NOTE: UNEDITED DOCUMENT
TRANSCRIPT OF THE PROCEEDINGS
PRESIDENTIAL ADVISORY COMMITTEE
GULF WAR VETERANS' ILLNESSES
OMNI NETHERLAND PLAZA 35 FIFTH STREET
JULY 23, 1996
Pesidential Advisory Committee Members:
Doctor Joyce Lashof, Chairperson
Doctor Davis Hamburg
Doctor John Baldeschwieler
3 INDEX OF SPEAKERS
Elner Kumler 5
Lisa Dunster 14
Shannon Gentile 19
Brigham Young 22
Ronald Sester 33
Tony Carpenter 41
Bruce McEwen 48
Paul Black 56
Frances Murphy 96
Steven Southwick 107
Charles Engel 124
Susan Proctor 146
James Stokes 156
4 1 DR. HAMBURG: I'm Dr. David Hamburg, a member
2 of the present committee and chairman of this particular
4 On my right is Dr. Joyce Lashof, the overall
5 chairman of the Presidential Advisory Committee on Gulf
6 War Veterans' Illnesses. We have several members of the
7 committee here, as well as the staff of the committee.
8 We are very pleased to be here. It's an
9 important meeting, which will mainly be devoted to
10 looking into the scientific and critical work at the
11 frontiers on the biology and psychology and stress.
12 But first in our more general function we want
13 to hear from those who might wish to speak, veterans and
14 their families, other people interested in the matter.
15 We have asked in advance to have people who
16 would like to comment. This is the time for public
17 comment. Let me call first on Kevin Jenson of Englewood,
18 Colorado. Is Kevin Jensen here? It's a long way from
19 Colorado, I suppose. Well, maybe he'll be here later.
20 Let me ask then next about Mark Yaeger from
21 Indianapolis, Indiana, not quite so far? Is Mark Yaeger
22 here? No, not yet anyway. Sometimes these people are
23 arriving in the course of the day. We try to work them
24 in if we possibly can to make their remarks.
25 Shannon Gentile of Cincinnati. Is Shannon
5 1 here? Evidently no. Rebecca Tack of Lexington,
2 Kentucky. Is Rebecca Tack here? No, I guess not.
3 All right. Ronald and Kaye Setser Oxford,
4 Ohio. Ronald and Kaye Sester. No.
5 Elner Jean Kumler, Cincinnati.
6 MS. KUMLER: Yes.
7 DR. HAMBURG: Okay.
8 MS. KUMLER: First of all I'd like to welcome
9 you all to Cincinnati and to thank you for coming.
10 I want to talk to you today about my son,
11 Gregory, if I can make it. I gave you -- I'm sorry. My
12 son, Greg, enlisted in the Navy in 1981. My husband and
13 I were both from the Navy, and he joined the Navy because
14 he had no other choice.
15 He was born in a Navy hospital at Great Lakes,
16 Illinois, on September 28th, 1959. He joined the Navy,
17 like I said, in 1981. He was stationed in San Diego,
18 when he found out in 1983 that he was HIV positive.
19 He worked very hard at keeping up his T counts,
20 cell count and his health, to stay in the Navy. He was -
21 - while he was there he was asked to join the Special
22 Forces and went under that training.
23 He spent months in that training, you know,
24 underwater demolition and desert survival part and
25 everything else, and the reason I mention this to you is
6 1 to let you know what kind of physical shape he was in.
2 He went to Desert Storm in August, in the
3 middle of August. He was one of the first people, you
4 know, one of the first groups over there. He was over
5 there early. And he used to call me and let me know how
6 things were going and tell me that he could see the
7 missiles being shot down and he could -- you know, and
8 they had alerts where they put on their gas mask and
9 everything else, and that they had to shower with their
10 shoes on and he would have a foot fungus and things like
12 You know, he would call every few days because
13 basically he was bored, waiting for the war to start. He
14 was -- as I said, he was a yeoman in the Navy, stationed
15 with the Marines at Camp Pendleton on the hover landing
17 And when the war started, they made him a bow
18 gunner on the hover landing craft.
19 He was part of the amphibious landing that went
20 on in Kuwait City, and while in Kuwait City the Marines
21 were clearing the mines and he saw a public telephone and
22 called me from the war to tell me that he was okay at
23 that time, and that he could see the oil wells burning,
24 and that when the wind shifted the smoke was real thick
25 and they had to put on their masks.
7 1 After the war he went back to Camp Pendleton.
2 I believe he came back in June and went back to Camp
3 Pendleton. At that time he went right back to the base.
4 He didn't get to come home on leave.
5 He came home on leave in July of that year, and
6 at that time he became ill. He started running a
7 temperature and he broke out in a red rash of spots,
8 almost like measles except the rash was a brighter red
9 and the spots seem to just look different.
10 He went to a local doctor who gave how much
11 something, I suppose for the temperature and stuff, and
12 told him he really didn't know what it was.
13 And my son was pretty sick because he spent
14 most of his leave in bed at home, which as soon as he
15 felt better, he immediately wanted to go visit his
16 friends and everything else.
17 Then after that he went back to Camp Pendleton.
18 Then in November he was stationed at the Pentagon in
19 Washington, D.C. He flew through and visited us for a
20 few hours on the way to Washington, D.C., and he was
21 fine. He was in fine health and everything else.
22 On Christmas night, 1991, he called from the
23 Navy Hospital at Bethesda, Maryland, to say that he was
24 having some problems and that there was fluid around his
25 heart, and that they were going to do some tests and
8 1 things like this, but not to worry, he'd be okay.
2 And so apparently they removed the fluid from
3 around his heart and he told me not to bother to come to
4 Washington, he would be checking out of the hospital in a
5 couple of days, which he did. He checked out of the
6 hospital in a couple of days.
7 A few weeks later he's having trouble breathing
8 again, and he's back in the hospital. And he gets --
9 they do more fluid -- remove more fluid, run more tests,
10 and he tells me, you know, I'll be fine, don't bother to
11 come, I'll be okay.
12 So a few more weeks, he's back in the hospital
13 again, the same thing. I go to see him then, and spent
14 some time with him, and about two days after I get there,
15 they discharge him again, but the whole time I'm there
16 there's all kinds of doctors seeing him.
17 There's HIV doctors seeing him. There's lung
18 doctors and there's this part -- every part of his body -
19 - there was three and four doctors. I mean, they came
20 all day looking at him, all of them shaking their heads,
21 not having any answers. More and more tests, biopsies
22 done on his lungs, this and that and the other.
23 No one had any answers. They didn't know if it
24 was a fungus that was in his lungs, and if it was a
25 fungus I was told they had to know what kind of fungus
9 1 treat it.
2 They did not know what was wrong with him.
3 They discharged him and I went home with him to his
4 apartment and watched his regimen of how he conducted
5 himself every day.
6 He woke up. He lifted weights. He walked and
7 he ran. He -- since he was HIV positive, he explained to
8 me that you needed to wash your food. You needed to make
9 sure everything was thoroughly cooked. You didn't eat in
10 restaurants like you used to.
11 He was so fanatical about his health and he was
12 in such good physical condition, the best condition I had
13 ever seen him in, as far as muscular, looking good, and
14 in fine shape.
15 I returned home and he called me one day and
16 said he was back in the hospital at Bethesda, and it was
17 the same old problems, except now that they had a new
18 treatment that they wanted to try him at the National
19 Institute of Health, and he was being transferred across
20 the street to the National Institute of Health, to try
21 this new treatment, which he volunteered for.
22 And he told me -- he gave me a phone number
23 that was going to be his room over there. So that
24 evening I thought I'd wait until he got settled in, and
25 give him a call.
10 1 I called and they said that he was not in his
2 room, that he was in the intensive care, and that the
3 family better get there quick. I don't really -- I can't
4 remember how long we were there, but still it was more
5 and more doctors.
6 Now he had three and four doctors for every
7 part of his body, but they're all different doctors.
8 Plus the doctors from Bethesda come over to see him, the
9 same doctors that he had before. No one has any answers.
10 They put him on a respirator, which he didn't
11 want, but I talked him into it. And they said that his T
12 count came back after the treatment, that the treatment
13 was working wonderful, but he was dying.
14 His lungs weren't working. All I can say is
15 that I think my son would be alive today if he hadn't of
16 gone to that war. No one had any answers. I don't have
17 any answers. I hope you find some answers and can help
18 these people that are still sick.
19 That's all.
20 DR. HAMBURG: Thank you very much. We also
21 appreciate you took the time and the trouble to prepare a
22 careful statement, which we will study and try to learn
23 from it.
24 Do you feel you want to answer a few questions?
25 MS. KUMLER: Yes, sir.
11 1 DR. HAMBURG: We appreciate that. I know it's
2 very difficult but it is awfully important, obviously.
3 Who would like to ask questions?
4 MS. KUMLER: Yes, sir.
5 MR. CASSELLS: What was your son's job in the
6 Gulf War?
7 MS. KUMLER: He was the bow gunner on one of
8 the hover landing craft with the Fifth Marine Division.
9 They stayed right outside of Dhahran or something,
10 however you say it, with the Marines, and he said the
11 conditions were not too wonderful, living with sand
12 fleas, scorpions, and things like that, and somehow
13 diesel fuel got mixed with their water one day and the
14 showers were not too wonderful, but you know, it wasn't
15 all that bad, he said, you know.
16 MR. CASSELLS: He didn't speak of any specific
17 exposure that --
18 MS. KUMLER: No, other than the fact that he
19 saw the missiles and he saw them being shot down, and
20 then they had tests to put on their gas masks and stuff.
21 I don't know, some alarm would go or something, that they
22 would put on their mask and stuff like that, but that's,
23 you know, all I know is what he told me on the phone. I
24 don't know other than that.
25 DR. LASHOF: Was he in actual combat at all
12 1 where he was --
2 MS. KUMLER: Well, they went to three islands
3 he told me. Two islands were deserted and the third
4 island there were like 1500 soldiers who gave up. They
5 threw down their guns and just put their hands up and
6 gave up, as they approached them, and they took those
7 people as prisoners.
8 And then they went into the City of Kuwait
9 where they removed the minds and stuff, so when he called
10 me, he called me from a bombed out hotel. There was a
11 phone standing there and he was just trying to see if it
12 worked and called me and said hi, I'm at the war, you
14 DR. LASHOF: Was that the only time he was
15 overseas, I mean, in the Gulf War?
16 MS. KUMLER: No. I noted there he was in Cuba,
17 he was in Iran on other tour duties. Yes, he was other
19 DR. LASHOF: But not in combat?
20 MS. KUMLER: Not in combat, no.
21 DR. HAMBURG: Other questions? Did your son
22 ever mention exposure to radioactive material at all?
23 MS. KUMLER: No. No, not that I know of. He
24 never mentioned it to me. A lot of things he did over
25 the years were like security sensitive things, so he
13 1 could not tell me some things.
2 Something happened in Cuba once but I don't
3 know what. All I know is that he was in Cuba, something
4 happened, and he had to go to Washington for a hearing,
5 but he was not allowed to tell me what that was about.
6 DR. HAMBURG: Any other -- thank you very much
7 for appearing.
8 MS. KUMLER: I just want you to know that he
9 was a real live person, you know, not some number or not
10 some file. He -- we miss him and I think that it had not
11 been for this war, he would be here. And the horrible
12 part was praying that he made it through the war, and
13 thank God he came home okay, and then a few months later
14 he died. I could almost handle it if he had been shot.
15 I know that sounds stupid, but I think I could have
16 handled it better.
17 DR. HAMBURG: No, it doesn't sound stupid at
18 all. We understand what you mean. What you said toward
19 the end of your remarks I think is very fundamental, that
20 is, learn everything we possibly can from his experience
21 and others like that, so it can help a lot of people in
22 the future. That's what we're trying to do.
23 Thank you very much.
24 MS. KUMLER: Okay.
25 DR. HAMBURG: All right. Next speaker is from
14 1 Cincinnati, Lisa Dunster.
2 MS. DUNSTER: Again, I welcome you here and I
3 thank you for coming. I'm a veteran of the Gulf War. I
4 served as a specialist in the Ohio Army National Guard
5 and was activated in November of 1990, left for Saudi
6 Arabia the day after Christmas in 1990, and returned home
7 in May of 1991.
8 I didn't really have much prepared because I
9 didn't learn about this until the 11 o'clock news last
10 night. However, I think that what I have to say will be
11 fairly brief, but yet I'm concerned as a veteran and also
12 because I think there are a lot of things that need to be
13 addressed and haven't been concerned or stated.
14 Since I have been home I have experienced some
15 severe muscle problems, primarily with my legs, and
16 doctors have not been able to tell me exactly what the
17 cause is.
18 One doctor initially told me that it was
19 because I was getting older and I was 25 when he gave me
20 this information. I worked out at the "Y" and I was a
21 program director for the YMCA, but when I came home
22 worked out roughly five days a week and was probably in
23 the best physical shape I had been in in years.
24 So I was not satisfied with that response. In
25 order to get another opinion I had to switch doctors with
1 my insurance company. I did so. He did discover a major
2 chemical imbalance in my system. My potassium level was
3 very low. Calcium levels, high. Sodium levels high.
4 I'm not a salt person. I don't salt my foods.
5 His concern with this was that possibly my
6 system didn't readjust when I came home, but again it's
7 nothing that he could confirm for me.
8 What they did was they put me on a vitamin
9 regimen at that time to try to get my levels up to a
10 normal level, and I was asked not to do any sports. I'm
11 a softball player. I was asked to refrain from doing
12 that for a season and to stick to walking until my
13 potassium level got higher, because he was concerned for
14 my heart.
15 I can't say for sure a hundred percent that
16 this was the cause, caused from my tour of duty in Desert
17 Storm, particularly in Northern Saudi Arabia. We were
18 approximately ten miles from Iraq, probably 30 miles or
19 so from Kuwait.
20 So I guess my concern as a veteran is I don't
21 expect you to be able to tell me tomorrow or next week or
22 whatever that that indeed in a cause, but it is a concern
23 that was discovered right when I came home and the muscle
24 problems were so bad, in fact, I was admitted to the
25 hospital and from playing a softball game, all of my
1 quadriceps completely locked up into a permanent
2 contracted position.
3 They gave me muscle relaxers in both of my hips
4 and told me at the hospital they had no idea what was
5 wrong and sent me home and told me to go to my family
7 I have since told you the responses that I
8 received there. My other concern as a veteran is as a
9 female and being 30 years old and being married and
10 considering having a family, I have also read some
11 reports and some things in magazines that have shown that
12 there have been reproductive problems and problems with
13 children who have been born to veterans of Desert Storm.
14 Most of the problems that I have read, of
15 course, have involved the father as being the veteran and
16 I'm not positive how many studies have been done of
17 female veterans who have given birth to children since
18 they have come home, but that is a concern that I have
19 and that is a great risk that I myself feel I either
20 choose to take or not to take based on what I'm able to
21 read and the information that I'm able to give.
22 So I just ask that you make this process as
23 speedy as you can. I know that that's your desire as
24 well, and to make the information as inclusive as you
25 can, because it will help in making such a decision.
17 1 Thank you.
2 DR. HAMBURG: Thank you very much. We
3 appreciate your doing this on short notice. Would you
4 answer a few questions?
5 MS. DUNSTER: That's fine.
6 DR. HAMBURG: Can you tell us a bit more about
7 your experience during the Gulf War, when you were there,
8 what you did and what -- if you had any difficulty and so
10 MS. DUNSTER: Sure. I was in the water
11 purification unit. We were located next to a very small
12 village. I don't even know the name of the village right
13 off -- what was considered the suicide strip.
14 The village maybe had 50 or 60 residents. They
15 were about a mile and a half from our base camp and we
16 actually took one of their water facilities and took the
17 water from their tower and purified it for drinkability,
18 because obviously there were still some things in the
19 water that we weren't able to process.
20 So I served in a mechanic in that unit. While
21 we were there we had numerous -- I can think of
22 specifically two different occasions where the chemical
23 detectors did go off. We went to full gear a total of
24 three times, and sat in our bunkers one night for
25 approximately I would say seven to eight hours.
18 1 I did keep a journal the whole time I was
2 there, so I did try to write those things down as I was
3 there, and again, I had the same vaccines that I imagine
4 most other soldiers who are in the desert had, Amthrax
5 (phonetic), the number of vaccines that we went through
6 here before we left -- Amthrax (phonetic) was given to us
7 there in the field. And again, we had the PT tablets. I
8 don't know how to pronounce it exactly. I do have that
9 written down as well. I think you know what I'm speaking
11 We were ordered to take those. It was not
12 optional. We were threatened with Article 15 if we did
13 not take the pills, and it was indeed such a threat as
14 they would stand in front of them, you would take the
15 pill, and they would check your mouth to be sure that you
16 swallowed it.
17 After taking the first PT tablet, it was
18 approximately 12:45 or 1:00 in the morning. I had just
19 come off of guard duty. We were ordered to take them.
20 They woke everyone up, made us take them.
21 My heart raced for a number of hours. I had
22 cold chills. We were told to go back to sleep. There
23 was no way in heck I was going back to sleep with the way
24 that my body was reacting.
25 All of the females in my unit -- there were 12
19 1 of us -- immediately had another menstrual cycle, even
2 some who had just completed their menstrual cycle
3 previously. Men had blood in their urine, some reactions
4 that made us all a little nervous.
5 I took the pill a total of three times, after
6 which they quit watching us take it, and when they
7 ordered us to take it, I would pop it into the sand,
8 because I was not comfortable with the reaction that my
9 body was having to the drug, and I did ask them what
10 types of conditions people had that they should not take
11 this drug, because I had an innocent heart murmur. They
12 couldn't tell me.
13 We had people in the unit, older gentlemen who
14 were on heart medication. There was no warning given to
15 them as to if this medication would interact with their
16 heart medication.
17 So it was just kind of frustrating. They felt
18 kind of in the dark, but at the same time, they thought
19 if it was supposed to save their life, what options do
20 you really have anymore?
21 So that's basically I guess my experience.
22 DR. HAMBURG: Thank you. Other questions?
23 Okay, Thank you very much. Shannon Gentile.
24 MS. GENTILE: I'm the girl friend of Tony
25 Carpenter, a Gulf War vet. She was very sick and
20 1 disabled. He can't go to work. It takes everything he
2 has to get up in the morning.
3 I'm very concerned at all the information I
4 have found. I know ten to twelve hundred soldiers have
5 already died, and these agents, the government agents
6 knew about what Iraq had. It was made here in America.
7 There has been an organism identified called
8 mycoplasma climidius by Dr. Nicholson in Texas. The
9 treatment, there's an antibiotic that can be taken but
10 the vets are denied to be tested for this.
11 I have asked VA for Tony to be tested and they
12 say, oh, we haven't found anything. There is no such
13 thing, and they say it's all psychological with them.
14 Antidepressants -- and these antidepressants cause the
15 same side effects that he is having.
16 I understand that in 1972 that the United
17 States and Iraq agreed that they would not experiments
18 make or sell or use any biological chemical warfare, but
19 I understand that they admitted now that we were war
20 crime charges and penalties against them.
21 But it's time for them to admit what they did.
22 I guess if they don't, thousands of Americans are going
23 to die that are involved with the military, because it's
24 transmittable, sexually and by casual contact.
25 The Nicholsons believe that a lot of it can
21 1 linger up to seven years into their garb that they
2 brought home, and that's how a lot of family members can
3 get sick, by just being in contact with their ponchos of
4 their duffle bags, and it's transmitted.
5 That's how soldiers are all over that were in
6 the Gulf War got it. I mean, that compounded the rash,
7 because their bunk or their pals may have been in the
8 Gulf War.
9 I have plenty of friends that are sick. And I
10 just want them to acknowledge it and start treatment.
11 There is an antibiotic that can help them that can't cure
12 the previous damage that was done, that they can start
13 giving them help.
14 I'm very concerned because I'm involved that
15 I'm going to have problems having a child. I was sick
16 for six years and told I was never ever going to have
17 children, but now I'm better and now I am faced with the
18 fact that my child can be deformed, stillborn, or have
19 other illnesses when it's born.
20 I just don't think it's right that they
21 violated my rights as an American. I wasn't in the
22 military but yet I was violated. And they're not telling
23 the truth.
24 The thing is that the soldiers have fought for
25 us and they have a real right to be treated with respect.
22 1 They risked their lives. They didn't want to come home
2 and die because the military and the government is
3 ignorant, but they did to sell something like this to
5 I just want you to find out and the courage,
6 the truth, for all America, because it's going to be an
7 epidemic if not treated now and I feel for anybody -- I
8 feel bad for everybody that is sick and has died. My
9 sympathy goes out to the families because I know the fear
10 that they have in what's going to happen.
11 That's really what I wanted to say, and just
12 enter the facts about military that affects everyone in
14 DR. HAMBURG: Thank you very much. What you
15 said is something we very much believe and this is not a
16 problem that just affects the veterans. It affects the
17 whole country. Is it okay to answer some questions?
18 MS. GENTILE: Yes.
19 DR. HAMBURG: Who would like -- I think we
20 don't have any questions. Thank you very much. We
21 appreciate your coming and giving us your message.
22 The next speaker is Brigham Young, a Gulf War
24 MR. YOUNG: Good morning, American, or whoever
25 at this time. My name is Brigham Young. At this time
23 1 that I was at an advisory committee meeting this morning.
2 Okay. I've been waiting on an opportunity for
3 a long time, about four years, to be able to stand up and
4 tell people what's going on with this Gulf War thing.
5 I've been hospitalized 27 times over the past
6 three and a half years for four or five weeks at a time.
7 For the first nine stays in the hospital have no
8 etiology. That means there's no known cause, but for my
9 organs in my body to be 12 years in military service
10 healthy, to be sick.
11 My kidneys are messing up. My pancreas doesn't
12 function. I take a whole page full of medications on a
13 daily basis.
14 Okay. When I first came home I was told I
15 couldn't say where I been and what I done and what I
16 seen, you know, that people should have a security
17 clearance, you know, in order for them to hear it,
18 whatever it was I had to say.
19 Right now I don't know if I'm saying too much.
20 Any questions you want to ask me, I can answer them for
21 you. I will -- I don't know where I stand with this, if
22 I'm going to be in any type of trouble, but everything
23 the people said, you know, is true.
24 I've had -- when I first came home they kept
25 telling me, treating me like a common street person. I
24 1 was chased away from the hospital by security because I
2 didn't have identification in my pocket, 214. They
3 treated me like a common street person. They stereotyped
4 me just like the average black person.
5 You know, and there's a lot of things -- I
6 don't think this one day could answer or could tell you
7 all the things that I have to tell you today. I hope you
8 get back to me, you know. I hope you listen, Jessie
9 Brown. I missed you when you was at the hospital on
10 August the 19th a few years back, you know.
11 If anybody is watching on the news, the
12 director of the hospital, Dr. Rozell, chief of medicine,
13 and all the people over there, Dr. Braunbowski, the
14 people who want me to be established as somebody crazy,
15 somebody out of my mind, want to run me up to the eighth
16 floor, when I want to come before these people, what's
17 been going on over there at the hospital.
18 I been through it, three and a half years of
19 it. They don't have the program. They don't know what
20 to do at the hospitals. Everything was research and
21 study in the beginning, okay.
22 These people come here with these problems.
23 They don't know how to handle it. I got a whole lot of
25 I was a quartermaster over there. I handled
25 1 all class one combined ammunition over there, I mean
2 anything from bulk fuel to ammunition, to clothing issue,
3 to graves registration, to whatever you could -- any
4 mission that you could think of to what happened over
5 there in the gulf. I was there and part of it.
