present

during the 12 months prior to intake or

whether symptoms fulfilling DSM-III-R criteria

existed prior to deployment to the Gulf Ž pre-war ..

This stratification procedure led to our sample of

PGVs fulfilling DSM-III-R Axis I diagnostic criteria

either pre-war andor at any point post-war.

The comprehensive medical and psychological

evaluation produced the final diagnostic categories

used in this study.

Of the 147 PGVs, 95 were included in the final

study. Of those, 42 PGVs were healthy Ž PGV-H.

and 53 suffered from GWI Ž PGV-F ., defined as

presence of severe fatiguing illnesses. PGV-F fulfilled

clinical case definitions for the following

fatiguing illnesses: CFS Ž n24 .; CFS with MCS

Ž n17 .; ICF Ž n5 .; and MCS Ž n7 .. Seventeen

veterans were excluded due to the presence

of a medical cause for their fatiguing illness; 19

were excluded due to DSM-III-R diagnoses of

alcoholsubstance abuse that occurred within the

2 years prior to intake Žveterans were not excluded

if they reported alcoholsubstance abuse

prior to this 2-year exclusionary window.

or of

schizophrenia, eating disorders, or mania at any

time; and 16 were excluded due to insufficient

criteria to allow the diagnosis of CFS, ICF, andor


2.3. Data analysis

One-way ANOVA or Students t-test was used

to compare continuous data across groups Ži.e.

demographic data, healthexposure items on Devens

questionnaire .. Post-hoc comparisons were

tested for significance using Tukey’s LSD test

with significance set at 0.05. Two-tailed Fisher’s

exact tests and chi-square analyses were used to

evaluate the statistical significance of all dichotomous

measures between groups Ži.e. presence of

DSM-III-R Axis I psychiatric disorder, physicianassessed

fatiguing illness symptoms at the time of

medical evaluation ..

The initial analysis compared frequency dis-


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G. Lange et al. Psychiatry Research 89 1999 3948

tributions of PGV-H and PGV-F. In a second

analysis both groups were further divided on frequency

and number of DSM-III-R Axis I diagnoses.

3. Results

PGV-H and PGV-F subjects did not differ in

age, gender, rank or ethnicity Ž see Table 1 .. Although

PGV-F reported less formal schooling

than PGV-H Ž F 19.06, P0.001 .


, all members

of both groups had at least a high school


3.1. DSM-III-R Axis I psychiatric diagnoses:


Of all 95 participating veterans, six of 42 Ž 14% .

PGV-H and 33 of 53 Ž 62% . PGV-F fulfilled diagnostic

criteria for post-war DSM-III-R Axis I

psychiatric disorders ŽFisher’s exact test; P

0.001; see Table 3 .. Table 2 shows the distribution

of specific DSM-III-R Axis I diagnoses for both

groups of veterans. The distributions of MDD,

PTSD, Simple Phobia and Social Phobia were

significantly different between PGV-H and PGV-

F, while the occurrence of alcohol abusedependence

Žoccurring more than 2 years prior to intake.

and agoraphobia was equal between groups.

Dysthymia, GAD, somatization disorder, panic

disorder, compulsive disorder, and cannabis

abusedependence Žoccurring more than 2 years

prior to intake.

occurred only in the PGV-F group.

Two of six PGV-H Ž 33% . with post-war Axis I

diagnoses and 29 of 33 PGV-F Ž 88% . with postwar

Axis I diagnoses maintained their diagnoses

in the 12 months prior to study intake ŽFisher’s

exact test; P0.002 ..

In a second analysis, we only compared those

PGV-H Ž n6. and PGV-F Ž n33.

with post-war

DSM-III-R Axis I diagnoses. This was done to

examine whether there were differences in the

frequency and type of psychiatric diagnoses

observed between PGV-F and PGV-H. Both subgroups

were similar in gender, ethnic background,

rank, age and education Ž data not shown ..

Examination of the data revealed that the

Table 1

Demographic data for healthy and fatiguing illness Persian Gulf veterans Ž n95. a




Mean Ž S.D. . Mean Ž S.D. .

Ž . Ž .

