THE FOLLOWING LECTURE HAS BEEN APPROVED FOR ALL STUDENTS BY BIRMINGHAM CITY UNIVERSITY health.bcu.ac.uk/craigjackson This lecture may contain information,

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The Psychology of The Psychology of Gulf War SyndromeGulf War Syndrome

A strange and curious A strange and curious condition caused by an condition caused by an

unusual warunusual war

Prof. Craig JacksonHead of Psychology Division

BCU

[email protected]

Headlines of Gulf WarHeadlines of Gulf War

BABY IS GULF WAR BABY IS GULF WAR SYNDROME VICTIMSYNDROME VICTIM

JABS LINKED TO GULF JABS LINKED TO GULF WAR SYNDROMEWAR SYNDROME

MORE THAN 10,000 DEAD MORE THAN 10,000 DEAD FROM GULF WAR SYNDROME!FROM GULF WAR SYNDROME!

History of Gulf WarHistory of Gulf War

Aug 1990: Iraq invaded KuwaitAug 1990: Iraq invaded Kuwait

Aug 1990 - Jun 1991:Aug 1990 - Jun 1991:Allied Troop DeploymentAllied Troop Deployment

697,000 by USA697,000 by USA53,000 by United Kingdom53,000 by United Kingdom4,500 by Canada4,500 by Canada

Feb 1991:Feb 1991:Iraq expelled from KuwaitIraq expelled from Kuwait

History of Gulf War SymptomsHistory of Gulf War Symptoms

Within months of end of war some veterans reported symptomsWithin months of end of war some veterans reported symptoms

Some studies tried to identify the key clinical features of ill health in veteransSome studies tried to identify the key clinical features of ill health in veterans

US Government invited sick veterans to join voluntary medical registriesUS Government invited sick veterans to join voluntary medical registries

Many presented with non-specific symptomsMany presented with non-specific symptoms

Non-Specific????Non-Specific????

Most common primary diagnoses among 20,000 vets were:Most common primary diagnoses among 20,000 vets were:musculoskeletal disorders (18.6%)musculoskeletal disorders (18.6%)psychological conditions (18.3%)psychological conditions (18.3%)multi-system conditions (17.8%).multi-system conditions (17.8%).

No evidence of a unique illnessNo evidence of a unique illness Joseph 1997Joseph 1997

History of Gulf War SymptomsHistory of Gulf War Symptoms

Collection of symptoms in soldiers who served in Persian Gulf War (1990-1991)Collection of symptoms in soldiers who served in Persian Gulf War (1990-1991)

Highly variableHighly variable

Include:Include:• RashRash• FatigueFatigue• Muscle painMuscle pain• Joint painJoint pain• HeadacheHeadache• IrritabilityIrritability• DepressionDepression• Sleep disturbanceSleep disturbance• Gastrointestinal problemsGastrointestinal problems• Respiratory problemsRespiratory problems• Cognitive deficitsCognitive deficits

SOLDIER HAILS GULF SOLDIER HAILS GULF CASE WINCASE WIN

Dilemma of Gulf War SymptomsDilemma of Gulf War Symptoms

The studies demonstrate an increase in reporting of symptoms in veterans The studies demonstrate an increase in reporting of symptoms in veterans who served in the Gulf conflict, compared to those not deployed or who have who served in the Gulf conflict, compared to those not deployed or who have served elsewhere.served elsewhere.

However, similar symptoms were reported in all control groupsHowever, similar symptoms were reported in all control groups

No obvious unique collection of symptoms in Gulf War veteransNo obvious unique collection of symptoms in Gulf War veterans

Data rely on self-reported symptoms, and lend themselves to response biasesData rely on self-reported symptoms, and lend themselves to response biases

Dilemma of Gulf War SymptomsDilemma of Gulf War Symptoms

Variety and multiplicity of symptoms no consistent pattern exists . . .Variety and multiplicity of symptoms no consistent pattern exists . . .