6 General Gus Pargonis if you're out there
7 listening, I worked for you over there and you know what
8 we did -- and they treating us like crap out there, man,
9 and it's not fun. I have felt lower than anything since I
10 been home.
11 I was forced out here. The military was my
12 first love. I feel like they turned their back on me and
13 a whole lot of other people. Not just Gulf War era vets,
14 Vietnam era vets, Korean war era vets and these people
15 don't know what to do.
16 These people are getting tired. It's four years
17 later and if there was not the things like that --
18 somebody is still thinking about this, thank God. My
19 prayers have been answered. Somebody still cares about
20 what happens to them guys. We've got guys over there
21 now. They never figured out what happened from the first
22 time, okay.
23 Just like I say, I was a healthy person. I
24 look like a healthy person standing up here, but I'm not.
25 I'm up out of my bed. I'm standing here on reserved
26 1 energy. Okay, I take medicines like Cryon (phonetic). I
2 have digestive problems. What she said about the nerve
3 agents that they made you take, but it's true. I mean,
4 people had abdominal pains and nausea and vomiting and
5 they told us that it was too hot to eat. You couldn't
6 consume meals and stuff like that. When you're in the
7 military, you don't have time to stop.
8 It's just like that money over there in
9 finance, they didn't have time but if a dollar ain't
10 important, they didn't have time to keep records for
11 dollars. You ain't going to find these medical records
12 when you see boys throwing up and having these problems
13 constantly, you know.
14 A lot of this stuff ain't there, but these
15 people came back up and you look at these hospitals and
16 posts and military base, Air Force, whatever, maybe
17 you'll see that these people had a lot of these symptoms
18 when they came back to the country. Nobody didn't just
19 know what to do, you know.
20 You need for this country to find out and if
21 you don't know. Be professional enough to say you don't
22 know what it is, but it is something going on. I'm
23 living proof.
24 My name is Brigham Young. I'm a resident here
25 in Cincinnati and if you've got any questions that you
27 1 want to ask me, feel free to ask me.
2 DR. HAMBURG: Thank you very much, Mr. Young.
3 Any questions?
4 DR. LASHOF: Can you tell me just what you did
5 in the Gulf War, where you were and what you were exposed
7 MR. YOUNG: I'm a quartermaster, okay. I
8 handle all class one through nine missions. That's from
9 a shoestring to anything from ammunition, to boots, the
10 clothing issued, to -- I was with the 251st Services
11 Support Company, and we flew into a place called Dahraan.
12 It's was a port, the main port.
13 We then went from there to a place called KKMC,
14 King Khalid Military City, which is south of Iraq. We
15 set up a bulk fuel site. We had two or three hundred
16 thousand gallon fuel bladders where we had distributed
17 fuel to over 58 different companies that we were direct
18 services support for.
19 What they said about that water not being able
20 to be purified in the beginning, our shower waters and
21 stuff were transported in fuel trucks, which we had to
22 decontaminate and clean out whatever, which in a
23 situation like that when -- the place if you ask me, it
24 was a dump site.
25 When we set up our log bases, we had trash
1 already under the ground. This place ain't nothing --
2 nothing grow over here. As far as your eyes could see,
3 it ain't nothing but sand and sky. Grass don't grow.
4 Trees don't grow. You see no cattle farms.
5 I was stationed at KKMC. I delivered fuel to
6 a place called Hofhut. I went to Bahrain and all of them
7 down that highway. Pieces of equipment that came in and
8 out of that country. Whether it was army, navy, marine
9 corps, whatever. They didn't come in and out of the
10 country without being handled by myself and people like
11 me. That stuff had to be decontaminated.
12 We had to set up stations to decontaminate
13 every piece of equipment before it left where it was at.
14 When it got to port it had to wrapped and decontaminated
15 before it left that company to come back home, we had to
16 decontaminate it again before we put it back on the
18 Okay. The work conditions -- what you saw on
19 TV in America ain't what the conditions -- what the
20 soldiers were under. You know, I mean, we had a lot of
21 around the clock working days. We -- talk about guys
22 covers with sand. Guys that don't get baths.
23 You have to -- I don't know if I can say this -
24 - just like what the lady said about people having
25 problems with children being born. I have experienced
1 that, you know, and I can't really speak on the matter
2 because of my situation at home -- my family, the way
3 things are going now, but if you want to ask me something
4 about that after this, I got all the proof you want in my
6 But any information that you want, as far as
7 what happened, I handled bulk fuel, water purification,
8 field laundry and bath for those people over there, you
10 I was direct support for all the medical units.
11 I made sure they had ice and everything they needed for
12 the medications, anything -- anything that you could
13 imagine that those soldiers needed was my mission, from
14 weapons to ammunition, to fuel, to whatever.
15 DR. HAMBURG: Thanks very much. Any other
17 MR. CROSS: Mr. Young, you were discharged
18 after 12 years, you said?
19 MR. YOUNG: Well, I chose to be, let me tell
20 you, after 12 years.
21 MR. CROSS: Are you under any disability at
22 this time?
23 MR. YOUNG: Well, it took them four years to
24 get me what they call a non-service connected disability,
25 okay. When I came home -- before I went over to that
30 1 country, I stayed over there in that country 11 months,
2 mind you, and coming back home I stayed sick for 11
3 months straight where I was in and out of Cincinnati VA
4 Hospital for something unknown.
5 Okay. Well, it's not my fault that when I
6 first went into the hospital, everything was under --
7 they didn't even have a program the first 11 months.
8 They never had -- they didn't even have a research and
9 study program for Persian Gulf people, and they just
10 treated me like nobody, like nothing.
11 I had parasites in my stomach and in my large
12 intestine when I first came home that didn't come from
13 this country. Okay. And from that my stomach is
14 sensitive. My large intestine -- my pancreas doesn't
15 work and it's because of that. My liver is not
16 functioning just because of that.
17 Today I have to take insulin. I'm diabetic
18 because of what those parasites did to my stomach and did
19 to my pancreas and my liver, okay.
20 The skin that she's telling you about, rashes
21 like this stuff running up the back of my leg. They had
22 to cut it off, shave it off, like up here in my thigh,
23 thigh area, you know, the stuff that you see that's
24 growing up my back and up the crack of my butt, it's been
25 all up my neck and stuff like that, you know, that I
31 1 didn't have before I went there.
2 You know, those hot flashes and stuff, those
3 mood swings like I sweating in bed, me and my wife done
4 bought two beds. I have nightmares, you know, stuff that
5 they try to pretend, that they say is all in my mind.
6 But I been in the hospital 27 stays, four or
7 five weeks at a time, okay, with all the labs you want to
8 see. I'll release it to the world to see. You know,
9 been a lot of things looked over, okay, a lot of follow-
10 up, treatment that these people supposed to get, they
11 ain't getting, I ain't getting.
12 I had a Persian Gulf social worker that they
13 put out there for me just to pacify me when I first came
14 home, and I had him for six months, maybe a year, and
15 then his assignment was up. He was gone and it's two and
16 a half, three years later, and they haven't put nobody in
17 that position for me to go talk to, tell them how I feel
18 when I can't pay my bills or why I don't have none of the
19 trophies that I collected or why I'm not in the military
20 no more, because my kids couldn't eat those trophies,
21 because they want to look over something that's real,
22 that's real. I'm living proof that it's real. I'm going
23 to tell the world that it's real.
24 I might be in some trouble, you know what I'm
25 saying -- certain things people can't say for the press,
32 1 to the public, they suppose to have treated me, but
2 anything you want to know, you can come ask me. I ain't
3 afraid to tell it no more. You know, I don't have
4 nothing to live for.
5 My grandmother passed away when I was over
6 there. I was in out of that country -- my best friend
7 the world. It killed her. Both my parents aren't here
8 no more. They say I'm angry because of that. I'm not
9 angry because -- I'm angry because I couldn't do the
10 things that I should have been able to do with my parents
11 before it was time for them to leave here, you know,
12 because I was sick or hospitalized and my mother spent
13 her last day worrying about me and how I was going to
14 make it and how my kids was going to make it.
15 My incentive is this. The military was my
16 first love. Mine, Brigham Young, not my wife and kids.
17 My wife and kids have to live through this and they
18 suffer with this through me every day.
19 My kids and my wife, they need therapy because
20 of me. You know, I went over there to die for my country
21 and whatever it was they thought that they was believing
22 in. That's my family. That wasn't my wife and kids --
23 I'll die and go to hell for them. They didn't ask for it
24 to be -- to live in the world and be treated the way
25 they're being treated, you know.
33 1 I'm diabetic. I can't even -- I don't -- I
2 can't even buy life insurance for myself and I have
3 people to help me. What are my children supposed to do?
4 Will they be able to go to college, you know? Won't
5 nobody hire me. You know, I mean, with the type of
6 medication that I'm on and the treatment of treatment
7 that I'm on. I've been to every veteran job fair. I've
8 been down there to work with Paul Rouson of the Veterans
9 Service Commission, the Vet Council, Bernine Evans and
10 all those guys, Jim Maxwell, Chappie King.
11 I've tried everything to be employed and I
12 can't be employed. I have to make my own way. My kids
13 didn't ask for this. I served this country and what's
14 happening to me, I could deal with that, you know, but
15 just like what they said about -- there's a lot of things
16 being looked over where it's a lot of things being looked
17 over. And it's time to fix those things, you know.
18 DR. HAMBURG: Thank you very much. We hear you
19 and get your message and appreciate your coming here on
20 short notice. Thank you very much.
21 MR. YOUNG: Okay.
22 DR. HAMBURG: Now we have other veterans, Ron
23 Setser and Kaye Setser from Oxford, Ohio, please.
24 MR. SETSER: My name is Ron Setser and I want
25 to thank you for the opportunity to come here today and
34 1 address this committee, to voice some of my concerns and
2 comments about the treatment of Gulf War veterans, with
3 illness which surfaced after they came home from their
4 participation in the Gulf War.
5 My wife was unable to be here today because we
6 have been dealing with this problem for more than four
7 years now, and she is emotionally not able to cope with
8 something like this.
9 I understand the purpose for this meeting is to
10 discuss the role of stress and these health problems.
11 There has already been much said about the stress these
12 veterans endured during their participation in Desert
13 Shield and Desert Storm.
14 However, the stress as I believe to be the most
15 damaging to these veterans are those they have faced and
16 still continue to face since they returned home and
17 became ill.
18 These stresses are created by our Department of
19 Defense, by the Veterans Administration, and the American
20 Government, when these veterans try to get help with
21 their medical problems.
22 The reason we believe this is that my son Jeff
23 is one of the more than 30,000 veterans suffering from
24 Gulf War symptoms. These young men and women have
25 suffered serious, sometimes fatal health problems since
35 1 returning from the Gulf War.
2 It is important to realize that in spite of the
3 good intentions and laudable goals of groups such as this
4 committee, there are still many unseen, unrecognized, and
5 almost insurmountable road blocks which prevent many of
6 these people from getting appropriate treatment and the
7 care they deserve.
8 Most have tried for more than four years to get
9 medical and financial help from the government they
10 served so well. They are still trying. They are still
11 dying, and are still getting no help.
12 I'd like to tell this committee about some of
13 the road blocks my son and I have run into while trying
14 to get him medical care through the VA.
15 The most insidious of these is the basic
16 official definition of Gulf War Syndrome. The DOD and
17 the VA state that Gulf War Syndrome is an undiagnosed
18 illness that comes from a single cause.
19 Because the illness has so many different
20 symptoms, and because all who are ill do not have the
21 same symptoms, we have not yet found that single cause,
22 and because some of the symptoms can be identified as
23 illnesses, such as my son's breathing problems are
24 diagnosed as asthma, his extreme and continual lack of
25 energy is defined as chronic fatigue, and the continual
36 1 bone and joint pains have been labeled as arthritis.
2 Therefore, these cannot be part of an
3 undiagnosed illness and, therefore, are not considered
4 Gulf War related and cannot be treated or considered for
5 compensation or disability. This is a catch 22 situation
6 that continued to prevent treatment for many of these
8 Another serious road block is that the VA
9 system, medical system, does not seem to be able to
10 coordinate its many parts and services for the benefit of
11 the patients. For example, an outpatient was given a
12 prescription for medications and an order for a wheel
13 chair by his VA doctor.
14 The patient was told by VA patient services,
15 however, that he could not have the wheel chair because
16 he was not classified as disabled. For that same reason
17 the VA pharmacy made this patient pay for his medication.
18 Also of great concern is the fact that the VA
19 and the DOD released statistical conclusions about the
20 numbers of veterans affected by these medical problems
21 and the extent of their illnesses, without any
22 explanation about the way in which these numbers were
24 As a statistician, I truly question whether
25 these statistics do in fact accurately reflect the health
37 1 problems these veterans continue to face.
2 I also wonder why the military, which has a
3 real incentive not to find a cause of these problems,
4 less they be held in some way accountable for them,
5 designed and agreed to the protocol, the specific battery
6 of medical tests which would be used to diagnose the
7 illness of the sick veterans.
8 I also wonder why this protocol does not
9 include any of the medical tests identified and
10 recommended in the report of Senator Donald Regal, Jr.,
11 and Alphonse Di Amato, called the U.S. Chemical and
12 Biological Warfare Related Dual Use Experts to Iraq and
13 their possible impact on the health consequences of the
14 Persian Gulf War, issued more than two years ago on May
15 the 25th, 1994.
16 Further, I wonder why I was told by the VA
17 Hospital in Washington, D.C. that none of these tests
18 could or would be run on my son, even though we had
19 specifically requested them and they could not diagnose
20 his problems using the protocol.
21 Yet the Veterans Administration, which is
22 responsible for the medical treatment of and disability
23 payments to the sick veterans, is also the organization
24 responsible for the medical testing, diagnosis and
25 determining of disability for these sick veterans is, I
38 1 believe, an unacceptable conflict of interest and should
2 be somehow corrected.
3 It is impossible to deal with an organization
4 which does not want to deal with the problem. Whether
5 there is a single cause for these health problems,
6 whether the government, the VA or military establishments
7 may be blamed for these health problems, or whether these
8 organizations don't want to deal with these health
9 problems, is of secondary concern.
10 That these young veterans are sick and dying
11 without any real help is of utmost concern. I believe it
12 is unconscionable that these sick veterans who fought so
13 bravely for their country now have to fight that country
14 for their own survival.
15 In conclusion I offer a quote from one of these
16 sick veterans who typifies what I believe are the
17 sentiments of many. I wish I could apply to the United
18 States for political asylum because I really feel like my
19 government I at war with me and not protecting my
20 interests. Thank you.
21 DR. HAMBURG: Thank you very much for carefully
22 preparing those statements. Are there questions?
23 MR. CASSELLS: Can you tell us where your son
24 served in the Gulf?
25 MR. SETSER: I can tell you basically where he
39 1 served. He would like to have come here today to tell
2 you himself, but he is too ill to travel from Georgia
3 here. He is so ill that he has not been able to work for
4 more than four years.
5 He was in the 24th Infantry Division. There
6 was a group that was essentially in Iraq from the time
7 they landed at Saudi until long after the war was over.
8 He is a helicopter electrician and as such was required
9 to go on every flight that his helicopter took and
10 flights of other helicopters that he was also responsible
12 At one point he -- and it's one of the most
13 awful things I think that he has to remember -- is that
14 at one point they had to drive up to famous road that we
15 saw in the news areas where the trucks and cars and all
16 were bombed out, and there were three people in this Jeep
17 and two of them had to get out and physically pull bodies
18 out of the way on this road to let the Jeep get through.
19 There's also some additional information that
20 has come out recently from Senator Di Amato which links
21 very closely the destruction that we performed on some
22 the chemical storage -- chemical and biological storage
23 areas, combined with weather maps and patterns for dates
24 that show very clearly that many of our people were
25 exposed to some of these things.
40 1 DR. HAMBURG: Are there questions?
2 DOCTOR. LASHOF: How soon after his return did
3 he become ill and what are the major symptoms he now has?
4 MR. SETSER: Okay. He came home from Iraq on
5 March the 27th, his birthday. He stayed in the military
6 -- he had been in the military for nine years. He stayed
7 in the military until April, and he elected to separate
8 from the service at that point.
9 No indication of illness. The day after he
10 finished his military time, he began his new job at the
11 company in Savannah that works on military helicopters.
12 It's an aviation company.
13 Everything seemed to be fine. He tried the
14 American dream, bought a house for his wife and his two
15 sons, worked steadily and well for about an additional
16 four months.
17 He suddenly had to be hospitalized with
18 breathing and lung problems. He was in the hospital for
19 about a week. It took about a month for it to become
20 cleared up enough for him to go back to work. He worked
21 to finish another month, had the same kind of an
22 incident, and has never recovered.
23 So it was I would say four to six months after
24 he came back.
25 DR. HAMBURG: Thank you very much, Mr. Setser.
41 1 Appreciate your being here. I'm not quite certain about
2 Tony Carpenter. Did Tony Carpenter want to speak?
3 MR. CARPENTER: I'm Tony Carpenter. I served
4 in the military for three years. And before that time I
5 was an athlete. I went to the military to be all I could
6 be. I was proud of myself as an athlete and in the field
7 of electronics, where I entered the military under
8 electronics, communication specialist.
9 I started with 82nd Airborne Division. I had
10 no problems up until my military career. And then we
11 went over to Saudi and I'd just like to start out with a
12 speech -- I just want to tell you all to start off, this
13 is not just a Gulf War Syndrome to me.
14 It's a veteran -- it's a veterans of every war
15 and any military personnel, even in peace. You see, when
16 I was a child I heard about Hitler and the evil he did,
17 and the experiments in his quest for a super race.
18 And now -- and how the world came together and
19 stopped the man in his man scientist from the intolerable
20 crimes against humanity.
21 Then I heard about Vietnam and the crazy things
22 they had to go through, the experiments and agents and
23 the homecoming.
24 It is so appalling that it was for the most
25 part unbelievable. For no man would go through all that
1 bull and come home to mental abuse by their own and put
2 up with it. And now as I sit here tripping over all the
3 facts and words, the inoculation shots, the events, the
4 destruction, the alarms, and now I'm not just talking
5 about chemical alarms, but biological alarms as well that
6 were never set off with bells or sirens, just straight
7 hard facts.
8 A dead body that we found in the very water, in
9 the reservoir that we drank from. I find myself in the
10 same situation as I did as a child, but on the other side
11 in the appalling unbelievable reality. I find myself
12 upset and angry but at the same time, realizing that all
13 the people that have been saying it's all in my mind
14 never even were there.
15 I start to get mad, because the very ones that
16 are patriotic, that stand and fight and die for your
17 freedom and rights, are being stripped of their own,
18 abused, misused, beaten down and treated like liars from
19 people that are doing what they're told to do by bosses
20 that have been schemed from the beginning.
21 America, a strong and powerful, but blind. How
22 many times must we American citizens get smacked in our
23 face before American takes the blindfold from our eyes
24 and the lies from our ears?
25 That's all I've got to say.
43 1 DR. HAMBURG: Thank you, Mr. Carpenter. Any
3 MR. CARPENTER: I'd like to mention my problems
4 too, as well. The VA, it's pathetic. I've been going
5 there for the last five years. I fought this thing till
6 late '93 I fought it. I tried to work. I didn't know
7 what was wrong with me. I quit drinking. I thought
8 well, maybe that would ease the diarrhea, because I
10 I quit smoking. Well, that didn't stop the
11 coughing, didn't stop my nose bleeds, night sweats.
12 Nothing stopped. The pain in my joints and muscles.
13 I'd like to read to you a list of things they
14 say are Gulf War Syndrome. Aching joints, anxiety,
15 autoimmune like disorders, bleeding gums, blurred vision,
16 breathing problems, cardiac arrhythmia, chemical
17 sensitivities, chest pains, chronic fatigue,
18 concentration loss, depression, diarrhea, dizziness, eye
19 pain, redness and other visual problems, frequent
20 coughing, hair loss, headaches, hives, light sensitivity,
21 loss of balance, muscle spasms, memory loss, nervousness,
22 night sweats, sex problems, skin rashes, stillbirths,
23 stomach pain, upset cramps -- upset stomach, cramps,
24 thyroid problem, urination problem.
25 I had every single one of these problems that I
44 1 could possibly have except for the fact I can't carry a
2 child. I went to the VA not knowing what was wrong with
3 me, before they even told me to go to the Persian Gulf
5 And then the doctor had the gall to tell me,
6 don't have any children, there's something wrong. But
7 no, they're willing to tell me all this stuff, but
8 they're not willing to help me through it.
9 If it wasn't for my mom and people who care,
10 I'd be out on the street right now. And it's our
11 community that is helping us, we don't get any
12 disability. They don't even want to admit there's a
13 problem. It's time to open our eyes.
14 DR. HAMBURG: Thank you very much. We
15 appreciate your coming and telling us this. It's
17 Let's see if there's anyone else in the
18 audience who would like to speak. These are the only
19 speakers that I'm aware of or if someone would like a few
20 minutes, we can do that. Yes. Come up.
21 MS. DUNSTER: One of the things that I did not
22 mention that I found curious when I came back to Fort
23 Knox is that we were all listed on our medical file as
24 having a normal abnormality of the lung, which to me was
25 about an ironic thing to write on the file, because how
45 1 can you have a normal abnormality of the lung?
2 And the reasoning that the doctors gave us was
3 because all of the veterans who were coming back were
4 showing this, which made the abnormality normal.
5 I just did want to state that for the record
6 because I don't know if that's something that you've
7 heard of but I know that I did see it written
8 specifically on my medical file.
9 Thank you.
10 DR. HAMBURG: Thank you. Appreciate very much
11 those of you who have taken the time and trouble and
12 giving your thought and the deep concern to these matters
13 to share them with us. Now we'll take a break. I
14 suggest you come back here shortly, before 11:00, so that
15 we can start promptly at 11:00. Thank you very much.
17 DR. HAMBURG: For those of you who aren't
18 familiar with the committee, we've been having meetings,
19 both for public comment and for scientific and clinical
20 analysis in different parts of the country over the past
21 year or so, and we met about a month ago in Chicago and
22 focused on a different topic.
23 The particular focus for Cincinnati happens to
24 be stress and biology and psychology of stress. It is
25 emerging front in the life sciences. The life sciences
46 1 are very broad and very dynamic these days.
2 They include effective inquiry of everyone
3 involved in the organization, molecules, cells,
4 populations and behavior. All of these have emergent in
5 the past half century, with the end of another war, World
6 War II, the American people saw the immense power of
7 science and technology.
8 For example, in the experience with antibiotics
9 came into widespread use during World War II, and so
10 millions of people set out to support research on an
11 unprecedented scale, especially through the creation of
12 the National Science Foundation and National Institutes
13 of Health.
14 We really forget how little is known of the
15 living organisms then and how little medicine had to
16 offer in diagnosis, treatment or prevention, just about
17 half a century ago. It's a different world now, and yet
18 we are still in the midst of a kind of revolution in --
19 about medical and behavioral science, the sciences of
21 Most of the research is so recent that much
22 more is unknown than known, even though the balance is
23 tilting in the right direction.
24 Today's topic is one of interest and concern to
25 people everywhere, yet most of what we reliability know
47 1 has only been discovered in the past two decades.
2 Stress focuses on ways in which the human
3 organism adapts to very difficult circumstances. This
4 curiosity about stress is lent in many scientific
5 directions, far from its point of origin and it shows how
6 advances in one field can stimulate others, so that today
7 it's a deep rooted field. You have to get many angles
8 and many techniques and many concepts to make sense out
9 of these problems.
10 The body's response to the stress involves many
11 different systems, probably more than we even realize
12 now, but a great deal of work is going on with the
13 hormones, the cardiovascular system, heart, lung
14 circulation, and the immune system, the defense against
15 agents that invade the body, and altogether rapid
16 advances are being made in biochemical, anatomic,
17 physiological, pharmacological, pathological and the
18 nerve system.