Age 34.1 7.86 34.0 8.27 0.98

Gender 7 Ž 17% . Females 14 Ž 26% . Females 0.47

35 Ž 83% . Males 39 Ž 74% . Males 0.76

Ethnicity 30 Ž 71% . Caucasian 37 Ž 70% . Caucasian 0.79

5 Ž 12% . AfricanAmerican 6 Ž 11% . AfricanAmerican

5 Ž 12% . Hispanic 9 Ž 17% . Hispanic

2 Ž 5% . Asian 1 Ž 2% . Asian


Self-reported 13 Ž 43% . Enlisted 18 Ž 47% . Enlisted 1.0

rank during 9 Ž 30% . Non-com. officers 15 Ž 39% . Non-com. officers 0.65

deployment 8 Ž 27% . Officers 5 Ž 14% . Officers 0.37

Years of formal 15.19 Ž 2.05. 13.47 Ž 1.78.



a Abbreiations PGV-H, healthy Persian Gulf veterans; and PGV-F, Gulf War veterans with fatiguing illness.

b Fisher’s exact test, two-tailed.

c Chi-square test.

d Only 30 of 42 PGV-H and 38 of 53 PGV-F responded to this question.



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G. Lange et al. Psychiatry Research 89 1999 3948 43

Table 2

Frequency distribution of post-war DSM III-R Axis I diagnoses in PGV-H and PGV-F a

DSM-III-R diagnosis present PGV-H Ž n42. PGV-F Ž n53.


Major depressive disorder Ž MDD. 1 Ž 2% . 19 Ž 36% .


Post-traumatic stress disorder Ž PTSD. 1 Ž 2% . 12 Ž 21% .


Alcohol abusedependence2 years prior to intake 4 Ž 7% . 4 Ž 8% .


Simple phobia 2 Ž 5% . 11 Ž 21% .


Social phobia 1 Ž 2% . 11 Ž 21% .


Agoraphobia 1 Ž 2% . 5 Ž 3% .


Dysthymia 7 Ž 13% .

Generalized anxiety disorder Ž GAD. 4 Ž 7% .

Somatization disorder 3 Ž 6% .

Panic disorder 2 Ž 4% .

Compulsive disorder 2 Ž 4% .

Cannabis abusedependence2 years prior to intake 1 Ž 2% .

a Percentages in both groups do not add up to 100%, because veterans may be diagnosed with more than one disorder.

b Significance of frequency distribution was tested using a two-tailed Fisher’s exact test.


PGV-F group consisted of significantly more veterans

with post-war multiple Axis-I diagnoses



compared to the PGV-H group 25.47, P

0.001 .. Fig. 1 shows the detailed distribution of

post-war Axis I diagnoses for both PGV-H and

PGV-F after stratification into those with no

Axis-I diagnosis, those with one Axis-I diagnosis

and those with more than one Axis-I diagnosis.

Compared to PGV-H, the PGV-F group comprised

significantly more veterans with post-war

multiple DSM-III-R Axis I diagnoses Žn1 and

23, respectively; Fisher’s exact test; P0.001 ..

However, similar numbers of PGV-H and PVG-F,

carried only one psychiatric diagnosis Žn5 and

10, respectively, Fisher’s exact test; P0.58 ..

When only one post-war Axis I diagnosis was

Fig. 1. PGV-H, healthy Persian Gulf veterans; PGV-F, Gulf veterans with fatiguing illness. Distribution of post-war Axis I

diagnoses after stratification of groups into those without any, those with only one, and those with more than one post-war Axis I



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G. Lange et al. Psychiatry Research 89 1999 3948

present, some PGV-F in this group had Axis I

diagnoses similar to those found in PGV-H, while

other PGV-F suffered from a broader spectrum

of disorders. That is, PGV-H only reported symptoms

congruent with alcohol abusedependence

Ž n3, 60% . and anxiety disorder Ž n2, 40% ..

In contrast, PGV-F with only one Axis I diagnosis

manifested not only these two diagnostic categories

Ži.e. alcohol abusedependence, n2,

20%; anxiety disorders, n4, 40% ., but also

MDD Ž n2, 20% . and PTSD Ž n2, 20% .. In

summary, six of 10 PGV-F had post-war Axis I

diagnoses similar to the PGV-H group, while the

diagnostic profile of the remaining four PGV-F

was different from that of the PGV-H. Thus, in

addition to the 20 PGV-F with no DSM-III-R

diagnosis another six had the same post-war psychiatric

profile as the PGV-H group for a total of

49% of the entire group of PGV-F.

The presence of multiple DSM-III-R psychiatric

diagnoses was almost entirely attributed to

veterans of the PGV-F group Ž i.e. 23 out of 33 ..

