In addition to relying on their own knowledge of relevant scientific literature, these scholars read nearly 300 articles on several topics, for example, the relationship of symptoms to extreme exposures and events, defining a disease or syndrome and exposures of past concern.

Some general statements that evolved from this meeting include:

• Nearly twelve years of studies and reports regarding a possible “Gulf War syndrome” have led to concerns of a “World Trade Center syndrome” and lingering illnesses reported by U.S. postal workers handling irradiated mail (to get rid of any possible anthrax spores).
  
• These events remind us that unexplained symptoms occur frequently after war and are likely after terrorist attacks.
  An important social priority is to recognize, define, prevent, and care for individuals with unexplained symptoms after war and related events (e.g., terrorism, natural or industrial disasters).
  
• The resulting consensus statement finds that different, yet overlapping, groups of unexplained symptoms occur after war and may also occur after terrorism.
  
• These symptoms constitute a valid illness; although, finding a cause is difficult for many reasons.
  
• Veterans’ unexplained symptoms have included fatigue, dizziness, shortness of breath, headache, difficulty sleeping, joint stiffness, chest pain, depression, persistent anxiety, and a sense of being distant or “cut off” from others.
  
• Similar illnesses occur commonly in the civilian population too, suggesting war is only one of several potential triggering events.
  
• PTSD (Post-traumatic Stress Disorder) may also occur after any catastrophic or life-threatening event. PTSD was originally called ‘post-Vietnam syndrome’ because of the large number of veterans of that conflict who reported these symptoms. The symptoms considered most characteristic of PTSD are emotional and include recurrent memories of an event which may occur at any time, distressing dreams, flashbacks, and avoidance of thoughts and activities associated with the trauma. However, physical symptoms are also common in PTSD, including difficulty with sleep and impaired concentration.
  
• A second overlapping pattern of illness after war includes unexplained physical symptoms. Again, there is evidence to suggest that unexplained physical symptoms occur more often among war veterans than among similar individuals who are not war veterans.
  
• Consistent evidence suggests that unexplained symptoms and illnesses occur after war. To a lesser extent, the findings are similar after other catastrophic events. These unexplained symptom syndromes go by a variety of names. Most of them are difficult to defend as new or unique diseases, but that does not mean that these symptoms are not real, or that these individuals are feeling unwell.
  
• Our understanding of illnesses, particularly those based on symptoms alone, is shaped by current culture, ideas, and beliefs.
  
  • Social and historical factors have influenced the names of medically unexplained symptoms (e.g., “soldier’s heart”, neurasthenia, chronic fatigue immune dysfunction syndrome, hysteria),
    
  • Theories that relate to a suspected cause have also influenced people’s understanding of these illnesses (e.g., psychological repression, chronic infection, environmental toxicities, immunologic dysfunction),
    
  • Diagnosis of these illnesses is based on populations at risk (e.g., “yuppie flu”, Gulf War syndrome), and by eliminating other possible diseases or illnesses
    
  • Treatment and management techniques, whether rooted in science and proper investigation or in preferences of the population influence thoughts about these illnesses (Examples of each include: psychoanalysis, corticosteroids, exercise, low-level toxin avoidance).

Though history shows that new diseases are occasionally recognized, there are many more examples of unexplained symptoms receiving new names and identities in different historical and medical contexts.

• During World War I, medically unexplained symptoms were commonly interpreted and treated as a cardiac problem (“disordered action of the heart”) or as a neurological problem caused by microscopic hemorrhaging (“shell shock”).
  
• Similar symptoms after the Gulf War have been explained as low-level environmental toxicities.
  

It has been suggested that illnesses should not adopt names that presume a cause (e.g., PTSD, Gulf War Illnesses) because this assumption gradually becomes accepted without actually being proven by scientific study.

In many areas of science and medicine, we know more about what does not work than what works for medically unexplained symptoms after war or terrorism.

• After every major conflict since World War I there have been important studies of the management of unexplained symptoms that seem to develop after wars.
  
• These studies have usually concluded that training and unit cohesiveness are protectors against potential symptom development, and that once in combat, the intensity of battle is also an important factor
  
• Despite the quantity of studies of possible predisposing factors, large numbers of veterans continue to experience unexplained symptoms after war. Nonetheless, available research allows speculation on what preventive and clinical factors may be helpful.
  
• There are no known medical tests that predict an individual’s risk of unexplained symptoms after war. Unfortunately, this particular question has not received much study.
  

One possible tactic is to prepare all or subgroups of individuals for war or terrorist exposures using appropriate psychosocial interventions. Cognitive-behavioral theory says that expectations and beliefs determine emotional and behavioral responses to external events. Cognitive-behavioral interventions that prepare military personnel or first responders for the realities of wartime and terrorist events may lead to more adaptive behavioral and emotional responses to these events. If used in pre-deployment training, these approaches may help prevent unexplained symptoms after war or terrorism.

• Studies from World War II show that troops with a realistic idea of what war involved before they entered battle were less likely to suffer breakdowns than those holding distorted or glamorized views.
• Research in both animals and humans suggests that exposure to several stressors in a relatively short period of time leads to effects that last longer than if the same exposures occur over a longer period of time. It may be helpful, then, to expose troops to necessary similar stressors in advance of deployment to lessen the impact of them once war or terrorism are inevitable.
  