19 Only a few decades ago this was almost entirely
20 a great void, an unknown, and much has been filled in in
21 a very short time, but we don't want to promise too much.
22 We are trying to work at the frontiers of knowledge in
23 this field. It is a very dynamic field, and yet until
24 recently there were very few major laboratories engaged
25 in and the amount of support for it was very limited, so
48 1 that there are great unknowns.
2 But we will try today and in the time
3 subsequent to this event to make as much sense out of it
4 as we possibly can. There was an earlier briefing for
5 the staff, a full day occasion in which leading
6 researchers came in and met with the staff, in order to
7 fill them in and to prepare for this meeting.
8 Obviously in a few hours we can only get an
9 overview, but I think it will be a very stimulating and
10 useful one.
11 So we start with a very broad overview of the
12 field, provided by one of the leaders, one of the people
13 who has made major substantive contributions, Dr. Bruce
14 McEwen of the Rockefeller University.
15 DR. McEWEN: Thank you very much. Ladies and
16 gentlemen, I come to you with 30 years of experience in
17 the field that's now called neuroscience, studying the
18 relationship between circulating hormones, especially
19 circulating stress hormones, in the brain.
20 I haven't spoken to a group such as this
21 before, and I must say I come with great sympathy for the
22 experiences of the veterans that I've had a chance to
23 hear this morning.
24 I also come with a great sense of admiration
25 for your Chair, who I should point out is widely
49 1 acknowledged as the father of the field of stress
2 research. So the comments that he made in introducing it
3 reflect his deep and long-lasting understanding and
4 interest in this area.
5 I'm going to show some slides. If we could
6 have the first slide, please. And I'm sorry that perhaps
7 those of you in the back can't see it too well, because
8 I'm standing in the way. I don't know if you want to
9 move over in that direction.
10 I want to put my remarks in a perspective of
11 the life cycle, and make the point, both the beginning
12 and the end, that what happens in adult life and
13 adolescence and what happens in the aging process, all
14 are in part reflections of events that take place early
15 in life, because as the developing fetus is experiencing
16 events such as stress to the mother and to itself through
17 malnutrition, or perhaps alcohol or drug abuse, there are
18 consequences that include things such as low birth
20 There is also parental neglect, buffering by
21 the parents in normal situations, development perhaps of
22 learning disabilities affecting the ability to achieve in
23 school, leading later on to such things as anti-social
24 behavior, substance abuse, and then we probably have a
25 substantial genetic base, such as schizophrenia and
50 1 perhaps depressive illness can be triggered and
2 sensitized by early experiences.
3 And that also includes post-traumatic stress
4 disorder, for which there are indications that early
5 experiences, especially abuse and neglect, may be a
6 sensitizing factor.
7 And then we have senescence and the way in
8 which the brain, as well as the rest of the body ages,
9 and there are some indications that early experiences set
10 the stage for the rate at which the brain and body
11 actually age.
12 And as Dr. Hamburg said, all of these represent
13 a very dynamic field of investigation, and there are a
14 lot of questions and very few solid answers.
15 What I'm going to try to do for you is to give
16 you a panorama of what I think to be some of the most
17 solid leads.
18 Now, the first segment of the talk -- I'm
19 trying to address -- I'll try to address the question of
20 what does stress mean for health and for specifically
21 from common disorders, particularly those associated with
22 the cardiovascular system.
23 Later on I'll try to build toward the
24 situations that pertain more directly to the experience
25 of veterans.
51 1 If we could have the next slide? We have --
2 okay, good. What I want to do now is to give you a
3 panorama, looking across species of animals, and I want
4 to start with an experiment that we've been involved with
5 with a group from the University of Hawaii, in which you
6 put five male rats and two female rats together in this
7 visible burrow shown here.
8 There's an open surface area. There are
9 several chambers where the animals can go. There are
10 closed tunnels. All of this can be observed and recorded
11 with a video camera from the top. There's water and
12 food, and what happens very quickly is that one male rat
13 emerges as dominant, and he controls the access to the
14 food and the water, as well as the access to the females.
15 Now, we don't know so far what is happening to
16 the females. We do know that in the males there is a
17 very clear difference, both in the body and in the brain,
18 that develops as a result of this dominance hierarchy.
19 Both the dominants and the subordinates show
20 physical signs of stress. They show signs of stress in
21 terms of their hormone secretion, in terms of their body
22 weight, in terms of their immune system, their thymus
23 rate, which is part of the immune system is lower, and
24 more so in the subordinate animals than in the dominants.
25 Their body weight is lower. This is
52 1 particularly true of the subordinate animals, and their
2 testosterone level is lower. This again is particularly
3 true of the subordinate animals.
4 When we look at the brains of these animals, we
5 find that there are a number of changes, and since I
6 don't want to get into technical details, I will
7 highlight with two examples something I'll talk about
8 later in the structure called the hippocampus, which is a
9 structure involved in learning and memory, keeping track
10 of facts and events, neurons actually atrophy.
11 They lose their processes. They lose synaptic
12 contacts, and `as a result the animal's ability to learn
13 and remember becomes somewhat compromised.
14 Other changes in the neurochemistry of the
15 brain are reminiscent, especially again, the dominants
16 will show a certain set of changes, the subordinates show
17 another set of changes.
18 In the subordinate animals the changes which we
19 see are characteristic of what happens, what is thought
20 to happen in the brain of human depressed individuals.
21 So we think that the neurochemistry of the subordinate
22 rat brain becomes somewhat like that of the depressed
23 human brain. So the brain is very much affected by these
25 Now, moving along to another species and
53 1 another kind of study, studies for a number of years at
2 Bowling Green University Medical School have studies of
3 vervet monkeys living in social groups.
4 And here the distinction is between animals
5 that are put and maintained in a group in which a
6 dominance hierarchy is established, and this pertains to
7 males, and another situation in which the animals are
8 mixed every month or so and are forced to establish a new
9 dominance hierarchy, so they're continuing to vie with
10 each other for the dominant position.
11 Now, what's measured here is the thickness of
12 plaques in the coronary arteries, reflecting the
13 development of atherosclerosis, and what is shown that in
14 the stable hierarchy, dominant an subordinate males have
15 the same plaque area, but in the unstable hierarchy, it's
16 the dominant animals, the ones who want to be dominant,
17 that actually have the greatest plaque thickness. In
18 other words, the stress of vying for the dominant
19 position accelerates the process of atherosclerosis.
20 In the same set of studies, looking at females,
21 measuring plaque development, you'll notice on the far
22 right, the open bar, are normal females who are not
23 subordinate or are socially dominants, and on the left
24 males and the well-known fact that the ovarian hormones
25 protect females from the development of atherosclerotic
54 1 plaques, as illustrated by the higher plaque thickness in
2 males and the much smaller thickness in females.
3 But a female's ovariectomized the hatch bar in
4 the middle, that is deprived of their ovarian hormones,
5 they develop the same degree of plaque thickening as the
6 males, and the black bar in the middle of the female
7 panel, these are socially subordinate females, and they
8 also show an acceleration of plaque development.
9 So again, here are other manifestations of a
10 psychosocial stress, a simple fact consequences of being
11 in a dominant or subordinate position.
12 Now moving on to the much more complex human
13 organism, this is a slide from a study on the British
14 Civil Service System, which has been divided into six
15 classes reflecting employment grade, which is a
16 reflection then also of education and income.
17 Now, all of these people have access to health
18 care and yet these studies by Dr. Maunuck and co-workers
19 show in terms of high blood pressure that the people at
20 the highest end of the scale, the people who are the
21 ministers and at the top of the rank, have the lowest
22 frequently of elevated blood pressure, whereas gradually,
23 as one goes down the scale to the lowest scale, there is
24 a rather regular increase in the frequency of high blood
25 pressure, so that the lowest class of employment has the
1 highest frequency of blood pressure.
2 The same thing is true of mortality by
3 occupational status, and this is true both of men and
4 women, although here the women were categorized, not
5 according to their own occupational status, but the
6 occupational status of their husbands.
7 But again, there's a gradient with the lowest
8 mortality, the highest occupational status, and the
9 highest mortality with the lowest occupational status.
10 Now, obviously there may be many factors,
11 smoking, diet and other factors intervene, not trying to
12 explain it away in any simple way in terms of mechanism.
13 Another example is the remarkable change after
14 the fall with communism in death rate and morbidity
15 between 1989 and 1993, in Eastern Europe. This is
16 particularly the case in Russia where the social
17 instability appears to be the most prolonged. The life
18 expectancy has declined for men from 64 to 59 years and
19 the death rate has increased by 35 percent.
20 The causes of death include homicide and
21 suicide, and also a very large component of
22 cardiovascular related disorders, the cardiovascular
23 system in general appears to be one of the most
24 vulnerable in all these studies that I've been describing
25 for you.
56 1 Now again, the causes can be many, but one
2 thing that's clear, this is characteristic of men and men
3 have to -- where women tend to have social groups and
4 tend to function much better in difficult times, because
5 they form social networks, men have great difficulty,
6 unless they're affiliated with a female social network,
7 and I think the increased death rate in males reflects
8 this fact, that not every male, that many males, are
9 somewhat socially isolated.
10 And that brings me to another point about both
11 animals and humans is that as I said earlier, in animals
12 unstable dominants increases the activity of the stress
13 hormones and I'll tell you about these in a minute.
14 Social isolation and early material deprivation also
15 increase the activity of stress hormones.
16 And affiliated behaviors, social support in
17 animals tends to decrease the activity of stress hormone
18 systems. And in humans we know that hostility increases
19 stress hormone activity, but maternal separation early in
20 life, as in animals, increases activity, and social
21 support in general decreases the activity of stress
22 hormone systems, so again emphasizing the importance of
23 social networks and social interactions and also things
24 like conflict, as factors which drive the production of
25 stress hormones.
57 1 Now, this is a summary of the stress response.
2 There is a neurostress response, which is depicted on the
3 right, and involves the release of catecholamine such as
4 adrenaline, the fight or flight hormone, and this is an
5 almost immediate response to a stressful situation.
6 There's also the production from the brain of a
7 hormone called CRH, which stimulates in a cascade a
8 pituitary gland to produce ACTH, and that in turn causes
9 the adrenal cortex to produce the stress steroid,
10 cortisol, in the human being. And this is a slower
12 Now, both of these events, the rapid activation
13 of the autonomic nervous system and adrenaline secretion
14 and the slower release of glucocorticoids are very
15 essential part of the body's ability to adapt to
16 stressful events.
17 If we don't have normal function of these
18 systems, we do not do very well at all when we're under
19 stress, and yet the paradox of these stress hormones is
20 that although they protect and help us adapt, and do
21 something which we call containment, for example, keeping
22 an inflammation under control -- that's why we take --
23 put cordaid on an inflammation on the skin.
24 Nevertheless, if they are turned on and then
25 very frequently, and not turned off again, or if they're
58 1 turned on and off very frequently, they can produce
2 something which we call allostatic load. Allostasis is a
3 term that applies to adaptive changes, to change the
4 secretion of hormones that help us adapt. And allostatic
5 load is the price of allostation, because if these
6 hormones are then secreted too much or for too long, they
7 can lead to consequences, such as atherosclerosis,
8 obesity, and atrophy of nerve cells in the brain.
9 And under extreme conditions, when there is
10 excess endogenous hormone or the body is exposed to
11 excess synthetic adrenal hormones for some purposes, then
12 there may actually be damage and actual loss, and this is
13 particularly devastating in the brain where nerve cells
14 do not regenerate.
15 Now, allostatic load then is allostasis is what
16 happens when the body is adapting. Allostatis is
17 achieving stability or homeostasis through the ability to
18 produce these hormones and to change or adapt.
19 When there is too much stress and too much of
20 this hormone secretion, it's like having a seesaw with
21 two heavy weights on the other end. The body maintains
22 balance but maintains homeostasis, but the heavy load on
23 the seesaw causes a wear and tear on the body, which
24 eventually results in pathology.
25 Now, there are different forms of allostatic
59 1 load. The most common form is very frequent stress.
2 This is true of the monkeys in the dominants hierarchy,
3 the dominant monkeys. They're stimulated. Their blood
4 pressure rises during social encounters. When this
5 happens very frequently, this is one of the primary
6 causes for increasing atherosclerosis and plaque
8 But sometimes the frequent stress results in a
9 failure to shut down the system, actually to turn off the
10 stress response. A good example of this, on assembly
11 lines in the Volvo factory, Sweeden, characteristic
12 classic assembly line, people working at a certain rate
13 to do their job as the cars pass by.
14 Volvo engaged a group from the University of
15 Stockholm and they measured blood pressure in these
16 individuals, and found that assembly line workers had
17 elevated blood pressure, not only on the job but in the
18 evening and even on weekends. They couldn't turn it off.
19 Again, a prescription for things like
20 atherosclerosis. When they revised the system and made
21 teams that allowed workers to interchange jobs, and work
22 as a collaborative group, social support, it immediately
23 reduced blood pressure and resulted in greater job
25 Now, there's another form of allostatic load,
60 1 which has just been recognized, and that is when the
2 conventional stress hormones, particularly the cortisol
3 secretion, becomes inadequate and this is known to happen
4 in animal models as a result of severe trauma.
5 For example, some of the subordinate rats I
6 mentioned at the beginning actually ceased to be able to
7 produce a stress response during the course of the time
8 in this visible bale, where they are subordinate to the
9 dominant animals.
10 And this also appears to be the case in
11 syndromes such as chronic fatigue syndrome, and also
12 there's now some evidence that in post-traumatic stress
13 disorder there is an inadequacy, a reduction in the
14 actual adrenal steroid or cortisol stress response that
15 may be the result, perhaps the delayed result, of the
16 early traumatic event that's turning these systems on as
17 shown on the left.
18 When that happens other systems, such as
19 inflammatory cytokines and other systems of the body that
20 are normally contained by the body's stress hormones are
21 in fact then hyperactive, because they don't have the
22 containing effect of the stress hormone.
23 Now, the brain is the master controller of the
24 stress response, the interpreter of what is stressful,
25 and I want to concentrate briefly and tell you about two
61 1 brain structures. The little body down at the bottom is
2 called the amygdala, and this is called the hippocampus.
3 Now, the amygdala helps interpret and remember fearful
4 events, traumatic events, and these are known to be very
5 long-lasting memories.
6 The hippocampus helps to remember the context
7 in which events took place, helps us to remember what
8 happened today or yesterday. It helps us keep track of
9 the events in our daily lives. These two structures work
10 together to mediate emotion and memories that are
12 When something happens the amygdala and
13 hippocampus process that event, and we have to then make
14 a decision whether this is threatening or not
15 threatening. If it's threatening, then certain responses
16 will occur, including hormonal stress responses, and if
17 this happens repeatedly, the allostatic load will be
19 If the event is judged to be non-threatening by
20 the brain, then the allostatic load will be low, and the
21 individual goes on to other things.
22 Now, what happens in the brain itself? And
23 since I don't want to take too much more time, I'll tell
24 you very briefly what I mentioned earlier, that when an
25 animal is repeatedly stressed, cells in the hippocampus
62 1 undergo atrophy. They actually lose processes. They
2 lose synaptic connections and the ability of the
3 hippocampus to perform its memory function is
4 compromised. It's not entirely lost, but the animal's
5 memory is impaired.
6 And we know a lot about the mechanism, which I
7 will now try to describe for you. We know that
8 endogenous neurotransmitters are involved. We know that
9 stress hormones are involved. We know that many forms of
10 stress will cause the atrophy. And we also know how to
11 prevent or block the atrophy with external drug
13 Now, where this is important is the fact that
14 when stress goes on for a very long time, as in this
15 study on vervet monkeys, by Doctors Uno and Sapolsky,
16 when stress goes on for a very long time, many months,
17 there appears to be permanent loss of cells. The
18 hippocampus of the stressed animal has fewer nerve cells,
19 showing signs of a substantial loss of nerve cells, so
20 there may be then a permanent, irreversible damage.
21 Now, this slide I'm afraid projects terribly.
22 I don't know why, but it's in a way the most important
23 slide. If we could perhaps adjust it -- there have been
24 two studies so far published in the United States on what
25 happens to war veterans. I don't know, do I have two of
63 1 them together? I think I have them in the same slot. So
2 if you can just take them out and put them in one at a
3 time. All right. This one I'll show first.
4 This is a CAT scan of the brain, and here is
5 the hippocampus. The hippocampus is here and in two
6 subjects there is atrophy. Thank you. There's atrophy
7 of the hippocampus. Now, this atrophy has been seen with
8 elevated stress hormones in Cushings Disease. It has
9 been seen in recurrent depressive illness. It's been
10 seen in Alzheimer's Disease, and even in early stages of
11 aging that are leading to cognitive impairment and maybe
12 to dementia and it's been seen in two studies in the
13 United States in combat veterans, one at Yale and one at
15 And the next slide will finally project. This
16 is one of these studies from Dr. Roger Pitman and what
17 this looks at is hippocampal volume in individuals who
18 had combat experience, I believe, from the Vietnam War.
19 So this is many years after that time.
20 And this is an assessment of the amount of
21 combat exposure and this is an assessment of hippocampal
22 volume, and you can see that there is a rather regular
23 and highly correlated decrease in hippocampal volume with
24 increased combat exposure.
25 The individuals in the red dots had diagnosed
64 1 post-traumatic stress disorder. Now, this disorder was
2 loss of hippocampal volume, may represent a permanent
3 loss of nerve cells, or it may represent an atrophy which
4 is maintained by factors we don't understand.
5 That is an important distinction because if it
6 was the former, it may be treatable.
7 And then the final point I wanted to make very
8 briefly is that early stressful experiences increase the
9 rate at which the brain ages, that prenatal stress in
10 animal models -- it hasn't been shown in humans as yet --
11 results in a more rapid brain aging, whereas an old
12 postnatal experience in rats that's called handling,
13 which is a form of gentle stimulation, actually reduces
14 the adult stress response in novel situations, and
15 reduces the rate at which the brain and particularly the
16 hippocampus agents, without any long intervention of
17 stress in adulthood, but what it suggests, and bringing
18 back the first slide, last you can see then why I have
19 mentioned the connection between these various events,
20 but what happens early in life may set the tone for the
21 response of the body's stress hormone access, and may
22 allow it to be turned on more readily and to be more
24 Or it may have the opposite effect, for
25 example, parental buffering, the opposite effect to
65 1 reduce the activity in this system, and what happens
2 later on in life, maybe a reflection of that intrinsic
3 reactivity, as well as the experiences the individuals
4 undergo during their young and adult life.
5 Thank you very much.
6 DR. HAMBURG: Thank you very much, Dr. McEwen.
7 We asked Dr. McEwen to take on a very difficult task of
8 covering the entire field and multiple systems in a few
9 minutes, and he's done it extremely well.
10 I think what we better do in view of the time
11 pressures is to get Dr. Black and then have questions
12 addressed to both of you. Dr. McEwen, thank you very
13 much indeed.
14 I'm just underscoring the sentence -- two
15 points Dr. McEwen made that are important for our task,
16 and many others have importance as well, but one is that
17 it's certainly fair to say that these stress hormones,
18 like adrenalin and noradrenalin and cortisol affect
19 virtually every sort of tissue in the body. So that
20 there are powerful ramifications from a difficult
21 stressful experienced mediated by the brain and to the
22 hormone that effect every cell and tissue.
23 The second point is that if these stress
24 hormones and other stress responses go on over an
25 extended period of time, they can be one of the
66 1 contributing cause of factor to a variety of diseases.
2 So those are two messages we have to take away
3 from this. There nothing imaginary or unreal about this
4 at all, because it's very tangible and concrete and the
5 biological implications of the multiple stress responses.
7 Thank you very much, Dr. McEwen. Now, Dr. Paul
8 Black, another active investigator in this field on a
9 more specialized topic, particularly immunological
10 aspects of stress. Dr. Black is in the Department of
11 Microbiology at Boston University School of Medicine.
12 Welcome, Dr. Black.
13 DR. BLACK: Thank you, Dr. Hamburg. And I'd
14 like to thank the committee for the invitation and I'd
15 like to reiterate what Dr. McEwen said about the victims
16 and their afflictions and I think I for one and many
17 other think there's no question that something is making
18 them sick.
19 The medical profession is trying very
20 desperately to figure out just what and how to fit this
21 all in.
22 What I'd like to do this morning is just make
23 the following points. I'd like to try and convince you
24 that the brain and immune system interact, that the brain
25 sets out hormones, transmitters, neuromediators, peptides
67 1 and hormones that react on the immune system, and I'd
2 like to also try and convince you that the immune system
3 and its products, that is cytokines and inflammatory
4 products, feed back to the brain and give the brain a
5 message to stop this immune activity.
6 That's one thing. And I'd like -- secondly I'd
7 like to tell you how this all works and what are the axis
8 and what are the molecules. Then I'd like to deal with
9 stress and how that perturbs various structures in the
11 I'd like to say for start -- could I have the
12 first slide, please, that the brain and immune system
13 interact, and this is evidence that's been accumulating
14 over the last 20 years and it's all very firmly
16 One is that if one affects the hypothalamus, if
17 one lesions the hypothalamus, there are changes in the
18 immune response. The hypothalamus is a small structure
19 at the base of the brain which takes incoming signals
20 from the external world and from our internal world, our
21 internal environment, and reacts and it aim is to keep
22 the body in homeostatic equilibrium.
23 It is also the structure which perceives danger
24 without and danger from within, if you will, and tries to
25 accommodate for that with various functions. So
1 lesioning the hypothalamus affects immune function.
2 Also there are receptors on leukocytes cites
3 and on macrophages, I might add, for hormones and
4 neurotransmitters. So it says to us that the immune
5 system is ready to receive brain signals.
6 And we know that various hormones, various
7 neurotransmitters and peptides influence immunity
8 function. There's no question about that. They either
9 shut the immune system on or off and it's just been
10 chronicled what these do and what the receptors are.
11 Then we know now that not only does the brain
12 affect the immune system, but the immune system sends out
13 its mediators, as I said, and feeds back to the brain and
14 tells the brain to shut off the immune system, and I'd
15 like to reiterate what Dr. McEwen said, if there's a
16 period of these cytokines and immune transmitters, to
17 tell the brain and for the brain to signal a decrease in
18 immune function, there may result other immunity and a
19 persistently hyperactive immune system.
20 And this we have good reason to believe exists,
21 certainly in certain animal systems.
22 Also we know that the neuroanitomical and
23 neurochemical evidence that the brain -- that nerves
24 innervate the lymphoid tissue. The primary lymphoid
25 organs, the thymus and the spleen. The secondary
1 lymphoid organs, the thymus and bone marrow, the
2 secondary lymphoid organs, the spleen and lymph nodes.
3 Do have innervation by the automonic nervous system. The
4 automonic nervous system is the system which mediates
5 emotion and it says if there's a direct connection
6 between emotional state, affective states and the
7 response of the immune system.
8 And here different behavioral states are
9 associated with immune responses. And we know that as
11 Another powerful piece of evidence is
12 conditioned immunosuppression. That is very simply the
13 fact that Pavlovian conditioning, it means if you give an
14 animal a signal, in this case, saccharin, and then an
15 immunosuppressive agent like cyclophosphamide. The
16 animal will be immunosuppressed, with one single paring
17 of this.
18 If you then give the animal, when it's immune
19 system has recovered, a condition stimulus, the
20 saccharin, which produces a taste sensation, a burning of
21 the tongue, and no immunosuppression, the immune system
22 is suppressed, a remarkable experience in which tells us
23 -- says that the brain somehow knows how and can remember
24 to suppress the immune system.