Only one PGV-H was diagnosed with multiple

psychiatric diagnoses, namely PTSD, MDD, anxiety

disorders Ž i.e. simple phobia and agoraphobia .,

and alcohol abuse Žoccurring prior to 2 years

before intake .. Of the 23 PGV-F fulfilling criteria

for multiple psychiatric diagnoses, MDD was

observed in 18 Ž 78% ., anxiety disorders in 14

Ž 61% ., PTSD in 12 Ž 52% ., dysthymia in six Ž 26% .,

alcohol andor cannabis abusedependence occurring

in the 2 years prior to intake in five

Ž 22% ., somatization disorder in three Ž 13% ., and

compulsive disorder in two Ž 9% . PGV-Fs.

3.2. DSM-III-R Axis I psychiatric diagnoses: pre-war

One might expect that the presence of pre-war

psychiatric disorders in the veterans studied may

have had an influence on their GWI status as well

as their post-war psychiatric status. Therefore, we

asked a number of related questions: first, did

pre-war psychiatric status predict whether a veteran

developed GWI or not? The answer is no

Ž see Table 3 .. No significant difference existed in

frequency of pre-war Axis I diagnoses between

PGV-H and PGV-F Ž Fisher’s exact test, P0.12 ..

The distribution of individual pre-war Axis I

diagnoses is shown in Table 4. Compared to

PGV-H, the frequency of pre-war alcohol

abusedependence was significantly higher in

PGV-F. The distributions of MDD, PTSD, simple

phobia and social phobia were similar between

groups, while agoraphobia and generalized anxiety

disorder Ž GAD.

occurred only in PGV-Fs

prior to deployment.

The second question was whether the presence

of pre-war psychiatric Axis I disorder predicted

post-war psychiatric status in PGV-F but not in

PGV-H. Again, this prediction was not supported.

Pre-war Axis I diagnoses were as common in

PGV-Hs with and without post-war Axis I diagnoses

Žthree and six of 42, respectively, Fisher’s

exact test, P0.10.

as they were in PGV-Fs with

Table 3


Post-war Axis I diagnosis

Post-war no Axis I diagnosis

Frequency distribution of post-war DSM-III-R Axis I diagnoses

PGV-H Ž n42. 6 Ž 14% . 36 Ž 86% .

PGV-F Ž n53. 33 Ž 62% . 20 Ž 38% .

Pre-war Axis I diagnosis

Pre-war no Axis I diagnosis

Frequency distribution of pre-war DSM-III-R Axis I diagnoses

PGV-H Ž n42. 9 Ž 21% . 33 Ž 79% .

PGV-F Ž n53. 20 Ž 38% . 33 Ž 62% .


Significance of post-war frequency distribution was tested using a two-tailed Fisher’s exact test Ž P0.001 ..


Significance of pre-war frequency distribution was tested using a two-tailed Fisher’s exact test Ž P0.12 ..


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G. Lange et al. Psychiatry Research 89 1999 3948 45

Table 4

Frequency distribution of pre-war DSM-III-R Axis I diagnoses in PGV-H and PGV-F a

DSM-III-R diagnosis present PGV-H Ž n42. PGV-F Ž n53.


Major depressive disorder Ž MDD. 1 Ž 2% . 1 Ž 2% .


Post-traumatic stress disorder Ž PTSD. 1 Ž 2% . 4 Ž 8% .


Alcohol abusedependence 3 Ž 7% . 13 Ž 24% .


Simple phobia 2 Ž 5% . 7 Ž 13% .


Social phobia 1 Ž 2% . 5 Ž 9% .


Agoraphobia 2 Ž 4% .


Generalized anxiety disorder Ž GAD. 1 Ž 2% .

Somatization disorder

Panic disorder

Compulsive disorder

Cannabis abusedependence 3 Ž 7% . 2 Ž 4% .


a Note. Percentages in both groups do not add up to 100%, because veterans may be diagnosed with more than one disorder.

b Significance of frequency distribution was tested using a two-tailed Fisher’s exact test.


and without post-war diagnoses Ž15 and five of 53,

respectively, Fisher’s exact test, P0.16 ..

Third, did pre-war psychiatric status predict

whether PGV-Fs had a post-war psychiatric profile

similar or dissimilar to that of PGV-Hs? No

significant difference in frequency of pre-war psychiatric

diagnosis was found between PGV-Fs

with a profile resembling PGV-Hs Ž eight of 26.

and those whose psychiatric profile was dissimilar

from that shown by healthy PGVs Ž12 of 27,

Fisher’s exact test, P0.57 .. However, significantly

more veterans with more than one pre-war

psychiatric diagnosis were in the subgroup of

PGV-Fs whose post-war psychiatric status did not

resemble PGV-H. Seven of the eight PGV-Fs

with psychiatric profiles similar to PGV-H had

only one pre-war diagnosis while only four of the

12 PGV-Fs with psychiatric profiles dissimilar to

PGV-H had only one pre-war Axis I diagnosis

Ž Fisher’s exact test, P0.03 ..

