GULF WAR SYNDROME. Dennis A. Kelly, Ph.D. Pacific NW Neuropsychological Society 11 November 2002
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1 GULF WAR SYNDROME Dennis A. Kelly, Ph.D. Pacific NW Neuropsychological Society 11 November 2002
2 THE GOOD NEWS Only 47 days Shortest war in U.S. history Fewer than 300 deaths and 400 wounded (only 147 combat deaths) Compared with estimated 100,000 Iraqi soldiers killed and 300,000 wounded Mass chemical and biological attacks did not occur
3 THE BAD NEWS Reports of frequent sounding of chemical alarms, dead animals Reports of strange, debilitating symptoms Beginning with reservists, then spreading to active duty, family members, then from Americans to other nationalities
4 RISK FACTORS FOR GWS SX. Chemical Warfare Agents Biological Warfare Agents Vaccines and Nerve Agent Antidotes Parasites and Bacteria Oil Well Fires Depleted Uranium Other Environmental Hazards (e.g., CARC Paint, Fumes from Fuel) Stress
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6 CCEP Evaluation: Medical history / Gulf War Risk-Factor Questionnaire Physical examination Basic and additional lab tests Specialty consultations from neurology, infectious diseases, psychiatry, neuropsychology
7 GENERAL PRINCIPLES OF NEUROTOXIC DAMAGE Direct (Injury to Neurons) Indirect (Injury to Other Organs) Central NS vs. Peripheral NS Anoxia Selective Vulnerability of NS to Neurotoxic Damage Acute vs. Sub-Acute vs. Chronic Effects
8 Selective Vulnerability of NS to Neurotoxic Damage Neurons cannot regenerate Tendency of many neurotoxins to be lipophilic ( fat-loving ) Many neurotoxins cross blood-brain barrier Architecture of neurons expose surface area to neurotoxins Delicate electrochemical balance
9 Acute vs. Sub-Acute vs. Chronic Effects Acute exposures are usually quite noticeable in their effects Exposures in GW were mostly subacute (low agent exposure) Caveat: Multiple possible exposures Chronic low-level exposures can lead to silent neurotoxic syndromes analogy of Parkinson s Disease Difference between chemical and biological agents
10 Well-Recognized Human Developmental Neurotoxicants Ethanol Mercury Lead Dilantin PCB s PBB s Pesticides Ionizing Radiation Cadmium Anesthetics Cocaine Methadone Heroin
11 Challenges in Assessment of Neurotoxic Syndromes Exposure ambiguities Lack of neurochemical markers/ corroborating medical evidence Premorbid function Clinical vs. epidemiological assessment Differential diagnosis Political/legal ramifications
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13 RESEARCH QUESTIONS as compared with controls, 1. What was the prevalence of various psychophysiological stressors among Gulf War veterans? 2. What is the prevalence of neurological and neuropsychological deficits? 3. What is the prevalence of psychological symptoms and/or diagnoses?
14 Psychophysiological stressors? The theater of operations was a hostile environment. The majority of GW veterans report high levels of stressful experiences during the war. In several studies, ill GW veterans consistently reported more combat stressors than healthy GWV, such as deaths among unit members.
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16 Haley et al. GW Syndromes: 1. Impaired Cognition -- Pesticide containing flea collars 2. Confusion Ataxia -- PB tablets & nerve gas 3. Central Pain -- PB tablets & DEET
17 Garth Nicolson & Mycoplasma: Systemic chronic microorganism infections can cause chronic fatigue, reoccuring fevers, night sweats, joint and muscle pains, stomach upsets and cramps, diarrhea, breathing problems, sleep disturbances, sinus congestion/pain, headaches, skin rashes, kidney pain, dizziness, nausea, short term memory loss, vision problems, such as light sensitivity, blurred vision and floaters, hair loss, urination problems, eye pain, heart and thyroid problems and in extreme cases autoimmume-like disorders, such as those that lead to muscle degeneration and paralysis.
18 MAMC GW Top Presenting Complaints (% of Pts. Reporting): Memory Sleep HA Concentration Fatigue Irritable Depression Medical Probs. Anxiety
19 MAMC GW Neuropsych. Battery Shipley Institute of Living Scale Neurobehavioral Cognitive Status Exam Rey Auditory Verbal Learning Test Symbol Digit Modalities Test Trailmaking Test Fingertapping / Grooved Pegboard Personality Assessment Inventory
20 MAMC OVERALL TEST RESULTS Strengths : Weaknesses : Shipley IQ NCSE WNL Trails A +.2 SD Trails B Mean AVLT Tot. +.3 SD Tap/GPB Mean SDMT Writ. SDMT Oral AVLT Intr. PAI -.5 SD -.4 SD SD SD
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22 Neuropsychological deficits? Self-reports of memory and concentration problems tend to be more frequent among deployed GW veterans than among control subjects. However, performance is similar on most objective neuropsychological tests. On a small proportion of tests, GW veterans perform significantly more poorly than controls. After adjustment for psychological distress, differences between the two groups usually diminish.
23 Neurological deficits? Neurological studies to date with several populations show that most Gulf War veterans do not demonstrate gross objective evidence of neurological diseases, either in the CNS or PNS. However, several studies are in progress performing neuroimaging in GWV and NDV, including conventional MRI, functional MRI, magnetic resonance spectroscopy, and SPECT.
24 Psychological symptoms and/or diagnoses? GW veterans have been diagnosed with significantly higher rates of posttraumatic stress disorder (PTSD) and major depression than non-deployed veterans. In two large cohorts, GW veterans diagnosed with PTSD or depression also reported physical symptoms in many organ systems at higher rates than non-deployed or healthy Gulf War veterans.
25 Subjective Appraisal of Threat -- Perceived to be Higher When: Invisible Exotic vs. Commonplace Man-made vs. natural Delayed effects Unfair -- (targets innocents)
26 OTHER THEORIES: Chronic Fatigue Syndrome Fibromyalgia Multiple Chemical Sensitivity (Ecological Illness) Somatization Disorder
27 SOME CONCLUSIONS: A lot of GW vets and their families really are sick. Fog of War & and Fog of Science we don t understand why (Unexplained Illness) Not one syndrome with one cause. Science is better than pseudoscience. Cause & effect is not the same as correlation.
28 CONCLUSIONS (Cont.) Clinical vs. epidemiological studies More study on long-term effects of low level exposures Some implicated chemicals are common in everyday life. If vets chronic illnesses are the result of exposure to low levels of such chemicals, then all of us are at risk. Governments & media of a free society need to be more honest and responsible
29 Selected Websites: Office of the Special Asst. for Gulf War Illnesses UK Ministry of Defence Gulf War Site Special Oversight Board for DOD Investigations of GW Chemical & Biological Illnesses Center for Disease Control American Gulf War Veterans Association
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