25 The next slide, please. Now, Dr. McEwen has
70 1 made my task a little easier, so I don't have to go
2 through the axis, but this is very -- this is the brain
3 and this is the hypothalamus, the area I spoke about, and
4 I don't want you to try and figure out what everything
5 is, but as Dr. McEwen said, the hypothalamus puts out a
6 molecular CRF, corticotropin releasing factor.
7 And this is a stress hormone, we believe, that
8 sets everything in motion, and very, very briefly the CRF
9 produces ACTH, which produces corticoids from the adrenal
10 and that's a stress hormone.
11 Also CRF goes down and in the locus coeruleus
12 here in the brain stem, it signals that to produce
13 adrenalin and noradrenalin, and these also be emergency
15 So these are the emergency hormones. They are
16 both immunosuppressive. They are both generally produced
17 by stress and as Dr. Hamburg said, they affect many and
18 most cells in the body.
19 The immediate reaction of a stressful
20 situation, an overwhelming threat to the animal's being,
21 that is, an impending attack by a predator is to put out
22 these hormones.
23 Next slide, please. And when it puts out these
24 hormones, it's activation by the sympathetic nervous
25 system. I don't want to try and go through all this, but
71 1 these are all the hormones that are known to insulins and
2 neurochemicals, and other transmitters, the immune
4 These are the immune mediators, and as I was
5 just saying, when there's stress, the brain puts out
6 corticotrophin releasing factor, CRF, and that stimulates
7 corticoid production and it stimulates adrenalin and
9 It's fascinating that all of the other
10 functions in the pituitary are shut off. Those are the
11 vegetative functions like follicle stimulating hormone.
12 In other words, reproduction is shut off. Growth is shut
13 off. Appetite is shut off. Sexual activity is shut off.
14 And thyroid function is shut off, so the body exquisitely
15 immobilizes itself to deal with this situation in a fight
16 or flight way.
17 And this critical CRF is signaled by higher
18 centers in the brain and various nerve transmitters such
19 as serotonin, acetylcholine and noradrenalin itself. So
20 these are the axis and these are the molecules and this
21 is how stress is perceived in an acute way.
22 What now are the effects of stress? One, first
23 and foremost, is the depression in immunity, because the
24 animal doesn't need an immune system in that ten minutes
25 of fight or flight.
72 1 He'll need -- the animal will need the immune
2 system to deal with infection and organisms and the
3 inflammatory response a little later, but the immunity
4 can go for the early part, and that's why I believe that
5 there's immune suppression, having said that there's
6 immune suppression, these molecules, corticoid steroids
7 and noradrenalin, norepinephrine and epinephrine do start
8 the inflammatory state.
9 And my message later is going to be that stress
10 may induce or partake in the formation of an inflammatory
11 reaction, which is different from an immune reaction,
12 which might occur much later, but the effects then of a
13 depressed immunity later on and this results later in a
14 loss of resistance to infection, and we know that
15 stressed people have more infection.
16 It results in a loss of immune surveillance, a
17 function which we have to survey out cancer cells and we
18 know from many, many experiments that stressed animals
19 get cancer more. They get cancer with a lower number of
20 cancer cells transplanted, and they generally are more
21 susceptible to cancer. Humans too who are
22 immunosuppressed are more susceptible to cancer.
23 Now, what about the other things? What about
24 the other aspects? I'd like to talk now about the HPA
25 axis, which just means the hypothalamus, pituitary,
73 1 adrenal axis, and this is the axis that I've been talking
2 about. It's CRF put out by the hypothalamus, that goes
3 to the pituitary, and puts out -- simulates the
4 production of ACTH, which makes corticoid.
5 This is a very important axis. It says to us
6 that the pituitary, that there are positive and negative
7 factors in the hypothalamus and there are positive and
8 negative factors in the pituitary -- immune function, but
9 it's in the pituitary is under hypothalamic control.
10 What it tells us is that there's an exquisite
11 capacity to regulate immune function by the hypothalamus
12 in the pituitary.
13 But just coming back to the HPA axis, the HPA
14 axis stimulates the production of corticoid and corticoid
15 then feeds back to the brain and shuts off -- it shuts
16 off ACTH and it lowers the immune response, and this is
17 the body's protection. It lowers the production of these
18 things normally. That is the corticoid feedback and shut
19 off CRF.
20 If corticoid failed to do that, if corticoid
21 failed to shut off the CRF, CRF goes uncontrolled and
22 puts out a lot of ACTH and cortisone and we see this in
23 major depression, high levels of corticoid, high levels
24 of ACTH, which are not suppressible by dexamethasone.
25 This is a well-known phenomenon and it is indicative of
74 1 some disorder in the HPA axis. It won't respond.
2 If you have a low threshold of response, if the
3 HP axis doesn't normally respond to the feedback of
4 corticroids, and it won't shut off, it won't shut off the
5 production of the immune system by the cytokines that
6 come up from the immune system and stimulate CRF to
7 produce these immunosuppressive molecule, if that doesn't
8 happen, then we think -- in other words, that may be
9 confusing, but what I told you before is that cytokines
10 normally feed back to the brain.
11 They normally stimulate the production of CRF.
12 CRF then produces corticoid by ACTH, and it produces
13 noradrenalin and adrenalin and that's the stress
14 response, isn't it?
15 So the body then is responding to an internal
16 stress, that is the cytokines and overactive immune
17 system by putting out corticoids and catecholamines and
18 tries to suppress the immune response.
19 In other words, the body is responding to an
20 internal stress, just as it does to an external stress,
21 by stimulating CRF, which stimulate corticoids and
23 Now, if that doesn't happen, there aren't
24 corticoids and cytokines which normally suppress immune
25 system, then the immune system is left open and
75 1 hyperactive and we think that happens in chronic fatigue
2 syndrome and we think that happens in certain autoimmune
3 diseases. It certainly happens in the Lewis rat, which
4 gets autoimmune diseases easily.
5 Now, and it's been shown in the Lewis rat that
6 they don't make CRF well, and what little they make is
7 not sufficient to make corticroids, which is not
8 sufficient to shut off the immune response, so we're left
9 with a hyperactive immunity, and a hyperactive immune
10 response, which may result in autoimmunity and may
11 exacerbate what I'm going to talk about now.
12 And what I'm going to talk about now is the
13 idea of allergies and hypersensitivities, because we're
14 all very interested in that, because of the multiple
15 chemical hypersensitivity syndromes, and certainly the
16 Gulf War veterans were exposed to a plethora of things
17 that this panel knows and that the Gulf War veteran
19 Let me make the following quick points about
20 allergy and asthma and hypersensitivity. One, we know
21 the mind can affect the production of allergies. The
22 brain can affect the production of allergies.
23 Now, that's a flagrant statement and why do I
24 say that? I say that because there's fascinating
25 evidence that's now being produced that shows in a
76 1 multiple personality disorder, where you have multiple
2 personalities, one of the personalities may have
3 allergies and the other personality doesn't.
4 That's a phenomenal instance which says to us
5 that the brain must be capable of adducing an allergic
6 state, because everything is constant in the multiple
7 personality, same age, same sex, same genetic background,
8 everything is the same. They act as their own control.
9 The one different thing is the affective state
10 and the fact that that may produce an allergic state to
11 certain things is really fascinating.
12 But number two, even without that evidence, we
13 know that stress can produce hives. This is well
14 documented by allergists and even asthma, it can bring on
15 these things, and we know now that stress can induce a
16 TH-1 to TH-2 switching. It's called isotopic switching
17 in immunology.
18 And the TH-2 case cell makes IGE, which is the
19 antibody that mediates hypersensitivity and allergy. So
20 that may be one reason that stress may enhance the
21 allergic response.
22 We also know that sub-optimal levels of an
23 allergin or an immunogen, when accompanied by stressful
24 reactions, will result in an allergic response, whereas
25 it wouldn't without the stress.
77 1 So there's good evidence that all allergists,
2 all immunologists know that stress compounds allergic
4 Does everybody get this? And the answer of
5 course is no, there's different levels of sensitivity, as
6 you all know, and there are different and many factors
7 involved with atopy or the tendency to become allergic,
8 such as hereditary background, and things like that.
9 And also we know the coping ability of one to
10 handle stresses is a very important factor. So we
11 shouldn't expect everything to get sick, just like we
12 shouldn't expect everybody to get the post-traumatic
13 stress syndrome and they don't. Certain individuals do
14 for many, many reasons which this panel knows very, very
16 So certain individuals might get it because of
17 their ability to cope, because of their genetic
18 background, because of many other factors within their
20 We also know now that Substance P, which is a
21 neuropeptide from the brain, Substance P is involved in
22 many stress reactions. Substance P is an undeca
23 (phonetic) peptide. I'll show you in a minute, and it is
24 responsible for mediating multiception, that's pain in
25 the central nervous system, and also neuroinflammation.
78 1 Substance P, and it -- we've shown and one of
2 the labs has shown that this may be involved in the
3 stress response of macrophages, in which they produce a
4 lot of pro-inflammatory cytokines.
5 But now I'd like the next overhead, please, if
6 I just could have one overhead. My one overhead, please.
7 I want to show some recent work which has shown how an
8 immunogen inflammation may be intertwined with a
9 neurogenic inflammation.
10 And that is some work with certain allergens
11 and the mediation of immunologic inflammation and
12 neurochemic switching.
13 Here's it postulated that certain chemicals
14 may interact with the brain, with nerves. Peripheral
15 sensory nerves. They are receptors on peripheral sensory
16 nerves that have receptors for various chemicals.
17 This results in the elaboration of Substance P,
18 which is elaborated with any type of inflammatory
19 response or signaling of the nerves, and this Substance P
20 then reacts with the mass cell (phonetic), which is --
21 excuse me -- this is a mass cell, and the interaction
22 with Substance P elaborates histamines.
23 This is well known that a Substance P receptor
24 mass cells and there are histamine, is the mediator of
25 many acute allergic immediate elite allergic reactions.
79 1 This histamine may also react with a receptor
2 on a peripheral sensory nerve and more Substance P is
3 elaborated. So we have the presence of Substance P from
4 this interaction and Substance P from that, and
5 histamine, which may react on the target cell, and cell
6 of bronchial necrosis cell, and other cells.
7 So these are two known mediators of immunologic
9 And what these investigators found is that the
10 Substance P may also go up the nerve, which we know it
11 does, and it may come down another nerve called the axon
12 reflex, even the same nerve, and this Substance P then is
13 further elaborated at a different site, which is not
14 exposed to the allergin or the immunogen and may react
15 with mass cells to produce histamine, which may then
16 react with target cells.
17 There's Substance P produced here because
18 that's coming down the nerve here, and Substance P
19 histamine again, react not only with the mass cell --
20 Substance P, not only with the mass cell but with the
21 peripheral target cell, at a distant locus, distant from
22 the from the original locus where one can meet the
23 contact with the chemical or allergin, so this is called
24 neurogenic inflammation and the ideal is that neurogenic
25 inflammation may give an inflammatory response at a site
80 1 distant from the site at which original contact was made.
2 So this here is a very fascinating interaction
3 with immunologic activation and neurogenic activation and
4 when we say neurogenic, we mean nerves and we mean the
5 central nervous system and stress can certainly intervene
6 in this regard.
7 Now, one last word about some work that we've
8 done, and we have shown now that stress results in the
9 elaboration itself of cytokines, the pro-inflammatory
10 cytokines into locum one, necrosis factor alpha, and into
11 locum six.
12 These are the pro-inflammatory cytokines. In
13 general inflammation, when the body is exposed to an
14 infection or endotoxin, these pro-inflammatory cytokines
15 are elaborated from macrophages.
16 These pro-inflammatory cytokines tell the river
17 to induce the acute phase reactants, acute phase protein
18 and competent components, things needed for
20 So we feel that -- and we found that these are
21 mediated by Substance P. So we feel that Substance P is
22 the mediator of this and that stress itself may induce
23 the early components of an inflammatory reaction with the
24 cytokines and acute phase proteins.
25 So we think that may mean that stress may be a
1 factor, a participant in the inflammatory responses of
2 certain pieces of information, for which we don't know
3 the etiology, namely rheumatoid arthritis, inflammatory
4 bowel disease, and asthma, which are our target diseases
5 that we're looking at and thinking about, and that it may
6 do so by a Substance P dependent mechanism.
7 So here you have a union between a mediator
8 that mediates a stress response that is Substance P and a
9 mediator that mediates a immunologic response, Substance
10 P, which is well known to be involved in asthma and other
11 diseases and which are known to affect the peripheral
12 cells in the body, peripheral target cells.
13 So I think this is just fascinating in the
14 sense then that multiple chemical hypersensitivity are in
15 an allergic state or a hypersensitive state, may occur,
16 but that the very components that mediate this are the
17 very components that may mediate a stress response
18 whereby pro-inflammatory cytokines are activated from
19 microphages and I think that the well-known compounding
20 of an allergic or chemical reaction with a stress
21 response, as it's seen here neurogenic inflammation, and
22 immunological inflammation is a very fertile ground that
23 we must look at in analyzing the Gulf War Syndrome.
24 Thank you very much.
25 DR. HAMBURG: Thank you, Dr. Black. You're
1 obviously at the frontier of a fascinating field. We
2 look forward to it with enthusiasm. We have a few
3 minutes for questions from the panel, either to Dr.
4 McEwen or to Dr. Black. John, you want to begin?
5 DR. BALDESCHWIELER: Yes. Let's start with Dr.
6 McEwen. You mentioned neurochemical changes associated
7 with stress and Dr. Black mentioned a few specific,
8 peptide P for example. Is it possible to develop assays,
9 diagnostic assays, which would be based on the
10 circulating titters of some of these specific substances?
11 DR. McEWEN: Well, it's common practice with
12 suitable clinic controls to in special cases to withdraw
13 for example, cerebral spinal fluid from humans and to
14 assay some of the chemicals that I referred to in the
15 brain like CRF and so on, some of the things that would
16 change, be expected to change.
17 It's also possible and it's an active area of
18 investigation to actually measure peripheral hormones.
19 It's been that way for a long time, measure
20 catacolomines, measure cortisol.
21 A new assay for salivary cortisol is just
22 having to take saliva rather than blood, has become very
23 useful in the study of stress responsiveness. The
24 problem is in human subjects is that these agents are
25 often elevated in response to particular situations so
83 1 you can't just expect to go in and take a sample at any
2 one time and expect to see something that represents
3 perhaps events that took place a long time ago.
4 So really the assays are there. We can't of
5 course do much more than that. We can add to that things
6 like MRI, to look at hippocampal volume and other things
7 about the brain that are going on, but even those are
8 snapshots of what exists at a particular time, and yet we
9 can, if we ask the right questions, find out what's
10 happening then and ask questions that may help us
11 understand what happened before.
12 DR. BALDESCHWIELER: But, for example, if there
13 really is a chronic stress, then your hypothesis would
14 suggest that there really are differences in relative
15 titters of --
16 DR. McEWEN: I guess if I take the one example
17 that I finished off with, namely the decreased volume of
18 the hippocampus, which I think has great potential
19 significance for what it means that the time a person has
20 this, and it's a reflection of what took place many years
21 before, this could either represent a permanent loss of
22 damage of neurotissue and that we know in animal models
23 does happen, so cells may actually be lost and that's why
24 the hippocampus is smaller, it is the most vulnerable
25 area of the brain to things like stress.
84 1 The other possibility is that this reduced
2 volume may represent a hyperactivity of neurochemical
3 systems and these we could actually measure. It hasn't
4 been measured yet, using positron emission tomography,
5 for example, to measure blood blow, and glucose
6 utilization, to find out if this area of the brain
7 chronically lights up.
8 We know that that happens in depressive
9 illness, that certain areas of the brain, the funnel
10 cortex and anigula light up with this method, so that
11 would be a way of actually finding out if this area of
12 the brain is hyperactive, and then of course the dream
13 that I have is perhaps if that's the case, the
14 hippocampal atrophy might actually be treatable. It
15 might not represent permanent cell loss, but it might
16 represent something that could be treated if we knew how
17 to calm down that hyperactivity. That's still
19 DR. BALDESCHWIELER: Now, it's obvious that
20 what I'm driving at here is whether one could devise an
21 assay that would either give us some clue as to
22 susceptibility to effects of stress, and/or an assay that
23 would later tell us whether indeed we're dealing with a
24 problem whose roots are chronic stress.
25 DR. McEWEN: One of the things which I know
85 1 that Dr. Pitman and other individuals in this area intend
2 to do is a prospective study, looking at victims of
3 trauma, some rape for example, or some natural disaster
4 or some -- and actually follow them over a period of time
5 to make some of these measures, to actually see what the
6 evolution is of the physiologic response, and then of the
7 body changes, because the fact that there is a delay in
8 the appearance of some of these symptoms and then a
9 prolonged nature of these symptoms, means that in order
10 to fully understand it, we have to follow people
12 And then we may know what represents a change
13 at a particular time, maybe a year or five years later,
14 but we really have to start from the beginning in order
15 to establish causality because it may be that early
16 stress response, the uncontrolled and maybe not shut off
17 stress response that's actually is causing these problems
18 and leading to a cascade of events that results in a
19 collapse of the whole system, and the inability to
20 respond normally down the road.
21 DR. BALDESCHWIELER: Paul, you mentioned the
22 ratio of TH-1 to TH-2 cells. Is that a potential basis
23 for an assay of stress response?
24 DR. BLACK: It could. It's just been found and
25 it could. I'm unable to tell you specifically that it's
86 1 an allergin, but it may be -- it is probably the
2 mechanism where IGE is increased in allergic states and
3 in the perpetuation of chronic allergy. It could be to
4 analyze IGE.
5 DR. HAMBURG: Questions?
6 DR. LASHOF: Following along the same line,
7 obviously John is looking for, is there a way to diagnose
8 in people, show a Gulf War Syndrome, whether there is any
9 way to determine whether it is due to the kind of
10 mechanisms you've both described, and what kinds of
11 research are either of you doing along that line at this
13 DR. BLACK: I think one would like to know for
14 instance what, based on levels of various stress
15 hormones, norepinephrine, epinephrine, corticoid steroid,
16 and even the reactivity of their HBA access to
17 dexamethasone, comparatively easy things that are always
18 done, generally done with depressed patients,
19 norepinephrine and epinephrine, the emergency hormones.
20 The other thing would be to see if what their
21 IGE levels are, and that. One can't do Substance P
22 assays on the blood, because one could take their
23 macrophages and see if they respond to SP, if there are
24 more SP receptors or see if they have an exuberant
25 response to cytokines, more than normal, to see whether
87 1 they're producing a lot of cytokines, which can give an
2 inflammatory reaction and perpetuate an allergic state,
3 together with the stress hormones.
4 One could do those things. The thing that's
5 worrisome, the thing that I have -- that I worry about
6 and that mystifies me is how can it go on so long after
7 the removal from the allergin or the chemical, and unless
8 one sets -- unless one permanently damages the brain and
9 the hippocampus is a famous way of decreasing gluco
10 corticoid receptors so they don't respond to gluco
11 corticoid feedback, and the immune system stays
12 activitated. Would you agree with that, Bruce?
13 DR. McEWEN: Yeah, I think that's certainly a
14 very interesting possibility, that these deficits in
15 immune response and other changes of this kind reflect
16 the actual changes that have taken place in the brain,
17 and it's a very important role in influencing these
19 This is something that again is at the
20 forefront of research. We don't have any answers. I
21 think following Paul's comment, the idea I think of
22 looking and being sure that there are certain features,
23 such a the hyperactivity of some of these cytokines
24 systems in these veterans who show these symptoms, and
25 then as I said earlier, trying to study in a prospective
88 1 study the actual evolution of this, because of this --
2 the long time intervals and getting at this question of
3 whether there is perhaps a permanent deficit, for
4 example, in the brain, that could be at the seat of the
5 entire problem.
6 DR. BLACK: -- how much people study
7 dexamethasone response and investigated HPA access. It's
8 just starting in chronic fatigue syndrome, things like
9 that, and in autoimmune disease, but one could subject
10 animals to these type things, even the Lewis rat, which
11 is very sensitive.
12 DR. LASHOF: I was just going to ask further
13 are either of you funded to do further research
14 specifically around the relationship to your theories to
15 the Gulf War illness?
16 DR. McEWEN: Our work is on animal models. I
17 can't say that we have an animal model that's suitable
18 yet. We have some ideas in our rat studies of things
19 that might actually tell us mechanisms that might be
20 applicable, but it's still a long way away from applying
22 I think the problem of increasing research
23 funding in this area is a very important one, so that
24 people can do this kind of research.
25 DR. BLACK: And the answer for me is no. This
89 1 is very hard research to get funded by the NIA. My hot
2 field is psychoneuroimmunology, and it's a field between
3 psychiatry, psychology, neuroindicronolgy and immunology,
4 and it's a difficult situation to know who is to review
5 these and get a good fair review, because frequently they
6 go a mental health study section, immunology or sometimes
7 they go to the -- but it's a new area and stress response
8 is just acquiring credibility. I won't say just, but
9 maybe the last five, six, ten years, as Dr. Hamburg said.
10 DR. HAMBURG: Thank you.
11 MR. CROSS: We heard this morning one of the
12 gentlemen in the public comment had a long list of
13 symptoms, sweat, aching joints and that type of thing,
14 and I'm sitting here and listening, and I think what
15 you're saying is based on your research some of those
16 symptoms could be caused by stress, and I think that's
17 what the veterans are asking, is potentially their
18 illness, is it caused by high stress and I think that is
19 what you're saying, isn't it?
20 MR. BLACK: I don't think so. I don't think
21 they're caused by stress. I think stress is a
22 compounding factor, which makes the chemical sensitivity
23 occur or worsen. I think it's an adjunct.
24 I'm an M.D. and I see many patients and talk to
25 many dermatologists. They said they don't know if stress
90 1 can induce cirrhosis But it's certainly a compounding
2 factor when people with cirrhosis stress, they get
3 flaking and itching and there's no question, so I'm
4 saying it's a compounding factor.
5 What is occurring, if we're going to ascribe
6 all this to a chemical sensitivity, is that there's an
7 ongoing immune reaction which is failing to be
8 suppressed, either by organic changes in the brain or by
9 HPA dysfunction, hypersensitivity or something. And that
10 can happen, I think, and as it can with autoimmune
11 diseases, the failure to turn off this.
12 DR. McEWEN: I'd like to put it just a little
13 differently. I think what we're talking about are
14 individual differences in both the experiences that have
15 been undergone and also how the body has reacted to it,
16 and I would talk not just about stress but about trauma,
17 and I think we're talking about a severe psychological
18 trauma during the time of the exposure in the war
19 theater, which has resulted in a sensitization so that
20 then stresses and other events later in life, through
21 processes that we're still obviously struggling to
22 understand, has resulted in a very different, unique
23 pattern of response in certain individuals.
24 But I'd like to talk about trauma early on and
25 it seems to me that, especially hearing some of those
91 1 stories this morning, that it is within the realm of
2 scientific possibility, even likelihood, that these are
3 the results of this traumatic event and that it's changes
4 in the brain and in the rest of the body that have
5 resulted in these long-term changes that are now reported
6 many years later.
7 MR. CROSS: What original event? Do you mean
8 pre-exposure to the trauma?
9 DR. McEWEN: We have to think the trauma of the
10 war and the individual differences that are perhaps
11 related to earlier life experiences as well, because we
12 do know that parental loss, other events early in life,
13 may sensitize individuals to respond in a certain way to
14 traumatic events. That's taking it back one step
16 MR. CROSS: In other words, in any given group
17 of troops that we're sending over into an area, there are
18 people predisposed to be affected by this?