. . . Therefore impossible to suggest a common underlying disease process. . . Therefore impossible to suggest a common underlying disease process

This makes it unlikely that a single cause will explain ill health in Gulf veteransThis makes it unlikely that a single cause will explain ill health in Gulf veterans

No study has found consistent abnormal clinical or laboratory findings among No study has found consistent abnormal clinical or laboratory findings among ill Gulf veteransill Gulf veterans

The Veterans’ CaseThe Veterans’ Case

1.1. Military authorities exposed service personnel to unreasonable medical Military authorities exposed service personnel to unreasonable medical and environmental hazardsand environmental hazards

2.2. Military authorities have since failed to Military authorities have since failed to a)a) generate, record and act on information of relevance to veterans’ generate, record and act on information of relevance to veterans’

illnessesillnessesb)b) have withheld and destroyed informationhave withheld and destroyed informationc)c) have distributed misleading informationhave distributed misleading information

a)a) AA nd have obstructed enquiries by others. nd have obstructed enquiries by others.

3. 3. Diagnosis and treatment of illness has been impeded by the Diagnosis and treatment of illness has been impeded by the unprecedentedunprecedented nature of the medical conditions, but also by the military nature of the medical conditions, but also by the military authorities’ own obstructive behaviour. authorities’ own obstructive behaviour.

The UK Ministry of DefenceThe UK Ministry of Defence

““The Ministry of Defence accepts some veterans have become illThe Ministry of Defence accepts some veterans have become ill

Many believe this ill health is unusual and directly related to service in the GulfMany believe this ill health is unusual and directly related to service in the Gulf

UK Gulf veterans report more ill-health than other comparable groups UK Gulf veterans report more ill-health than other comparable groups (Unwin et al 1999)(Unwin et al 1999)

This is not unique to Gulf veterans as the same symptoms are seen in UK This is not unique to Gulf veterans as the same symptoms are seen in UK military personnel who did not deploy to the Gulfmilitary personnel who did not deploy to the Gulf

Gulf Conflict veterans report having more of the symptoms and are suffering Gulf Conflict veterans report having more of the symptoms and are suffering more severely from themmore severely from them

Some veterans have recognised medical conditions, but a large number of non-Some veterans have recognised medical conditions, but a large number of non-specific, multi-system, medically unexplained symptoms are also reported”specific, multi-system, medically unexplained symptoms are also reported”

Theory #1 Vaccine OverloadTheory #1 Vaccine Overload

The Theory. . .The Theory. . .

GW1Vs received at least 17 different GW1Vs received at least 17 different Vaccines: e.g. PyridostigmineVaccines: e.g. Pyridostigmine

Established vaccinesEstablished vaccines PoliomyelitisPoliomyelitisYellow feverYellow feverCholeraCholera

Experimental vaccinesExperimental vaccines Anthrax Anthrax Botulinum toxoidBotulinum toxoidPertussisPertussis

MOD says UK troops received 10 typesMOD says UK troops received 10 types

Adjuvants and viral genomes!Adjuvants and viral genomes!Squalene polymer antibodiesSqualene polymer antibodies Rook & Zumla (1997)Rook & Zumla (1997)


The EvidenceThe Evidence

GWS symptoms X3 more likely in vaccinated vetsGWS symptoms X3 more likely in vaccinated vets

GWS in GWS in 34% vaccinated vets34% vaccinated vets 12% vaccinated but non-deployed vets12% vaccinated but non-deployed vets

4% in non-vaccinated vets4% in non-vaccinated vets

GWS lowest in troops on ships (21%)GWS lowest in troops on ships (21%)

GWS highest in those in Iraq / Kuwait (42%)GWS highest in those in Iraq / Kuwait (42%)

Steele 2001Steele 2001



Compared with troops in Bosnia conflict, and those not deployed in Gulf:Compared with troops in Bosnia conflict, and those not deployed in Gulf:

GWVs reported significantly more symptoms:GWVs reported significantly more symptoms:

Twice as likely to have GWS diagnosisTwice as likely to have GWS diagnosis

Number of vaccinations increased likelihood of GWS:Number of vaccinations increased likelihood of GWS:

Vaccination before conflict less problematic than vaccination during Vaccination before conflict less problematic than vaccination during conflictconflict

Ismail 2002Ismail 2002



US Department of Defence (1997)US Department of Defence (1997)

Initiated Anthrax Vaccination Immunization ProgramInitiated Anthrax Vaccination Immunization Program

2.4 Million military personnel2.4 Million military personnel

Adverse reactions in personnel were similar to symptoms of GWSAdverse reactions in personnel were similar to symptoms of GWS

French troops were not exposed to the same cocktail of drugs as British and French troops were not exposed to the same cocktail of drugs as British and US service personnel, and have not reported any 'Gulf War Syndrome'US service personnel, and have not reported any 'Gulf War Syndrome'

Theory #2 Depleted UraniumTheory #2 Depleted Uranium


DU – Low-level radioactive materialDU – Low-level radioactive material

Nephrotoxic when internalised in large quantitiesNephrotoxic when internalised in large quantities

Amour piercingAmour piercing

Those handling munitions were appropriately protected and no adverse Those handling munitions were appropriately protected and no adverse health effects have been reported in these troopshealth effects have been reported in these troops

Theory #2 Depleted UraniumTheory #2 Depleted Uranium

The Evidence. . .The Evidence. . .