Intervention during the event

By their very nature, war and terrorism are stressful events. It is important to understand that “stress” and “stressors” have scientific meanings other than what is frequently described in the press as “stress.” Biological, psychological, and social stressors are all a part of war and terrorist events. Scientific research looking at stress suggests that the nature and intensity of a stressor may not be as important as the environment and context in which the stressor occurs when it comes to certain physiological responses (for example, symptom development). Studies in animals and humans have shown that the negative effects of stressors are greater when individuals lack: 1) control; 2) predictability; 3) direction; and 4) social support.

• Observations from war usually, but not always, find that higher-ranking soldiers and those from units with higher esprit de corps have lower rates of illness. Support troops, often isolated and in small groups, tend to have higher illness rates even though they were exposed to less intense levels of fighting.
  
• To lessen the risk of poor health and to improve performance military units and first response teams should consider interventions aimed at improving cohesion, providing appropriate direction and leadership, and building a sense of individual responsibility and control. These tactics may help to reduce uncertainty under inherently chaotic circumstances, and hopefully insure against fewer cases, or at least less severe cases, of unexplained symptoms and poor health.
  

In summary, it is rare that a seemingly new illness, based on unexplained symptoms, is found to be directly related to unique environmental exposures or new disease processes. This is not to say that it is not possible. Indeed, some medically unexplained symptoms may sometimes be caused by environmental exposures or disease processes. However, it is difficult to clearly define and understand illnesses that are defined on the basis of unexplained symptoms because there is generally a lack of consistent physical examination, laboratory information, or medical images that can be used to develop a n illness definition. As a result, there is a greater chance that social and historical contexts to influence the illness recognition process, rather than illness contexts. The identification of unique or specific mechanisms for such illnesses is rare, and requires a combination of reproducible population studies and societal, clinical, and scientific agreement.

Symptoms after every war – A Historical Review

The health and illnesses of military personnel during and following previous wars has been the focus of many studies both in the U.S. and the U.K. Some findings include:

• In every armed conflict in which the United States has participated since the U.S. Civil War, there has been a population of veterans that has developed war or post-combat syndromes. After the 1990-1991 Operation Desert Storm in the Persian Gulf, this syndrome was called Gulf War Veterans’ Illness.
  
  
• Similar symptoms have characterized these war syndromes and typically include: pain, fatigue, impaired concentration and forgetfulness, sleep disturbance, shortness of breath, headache, and gastrointestinal problems.
  
  
• These same symptoms have been exhibited by veterans of previous armed conflicts, although the names for the condition have changed. Various names for this cluster of symptoms exhibited by members of the military include: Shell Shock, Neurasthenia, Soldier’s Heart, Da Costa Syndrome, effort syndrome, neurocirculatory asthenia, Disordered action of the heart (DAH), Combat Fatigue, Psychoneurosis, Post-Traumatic Stress Disorder (PTSD), etc.
  
  
• This same cluster of symptoms occurs in the general population. When occurring in the general population, it is more commonly known or described as Fibromyalgia and Chronic Fatigue Syndrome. These illnesses, combined with Somatoform Disorders, Exposure Syndromes, and Multiple Chemical Sensitivity, are referred to as Chronic Multi-symptom Illnesses.
  
  
• One study of six military conflicts (the Boer War, World War I, World War II, Malayan and Korean Conflicts, the first Gulf War) resulted in 3 clusters of post-combat syndromes. These three clusters were defined as Cluster 1 – a debility syndrome but without psychological or cognitive symptoms, Cluster 2 – a somatic syndrome focused on the heart, Cluster 3 – a neuropsychiatric syndrome with a range of associated somatic symptoms. Common symptoms to each of these clusters were: fatigue, difficulty completing tasks, shortness of breath, dizziness, and pain or headache.
  
  
• As it relates to symptoms, the illnesses associated with the Gulf War did not distinguish itself from other military conflicts. Authors of one study concluded that the combined stressors of war were more likely than the specific Gulf War deployment exposures to be a cause of increased symptoms among Gulf War veterans.
  
  
• As post-combat syndromes have occurred after all major wars in the past century, it is likely that they will continue to occur in the future. The post-combat syndrome should not be viewed as a new or unique illness, but understood as the normal response to the physical and psychological stress of war. Doing so may result in a more effective management of Gulf War Illness.

References

Hyams, K.C., Wignall, F.S., Roswell, R. War Syndromes and Their Evaluation: From the U.S. Civil War to the Persian Gulf War, Annals of Internal Medicine, 1996; 125:398-405.

Jones, E., Hodgins-Vermaas, R., McCartney, H., Everitt, B., Beech, C., Poynter, D., Palmer, I., Hyams, K., Wessely, S. Post-combat syndromes from the Boer war to the Gulf war: a cluster analysis of their nature and attribution, British Medical Journal, 2002; 324: 1-7.

Jones, E., Wessely, S. Case of chronic fatigue syndrome after Crimean war and Indian mutiny, British Medical Journal, 1999; 319:1645-1647.

Clauw, D., Crofford, L. Chronic widespread pain and fibromyalgia: what we know, and what we need to know. Best Practice and Research Clinical Rheumatology, Bailliere’s Clinical Rheumatology, 2003; 17; 4: 685-710.

Barrett, D., Gray, G., Doebbeling, B., Clauw, D. and Reeves, W. Prevalence of Symptoms and Symptom-based Conditions among Gulf War Veterans: Current Status of Research Findings. Epidemiologic Reviews, 2002, 24:218-227.

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