19 DR. McEWEN: Yeah.
20 MR. CROSS: And they're going to come back ill?
21 DR. McEWEN: Yeah, basically, yes.
22 MR. CROSS: And proof of this is the fact that
23 not everybody gets post-traumatic stress disorder, when
24 they may all be exposed to the same overwhelming evil of
25 a stress.
92 1 The other thing is reading the proceedings of
2 various committees, they have said that they agree that
3 post-traumatic stress disorder is a consequence of this
4 war and we know that. But they also have said that
5 there's probably more stress and apprehension in the Gulf
6 War than many other wars, because they were told that --
7 pretold that there was a possibility of biological
8 chemical warfare, and Sadam Hussain's personality and
9 techniques and things like that.
10 So people have argued that they brang about a
11 tremendous amount of anxiety and tension and stress to
12 this situation.
13 DR. HAMBURG: We're under some time pressure.
14 Maybe one more question. John.
15 DR. BALDESCHWIELER: Let me come back to the
16 measurement of the volume of hippocampus. I can envision
17 that this could be done rather rapidly with an MRI. But
18 what kinds of controls do you have? That is, I mean,
19 what's the normal variation in the volume of hippocampus
20 and without doing a control before a person is sent into
21 combat? Could you possibly --
22 DR. McEWEN: No --
23 DR. BALDESCHWIELER: -- significant change in
25 DR. McEWEN: One doesn't know that this wasn't
93 1 a preexisting event, unless you followed somebody. It's
2 I think in given with those response curve that Pitman
3 produced, it becomes less likely that that's the result
4 of some preexisting condition that people with a smaller
5 hippocampus for some reason had more combat exposure, but
6 all of these questions -- I mean, I'm not an expert in
7 this area, but I've heard Pitman and also people from the
8 Yale group -- I note Dr. Southwick will be talking this
9 afternoon -- struggle with these issues of proper
11 And I can't answer that question in the limited
12 time available but it is a problem and yet it is a
13 problem that I think they've dealt with quite reasonably
14 well, based enough to pass peer review.
15 DR. BALDESCHWIELER: Can you give me sort of
16 quantitative feelings or what would be a statistical
17 variation in hippocampal volume, is this a five or ten
18 percent --
19 DR. McEWEN: The differences that are being
20 reported within the controls that are chosen, which
21 represent of course age and sex matched and also military
22 experience and things of that sort, the actual volumetric
23 changes are on the order of seven to ten percent, and
24 differ between the left and the right hippocampus.
25 They are not large, but as I said, there are
1 three different studies, two of them published, which
2 have found essentially the same thing, struggling each
3 with their own control.
4 So it's possible to see it over and above the
5 noise of normal variations.
6 DR. BALDESCHWIELER: Do people with hippocampal
7 atrophy, do they exhibit a normal suppressive response to
8 dexamethasone because that's the way their corticoid
9 receptors are, type one, type two?
10 DR. McEWEN: Well, that's a complicated story?
11 PTSD, there's actually hypersensitivity to dexamethasone
12 suppression. With major depression where there's also
13 hippocampal atrophy, there's a reduced suppression, so it
14 doesn't just map out one on one.
15 DR. HAMBURG: I think we're going to have to
16 stop. Let me just add one brief comment. Both speakers
17 have touched in passing on genetic factors. They've
18 commented on individual differences in the handling of
19 stress responses generally, and make observation that
20 everyone in a combat situation is exposed to a remarkable
21 stressful experience, but not everybody gets sick and
22 everybody that does gets sick gets sick in the same way.
23 Obviously there are many sources of that
24 variation. The point is that these are not standard
25 responses. There are major individual differences and
1 the whole consistent individual differences in responses
2 to stress, and there is some work that ties genetics into
3 this so that there are genetic differences in the
4 processing of stress hormones within the body and the
5 processing of some neurotransmitters, so that that's an
6 important link in the future to make -- strengthen the
7 connections of genetic predispositions with the
8 environmental pressures of the stressful experience in
9 combat, and that may help to understand why some people
10 are so much more susceptible to a particular disease
11 under stress than others are.
12 So it's a very complicated, fascinating area,
13 and we thank Dr. McEwen and Dr. Black, for clarifying a
14 lot for us.
15 We're going to come back as close as we can to
16 one o'clock and going to get into more clinical and
17 public health aspects of the problem this afternoon.
18 Thank you very much.
20 DR. HAMBURG: Take our seats now. I apologize
21 to you. We ran into some logistical problems which
22 slowed us up. We're almost back on schedule. I hesitate
23 to start without the Chair, but I'm sure Dr. Lashof will
24 be here very soon.
25 So let us turn to stress related findings in
96 1 the VA Persian Gulf Health Registry and DOD's
2 Comprehensive Clinical Evaluation Program. I call first
3 on Dr. Frances Murphy, Environment Agents Services,
4 Department of Veterans Affairs. Thank you for joining
6 DR. MURPHY: Thank you for inviting me. I was
7 asked to present some of our Persian Gulf Health Registry
8 Information to put the VA experience with Persian Gulf
9 Veterans Health issues in context and talk about some of
10 the symptoms and the psychiatric diagnoses we've seen
11 from individual to have selected -- self-selected to come
12 in for this examination program.
13 Can I have the next slide? As you are aware
14 already, the VA has a wide-range of health care programs
15 that address some of the health issues for Persian Gulf
16 veterans. The registry is one of them.
17 However, we also have the referral centers
18 which deal with more difficult to diagnose cases and
19 unexplained illnesses in Persian Gulf veterans.
20 It's also important to recognize that Persian
21 Gulf veterans have been given special eligibility for VA
22 health care, and therefore some of the inpatient data
23 that we have may not be directly comparable to inpatient
24 diagnostic data that we have on other groups of veterans
25 who do not have the same eligibility.
97 1 We also have a number of other special medical
2 programs, including a program down at Birmingham which is
3 focused on evaluation of potential -- a group of veterans
4 who were potentially exposed to chemical and biological
5 warfare agents and a depleted uranium program and a group
6 of also medical research studies that some of which
7 address some of the issues that were talked about this
8 morning and some of the stress-related disease that could
9 potentially be seen in Persian Gulf veterans.
10 Can I have the next slide? You'll remember
11 that VA actually initiated its Persian Gulf programs very
12 early. We started the Persian Gulf Registry in August of
13 1992, and this was really set up as a health surveillance
14 system and to give Persian Gulf veterans an opportunity
15 to come in and access VA medical care.
16 We just updated our figures and now more than
17 60,000 Persian Gulf veterans have come in and completed
18 this Persian Gulf Registry health examination, which
19 includes a general physical examination, a complete
20 history, and some screening diagnostic tests.
21 If the physician performing the exam finds any
22 symptoms that suggest set of signs and symptoms that
23 suggest a particular diagnosis, they can go on and do
24 further evaluations or consultations as needed.
25 It's also important to recognize that over time
98 1 about 14 percent of the individuals who come in for the
2 registry examination don't have any complaints. They're
3 asymptomatic and simply want to be seen, because they
4 have concerns about their health after the Persian Gulf.
5 I think the other thing we need to remind
6 ourselves is the composition of people who went to the
7 gulf. The people who were deployed were somewhat
8 different than people deployed to other military
9 conflicts. There were more women.
10 Seven percent of the individuals who went to
11 the Gulf were women, and a total of about 16 to 17
12 percent were a combination of reserve and national guard
14 The mean age of employees deployed to the
15 theater of operations was 28.
16 I'll have the next slide. The composition of
17 the Registry does not really reflect those demographics.
18 In fact, we see that more women come in for the Registry
19 examination and we're seeing more reservists and guard
20 members than were deployed to the Gulf.
21 Some of that is probably related to the fact
22 that people who are eligible for VA care are out of the
23 military, which means that we would have seen more
24 reservists and national guard members because they were
25 eligible for VA care as opposed to military care.
99 1 The other thing is that the mean age of the
2 Registry participants is slightly older than those
3 individuals deployed to the Gulf. It's about 30 years,
4 and again this is to help us put this in context and to
5 again illustrate the fact that to draw conclusion about
6 the entire population of Persian Gulf veterans from the
7 Registry may not be valid, because we know that these
8 individuals are different in some ways from people who
9 went to the Gulf, overrepresentation of women,
10 reservists, national guard and also a slightly older
12 Can I have the next slide? This is the listing
13 of the ten more frequently complaints that we see in the
14 Registry examination process, and it's based on an
15 analysis of the first 52,000 individuals who came in for
16 the Persian Gulf Registry examination.
17 And this has been pretty consistent over time
18 from our first analysis of 7,000 through the current
19 data. Fatigue, skin rash, headache, muscle and joint
20 pains, cognitive complaints, including memory loss,
21 decreased attention, decreased concentrating ability,
22 shortness of breath, sleep disturbances, diarrhea, some
23 problems with skin, chest pain, and again the rate of
24 individuals coming in with no complaints, ranges over
25 time between about 12 percent and 15 percent.
100 1 And we consistently see those. Some of those
2 complaints could be indicative of psychiatric disease,
3 stress-related disease. We certainly see these symptoms
4 in individuals with stress.
5 However, there are also typical multi-system
6 complaints that you might see in a general primary care
7 population. There are also not necessarily pointing to a
8 particular diagnosis.
9 Certainly we might see a combination of joint
10 pain, fatigue, and rash in a rheumacologic disorder, or
11 we might see fatigue and joint pain as a manifestation of
12 a psychiatric disorder, so just the symptom distribution
13 doesn't tell us very much about whether these are stress-
14 related symptoms.
15 We also have to recognize that the Registry
16 doesn't have a causal link between these symptoms and
17 diagnostic information. We don't ask the physicians to
18 record what they think the cause of the diagnosis -- so
19 we can make some hypothesis and hopefully learn something
20 from this data.
21 Again, saying that any of these things are
22 stress related is very difficult.
23 And switch slides. And let's look at what kind
24 of diagnoses physicians who have done these Registry
25 examinations have given in the first 52,000 veterans who
101 1 have come through. And what we see is that there's a
2 very wide range, a whole spectrum of different medical
3 and psychiatric diagnoses that have been given to Persian
4 Gulf veterans who have completed this examination.
5 Mental disorders make up only 15 percent of
6 that total number, and if you look down at the bottom of
7 the slide, about 26 percent have no medical diagnosis, at
8 least on the phase one Registry examination.
9 And what those 26 percent represent isn't clear
10 from the Registry information. I think we have to look
11 further at some scientific research studies to further
12 design what those individuals actually represent.
13 Some of them may be healthy. Some of them may
14 have an undiagnosed illness, and it's impossible to
15 further characterize them from this data.
16 I think it's also important to recognize that
17 none of those percentages stick out in particular as
18 being different from what we might see in another
19 population of veterans. That doesn't mean to say that we
20 can directly compare this population to another primary
21 care population and have any scientific certainty that
22 there is no difference.
23 Again, the prevalence of diagnoses and whether
24 there's an increased rate of diagnosis of any of these
25 conditions in Persian Gulf veterans, can only be
102 1 definitively ascertained by well-designed research
2 studies. This is a health surveillance system and really
3 is a hypothesis generating tool.
4 Next. Initially we had a dramatic
5 overrepresentation of reservists and national guard in
6 the Registry, again probably related to the eligibility
7 of the individuals involved.
8 Over time, as people have left active military
9 service and are now eligible for the VA, the percentage
10 of active duty or individuals who served on active duty
11 in the Persian Gulf has gone up over time, but we wanted
12 to look at whether there were any recognizable
13 differences in the types of illnesses we were seeing in
14 the different military components, active reserve or
15 guard, and we can see that really there doesn't seem to
16 be any substantial difference in the distribution of the
17 kinds of diagnoses between active duty, reserve and guard
18 units, and the percentages of mental disorders which is
19 what your main topic of discussion is today, seem to be
20 pretty consistent over those three groups.
21 Why don't we go ahead and change slides? We
22 can break those down a little bit further and our
23 environmental epidemiology service broke out some of the
24 diagnoses of interest for us here. We can see that
25 anxiety states are diagnosed at under two percent in all
103 1 three groups.
2 Tension headaches, which may in part be stress
3 related but certainly have other musculoskeletal
4 etiologies like cervical spine disease, arthritis,
5 temporomandibular joint dysfunction, could potentially be
6 the cause for a muscle contraction or a tension type
7 headache, don't seem to be different between the three
9 Chronic PTSD is being diagnosed at a rate of
10 about two and a half to three percent in those
11 populations and depressive disorders we can say at about
12 2.5 percent. Again, not dramatic differences between
13 active duty, reserve and national guard, from the Persian
14 Gulf Registry data.
15 Why don't we go onto the next slide? People
16 have been interested in finding another group of deployed
17 veterans to compare to, and one of the groups that was
18 readily available to us was from our Agent Orange
19 Registry. We have a similar registry with similar
20 examination protocol for the Vietnam veterans.
21 And in fact the distribution of diagnoses is
22 slightly different between those of the Persian Gulf
23 veterans and Vietnam veterans. Persian Gulf veterans
24 have a lower rate of diagnosis on registry examinations
25 of neurotic disorders and alcohol dependence, and
104 1 approximately the same rate of diagnosis of PTSD,
2 interestingly, even though the combat situations were
3 dramatically different.
4 Let me go onto the next slide. The other
5 information that we have on the health of Persian Gulf
6 veterans comes from our hospitalization records. We have
7 the ability to look at all discharge diagnoses nation-
8 wide, on Persian Gulf veterans, and we can compare them
9 to Gulf era veterans.
10 But remember that we said the eligibility for
11 care in the VA is different between the Persian Gulf
12 veterans who automatically if they feel that their
13 condition is related to an exposure that occurred in the
14 Gulf are eligible for VA outpatient and inpatient care,
15 whereas Gulf era veterans, people who served in the
16 military at the same time but didn't get deployed, are
17 only eligible if they're service-connected or indigent.
18 So comparisons again need to be looked at with
20 We can see that again, both populations who are
21 admitted to VA hospitals are older than the average age
22 of 28 for the deployed individuals, and we're seeing
23 again a slight increase in the number of women in both
24 groups who are admitted to VA hospitals.
25 Let's go onto the next slide. If we look at
105 1 the diagnostic information from this PTF file, the
2 inpatient discharge file, we can see that if you look at
3 mental disorders, the rates of admission are pretty
4 comparable, maybe slightly increased rate of admission
5 for alcohol dependence in the Gulf veterans compared to
6 the era veterans, and a slight increase in mental
7 disorders overall, probably related again to the increase
8 in the rate of admission for alcohol dependence.
9 Now, again I would interpret that with a high
10 degree of skepticism, knowing that there is a dramatic
11 difference in eligibility for admission, and the VA has a
12 well regarded alcohol and substance abuse program, which
13 is not well covered by a lot of private health insurance
14 companies. So it may be that Persian Gulf veterans are
15 self selecting to come into VA hospitals for this care
16 more frequently, or the difference could be explained by
17 eligibility or it could potentially be a true difference
18 in the rates of that diagnosis in this population. It's
19 impossible to sort that out with just a look at this
20 hospitalization data.
21 And I think over the course of my discussion
22 you've heard me say a number of times that we have
23 limitations in what we can do with the VA Registry data.
24 Again, it's a self-selected population. It was set up as
25 a health surveillance system, and also to allow Persian
106 1 Gulf veterans to come in and have access to VA health
2 care but not as a research tool, and really not as a tool
3 to give us definitive answers.
4 I don't think that we can make any valid
5 definite -- draw any valid definite conclusions from this
6 information. I think it gives us a sense of the spectrum
7 of illnesses that we're seeing in this population, and I
8 think it tells us that the rates of psychiatric
9 diagnoses, at least from the basic information that we
10 have, from people who have self selected and voluntarily
11 come into the VA for the Registry examination, don't
12 appear to be above the population rates that you might
14 And I think we need to go on and do careful,
15 well-designed research investigations to better
16 understand the health issues in Persian Gulf veterans.
17 Some of those are underway. We'll hear from Dr.
18 Southwick in just a few minutes, and later this afternoon
19 from the Boston Environmental Hazards Research Center
20 from Dr. Susan Proctor.
21 And I think that they have some very
22 interesting information that will be much more helpful to
23 you actually than some of the very basic kinds of
24 information we have from the Registry.
25 DR. HAMBURG: Thank you very much, Dr. Murphy.
107 1 You've handled a great deal of information in a very
2 concise way and also treated the data with great care.
3 We appreciate that. I think it would be wise for us to
4 go on to Dr. Southwick and Dr. Engel and then have
5 questions for all, because I want to be sure that
6 everybody has an adequate opportunity as we go through
7 the afternoon.
8 Dr. Southwick is from West Haven VA Medical
9 Center, which of course is associated with Yale
10 University, an important source of research in this
11 field. Dr. Southwick, thank you for joining us today.
12 DR. SOUTHWICK: I want to thank the panel for
13 inviting me to share some experiences we've had in
14 working with combat veterans and today I'll talk about
15 trauma related and psychological symptoms and veterans of
16 Operation Desert Storm.
17 As you know, when an individual is severely
18 stressed, there are a number of experiences that are
19 common at the time of trauma. And these include intense
20 fear and terror, helplessness, loss of control, threat of
21 annihilate, normal adaptations to life are also
23 There also may be a constriction or a shutting
24 down, freezing behaviors for example, or disassociation.
25 It's not really happening to me, it's as if I'm watching
1 a movie.
2 Now, stress that cannot be controlled by the
3 individual, uncontrollable stress, has far greater,
4 negative, psychological and biological consequences, than
5 stress that can be controlled, controllable stress, and
6 animal studies have shown this repeatedly.
7 If you think about combat stress, if a mortar
8 shell, a scud missile, is flying overhead, you have no
9 control over where that's going to land. Child abuse is
10 another form of uncontrollable stress. If your father,
11 parent comes home intoxicated and abuses you, you have
12 very little control over that stress.
13 Now, post-traumatic stress disorder can result
14 from a wide variety of traumas, including natural
15 disasters, violent crime, child abuse and in this case
16 combat. And the symptoms of post-traumatic stress
17 disorder are remarkably similar across traumas. I'm just
18 going to go through them very quickly for those of you
19 who may not be familiar.
20 There are the re-experiencing symptoms where
21 the traumatic event is persistently re-experienced.
22 recurrent and intrusive distressing recollections of the
23 event, images, thoughts, perceptions that one cannot
24 forget, haunting images. There are recurrent distressing
25 dreams, nightmares.
109 1 Actually many of these nightmares are more like
2 precise replications than fantasy dreams that you and I
3 may have. We've interviewed Holocaust survivors and
4 World War II survivors who have had the same dream for 40
6 There's also acting or feeling as thought the
7 traumatic event were recurring, flashbacks. These are
8 less common, and there's intense psychological distress
9 and physiologic reactivity to reminders of the trauma,
10 for example, even a hot day may remind one of experiences
11 in the Gulf War, in Vietnam.
12 The second symptom calls for the hyperarousal
13 symptoms, and I'll be talking a little bit more about
14 these today, such as difficulty falling asleep or staying
15 asleep. Severely traumatized individuals often sleep
16 with one eye open basically. They dread nighttime. They
17 often will sleep at day break.
18 Irritability or outbursts of anger. We feel
19 that this is partly in response to fear, essentially a
20 fight flight response.
21 Difficulties concentrating and hypervigilance.
22 We see veterans who have full-blown PTSD. It's not
23 uncommon for them to sit with their back to the corner,
24 wherever they are, to have elaborate security systems and
25 guard dogs, and they have difficulties in crowded places
110 1 because they can't monitor everything that's going on,
2 and basically it's hard to feel safe.
3 Exaggerated startle response is another
4 hyperarousal symptom.
5 A third symptom cluster in PTSD are the
6 avoidance symptoms, where the individual persistently
7 avoids stimuli associated with the trauma, and there is a
8 general numbing of responsiveness, and their efforts to
9 avoid thoughts, feelings or confrontations about the
10 trauma, and efforts to avoid activities or places that
11 arouse recollection.
12 And this can lead to quite a restricted life,
13 as the individual finds more and more places where
14 reminders cause difficulties and in some cases
15 individuals can become housebound.
16 There's also a general numbing of emotional
17 responsiveness, difficulty forming loving relationships,
18 particularly if one has experienced significant amount of
19 death in their trauma.
20 There's also what's called a foreshortened
21 future, a sense that there really is no future.
22 These symptoms can, as I said, limit life quite
23 dramatically. Now, combat trauma has been talked about
24 in etiology of PTSD for a long time. In the National
25 Vietnam Veterans Readjustment Study, the NVVRS, which
111 1 included 15,000 Vietnam veterans in the community, 15
2 percent currently still have a diagnosis of post-
3 traumatic stress disorder. That's 500,000 of the
4 3,000,000 who served 20 years after the war. Prevalence
5 rates for a World War II prisoners of war are much
6 higher, at 47 percent and 50 percent, and the natural
7 course of post-traumatic stress disorder is not well
8 understood, and there are people who talk about acute,
9 chronic, delayed, intermittent, residual and reactivated
10 types, but in fact most of the data is retrospective or
11 antidotal subject to inaccurate recall.
12 There are very few follow-along prospective
14 With Desert Storm several research groups from
15 around the country began to study the natural course of
16 trauma in a prospective way, and we also did a small
17 study we're continuing, and our objective was to examine
18 prospectively the development of trauma-related symptoms
19 and psychological symptoms, quote, psychological
20 symptoms, over time.
21 We studied 84 national guard reservists from
22 one medical unit, one military police unit. Subjects
23 completed questionnaires about their exposure to combat
24 and to specific stressors, and rated the severity of
25 their symptoms of PTSD on two different scales.
112 1 Differences in symptom severity were analyzed,
2 at one month, six months, and two years after the
3 subjects' return from the Persian Gulf.
4 So we used two questionnaires to determine the
5 PTSD symptoms, the re-experiencing symptoms, avoidance
6 symptoms, and arousal symptoms. We used a PTSD symptom
7 scale from DSM-3-R and the Mississippi scale for combat
8 related PTST, which is a very accepted scale.
9 We also used two scales to determine the level
10 of traumatic exposure. The combat exposure scale is a
11 widely accepted scale, but it really was developed for
12 Vietnam veterans, so we developed our own Desert Storm
13 trauma questionnaire, which was more specific to the
14 experiences that Gulf War veterans had during their tour.
15 These questionnaires included items such as
16 threat to personal safety, seeing others killed or
17 wounded, death of a close friend, sitting with the dying,
18 being stationed close to enemy lines, witnessing the
19 gross disfigurement of bodies as the result of wounds.
20 I wanted to say that although the combat
21 exposure per se was relatively limited in the Gulf, you
22 can see that combat exposure was 1.3 out of one to five,
23 which is between mild and moderate.
24 In fact, there was a great deal of what we call
25 anticipatory anxiety as soldiers awaited for this massive
113 1 ground war and for scud missile attacks, et cetera, and
2 many veterans talk about being in a near constant state
3 of alert expectation.
4 In our medical unit that we've been following,
5 they actually were quite traumatized as in addition to
6 scud missile, potential attacks, they were exposed to
7 small arms fire, the witnessing of grotesque body
8 disfigurement and several of the unit members were killed
9 as others in the company were forced to watch.
10 Now, the overall PTSD scores, the Mississippi
11 PTSD score increased significantly from one month to two
12 years after the war. The increase between month and six
13 months was significant, while the increase between six
14 months and two years was not significant. In other
15 words, most of the PTSD symptoms developed by the first
16 six months.
17 Now, these scores are not high. However, they
18 are increasing. If you just look at the top line total,
19 the scores of the Mississippi go from 57 to 63 to 66.
20 Most of the change is within the first six months.
21 Again, these are not high scores.
22 And using the PTSD, DSM-3-R, based scale,
23 scores go from seven to eleven and stay at about eleven
24 at two years.