3.3. Physician-assessed fatiguing illness symptoms

and healthexposure items on Deens questionnaire

Physician-assessed severity of individual symptoms

specific to CFS andor MCS did not differ

significantly between PGV-F with and without

post-war Axis-I diagnoses. Likewise, both groups

responded similarly to the items evaluated on the

Devens questionnaire. Taken together, these data

suggest that neither illness severity nor selfreported

exposure to substances while serving in

the Gulf can explain the differences in frequency

and type of psychiatric disorder seen in PGVs.

4. Discussion

The results of the present investigation suggest

GWI in veterans with fatigue as a major symptom

cannot be explained solely by the presence of a

post-war Axis I psychiatric disorder. Of veterans

with GWI, 38% had no DSM-III-R diagnosis and

an additional 11% had the same single psychiatric

diagnosis as veterans in the healthy group

anxiety disorders since their return from the Gulf

and alcohol abusedependence that began after

the veteran’s return from the Gulf but stopped at

least 2 years prior to our evaluation. Thus, finding

a psychopathological profile similar to that of

healthy Gulf veterans in 49% of veterans with

GWI makes it clear that an Axis I psychiatric

disorder cannot explain the medical complaints of

this group of sick Gulf veterans and the contribution

of other risk factors has to be taken into


In contrast, the remaining 51% of PGV-F had

psychiatric profiles which were unlike those found

in the healthy veteran comparison group. This

subgroup of PGV-F differed from healthy Gulf


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G. Lange et al. Psychiatry Research 89 1999 3948

veterans in two ways: they had a much higher

frequency of post-war multiple comorbid Axis-I

diagnoses than PGV-H and the most common

psychiatric disorders seen in this group were MDD

andor PTSD. Both of these disorders are often

associated with fatigue ŽBaker et al., 1997; Gold

and Chrousos, 1999.

and other somatic complaints

Ž Sutker et al., 1994a, 1995b .. Thus, GWI

in this group of veterans may be related to the

presence of a psychiatric illness developed as a

result of wartime stress.

Importantly, pre-war psychiatric status neither

predicted GWI nor post-war presence of Axis I

disorder, except for a subset of symptomatic veterans

those whose psychiatric profile was dissimilar

to that of healthy veterans. This subgroup

of PGV-Fs was notable in having multiple psychiatric

diagnoses prior to deployment as well as

after their return from the Gulf. Thus, the somatic

complaints of the 51% of PGV-F whose

psychiatric profiles are different from those of

healthy control subjects may represent the occurrence

of lifetime psychiatric disorder.

This then brings us back to the 49% of PGV-F

studied here whose psychopathological profile resembled

that of PGV-H. The difference between

these PGVs and PGV-Hs was not in the presence

or absence of Axis I psychiatric diagnoses, but

instead was in the presence or absence of unexplained

medical symptoms. Since an underlying

Axis I diagnosis cannot explain the unexplained

medical symptoms in this group of Gulf veterans,

what other explanation might be invoked?

While we cannot exclude the possibility that

the presence of marked somatic complaints may

be due to war time stress ŽSutker et al., 1993,

1995a ., another possibility, suggested by Haley et

al. Ž 1997 ., could be exposure to environmental

toxins, specifically organophosphates. Certainly,

data exist to indicate that many of the symptoms

concerning the Gulf veteran can follow exposure

to these chemicals albeit usually after symptomatic

exposure ŽRowntree et al., 1950; Burchfiel

and Duffy, 1982; De Blecker et al., 1992; Lundberg

et al., 1995 .. Indeed, one recent article reported

the development of chronic fatigue syndrome

as a delayed reaction to chronic low-dose

exposure to these toxins Ž Behan, 1996 .. Since

such exposures can also produce organic mental

syndromes resembling DSM-IV psychiatric disorders,

subtle brain damage induced by neurotoxins

could be responsible for the somatic complaints

of GWI in some veterans with or without

comorbid psychopathology.