Elevated incidence of renal dysfunction have not been Elevated incidence of renal dysfunction have not been observed in personnel exposed to DU during the conflictobserved in personnel exposed to DU during the conflict

MoD is continuing research via an independent oversight MoD is continuing research via an independent oversight boardboard

Several major reviews have concluded that it is unlikelySeveral major reviews have concluded that it is unlikelyto be implicated in Gulf veterans' illnessesto be implicated in Gulf veterans' illnesses

Three-fold increase in birth defects in Iraq since 1991Three-fold increase in birth defects in Iraq since 1991

The Royal Society 2003The Royal Society 2003

Theory #3 Oil Fire SmokeTheory #3 Oil Fire Smoke


After ground war hundreds of oil wellsAfter ground war hundreds of oil wellswere set alightwere set alight

Plumes of smoke across the battlefieldsPlumes of smoke across the battlefields

Smoke is known to cause respiratory tract irritationSmoke is known to cause respiratory tract irritation

Personnel involved in tackling the blazes were appropriately protected Personnel involved in tackling the blazes were appropriately protected

Health of individuals working in the proximity of the fires was closely Health of individuals working in the proximity of the fires was closely monitoredmonitored




Monitoring studies found no evidence of increased levels of toxic gasesMonitoring studies found no evidence of increased levels of toxic gases

Was an increase in the level of fine particulate matterWas an increase in the level of fine particulate matter

Gulf veterans have commonly reported respiratory symptomsGulf veterans have commonly reported respiratory symptoms

Little evidence of pulmonary damage attributable to oil well smokeLittle evidence of pulmonary damage attributable to oil well smoke

Theory #4 Chemical / Biological Warfare AgentsTheory #4 Chemical / Biological Warfare Agents


Nerve GasNerve GasSarinSarin -- Cholinesterase InhibitionCholinesterase InhibitionVXVX Headaches, Diarrhoea, ParalysisHeadaches, Diarrhoea, ParalysisLewisiteLewisite

BacteriaBacteriaVirusVirusToxinsToxins

Theory #4 Chemical / Biological Warfare AgentsTheory #4 Chemical / Biological Warfare Agents


There is no objective evidence that Iraq utilised any chemical or biological There is no objective evidence that Iraq utilised any chemical or biological warfare (CBW) capabilitywarfare (CBW) capability

Documented that many detection devices alarmedDocumented that many detection devices alarmedduring the war during the war

Many personnel believed they were under Many personnel believed they were under chemical attackchemical attack

Frequent false alarms occurred as the devices were Frequent false alarms occurred as the devices were exquisitely sensitive, obtained at the expense of some exquisitely sensitive, obtained at the expense of some specificityspecificity

Theory #5 Post Traumatic Stress DisorderTheory #5 Post Traumatic Stress Disorder


Many attribute ill health to post-traumatic stress disorderMany attribute ill health to post-traumatic stress disorder

12% of all the veterans who attended were suffering from PTSD and somatic 12% of all the veterans who attended were suffering from PTSD and somatic symptoms (MoD's Medical Assessment Programme) symptoms (MoD's Medical Assessment Programme)

Gulf veterans were under considerable stress, not least from the constant Gulf veterans were under considerable stress, not least from the constant threat of chemical and biological weaponsthreat of chemical and biological weapons

Each conflict is associated with a unique Each conflict is associated with a unique environment / type of warfare and a unique environment / type of warfare and a unique combination of physical and psychological combination of physical and psychological stressors that may contribute to ill healthstressors that may contribute to ill health