25 In terms of the actual diagnosis of PTSD, you
114 1 have to meet a certain number of the criteria from each
2 category to make a diagnosis. Approximately ten percent
3 of the Desert Storm veterans developed full-blown PTSD
4 and as I said, one of our units was really quite
6 The veterans who met criteria for PTSD on the
7 Mississippi scale at one month or six months continued to
8 meet criteria at two years, so that in our sample if you
9 developed PTSD in the first six months, you continued to
10 have it at two years.
11 One of the most strongest findings to date in
12 the field of PTSD involves the relationship between the
13 level of traumatic exposure and the level of PTSD
14 symptomatology. The greater the combat, the greater the
15 likelihood of developing PTSD.
16 We did not exactly find this, although at two
17 years we did see a significant relationship between level
18 of combat exposure and level of traumatic symptomatology.
19 It turns out -- I don't have time to go into this -- this
20 is actually quite a complex relationship.
21 One of the reasons it's a complex relationship
22 is that there are other risk factors involved in
23 development of PTSD that numerous research groups have
24 discussed in other combat populations. We also in
25 preliminary results -- again, we have a very small hand
115 1 - found a trend or tendency for the history of family
2 trauma, that is, child abuse, a history of threat to life
3 during childhood, almost dying, a history of childhood
4 depression or anxiety, having a father who was in combat,
5 as well as level of combat exposure to be likely related
6 to the development of trauma-related symptoms.
7 Factors that we have not looked at that have
8 been discussed in the literature include personality
9 variables and degree of social support. As Dr. McEwen
10 mentioned, social support seems to buffer against the
11 development of PTSD in some cases.
12 We did a study in Vietnam veterans where
13 soldiers with a history of severe child abuse were more
14 likely to develop combat related post-traumatic stress
15 disorder than soldiers without a history of child abuse,
16 even after controlling for the level of combat exposure,
17 so the point is that there are numerous risk factors in
18 developing a PTSD. Combat exposure is certainly one of
19 the key factors.
20 Now, if we look at symptoms, nearly all
21 veterans reported one or more PTSD specific symptoms, one
22 month and six months after the war, two years after the
23 war 66 percent reported at least one symptom.
24 The most frequently endorsed symptoms at one
25 month were increased startle response, being watchful or
116 1 on guard, sleep disturbance and irritability. These are
2 all from the hyperarousal symptom cluster.
3 At six months and two years three of the
4 foremost frequently endorsed symptoms were from the
5 hyperarousal cluster. Intrusive memories, memories that
6 you don't want to think about, increased from one month
7 to six months to become one of the most frequently
8 endorsed symptoms at six months and two years.
9 So intrusive memory seemed to follow behind
10 hyperarousal symptoms.
11 The hyperarousal symptom cluster had a
12 significantly higher mean value at all three time points
13 than the re-experiencing cluster or the avoidance
14 cluster. The re-experiencing and avoidance symptom
15 clusters were not significantly different from each other
16 at any time point.
17 So in this graph the top line or the
18 hyperarousal symptoms and the other two are re-
19 experiencing and avoidance, hyperarousal is significantly
20 higher at all three time points.
21 Now, interesting we did a study in Vietnam
22 veterans, looking retrospectively, looking back over the
23 past 20 years of their life, and recalling as best they
24 could, year by year, what their symptom picture looked
117 1 And 57 percent recalled being on guard and 34
2 percent being easily startled, as either the first or
3 second symptom that developed, after or right around the
4 time of their return from the Vietnam War. Let's put it
5 this way, the first symptom that they noticed with regard
6 to PTSD were being on guard or being easily startled,
7 sleep disturbance. These are from the hyperarousal
8 symptom cluster. This is in fact similar to what we're
9 finding in the prospective study.
10 This is a graph of the 25-year course of
11 symptomatology has recalled retrospectively by Vietnam,
12 62 Vietnam veterans with PTSD and hyperarousal at all
13 time points.
14 Now, we also have done a small study of the
15 startle response in Gulf War veterans, and people
16 describe this and we think of this as a more objective
17 measure of startle, and so there's a way that you can
18 measure -- I won't go into the details -- the degree to
19 which an individual startles to sounds, and the magnitude
20 of acoustic startle response in ten Gulf War veterans
21 with PTSD was significantly greater than the response in
22 seven Gulf War veterans without PTSD and in 15 healthy
24 Most of what I'm going to be talking about from
25 here on in is about people who have PTSD. Not everybody
118 1 gets PTSD. The increased startle may reflect a
2 sensitization. Dr. McEwen talked about a sensitized
3 system of the fear alarm response created by the stress
4 of combat trauma.
5 Conclusions is very preliminary and small
6 studies that war affects nearly everyone, that most
7 combat-related symptoms develop rapidly within a period
8 of months. For some veterans PTSD can develop into a
9 chronic disorder, again for us it was a small percentage.
10 Hyperarousal symptoms appear to play a central
11 role in mid-development of expression of PTSD. That's
12 from this data, as well as other data.
13 It's interesting if you go back to the accounts
14 of World War II, you'll see this as well, and World War
15 I. We in experiencing symptoms do not in general explain
16 the onset and exacerbation of hyperarousal symptoms.
17 That's important because there are some notions that PTSD
18 is really a disorder of memory, and that the memories
19 intrude and in response to memories the individual
20 becomes hyperaroused.
21 There are other theories that PTSD is a
22 disorder of arousal and in response to arousal memories
24 A number of different pre-traumatic, pari-
25 traumatic, and post-traumatic factors influence the
119 1 likelihood of developing PTSD. There's a complex
2 relationship between the degree of combat exposure and
3 subsequent level of trauma-related symptomatology.
4 And the sequence of symptom development and the
5 natural course of the illness provide important clues to
6 underlying pathophysiology and treatment.
7 I'm not really sure how much time I have. Five
8 more minutes, I could talk a little bit about
9 hyperarousal in other combat populations. This chronic
10 state of hyperarousal is not new and it's gone by
11 different names in the past. Battle fatigue, combat
12 exhaustion, shell shock, operational fatigue, war
13 neurosis, irritable heart of soldiers.
14 The bottom line is that in the relatively small
15 number of Gulf War veterans that we have seen with PTSD,
16 it's very similar to the PTSD we've seen in other war
18 In the 1940's Cardner coined a term
19 "physioneurosis" to describe the physiologic arousal
20 resulting from severe psychological trauma. For Cardner
21 this was a neurosis with a profound underlying
22 physiologic basis.
23 Similarly, Grinker and Spiegel in the 1940's
24 described this state of hyperarousal as follows. They
25 seem to suffer from a chronic stimulation of the
120 1 sympathetic nervous system. They perspire freely, are
2 tremulous, restless, irritable, sleep poorly, and look
3 very sick.
4 At times these symptoms suddenly increase,
5 especially in response to a mild auditory and verbal
6 stimuli, and the patients react as if they had received
7 an injection of adrenalin. This was written in the
9 In fact, some researchers and clinicians were
10 so convinced at that time that symptoms of combat
11 neurosis were caused by biological alternations, that
12 bilateral denervation of the adrenal glands was advocated
13 as a form of treatment for highly symptomatic war
15 Consistent with these observations a host of
16 psychophysiologic studies in World War II, I, Korean and
17 Vietnam veterans, have shown a heightened cardiovascular,
18 that is blood pressure and heart rate response, to
19 reminders of combat, reminders such as sights, sounds,
20 and smells in the laboratory.
21 And trying to summarize this large number of
22 studies, basically heart rate and blood pressure tend to
23 be increased in response to these reminders, in combat
24 veterans who had PTSD, but not in combat veterans without
25 PTSD, or in combat veterans with other anxiety disorders,
1 suggesting that combat per se in and of itself does not
2 always cause these changes.
3 Intrigued by these findings, a group of
4 researchers, Mason And Giller, Coston and others, some at
5 West Haven, looked at the amount of adrenalin and
6 noradrenalin that individuals excrete in their urine over
7 a period of 24 hours.
8 They collected 24-hour urine and you analyze
9 how much adrenalin and noradrenalin was in the urine, and
10 basically what has been found is that you can -- I won't
11 go into the details -- that combat veterans with PTSD
12 tend to excrete greater levels of norepinephrine and
13 epinephrine than other psychiatric diagnoses, with the
14 exception of bipolar amenia during a manic episode and
15 that this appears to be the case over time chronically,
16 and these were about 15 years after the war for this
17 particular sample.
18 Similarly, our Rachael Uhoda has looked at 24-
19 hour plasma sampling, where plasma samples of
20 noradrenalin were drawn every hour for 24 hours, and you
21 can see that the mean plasma and noraepherine or
22 adrenalin level is higher at all time points for the
23 group of Vietnam veterans with PTSD compared to normal
25 We similarly did what's called a Yohimbine
122 1 challenge study where he used Yohimbine and alpha
2 receptor antagonist that penetrates the blood brain
3 barrier and causes a brief but robust increase in the
4 brain's noradrenalin system, so if you give Yohimbine and
5 your brain's noradrenalin increases.
6 And what we found was that 60 percent of the --
7 again this is a relative small sample -- but 60 percent
8 of the veterans had a panic attack in response to
9 Yohimbine and 40 percent had a flashback.
10 So basically what you're doing is you're
11 administering a chemical that increases -- does a number
12 of things, but primarily increases the noradrenalin and
13 you see panic anxiety symptoms and PTSD symptoms, a
14 number of PTSD symptoms, including intrusive thoughts,
15 hyperarousal, hypervigilance, out of body disassociative
16 sorts of experiences.
17 And in a sub-group significantly increased MHPG
18 levels, which is a breakdown product of norepinephrine.
19 So it would appear that a sub-group of PTSD
20 patients, at least combat veterans, have a hypersensitive
21 noradenergic system that responds to Yohimbine with a
22 host of anxiety-like symptoms and reliving symptoms,
23 including intrusive thoughts and flashbacks.
24 The question of sensitization has risen.
25 Preclinical evidence suggests that norageneric neurons
123 1 can become sensitized by repeated stressors and also can
2 become conditioned to a variety of fear related stimuli.
3 But some traumatized individuals, it's as if
4 the arousal symptom is hard to turn off. If you're
5 walking through the jungle for a year waiting to step on
6 a mine, if you're in the desert for months waiting for a
7 massive ground war, you find yourself in an alert state
8 of expectation and for some individuals that's hard to
9 turn down.
10 Again, behavioral sensitization refers to an
11 increased magnitude of response, following repeated
12 presentations of particular stimulus, and a stressful
13 event, biochemical, physiological and behavioral
14 responses to subsequent stressors can increase over time.
15 And one of the reasons that, understanding the
16 natural course of trauma-related symptoms is important
17 and one of the reasons it's very important to understand
18 the underlying pathophysiology is it allows for more
19 specific treatment, because it's very difficult to treat,
20 as we all know, very difficult to treat something that we
21 don't fully understand.
22 Thank you.
23 DR. HAMBURG: Thank you very much. Very
24 interesting, substantial presentation. We turn now to
25 Dr. Engel, with the Department of Psychiatry at the
124 1 Uniformed Services University of the Health Sciences.
2 Dr. Charles Engel, thank you for joining us.
3 DR. ENGEL: I was asked as I went to lunch
4 whether I was for or against Gulf War veterans, and I
5 guess I would hope that I can do a balance job of
6 presenting the comprehensive clinical evaluation program
7 as it pertains to mental disorders, by virtue of the fact
8 that not only am I an employee of the Army obviously,
9 based on my uniform, but I'm also a Gulf War veteran, so
10 I have a very active interest in learning more about this
11 health phenomenon that is occurring in Gulf War veterans.
12 And I'm going to speak to you in particular, as
13 I mentioned, about psychological conditions in people
14 coming to the Department of Defense for their
15 comprehensive clinical evaluation program.
16 As you're aware, there's been a great many
17 biological exposures that have occurred in Gulf War
18 veterans, and I'm going to skip over those for the most
19 part, just because we are talking specifically about
20 psychological kinds of stressors.
21 And I'm not really going to focus on even the
22 psychosocial stressors per se, simply because they are
23 listed here and I have a lot more material that I'd like
24 to be able to cover, but one which I would point out is
25 the isolation that many have felt amid post-war
125 1 celebration. There was a good deal of celebrating that
2 went on after the war, and I think there was a
3 significant and silent minority of people for who that
4 was actually a fairly stressful experience, because they
5 weren't really joining into that celebration.
6 And subsequently, a we all know, those of us
7 who are here, there have been increasing reports of some
8 sort of illness and the possibility even of congenital
9 anomalies related to that, and in 1994 in response to
10 that the Department of Defense initiated their
11 comprehensive clinical evaluation program to provide Gulf
12 War veterans an opportunity to receive a thorough health
13 care evaluation, as thorough as possible, within the
14 military system constraints.
15 Over the course of time a series of reports
16 have been presented to the Institute of Medicine on the
17 Department of Defense's clinical comprehensive clinical
18 evaluation program, and over the course of those reports
19 and dialogues, responses from the Institute of Medicine,
20 it has become apparent that psychologic conditions, using
21 the jargon of the ICD diagnostic categories, are the most
22 common primary diagnosis in Gulf War veterans reporting
23 for this care, and also the second most common overall
24 diagnosis and through the series of meetings with the
25 IOM, the IOM made clear its desire to further exploit
126 1 this issue of stress and its relationship to problems in
2 the -- health problems in Gulf War veterans.
3 I'm going to present to you some analyses that
4 I have done, and one thing I'd like to emphasize is that
5 there is a program management team that has designed and
6 essentially administered over the comprehensive clinical
7 evaluation program. I am not and have not even been a
8 member of that program management team. They've been
9 very helpful to me in making data available to analyze
10 and think about and look at, and I have helped them at
11 various stages, but I am not a voice of the program
12 management team.
13 These are my opinions about my educated
14 reasonings about the analyses that I've done with some
15 help from the program management team.
16 What we're going to be looking at is
17 essentially the prevalence of psychological conditions
18 diagnosed amongst Gulf War veterans during the
19 comprehensive clinical evaluation.
20 And another thing that I want to highlight
21 here, which is sort of a methodologic issue in making
22 sure that we know what we're talking about, I'm going to
23 use the awkward wording of sometimes psychological
24 conditions diagnosed to diagnosed psychological
25 conditions really to focus on and highlight the point
127 1 that what we're talking about is the epidemiology of a
2 diagnosis, the validity of that diagnosis could be
3 debated, but certainly the epidemiology of the diagnoses
4 themselves are clear.
5 So I'd like to talk about the relationship of
6 psychological condition diagnoses within the
7 comprehensive clinical evaluation to gender, occupational
8 impairment, a little bit about satisfaction with the CCEP
9 and then also to investigate the relationship between
10 veteran reported combat experiences and the number of
11 psychological condition diagnoses that they have, that
12 they've been assigned.
13 The methods of the CCEP -- I'll try to be brief
14 about that -- essentially it's a selective sample, to a
15 large extent a sub-selected sample of Gulf War veterans
16 who -- or their family members who wish to be further
17 evaluated for their potentially Gulf War related health
19 And the analyses that I'm presenting to you are
20 almost exclusively based on the initial 10,020 minus
21 those who were not on active duty and those who did not
22 participate directly in the Gulf War. Those people were
23 excluded, and that number dropped from 10,020 to about
24 9,800 participants in these analyses. So these are
25 analyses of people who were there.
128 1 In the CCEP they go through a -- first a phase
2 one assessment, which is close to their station or home.
3 It's a thorough primary care assessment, along with some
4 retrospective assessments of both psychological and
5 physiologic exposures. Based on whether or not a
6 satisfactory explanation is noted for the individual's
7 problem, they either are or are not referred to phase
9 Phase two occurs at one of many medical center
10 sites within the Department of Defense, and a series of
11 more intensive specialty evaluations occurs, including a
12 psychiatric assessment by design, includes a SCID,
13 structured clinical interview for DSM, as well as a CAPS,
14 the clinical assessment for PTSD scale, a fairly rigorous
15 assessment. But again, those are only the phase two
17 These are sample demographics. One thing in
18 helping you to interpret these demographics worth noting
19 is that the age is at the time of the assessment, so
20 although they're are quite a bit older than the 28-year-
21 old average age that was presented earlier, this is also
22 an average of about four to five years after the Gulf
24 Otherwise, you can see that as with the VA
25 sample, there tends to be more women in the sample than
129 1 in the general population in the military, or of those
2 deployed. There also tends to be a high proportion of
3 enlisted folks as well as primarily caucasian groups, and
4 relatively small difference in demographics between those
5 who participate in phase one versus those who participate
6 ultimately in both phases.
7 These are some of the diagnoses, the more
8 prevalent diagnoses that come up when looking at the
9 comprehensive clinical evaluation diagnostic data set.
10 The diagnostic data set includes up to seven diagnoses
11 for each individual so there is a primary diagnoses
12 listed here as well as whether or not they had any -- one
13 or more psychiatric diagnoses amongst their seven
15 And you can see that the more common diagnostic
16 groupings here are the somata form problems, anxiety
17 disorders and mood disorders. And a comment about the
18 somata form problem is the vast majority of those folks
19 seem to be subsumed under this group of tension headache
20 and some debate has occurred, and I agree it's an
21 important question whether tension headache can
22 reasonably be placed under a somata form problem, or
23 whether it would be seen as a pain disorder, or whether
24 it would be seen as something else, and I think that
25 would depend on the provider.
130 1 For the purpose of these I'm lumped them but
2 you can see that while in the primary diagnosis category,
3 while somata form problems appear to be fairly prevalent
4 at nearly five percent of those folks in the sample, when
5 you take away the 3.4 percent with tension headaches,
6 those with somata form problems as their primary
7 diagnosis drops down quite a bit lower on the list.
8 Again, anxiety and mood disorders, PTSD, about
9 5.3 percent of the overall sample had a diagnosis of PTSD
10 somewhere amongst their seven diagnoses.
11 So about one in 20 folks had post-traumatic
12 stress disorder diagnosed.
13 This slide is to highlight the fact that not
14 only were psychological conditions commonly diagnosed,
15 but they were commonly diagnosed together. Down here you
16 can see the number of psychological conditions diagnosed,
17 and the percentage of individuals in the sample analyzed
18 who had that number of diagnoses.
19 You can see that those -- and the curve to the
20 left is actually those in phase one and the curve in the
21 right are those in phase two, so what you can see is that
22 not only are they common in their co-morbid but also
23 those who reach phase two -- those who go through the
24 phase two part of the assessment, presumably those whose
25 symptoms are unsatisfactorily explained, after phase one,
131 1 have a particularly high prevalence in co-morbidity of
2 psychological condition diagnoses.
3 This highlights general relationships. What
4 you can see here are findings that are not world
5 shattering with regard to substance and mood, that as has
6 been shown in a wealth of epidemiologic literature and
7 various samples, both health care seeking and community
8 based, substance abuse diagnoses are significantly more
9 common among men, and mood disorder diagnoses are
10 significantly more common among women, and that all
11 diagnoses roughly occur at about the same rate across
12 both men and women.
13 An interesting non-finding is in the somata
14 form group, one would expect based on previous
15 literature, again in both health care seeking and non-
16 health care seeking samples, that the somata form
17 problems would be predominantly occurring in the women.
18 The fact that men have roughly the same rate of
19 somata form problems suggests that perhaps it goes back
20 to this -- or these diagnoses that are valid diagnoses
21 somata form problems. Are we dealing with essentially
22 idiopathic symptoms o some other etiology that are being
23 labeled as somata form problems.
24 So that's an interesting area of focus. It's
25 worth mentioning. The sorts of things that become
132 1 labeled as somata form by and large and things that are
2 symptoms in which a cause cannot be ascertained and
3 psychological causation is presumed.
4 Going beyond just a symptom picture, I think
5 it's important to look at the relationship between
6 impairment, functional impairment, in folks participating
7 in the CCEP as it relates to whether or not they were
8 diagnose with a psychological condition.
9 And while much has been said times about the
10 low numbers, below absolute numbers, mean number of lost
11 work days in the last 90, what this graph shows fairly
12 clearly is that as the number of psychological conditions
13 diagnosed increases, the number of lost workdays also
14 increases in a somewhat graded or dose response, if you
15 will, fashion, leading one to feel more strongly that
16 perhaps there is a causal link between severity of
17 psychological conditions and functional impairment.
18 The reason this becomes even more important is
19 if the population of CCEP attenders are looked at as a
20 whole. If you take a population based perspective and
21 look at this, what you can see is that while
22 psychological conditions has a mean lost workday of only
23 3.7 in the last 90, which would appear to be fairly low,
24 it's also a very prevalent condition, meaning that fully
25 3300 people out of the then 18,600 participants, that
133 1 this table is drawn from, that fully 3300 of those folks
2 lost 3.7 on average workdays related to a primary
3 diagnosis of a psychological condition, leading to fully
4 28 percent of overall lost workdays. That's 28 percent
5 of 43,000, almost 44,000 lost workdays in this
6 population, associated with a primary diagnosis of a
7 mental disorder.
8 By contrast, neoplasm, which had the highest
9 rate per person of mean lost workdays, nine out of the
10 last 90, only 144 folks in the entire sample experienced
11 that mean and, therefore, only three percent of the
12 43,000 lost workdays were due to neoplasm.
13 So what this highlights is that if we want to
14 take a population based perspective to this problem of
15 occupational impairment, a careful view of what can be
16 done for folks diagnosed with psychological conditions,
17 may be very cost effective.
18 And then finally, this slide highlights a
19 similar sort of, if you want to call it dose response
20 relationship between the number of combat experiences
21 that combat veterans participating in the CCEP related,
22 and the mean number of psychological conditions that they
23 were diagnosed with, suggesting again a relationship
24 between the severity of trauma that they faced and the
25 Gulf War, and their psychological condition at the time
1 of being seen for the CCEP, and also adding some validity
2 to this analysis is the fact -- I went back and looked
3 my diagnosis, which ones were related to number of combat
4 experiences, and the only psychiatric diagnosis that was
5 related to combat experiences was post-traumatic stress
6 disorder, other than overall group of diagnoses.
7 I'm going to just quickly look at this slide,
8 which illustrates a point made earlier, that those folks
9 who reach and are seen in phase two of the comprehensive
10 clinical evaluation program, psychological conditions are
11 very, very commonly diagnosed. Twenty-eight percent of
12 them have it as a primary diagnosis and over half of them
13 had one or more diagnoses.
14 So I won't dwell on the summary of results for
15 the sake of time and I know how we're doing here. But
16 just to highlight that 19 percent in this sample of CCEP
17 veterans have primary diagnosis of a psychological
18 condition, 37 percent overall.
19 This is lumping phase one and phase two had at
20 least one psychological condition diagnoses, depression
21 and anxiety and tension headache are the most common
22 diagnoses observed within the data, and there was a
23 moderate association noted between combat exposure or
24 combat experiences and psychological condition diagnoses.
25 Another point that I would make is that these
1 analyses were repeated in a multi-variable fashion,
2 adjusting for age, race, rank and number of medical
3 diagnoses, sort of as a way of adjusting for severity of
4 medical illness and the results remained essentially
6 Study limitations as were mentioned by Dr.
7 Murphy I think definitely apply. The sample is non-
8 systematically obtained, generalized ability is
9 uncertain. There's a definite health worker effect, that
10 is going on within the sample that the sickest Gulf War
11 veterans are -- were probably not represented in this
12 data set because it didn't start until 1994, and most of
13 those folks were no longer in the military.
14 That's likely to truncate some of the
15 relationships that are described here. Other problems is
16 that there were no explicit case criteria applied for
17 diagnoses, such as psychological condition diagnoses made
18 in phase one and no specific criteria for mental health
19 referral at phase two, making it again hard to interpret
20 what all this means.