A trial of psychopharmacologic intervention

may be critical in determining the validity of the

psychiatric or neurotoxic hypotheses. If the medical

complaints of some Gulf veterans reflect the

somatic manifestation of a psychiatric illness such

as MDD, PTSD, andor anxiety disorder, psychopharmacologic

treatment should diminish

medical symptoms in those PGVs. In contrast, if

the unexplained medical symptoms reflect CNS

involvement Ž Haley et al., 1997.

consistent with a

primary diagnosis of organic mental syndrome,

drug treatment would be less likely to diminish

medical symptoms.

The important findings of this study were that a

sizable proportion of veterans with GWI carried

multiple comorbid Axis I diagnoses after deployment

and that the psychiatric profiles of this

subgroup of veterans were unlike those of PGV-H.

However, while they did not differ from PGV-F

with psychiatric profiles similar to that of PGV-H

in either presence of somatic symptoms or pre-war

psychiatric illness, the occurrence of multiple prewar

Axis I diagnoses was significantly more frequent

in this veteran group. Thus, veterans with a

complicated psychiatric history prior to combat

often continue to show the same complicated

history plus develop somatic symptoms. It would

seem appropriate to attempt to screen out such

soldiers in order to protect them from the additional

medicalpsychiatric morbidity produced by

deployment and battle.

This study has several limitations. First, all data

were derived from PGVs on the DVA Gulf War

Registry. Since these individuals may be a

health-care-seeking group, they may not represent

the full distribution of PGVs with GWI

Ž Gray et al., 1998 .. Second, because the present

study only examined PGVs with severe fatigue as

a major symptom, the results may not generalize

to all persons with GWI. However, the findings of

Haley et al. Ž 1997 ., as well as other data on Gulf

veterans Ž Fukuda et al., 1998; Kang, 1998 ., seem

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G. Lange et al. Psychiatry Research 89 1999 3948 47

to indicate that severe fatigue is a common complaint

of veterans who report the onset of medical

symptoms following service in the Gulf. In fact,

Fukuda et al. Ž 1998.

report that 54% of all those

PGVs with symptoms of severe fatigue fulfilled

the case definition for CFS. Third, the data collected

rely on the establishment of psychiatric

diagnoses based on retrospective symptom reporting,

which is inherently noisy. Therefore, it is

possible that group differences may be a function

of subject recall bias. Nonetheless, the data reported

here indicate that psychiatric illness cannot

explain all cases of GWI, characterized by the

presence of severe fatiguing illness.


This work was supported by the Department of

Veterans Affairs establishing a Center for Environmental

Hazards Research at the East Orange

VA Medical Center.


Amato, A.A., McVey, A., Cha, C., Matthew, E.C., Jackson,

C.E., Kleingunther, R., Worley, L., Cornman, E., Kagan-

Hallet, K., 1997. Evaluation of neuromuscular symptoms in

veterans of the Persian Gulf War. Neurology 48, 412.

Baker, D.G., Mendenhall, C.L., Simbartl, L.A., Magan, L.K.,

Steinberg, J.L., 1997. Relationship between posttraumatic

stress disorder and self-reported physical symptoms in Persian

Gulf War veterans. Archives of Internal Medicine 157,


Behan, P.O., 1996. Chronic fatigue syndrome as a delayed

reaction to chronic low dose organophosphate exposure.

Journal of Environmental and Nutritional Medicine 6,


Burchfiel, J.L., Duffy, F.H., 1982. Organophosphate neurotoxicity:

chronic effects of sarin on the electroencephalogram

of monkey and man. Neurobehavioral Toxicology and Teratology

4, 767778.

Cullen, M.R., 1987. Workers with Multiple Chemical Sensitivities.

Hanley and Belfus, Inc., Philadephia, PA.

De Blecker, J.L., De Reuck, J.L., Willems, J.L., 1992. Neurological

aspects of organophosphate poisoning. Clinical Neurology

and Neurosurgery 94, 93103.

Fukuda, K., Straus, S.T., Hickie, I., Sharpe, M.C., Dobbins,

J.G., Komaroff, A., 1994. The chronic fatigue syndrome: a

comprehensive approach to its definition and study. Annals

of Internal Medicine 121, 953959.

Fukuda, K., Nisenbaum, R., Robin, L., Washko, R.M., Noah,

D.L., Thomson, W.W., Stewart, G., Reeves, W.C., 1998. A

chronic multi symptom illness affecting Persian Gulf War

veterans. Journal of the American Medical Association

280, 981988.

Gold, P.W., Chrousos, G.P., 1999. The endocrinology of

melancholic and atypical depression: relation to neurocircuitry

and somatic consequences. Proceedings of the Association

of American Physicians 111, 2234.