Theory #5 Post Traumatic Stress DisorderTheory #5 Post Traumatic Stress Disorder


Large numbers of veterans suffering from symptoms who do not have Large numbers of veterans suffering from symptoms who do not have psychological dysfunction - suggests that stress alone cannot account for ill psychological dysfunction - suggests that stress alone cannot account for ill health in all veteranshealth in all veterans

Symptoms in Gulf veterans are similar to those reported after other conflicts Symptoms in Gulf veterans are similar to those reported after other conflicts (Hyams et al 1997)(Hyams et al 1997)

The Gulf War cannot compare with previous wars in terms of human The Gulf War cannot compare with previous wars in terms of human casualties and other environmental factorscasualties and other environmental factors

Impossible to compare research done on different wars owing to changing Impossible to compare research done on different wars owing to changing nature of medicine, technology, and cultural factors nature of medicine, technology, and cultural factors

Media reporting in society contributes factors for ill health reportingMedia reporting in society contributes factors for ill health reporting

Theory #6 Pesticides / InsecticidesTheory #6 Pesticides / Insecticides


Widespread use of pesticides containing organophosphates (Ops) to combat Widespread use of pesticides containing organophosphates (Ops) to combat desert pestsdesert pests

Pyridostigmine bromide was given prophylactically as a counter-measure Pyridostigmine bromide was given prophylactically as a counter-measure against chemical attacksagainst chemical attacks

Pyridostigmine reversibly inhibits acetylcholinesterase at the neuromuscular Pyridostigmine reversibly inhibits acetylcholinesterase at the neuromuscular junction and prevents subsequent binding junction and prevents subsequent binding of nerve agentsof nerve agents

Causes cholinergic crisis (nerve paralysis)Causes cholinergic crisis (nerve paralysis)

Theory #6 Pesticides / InsecticidesTheory #6 Pesticides / Insecticides


The associations between reported exposure to pesticides and measures of ill The associations between reported exposure to pesticides and measures of ill health showed no significant difference between Gulf and Bosnia & Era health showed no significant difference between Gulf and Bosnia & Era veterans (Unwin et al 1999)veterans (Unwin et al 1999)

Usually gross evidence of toxic effects of high doses of OPs, there were no Usually gross evidence of toxic effects of high doses of OPs, there were no obvious acute effects in the war theatreobvious acute effects in the war theatre

Delayed effects of low-level exposure are not fully understoodDelayed effects of low-level exposure are not fully understood

Is plausible that there may be some role in veterans' illnessesIs plausible that there may be some role in veterans' illnesses

The MoD maintains it is unlikely to play a major role, but has commissioned a The MoD maintains it is unlikely to play a major role, but has commissioned a detailed study into the effects of OPsdetailed study into the effects of OPs

Possible TheoriesPossible Theories

(Multiple) Vaccines(Multiple) Vaccines Theory of a combination of Theory of a combination of stress and vaccinations stress and vaccinations

Post Traumatic Stress Disorder Post Traumatic Stress Disorder having effects having effects Hotopf et al (2000)Hotopf et al (2000)

DUDU

Oil Fire SmokeOil Fire Smoke

Chemical/ Biological AgentsChemical/ Biological Agents

Pesticides / InsecticidesPesticides / Insecticides

Complications. . .Complications. . .

Military populations generally healthier than civilians (Healthy Warrior effect)Military populations generally healthier than civilians (Healthy Warrior effect)

Gulf vets death rates are not higher than non Gulf vetsGulf vets death rates are not higher than non Gulf vets(including suicide and cancer)(including suicide and cancer)

Gulf vets have more accidents than non Gulf vets ! ? !Gulf vets have more accidents than non Gulf vets ! ? !

Over decade after deployment some GV still suffer ill-healthOver decade after deployment some GV still suffer ill-health

No unique Gulf war syndromeNo unique Gulf war syndrome

Only common GV related experience involves “perceptions of ill-health”Only common GV related experience involves “perceptions of ill-health”

GVs symptoms are worse for lower ranksGVs symptoms are worse for lower ranks

Huge bias - recalling more exposures, incidents, and inoculationsHuge bias - recalling more exposures, incidents, and inoculations

Health Perceptions of VetsHealth Perceptions of Vets

Military populations generally healthier than civilians (Healthy Warrior effect)Military populations generally healthier than civilians (Healthy Warrior effect)

17% of UK vets believe they have GWS (Chalder et al 2001)17% of UK vets believe they have GWS (Chalder et al 2001)

Belief in having GWS linked to:Belief in having GWS linked to:1)1) Knowing someone else with GWSKnowing someone else with GWS2)2) Being ill afterwardsBeing ill afterwards3)3) No longer in militaryNo longer in military4)4) High number of vaccinations before deployHigh number of vaccinations before deploy


Characteristics of Vets respondingCharacteristics of Vets respondingTo the surveyTo the survey

Chalder et al (2001)Chalder et al (2001)


Relationship between GWS and other outcomesRelationship between GWS and other outcomes

Chalder et al (2001)Chalder et al (2001)

The Future for GW1 Vets?The Future for GW1 Vets?