21 There was no specific screening done for mental
22 disorders and there is likely to be substantial variation
23 across different providers and their sensitivity in this
24 area, and validity of diagnoses and the traumatic
25 experiences as asked in the CCEP evaluation are
136 1 essentially unstudied and unknown.
2 And again, there was a limit of seven
3 diagnoses, and it's likely that not only some
4 psychological condition diagnoses, but other diagnoses
5 may have been left off the list, if there were more than
6 seven diagnoses present.
7 So conclusions that I would put forth from this
8 are that among Gulf War veterans seeking evaluation in
9 the comprehensive clinical evaluation program,
10 psychological condition diagnoses are especially common,
11 especially for those veterans whose symptoms remained
12 unexplained after the initial primary care phase of
14 They are associated with reports of traumatic
15 combat experiences. They often co-exist with other
16 psychological condition diagnoses, and they are
17 associated with significant occupational morbidity.
18 And not really gleaned from this data set,
19 which is from the literature, certainly on anxiety and
20 depressive disorders, which seemed to be the predominant
21 diagnoses in this data set, for many of these diagnoses
22 there are available treatments and so it's important to
23 see that those with treatable disorders receive the
24 treatments that they need and based on previous
25 literature, there's much to believe that at least those
137 1 who were seen in the phase one portion of the evaluation,
2 there's a substantial amount of under-diagnosis that goes
3 on in primary care with regard to mental disorders.
4 Many recommendations could be made based on
5 these findings. Some that seemed important to me is the
6 development of a prospective mental health surveillance
7 system within the military, so that we can come up with
8 prospective assessments of combat exposure and that
9 through the course of time a very standardized
10 methodology can be developed for tracking the
11 psychological conditions and other medical conditions in
12 folks post -- pre and post-combat.
13 And then finally I think this issue around
14 folks with somata form diagnoses, the lack of a gender
15 difference there raises some curiosities to me. I think
16 closer looks should be given to those participants who
17 have somata form diagnosis and perhaps design comparable
18 control groups to which they can be compared to learn
19 more about that.
20 That's it. Thank you.
21 DR. HAMBURG: Thank you very much, Dr. Engel.
22 All of three of you have condensed a lot of information
23 in a short time and presented it with clarity. I notice
24 you've been very careful about the limitations as well as
25 the strengths of your data, which we appreciate.
138 1 We have just a few minutes for questions. Who
2 on the panel would like to -- Dr. Lashof.
3 DR. LASHOF: Dr. Engel, a little clarification
4 on this somata form disorder. At one point you indicated
5 that tension headaches were essentially the vast
6 majority, it looked like highest number. At another
7 point you said something about people with undiagnosed
8 illness are often put into the somata form disorder. I'm
9 left a little confused.
10 Can you tell me among those with PTSD syndrome
11 diagnosis, whether there was any cluster of additional
12 symptoms such as fatigue, muscle pain, rash, memory loss,
13 the combination that we've been hearing over and over
14 again, among the veterans? That's the commonest cluster
15 that we've been hearing about and I wonder whether those
16 are also seen in those, given the diagnosis of PTSD?
17 DR. ENGEL: One thing I would emphasize is the
18 fact that PTSD diagnosis only occur in about five percent
19 of the overall population of CCEP participants. So I
20 think that there is some -- it's probably a little bit of
21 an overfocus on PTSD to try to place this entire whatever
22 it is into a PTSD frame work, although certainly there --
23 as is consistent with the information presented by Dr.
24 Southwick, there are substantial numbers of folks out
25 there with somata forms of PTSD as well.
139 1 That didn't address your question directly. On
2 the issue of whether there is a clustering of symptoms
3 that seems to be like this chronic fatigue or Gulf War
4 Syndrome sort of thing, that the people are describing, I
5 don't know the answer to that directly based on my
6 analyses, but my understanding in talking with the
7 program management team with the CCEP is that they've
8 looked for such clustering and not found it.
9 DR. MURPHY: I think I could -- you know, in
10 looking at this information between VA and DOD and trying
11 to understand the differences in the two systems and the
12 differences in the rates of diagnoses, it seems to me
13 that depending on a clinician's underlying theories about
14 disease, one physician might call a Persian Gulf
15 veteran's somata form disorder and another might say they
16 have chronic fatigue syndrome or fibromalagia or multi-
17 chemical sensitivity.
18 It just depends on what you define as a
19 diagnosis. Somata form disorder essentially is a multi-
20 system complaints with no organic medical etiology and
21 you know, if someone has fatigue and headache and joint
22 pain, do you call them somata form disorder? Sometimes,
23 and other clinicians might call them chronic fatigue
24 syndrome, depending on which set of criteria you choose
25 to use.
140 1 DR. ENGEL: I totally agree with that and I
2 think in a way that relates to my point of taking a more
3 careful look at those folks with somata form problem
4 diagnoses within the CCEP data set.
5 My reason for proposing that is that basically
6 what you do have are idiopathic symptoms and if that
7 patient reaches a psychiatrist, you know the old adage,
8 if you're a surgeon, you use the scalpel. If you're a
9 psychiatrist, you talk.
10 If you're a psychiatrist, you may label that
11 person with idiopathic symptoms as having a somata form
12 problem, whereas if that individual makes it to let's say
13 an infectious disease specialist who is not as interested
14 in the psychiatric realm and a firm believer in the
15 infectious disease foundation of chronic fatigue, they
16 may well label it chronic fatigue.
17 The issue is people don't really know what
18 these are. In the case of a somata form problem, it
19 ultimately ends up taking on the label of a psychological
20 disorder, which is -- it's a presumptive label, really
22 DR. HAMBURG: Any other questions? We have
23 time for one more.
24 MR. CROSS: Just to follow up on that, exactly
25 what you're saying, I sense that when a veteran shows up
141 1 and starts working with a clinician and comes up with
2 some kind of a best guess to what's wrong with him,
3 because there's so many variations that a clinician can
4 choose to treat the individual's perceived illness, that
5 therefore translates to the reason we get so many
6 veterans that show up and say they're not getting the
7 proper care from the VA that they deserve.
8 DR. MURPHY: No. I take exception to that. I
9 think that you can treat the symptoms and in many cases
10 the treatment might not be terribly different between the
11 treatment of somata form disorder and chronic fatigue
12 syndrome and a chronic pain syndrome. Some of the same
13 medications are used.
14 So I wouldn't say that the veterans are getting
15 inadequate treatment. I think that they are getting
16 symptomatic treatment and in many cases they're
17 frustrated because they're not being cured, but that
18 isn't unlike what you or I would experience, going into
19 any primary care provider.
20 Often what medicine does is give symptomatic
21 treatment when we don't know the cause.
22 DR. ENGEL: I think there is this phenomenon, I
23 guess, people being upset around being labeled as
24 psychiatric, but I guess I'm not really sure that I
25 understand your question exactly, but I do think that in
142 1 some cases, although distress is apparent on the part of
2 the veteran, that it may be that it offends their
3 sensibilities to some degree to be labeled as
4 psychiatric, and I think that in my own mind part of the
5 treatment for this phenomenon is to resist imposing your
6 own theoretical model for what causes it, and more
7 important is how can this person be returned to function?
8 How can this person reach a point in their lives where
9 they're able to function on a day-to-day basis?
10 And so a part of that means seeing the world
11 through that veteran's eyes. That veteran feels that
12 this I a physiologic condition in order to align myself
13 and improve their care, and not offend them to some
14 degree, regardless of what I might think. That's not to
15 say that I disagree with them.
16 But I would withhold my own quick opinion that
17 perhaps it is psychological.
18 DR. HAMBURG: One more question. John.
19 DR. BALDESCHWIELER: I presume, Frances, on
20 your analysis when you say 15 percent mental disorders,
21 that refers to diagnosable depression of schizophrenia
22 and so forth, and I think the hypothesis that really
23 arises from the morning presentation is that the observed
24 cluster of physical symptoms, and I think these are real
25 physical symptoms, has its origin in vulnerability to
143 1 stress.
2 And I guess I haven't heard in any of these
3 three presentations any kind of analysis that would
4 really detect that kind of causality. Am I saying this
6 DR. ENGEL: I did present the data that showed
7 that people -- there's a series of five questions that
8 were asked of veterans participating in the CCEP related
9 to different traumatic experiences they may have had, and
10 simply tallying up how many of those they answered
11 affirmatively, gave them a score, and I did show a table
12 that showed a relationship between the number of
13 traumatic experiences that they reported and the mean
14 number of psychological conditions that they were
15 diagnosed with in the CCEP, suggesting perhaps that those
16 traumatic experiences were at least for a sub-set of
17 those folks, responsible for their current psychological
19 DR. BALDESCHWIELER: But I think the thing I'm
20 struggling with is that the physical observables here are
21 real in the sense that pain is being felt and that
22 there's a biochemical trail that on can follow, that
23 leads to those observed physical symptoms.
24 And I think it's mislabeling it to call it
25 psychological, isn't it? I mean, there are real
144 1 observables here that one can measure if one is looking
2 for the right thing.
3 DR. MURPHY: I guess I would stratify further,
4 I don't think we can say that every Persian Gulf veteran
5 who comes in with multi-system complaints is going to end
6 up with a stress-related disorder or diagnosis. I think
7 that's much too simplistic.
8 I think it certainly probably explains a
9 fraction. We could debate about what percentage that
10 actually represents, but a fraction of Persian Gulf
11 veterans probably are suffering from stress-related
13 The theories presented this morning were very
14 interesting, and I think the preliminary data again is
15 intriguing, but I think we have to put it in perspective
16 that those are research hypotheses, they require further
17 testing, and it can't be directly applied clinically at
18 this point.
19 They really are -- at this stage they're to be
20 incorporated into research studies, so that we can better
21 understand what Substance P means, when we measure it in
22 spinal fluid of people with fibromyalgia and whether
23 stress is somehow related to those levels and the degree
24 of disability in some of these symptoms syndromes.
25 And I think that there are a large number of
145 1 Persian Gulf veterans who have conventional medical
2 diagnoses that have nothing to do with stress. They
3 would have gotten them either as a result of an exposure
4 that occurred in the Gulf, not stress related, or may
5 have gotten them even if they had stayed here in the
7 You know, there's a wide spectrum, but a
8 portion of these illness I think, you know, ultimately
9 may be related to stress and to causation.
10 DR. HAMBURG: I think we better move on.
11 DR. LASHOF: I just wanted to say that it might
12 be helpful to try to clarify some of this. The point I
13 was getting at before was if some of the physical
14 symptoms are due to stress as we heard this morning, if
15 that theory pans out, then you might expect that those
16 who get a clear-cut diagnosis, a post-traumatic stress
17 disorder, which is a recognized entity due to stress,
18 might also show some of the physical symptoms, the
19 asthma, the allergies, and some of the other thing that
20 we heard to stress, at least these are a group that
21 you're diagnosing as having a stress disorder, and I'm
22 wondering if one looks more thoroughly at that group,
23 whether you would find more or less of them having some
24 of these other physical symptoms that this morning were
25 postulated as due to stress.
146 1 DR. SOUTHWICK: I think that's a very important
2 question. We don't have any data that we can use to
3 answer that question, but one of the complexities is that
4 I imagine individuals have different vulnerabilities,
5 both physically and psychologically, so that while stress
6 causes PTSD or could cause PTSD in one individual, it may
7 not cause PTSD in another individual, but might in fact
8 manifest itself in some other somatic form. That's a
9 very good question if someone has the data to look at.
10 DR. HAMBURG: Thank you Dr. Murphy, Dr.
11 Southwick, Dr. Engel. Thank you very much for a very
12 interesting and informative session. It's a shame we
13 have to race on, but we do. Thanks so much.
14 Now, I call on Dr. Susan Proctor from the
15 Boston Environmental Hazards Center and Boston VA Medical
16 Center on risk factors, protective factors, and
17 differential outcomes in Gulf War veterans. Dr. Proctor.
18 DR. PROCTOR: Thank you very much for this
19 invitation. I'm not sure if you can read the title in
20 red. The red doesn't seem to come out very well, but I'm
21 going to talk about some data from part of phase three or
22 time three of this study we're doing right now that may
23 answer some of your questions about PTSD and health
24 complaints to some extent.
25 I wanted to recognize the colleagues that I'm
1 working with, Dr. Jesco Wolf, specifically Dr. Jesco Wolf
2 and Dr. Roberta White. Dr. Jesco Wolf initiated the Fort
3 Devens ODS reunion survey study, and I am going to be
4 presenting some preliminary data from time three, and Dr.
5 Roberta White is the research director of the Boston VA
6 Environmental Hazards Center.
7 The Fort Devens ODS reunion survey is a
8 longitudinal study of the U.S. Army, Persian Gulf war
9 veterans, who have been followed since their return from
10 the Gulf War.
11 In the spring of 1991, 2,949 people that came
12 back through Fort Devens were initially surveyed, in
13 largely a questionnaire kind of format, looking at
14 readjustment issues and psychological and physical health
16 They were resurveyed at time two, which is
17 winter of 1992, spring of '93, and roughly 79 percent or
18 2315 were surveyed at that time.
19 And currently right now at time three, we are
20 collecting data on a stratified random sample of 200
21 subjects from the time two sample. Women were over-
22 sampled in order to obtain an equal number of men and
24 This is the characteristics of the cohort at
25 time one. The mean age was -- can I focus from here --
1 30 years of age, so they're a little older than the Gulf
2 deployed group, but not by much.
3 The Devens cohort is importantly different from
4 the deployed sample in that it's largely guard and
5 reserve troops and primarily caucasian.
6 This is just a graphically represent how we did
7 some -- we did the sampling at time three to get a random
8 stratified -- cause a stratified random sample of 200
9 people. Primarily we wanted to select people that were
10 reporting high numbers of symptoms and people reporting
11 low numbers of symptoms to get an equal distribution
13 In general -- but we based it on the median
14 split of numbers of health symptoms reported at time two,
15 so it generally is a quasi random sample, the whole 3,000
17 Additionally we sampled, looking at high and
18 low units, because at later points in time we thought
19 that there might be some troop location data based on the
20 units, not on individuals, so we wanted to look -- have
21 the capability of looking at unit level information.
22 At time three we repeated most of all the
23 survey measure that were done at time two and these
24 include the Mississippi PTSD scale, combat exposure
25 scale, and the brief symptom inventory. Those are the
149 1 three major ones, but there were some other ones having
2 to do with social support and family support issues.
3 We've done -- doing comprehensive
4 neuropsychological testing, looking at memory and
5 attention, and motor control, also conducting
6 environmental interviews to look at self-reported
7 information on where troops were when they were in the
8 Gulf, as well as self-reported exposure circumstances,
9 experiences and also their current health histories.
10 We are also doing a comprehensive psychological
11 diagnostic interview, doing CAPS, the clinician
12 administered PTSD scale, which Dr. Engel described and
13 also the SCID, the structure clinical interview for DSM-
15 The data that I'm going to talk about today is
16 largely looking at some of the health symptom reporting,
17 as well as the psychological diagnostic data that's been
18 collected on roughly around 90 people from the time three
20 This is just -- they're asked one question to
21 generally rate their health before Operation Desert
22 Storm, while they were overseas, six months after ODS,
23 and one year past Operation Desert Storm, and now, and
24 this is just a percentage who rated their health as very
25 well. Very well was a five point lickert scale, very
150 1 well was five.
2 As you can see in general, people rate their
3 health as worse now or getting -- not very well any more.
4 This is the rates based on -- the PTSD rate is
5 based on the CAPS, clinician interview, and the other
6 psychological axes diagnoses are based on the SCID.
7 These are not mutually exclusive. Some people
8 have more than one diagnosis here, but this is a general
9 -- what we're seeing now at time three.
10 We had low rates of somata form disorder at 2.4
11 compared to some other rates I've seen, but PTSD rate in
12 this sample is around eight percent, which I'll talk
13 about a little later also.
14 What this slide shows, these are two two-by-two
15 tables. The top one is looking at people that are
16 considered in the low health group or people having --
17 reporting now or no numbers of health symptoms, the top
18 line, and the second line is the people on the high
19 health group.
20 And across the top is people that are less than
21 89 on the Mississippi PTSD scale and 89 is considered a
22 cut-off score for presumptive PTSD status. So basically
23 what the top two-by-two tables shows that there are five
24 people that would -- are considered having PTSD, based on
25 the Mississippi and all five of them are in the high
151 1 health group.
2 There are no people with presumptive PTSD on
3 the Mississippi that are in the low health group. The
4 bottom two-by-two table is similar, except for the PTSD
5 diagnosis is based on the CAPS, the clinician
6 administered PTSD scale. It is showing simile
8 This is just a slide looking at subject
9 characteristics between the three groups, the people that
10 are considered having high numbers of health symptoms and
11 PTSD, versus people with high numbers of health symptoms
12 without PTSD and people in the low health group without
14 In general the age and education are not
15 significantly different across the groups. As you would
16 expect, the combat exposure mean is significantly higher
17 in the people with PTSD.
18 The gender breakdown I relatively even. The
19 other information is based on looking at self-reported
20 information on what they do for jobs and what they might
21 have been exposed to, not in the Gulf particularly, but
22 other occupational jobs that they may have had.
23 This is looking at those same three groups and
24 their reports of headaches and forgetfulness and
25 difficulty concentrating. In general there are five
152 1 people that are with presumptive PTSD in the high health
2 group, and most all of them are reporting health
3 symptoms, those health symptoms, but you also see that
4 people without PTSD are also reporting a large number of
5 those health symptoms.
6 The bottom part of the slide looks at the
7 recent symptom inventory subscale for somatization and
8 depression, as well as the global severity index. In the
9 Mississippi PTSD the mean scores across these groups.
10 And what you see are the people that are in the
11 PTSD group are significantly higher on the BSI
12 depression, somatization and the Mississippi scale.
13 DR. LASHOF: I'm sorry. Since we can't read
14 the red, are these absolute numbers?
15 DR. PROCTOR: Yeah. The top table they are
16 absolute numbers. What is written in the red is the N's
17 which makes it hard to understand the -- sorry.
18 This is just a slide to look at showing some of
19 the PTSD prevalence rates in context. The top you can't
20 read in red, but the top is the data from the time three
21 data from the Devens cohort.
22 Current PTSD is eight percent and lifetime rate
23 is 12.6 percent but the lifetime rate is reduced to eight
24 percent, when you restrict the PTSD diagnosis as
25 resulting from a traumatic Gulf event.
153 1 We have a number -- well, not a number but we
2 have some people in our group that are Vietnam veterans,
3 and their PTSD is related to a traumatic Vietnam event.
4 We also have some people with sexual abuse and child
6 The numbers in the middle are from the sample
7 of Vietnam veterans. Coke -- all 1988 -- this is just
8 showing the lifetime PTSD rates, males and females, which
9 is dramatically higher than the Devens group, although we
10 are seeing higher rates in males than females.
11 The bottom numbers are from a U.S. community
12 sample from Kessler and all, 1995, which is actually
13 showing females with higher rates than males, but their
14 rates are somewhat comparable to the Devens rates that
15 we're seeing now.
16 In conclusion I just want to say that there are
17 several limitations in the particular analyses that we're
18 doing right now. First of all, it's just cross-sectional
19 data. We hope to be able to do some longitudinal data
20 from the time one and time two data over time, and also -
21 - we're also limited by a low base rate of PTSD and the
22 sample. There are right now five to eight people with
24 But it is our general impression right now,
25 given the data that we've examined, that those with PTSD
154 1 do report more health symptoms than those without PTSD,
2 and PTSD may contribute to increased health problems, but
3 PTSD most likely does not explain totally the increased
4 reporting of health symptoms by Persian Gulf War
6 Thank you.
7 DR. HAMBURG: Thank you very much. Questions?
8 Thank you. You answered my question that I -- thank you
9 very much. John.
10 DR. BALDESCHWIELER: The definition of PTSD for
11 this purpose is based on an interview the patient?
12 DR. PROCTOR: Yes.
13 DR. BALDESCHWIELER: What kind of questions are
15 DR. PROCTOR: They are questions asked about
16 the symptomatology that Dr. Southwick described, but it's
17 a standardized structure clinician administered interview
18 that's given regularly in clinical settings for diagnosis
19 of PTSD.
20 I can show it to you. I have one --
21 DR. BALDESCHWIELER: What I wonder is what's
22 the ground truth in a sense? Does that correlate with
23 other observables or --
24 DR. PROCTOR: What kind --
25 DR. BALDESCHWIELER: How do you know that this
155 1 is a valid --
2 DR. SOUTHWICK: It's widely accepted as a valid
3 instrument --
4 DR. PROCTOR: It requires a face-to-face
5 interview, a number of other studies that are being done
6 that use a Mississippi scale that are getting rates of
7 PTSD, is not a clinical interview structure. It's --
8 they're just given a survey to answer the questions.
9 DR. BALDESCHWIELER: On an operational sense,
10 PTSD is whatever it is that is determined by this
12 DR. PROCTOR: Yeah.
13 DR. BALDESCHWIELER: Could I just qualify, does
14 it follow the diagnostic and statistical manual criteria
15 it's basically focused on?
16 DR. PROCTOR: Yes. It's just very structured,
17 getting frequency and intense --
18 DR. BALDESCHWIELER: So it's entirely DSR-3 and
19 now four?
20 DR. PROCTOR: Yes.
21 DR. HAMBURG: Yes.
22 MS. BRIX: We've heard a fair amount today
23 about various risk factors that would put someone at
24 greater risk for developing a psychiatric problem if they
25 were exposed to stress. Dr. Proctor, could you talk a
156 1 little bit about protective factors that could cushion
2 someone perhaps if they were exposed to a very stressful
3 situation like combat or sexual trauma?
4 DR. PROCTOR: I can give you some information.
5 I'm not a psychologist, I will clarify that, say that up
7 Definitely social support aspects may buffer
8 some of the cases of PTSD -- whether a person gets PTSD
9 or not. There are lots of things that aren't known
10 specifically as to what could buffer, but I don't know --
11 I can't answer any further than that.
12 DR. HAMBURG: Other questions? Thank you very
13 much, Dr. Proctor. We appreciate your being with us.
14 And we now turn to Colonel James Stokes, the Army Medical
15 Department Center and School in San Antonio, a human
16 dimensions research program of the Army.
17 COLONEL STOKES: I want to thank you for
18 inviting me here today. I am speaking both about the
19 human dimensions research program, but the guidance I've
20 been given also is to look to how that's being applied
21 now, what we're trying to do to implement the results of
22 the previous research that's been done.
23 So I'm briefing you in addition to some of the
24 data on the human dimensions research program, how the
25 Army is organizing, operating some of the plans to
157 1 control stress and reduce stress-related casualties as
2 being applied now in Bosnia.
3 The challenge is how do we integrate the
4 research findings and the capabilities that the research
5 technology has given us into our ongoing field of mental
6 health and combat stress control activities, particularly
7 geared toward prevention and far forward intervention in
8 deploying units.
9 An important observation has been that there is
10 a very strong influence between leadership, unit
11 cohesion, other unit climate factors, and not only
12 mission accomplishment, which has always been a concern,
13 but of psychological symptoms at the time, physical
14 symptoms and complaints at the time, and stress
15 casualties at the time.
16 And there now is increasing data that these may
17 be persistent effects, that they may also show up in the
18 post-deployment period.
19 Much of the assessment and the research that
20 comes from this is the work of human dimensions teams
21 which are sent out by Army medical research and material
22 commands, specifically the Walter Reed Army Institute of
23 Research, the Department of Military Psychiatry, starting
24 actually long ago they had teams out in the Korean War
25 and Vietnam War, but the current work begins with teams
158 1 that were deployed over during Operation Desert Shield
2 before the ground war call took place. They were called
3 for by Senior Department of Army staff.