Gray, G.C., Hawkesworth, A.W., Smith, T.C., Kang, H.K.,

Knoke, J.D., Gackstatter, G.D., 1998. Gulf War Veterans’

health registries. Who is not likely to seek evaluation?

American Journal of Epidemiology 148 Ž. 4 , 343349.

Haley, R.W., Hom, J., Roland, P.S., Bryan, W.W., Van Ness,

P.C., Bonte, F.J., Devous, M.D., Mathews, D., Fleckenstein,

J.L., Wians, F.H., Wolfe, G.I., Kurt, T.L., 1997. Evaluation

of neurologic function in Gulf War veterans. A blinded

case-control study. Journal of the American Medical Association

277, 223230.

Hyams, K.C., Wignall, F.S., Roswell, R., 1996. War syndromes

and their evaluation: from the US civil war to the Persian

Gulf War. Annals of Internal Medicine 125, 398405.

Iowa Persian Gulf Study Group, 1997. Self-reported illness

and health status among Gulf War veterans. Journal of the

American Medical Association 277, 238244.

Jamal, G.A., Hansen, S., Apartopoulos, F., Peden, A., 1996.

The ‘Gulf War Syndrome’. Is there evidence of dysfunction

in the nervous system? Journal of Neurology, Neurosurgery

and Psychiatry 60, 449451.

Kang H. National Health Survey of Gulf War Era Veterans

and their Families. Conference on Federally Sponsored

Gulf War Veterans Illnesses Research, Washington, D.C.,

June 1998.

Lundberg, I., Michelsen, H., Nise, G., Hogstedt, C., Hogberg,

M., 1995. Neuropsychiatric function of housepainters with

previous long-term exposure to organic solvents. Scandinavian

Journal of Work and Environmental Health 21, 144.

Marcus, S., Robins, L.N., Bucholz, K., 1990. Quick Diagnostic

Interview Schedule 3R, version 1. Washington University

School of Medicine, St. Louis, MO.

Persian Gulf Veterans Coordinating Board, 1995. Unexplained

illnesses among Desert Storm veterans. Archives of

Internal Medicine 155, 262268.

Pollet, C., Natelson, B.H., Lange, G., Tiersky, L., DeLuca, J.,

Policastro, T., Desai, P., Ottenweller, J.E., Korn, L., Fiedler,

N., Kipen, H., 1998. Medical evaluation of Persian Gulf

Veterans with fatigue andor chemical sensitivity. Journal

of Medicine 29, 101113.

Rowntree, D.W., Nevin, S., Wilson, A., 1950. The effects of

disopropyl fluorophosphate in schizophrenia and manic depressive

psychosis. Journal of Neurology, Neurosurgery and

Psychiatry 13, 4762.

Sutker, P.B., Uddo, M., Brailey, K., Allain, A.N., 1993. Warzone

trauma and stress-related symptoms in Operation

Desert ShieldStorm Ž ODS.

returnees. Journal of Social

Issues 49, 3349.

Sutker, P.B., Uddo, M., Brailey, K., Allain, A.N., Errera, P.,

1994a. Psychological symptoms and psychiatric diagnoses in


( )

G. Lange et al. Psychiatry Research 89 1999 3948

Operation Desert Storm troops serving graves registration

duty. Journal of Trauma and Stress 7, 159171.

Sutker, P.B., Uddo, M., Brailey, K., Vasterling, J.J., Errera, P.,

1994b. Psychopathology in war-zone deployed and nondeployed

operation desert storm troops assigned graves registration

duties. Journal of Abnormal Psychology 103,


Sutker, P.B., Vasterling, J.J., Brailey, K., Allain, A.N., 1995a.

Memory, attention, and executive deficits in POW survivors:

contributing biological and psychological factors.

Neuropsychology 9, 118125.

Sutker, P.B., Uddo, M., Davis, J.M., Ditta, S.R., 1995b. War

zone stress, personal resources, and PTSD in Persian Gulf

War returnees. Journal of Abnormal Psychology 104,


Wolfe, J., Kean, T.M., Young, B.L., 1996. From soldier to

civilian: acute adjustment patterns of returned Persian

Gulf Veterans. In: Ursano, R.J., Norwood, I.A. Ž Eds. .,

Emotional Aftermaths of the Persian Gulf War: Veterans,

Families, Communities and Nations. American Psychiatric

Press, Inc., Washington, DC, pp. 477499.

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