Legally, GWS exists - - - - Medically, GWS does not existLegally, GWS exists - - - - Medically, GWS does not exist

Upto 9000 UK troops (of 53,000 deployed) may have GWSUpto 9000 UK troops (of 53,000 deployed) may have GWS

2800 (approx) UK vets have attended MOD 2800 (approx) UK vets have attended MOD assessment programmeassessment programme

This number is decliningThis number is declining

What of GWII?What of GWII?

Same problems to emerge?Same problems to emerge?

How will any symptom reports be handled?How will any symptom reports be handled?

Crackpots and the ConvincedCrackpots and the Convinced

Conspiracy TheoristsConspiracy Theorists

It didn’tIt didn’t

The Future for GW1 VetsThe Future for GW1 Vets

OrganisedOrganised

Medical recognition wantedMedical recognition wanted

Legal recognition acquiredLegal recognition acquired

Care for GWS sufferersCare for GWS sufferers

Info disseminationInfo dissemination

ReferencesReferences

Joseph S, and the Comprehensive Clinical Evaluation Program Evaluation Team. A Joseph S, and the Comprehensive Clinical Evaluation Program Evaluation Team. A comprehensive clinical evaluation of 20,000 Persian Gulf War veterans. Milit Med, 162:comprehensive clinical evaluation of 20,000 Persian Gulf War veterans. Milit Med, 162:149-55, 1997.149-55, 1997.

Unwin C, Blatchley N, Coker W, et al. Health of UK servicemen who served in the Persian Gulf Unwin C, Blatchley N, Coker W, et al. Health of UK servicemen who served in the Persian Gulf War. Lancet 353: 169-78, 1999.War. Lancet 353: 169-78, 1999.

Lee HA, Gabriel R, Bolton JPG, et al. Health status and clinical diagnoses of 3,000 UK Gulf War Lee HA, Gabriel R, Bolton JPG, et al. Health status and clinical diagnoses of 3,000 UK Gulf War veterans. J R Soc Med 95: 491-497, 2002.veterans. J R Soc Med 95: 491-497, 2002.

Ministry of Defence. Gulf Update. Issue 4. London: MoD, 2002.Ministry of Defence. Gulf Update. Issue 4. London: MoD, 2002.

Coker WJ. A Review of Gulf War illness. J R Nav Med Serv 82: 141-146, 1996.Coker WJ. A Review of Gulf War illness. J R Nav Med Serv 82: 141-146, 1996.

Rook G & Zumla A. Gulf War Syndrome: is it due to a systemic shift in cytokine balance towards a Rook G & Zumla A. Gulf War Syndrome: is it due to a systemic shift in cytokine balance towards a Th2 profile? Lancet 349: 1831-1833,1997.Th2 profile? Lancet 349: 1831-1833,1997.

Hotopf M, David A, Hull L, et al. Role of vaccinations as risk factors for ill health in veterans of the Hotopf M, David A, Hull L, et al. Role of vaccinations as risk factors for ill health in veterans of the Gulf War: cross-sectional study. BMJ 320: 1363-1367,2000.Gulf War: cross-sectional study. BMJ 320: 1363-1367,2000.

Hyams KC, Wignall FS, Roswell R. War syndromes and their evaluation: from the US Civil War to Hyams KC, Wignall FS, Roswell R. War syndromes and their evaluation: from the US Civil War to the Persian Gulf War. Ann Intern Med 125: 398-405, 1997the Persian Gulf War. Ann Intern Med 125: 398-405, 1997

Documents

THE FOLLOWING LECTURE HAS BEEN APPROVED FOR ALL STUDENTS BY BIRMINGHAM CITY UNIVERSITY health.bcu.ac.uk/craigjackson This lecture may contain information,