4 They conducted interviews down at the platoon
5 and company level, large sample of troops of all the
6 different types of combat arms, combat support, combat
7 service support units, and an even larger sample of
8 questionnaire surveys.
9 The questionnaire surveys, in addition to
10 addressing scenarios' specific problems have a brief
11 symptom inventory, which collects psychological data,
12 psychological distress, a health symptom check list,
13 which collects symptoms, basically a review of symptoms
14 for physical distress, and a unit climate survey which
15 assesses aspects of leadership, comradeship and unit
17 Follow-up studies from the Operation Desert
18 Storm have given some additional data. Let me provide
19 just a little bit of the information that came from
20 these, again the Walter Reed Army Institute of Research
21 is the principal group, but in the studies done doing
22 samples of both active and reserve component troops in
23 Desert Shield, Desert Storm, a pre-combat and immediate
24 post-combat, a delayed post-combat and then finally
25 follow-up studies on the troops.
159 1 I have a number of important findings. This on
2 this graph shows the percentage of the population who
3 were in fact exposed, according to their own self
4 reports, to highly traumatic events, as would be
5 expected. While most people had few or none, a small
6 number of people had many, but you can see a steady
7 increase in psychological symptoms with increasing
8 exposure to traumatic stress.
9 Out here we're dealing with very small sample
10 numbers, which I think can provide some of the
11 variability, but certainly notable increase in
12 psychological distress.
13 I think this does illustrate some of the issues
14 though. It's speculative, but why should we get so much
15 variation, even with the small sample? We do know that
16 troops who are partly self-selected to get into high
17 risk, high stress, danger, who have undergone tough
18 realistic training and who are expecting to be exposed to
19 highly traumatic events, are going to generally be much
20 more resistant than would people who find themselves in
21 it without either the mental or the training preparation.
22 But these were people exposed to clearly
23 traumatic events. The same data was looked at for people
24 who had just been exposed to increasing degrees of combat
25 or combat-like stress, without actually being themselves
1 in the extreme danger or traumatic events.
2 You can see there's very much the same trend
3 there, that the more people were exposed to combat in
4 general, the more they showed an increase in
5 psychological distress, both during and after.
6 It was noted that there is very much a role or
7 how the percent perceives the stress, and what they
8 expected and how they dealt with it.
9 An important conclusion from this is that
10 combat, and particularly the kinds of extreme events that
11 qualify people for post-traumatic stress disorder, are
12 only one of the important contributing factors to the
13 stress and the combat situation.
14 The combat related traumatic events correlate
15 well with the post-traumatic stress disorder symptoms, as
16 designed by the Diagnostical and Statistical Manual.
17 However, there is also what might be called a category of
18 deployment stress, simply being put into a threatening,
19 dangerous situation, long periods of exposure, even
20 though no actual highly traumatic event ever occurred to
21 you, can in fact produce substantial psychological
22 distress, which will not meet the criteria for PTSD,
23 first because there was no severe traumatic event, but
24 also because it doesn't have the same kind of symptoms of
25 hyperarousal, the intrusive memory.
1 It's just more a general worsening of
2 psychological well-being.
3 In some of those initial studies there was
4 suggestion, although they weren't collecting all of the
5 data needed to confirm it, but physical symptoms also
6 occurred in somewhat the same population.
7 This was then followed up in Samolia, human
8 dimensions research team deployed to Samolia, both in the
9 initial stages during the summer and in the final post
10 period, and one of the general observations there
11 confirmed that units that had good leadership, as defined
12 by leaders who kept the troops informed, kept them
13 focused on the mission, took care of their physical
14 needs, promoted good unit cohesion, had notably fewer
15 psychological and physical distress symptoms among their
17 The Veterans Administration, doing a follow-up
18 questionnaire on troops, both Army and Marine, who had
19 also returned from Somalia, looking at post-traumatic
20 stress disorder, found independently that it was the
21 units that had the low leadership that had the higher
22 rates of post-traumatic stress disorder.
23 This particular graph comes from a study that
24 the Walter Reed teams did in Haiti. You'll recall that
25 in Haiti, although they went in expecting that it might
162 1 be a combat insertion, there was in fact no combat,
2 relatively few of our units were in fact exposed to some
3 of the particular highly traumatic situations of
4 observing Haitian on Haitian violence.
5 But in a study there, first confirming that
6 troops who have good leadership, high leadership, have
7 relatively few not only psychological symptoms, but
8 health symptoms. Those with the poor leadership had
9 notably higher distress and symptoms, both psychological
10 and physical.
11 That also correlated with the degree to which
12 the troops had faith or belief in the value of the
13 mission. Those soldiers who had relatively low belief in
14 the value of the mission, but good leadership, it didn't
15 make a big difference in either their physical or their
16 mental distress.
17 I think that can be explained because good
18 leadership helps people keep people focused on the
19 immediate mission of their unit, whether or not they're
20 concerned about the bigger picture. They still feel what
21 they're doing is worthwhile and they're serving an
22 important purpose.
23 On the other hand, in the units with poor
24 leadership climate, not having a belief in the faith of
25 the mission, very dramatically increased both the
163 1 physical and the psychological distress symptoms.
2 That now is one of the issues under study in
3 Bosnia. The Walter Reed Army Institute of Research teams
4 on this occasion had the opportunity to do pre-deployment
5 interviews for troops who were in the process of training
6 at Hohenfelds training center, getting their final
7 preparation and calibration before going into the
8 theater, have now collected data from the same units in
9 mid-deployment. They expect to get mother data
10 collection before the troops return home, then will do
11 follow-up studies about six months after they return
12 home, and then the plan is that the Veterans
13 Administration will continue to follow the same
14 individuals, who sign appropriate consent forms, and get
15 long-term follow-up.
16 But let's switch now to what is the Army doing
17 in preparation to help strengthen our ability to prevent
18 both problems during combat or during the deployment and
19 post-traumatic stress problems later on.
20 I'll talk briefly about where we stand in
21 doctrine, make a very quick review of stressors and
22 stress. I'll talk briefly about what are defined in the
23 doctrine in the field manuals as who has responsibilities
24 for stress control, what are the Army mental health
25 assets available, and then we'll look at what are the
164 1 kinds of activities which these teams are carrying out
2 now, carried out in Haiti or carried out now in Bosnia,
3 and would expect to be carrying out in a future combat
5 For doctrine, since September of '94 we now
6 have combat stress control recognized as a medical
7 department functional area, and a basic battlefield
8 functional area.
9 The Field Manual 855, which is the general
10 planning for health support in the Theater of Operations
11 Manual has a chapter and appropriate annexes on combat
12 stress control.
13 Field Manual 251, Leaders Manual for Combat
14 Stress Control is available for leadership training and I
15 have pocket booklet copies of this for anyone in the
16 panel who would like one.
17 Field Manual 851 speaks specifically to how the
18 mental health assets and the combat stress control teams
19 should be working.
20 And then for conditions short of war -- this is
21 also covered in Field Manual 8-42, health service support
22 and operations other than war.
23 There are also a number of references that are
24 not yet doctrinal, but provide a lot of these items for
25 how to work in situations like Bosnia, where we gained
165 1 lot from the experience of our United Nations and other
2 NATO allies, who had been working in the Bosnia situation
3 for many years.
4 With the stressors, and I want to emphasize
5 that we're talking not just about combat. We recognize
6 there's deployment stress and many futures that go into
7 this short of full-scale combat.
8 Deployment stress at the best involves
9 separation from homes, separation from family, and that
10 is going to create potential problems for reunion when
11 you come home for everyone. Problems also develop during
13 For the reserves, in particular there's
14 disruption of their civilian career, and perhaps other
15 aspects of their civilian life.
16 The very nature component of all stress is
17 uncertainty, not knowing what's coming up. The stress
18 that you or the threat that you are fully aware of can
19 measure, can quantity, can prepare for, generally
20 produces a much less profound stress response, or a
21 neuroendocrine responses, than ones where you can't
22 predict what it is you're getting into.
23 Uncertainty alone triggers the stress response.
24 And certainly in Saudi Arabia in Operation Desert Shield,
25 Desert Storm, there was initially a lot of uncertainty
166 1 about whether Sadam Hussain was going to continue the
2 attack, what the mission would be, where the country
3 stood, what the rules of engagement were going to be, and
4 particularly the ambiguous threat regarding the NBC,
5 nuclear biological radiation threat.
6 And any deployment, but especially in Operation
7 Desert Storm, there were major problems with
8 environmental conditions, difficulties with sanitation,
9 certainly great difficulties with discomfort due to the
10 desert sand, dust, dirt, wind, the harsh climate, both
11 summer and winter, some aspects of the culture, although
12 many of our troops were kept isolated from it, still
13 created some sense or why are we here.
14 The issues of isolation and deprivation are
15 already talked about.
16 And then the obvious stresses, the danger of
17 going into combat, but for many of the troops in the rear
18 area who are never exposed to combat, the danger of
19 terrorism, even though that threat never did in fact
20 materialize, and of course during the war the threat from
21 the scud missiles.
22 Some people did observe serious problems with
23 disease or disaster. We fortunately suffered relatively
24 few casualties, but many people saw and were involved
25 with the Iraqi and dead and wounded, and with the
167 1 survivors for the dead from the atrocities that the
2 Iraqis on the Kuwaiti or on their own Shitte population
3 shortly after the ground war was over.
4 And, of course, of special concern to many
5 veterans now, the very difficult to document area of
6 toxic exposure with many both natural, human and possibly
7 even warfare related toxins are in the theater.
8 In our field manuals we are emphasizing that
9 stress is not our enemy, that stress, as has been pointed
10 out, is absolutely necessary to mobilize to deal with
11 high threat situations, and the issue is how to train
12 people, train units, so that that stress stays well
13 focused, so that it can be turned on and off when it's
14 needed, so that it's properly incorporated in units that
15 have high unit cohesion, trust and loyalty with each
16 other, a good sense of purpose, and in that context the
17 stress can bring out heroic behaviors.
18 We're also concerned with preventing misconduct
19 stress behavior, because people when under stress, and
20 particularly if they don't have any readily available
21 sanctioned way of reacting to the stress, it sometimes
22 boils over and problems of substance abuse or other
23 improper acts.
24 In the theater we're particularly concerned
25 with battle fatigue or conflict fatigue in operations
168 1 other than war, people who become temporarily
2 nonfunctional, purely as a result of the stress,
3 including both physical fatigue and environmental and
4 emotional fatigue.
5 The basic rule for combat stress or battle
6 fatigue is that these soldiers can generally be turned
7 around very quickly, if given reassurance, rest,
8 replenishment, activities which restore their confidence
9 close to their own unit.
10 What we're particularly concerned now, what can
11 we do to minimize post-deployment stress and where much
12 of the attention is going to post-traumatic stress
13 disorder, as defined only in people who have had extreme
14 traumatic stress, we have to realize that that also
15 applies to people with the looser forms of deployment
16 stress, but also what properly could be called
17 redeployment stress, that not all the stress occurs in
18 the theater of operation.
19 There may be an expectation on the part of the
20 troops and the family when they come that everything is
21 going to go back just the way it was before, and be
22 wonderful and fine, but that's in fact extremely
23 unlikely. There are almost certain to have been changes
24 even under the best of circumstances, that can produce
25 friction, marital and child difficulties and others, so
169 1 it's important to be taking active steps to help smooth
2 the reintegration.
3 And for those who perhaps are going to have
4 serious financial problems or employment problems, or are
5 in an active duty army who are facing reduction in force
6 or other major career changes, we need to help make sure
7 that those are being buffered as well.
8 But by post-deployment stress we're not just
9 talking about post-traumatic stress disorder, this range
10 of other potential problems that we need to be aware of
11 as well.
12 Under the doctrine as laid out in Field Manual
13 22-51, whose responsibility is it to control stress?
14 Well, in the military everything is the commander's
15 responsibility, starting at the lowest level and working
16 up to the highest level.
17 The commander has the responsibility for
18 controlling stress in the troops. The noncommissioned
19 officers, the NCO's, have a very major role in helping
20 the officer buffer this stress and try to help provide
21 the stress control that goes with it.
22 But ultimately in our Army, particularly as we
23 work in a power down mode, calling for high degrees of
24 initiative at the lowest level, ultimately stress control
25 is every person's, every soldier's responsibility, both
170 1 for himself or herself, and for their buddies.
2 The other staff have responsibilities defined
3 in the field manual. Medical personnel clearly have
4 responsibilities to recognize early signs of
5 dysfunctional stress and intervene early.
6 The chaplains have a very major role in this
7 and because there is a chaplain and a chaplain assistant
8 in each of the combat arms maneuver battalions, that puts
9 them particularly up close where the combat troops are.
10 The combat support, combat service support units, the
11 chaplains are basically working on an area support basis,
12 coming out of the higher headquarters, and so they don't
13 have the same density or the same close relationship with
14 the troops as they do in the combat battalions.
15 We talked specifically about division mental
16 health, and then of course there's also a significant
17 responsibility for home station agencies, family support
18 groups, the home station medical activity, and the
19 research agencies like the Walter Reed Army Institute of
21 Who are the assets available to provide this?
22 The Army has had a division psychiatrist since the
23 beginning of the First World War. It was briefly
24 forgotten at the beginning of the Second World War and so
25 it had to be rediscovered but we've had psychiatrists
171 1 assigned to each division essentially that long.
2 Since the Korean War we've had social worker
3 and a clinical psychologist assigned to each division,
4 assisted usually by six or seven mental health enlisted
6 And current doctrine calls for them to provide
7 one of these officers for the senior NCO to each maneuver
8 brigade. That's approximately a quarter of the division,
9 so that puts someone up close where they can be working
10 very closely with the chaplains, with the far forward
11 medical personnel, and in fact get around and if not meet
12 all of the troops, at least be seen by all of the troops
13 and meet many of them.
14 In Bosnia the First Armored Division has its
15 social worker in one of the brigade support areas, its
16 psychologist in another, and division psychiatrist is at
17 the division main base at Tusla and they are very
18 actively doing the prevent work that we'll talk about.
19 But they are now supported by a new unit, the
20 combat stress control medical detachment. It's in fact a
21 descendent of the unit that goes back to the Korean War,
22 which in fact grew from ad hoc units used in the First
23 and Second World War.
24 If you've ever wondered where Sidney
25 Greenfield, the psychiatrist on MASH came from, he
172 1 presumably came from one of the KO teams that were
2 operating in the Korean War.
3 But we have made a change in making these units
4 now not just something that gets activated and put
5 together when the whole army mobilizes or we deploy large
6 forces over, but that's working on a regular everyday
7 basis in garrison and field training and ideally deploys
8 with the same unit it would support in wartime.
9 So the combat stress control detachments, we
10 now have six of them in the active force and nine in the
11 reserve, consists of three small teams with a
12 psychiatrist, a social worker, two enlisted, and one
13 larger team that has psychology, psychiatric nurse,
14 clinical nurse, specialist and occupational therapy
16 There is one combat stress control detachment
17 in Bosnia now. It has one of its preventive teams up
18 with each of the brigade support areas, working directly
19 with the division psychologist or social worker, out very
20 actively getting out of the units a much as road traffic
21 ability and the requirements to go in convoy allow them
22 to, and it has its fitness or restoration team back at
23 the division main base or I understand that they've just
24 moved over to where the 212 MASH hospital is.
25 In the reserves we also have at this point five
173 1 larger combat stress control companies. They have the
2 same basic structure, the preventive teams, the fitness
4 At this point they have been activating
5 personnel to go over to Germany where they're helping
6 support the garrison health care mission, taking care not
7 only of soldiers or soldier families who would be taken
8 care of by the mental health people who deployed to
9 Bosnia, but working actively with family support groups
10 and the rear detachments at the headquarters.
11 What is it that doctrine requires these teams
12 to do or at Army in general to try to do? First of all,
13 it's very important to prepare people before deployment
14 for what they're getting into. Then to add good in-
15 country support, be prepared to support special critical
16 events, and finally to do a thorough job, both
17 immediately before and after redeployment, to try to
18 diffuse a lot of the stress issues.
19 And the preparation for pre-deployment, we feel
20 it's especially important in operations other than war,
21 but also in potential war scenarios, for the troops to be
22 as informed as we can give them in the time available,
23 why they're getting into what they're getting in, a
24 history of the area, some information about the cultural
25 and background of the people, and more than just the
1 five-minute mandatory briefing.
2 There are currently being issued, What is the
3 preventive medicine? What are the potential health
4 hazards in the theater that you need to be aware of and
5 what are the ways you need to take care of yourself and
6 your buddy, for the leaders to take care of the troops.
7 They do include some stress specific paragraphs
8 but that's an area where we believe we can provide more.
9 They may need some special stress orientation
10 to what are the particular threats they're going to get
11 into, and even inoculation, a chance to see and be
12 exposed to some of the potentially sights or sights and
13 sounds and other kinds of things that they might be
14 exposed to.
15 This could be gotten from videotapes we see on
16 the evening news, but not just show it as a horror story,
17 combine with good training on how to cope and how to deal
18 with it.
19 There may need to be special training, such as
20 the training that's being given in mine awareness for
22 And finally, extremely important to get family
23 support groups up and going and to make sure that
24 everyone gets their families or their significant others
25 included in the family support group network. Since our
175 1 units often do some cross leveling or bring in reservists
2 or other people who are coming in and joining strange
3 units, it's especially important to take care of that,
4 because they're the ones who are going to be at highest
5 risk from stress and whose families are going to be left
6 out of the support system unless a very active effort is
7 made to get them involved.
8 In contrary to the combat stress teams whether
9 from division or from the CSC units, are very active,
10 attending command and staff meetings, so as to educate
11 the leadership. They provide in-briefings for the units
12 as they arrive in country about what to expect. They
13 introduce themselves and what are the other issues.
14 They provide special training in stress
15 management techniques. They then on a regular basis go
16 out and talk with the leaders, the chaplains, medical
18 Particularly they conduct unit survey
19 interviews, which are in fact patterned after the
20 research technique of the Walter Reed human dimensions
21 teams. It's a systematic way of getting together small
22 teams of ten to 15 soldiers and finding out what their
23 experiences are and being able then to feed back to
24 command, maintaining appropriate anonymity, what is is
25 that's troubling the troops and how well leadership is
176 1 functioning.
2 We're strongly encouraging and helping training
3 leaders to do their own small unit, after action
4 debriefings, after anything goes awry. Bring the team
5 together and talk it through in a structured way.
6 It doesn't require a big, bad event. Just do
7 it routinely. It's very important to assure good
8 communication with the home front, but to see that that
9 stays positive.
10 We're now exploring the potential use of
11 telemedicine, modern high tech communications, to help
12 reach some of the far forward people.
13 When especially bad things happen, people in
14 units are killed, innocent civilians are killed, friendly
15 fire incidents, suicides, other such events, then it's
16 very important to step up and do some immediate
17 protective measures.
18 This, of course, is now well understood in the
19 civilian community, Critical Incident Stress Foundation
20 has volunteered debriefing teams in probably all 50
21 states by now, who work commonly with police, fire,
22 emergency medical technicians, medical personnel, after
23 any bad thing happened.
24 But the military is also developing this. I
25 speak for the Army but the Air Force and the Navy are
177 1 also working up this area as well, but part of it is the
2 critical event debriefing, having a trained come in and
3 debrief all of the personnel who were directly involved,
4 provide consultation to the leaders and chaplains, and
5 give whatever special education may be needed to help
6 head off further problems.
7 At the end of the tour even units which did not
8 have any particular critical events deserve an end of
9 tour debriefing. Many of the units can conduct these
10 themselves but if it's been a unit that's had difficult
11 times, and we know that as a result of our ongoing
12 surveys, then we can focus special effort to be sure that
13 they have a chance to talk through and reach appropriate
14 closure, talking through both the good times, the bad
15 times, and getting them back in perspective before they
16 come back.
17 Both the troops still in the field and the
18 families at home receive pre-deployment preparation.
19 They are familiarized with both what are some of the
20 expectable problems and how to deal with them, but
21 encouraged to seek help if things aren't working well,
22 don't wait until they've gotten really bad.
23 Similarly, once the reunion takes place some
24 structured activities to help make sure that it goes well
25 and that people are getting problems, quickly get into
178 1 positive help. And then finally, appropriate specific
2 follow-up, as indicated.
3 Speak very briefly about what is happening on
4 Bosnia. The Department of Defense, Assistant Secretary
5 of Defense for Health Affairs, has set up a program
6 requiring medical surveillance of all the troops have
7 been deployed to Bosnia.
8 This requires collection of data immediately
9 before their return, before they leave either Bosnia or
10 Hungry. Data collection included the physical exam, a
11 serum sample that's preserved for potential future tests
12 if needed, a physical symptoms check list, a depression
13 symptoms scale. These are the same ones that the Walter
14 Reed Research teams use -- no, correction, a different
15 set of scales from the Walter Reed Research Teams use,
16 shorter and more general for screening, a post-traumatic
17 stress scale, some questions about substance misuse, and
18 a brief survey of what kinds of events they were exposed
20 If anyone flags positive, if they answer either
21 that they are experiences significant symptoms of
22 depression, post-traumatic stress, substance misuse, at
23 that point they are interviewed while still in Hungry or
24 Bosnia by one of the mental health personnel already in
25 theater and familiar with the situation.
179 1 And, of course, some of the screening turns out
2 to be false positive. The person answered the question
3 interpreting it in a way that does not indicate they had
4 serious problems.
5 But those who are confirmed as having symptoms
6 of depression, PTS, post-traumatic stress, substance
7 related problems, are then referred for follow-up when
8 they get back to home station. And, in fact, there is a
9 program in place to in fact confirm that everyone who
10 does leave theater has had this done and does in fact
11 receive the follow-up that's expected.
12 Subject to your questions, that completes my
14 DR. HAMBURG: Thank you very much, a very well-
15 organized information on preventing damage in the future.
16 I think, as you see here, Dr. Lashof, our chairman, and
17 one other panel member have already departed. There are
18 problems about airplanes.
19 We could perhaps take one or two questions
20 because Colonel Stokes has given us so much information.
22 MR. CASSELLS: Colonel Stokes, do you have any
23 experience or information you can give us now as to the
24 success or at least the beginnings of any kind of success
25 with this program?
180 1 COLONEL STOKES: The difficulties of proving
2 the effectiveness of preventive measures are, of course,
3 obvious. So at this point we're still largely working on
4 the fact that the users find this extremely valuable.
5 We also can rely on some of the experience of
6 our allies who have been doing this kind of work longer
7 than we have.
8 For instance, on the matter of the pre-
9 briefings and post-briefings and critical incident stress
10 debriefing, we get very strong feedback from the units
11 and personnel that they themselves feel that it's
12 helping, and they then ask for more.
13 A king of longer term data that's still only
14 inferential, is that this is what many of the Vietnam
15 veterans or Persian Gulf veterans say they think should
16 have been done for them, and that had it been done, it
17 would be helpful.
18 We do have again a research assessment that is
19 looking for ways to document differences but again,
20 difficult to document preventive work.
21 MR. CASSELLS: What kind of acceptance has
22 there been of this program on the part of the line
24 COLONEL STOKES: Following some initial
25 hesitancy, because some of the line commanders have been
181 1 concerned that if you let people think about these things
2 or don't put the thoughts out of mind, that that will put
3 ideas in people's heads.
4 But once they see it at work -- again, this
5 needs to be done in a way that strongly emphasizes the
6 normality of stress, it's put in a preventive maintenance
7 model rather than a psychotherapy model, you word it to
8 leaders, you wouldn't think of bringing a tank or your
9 M16 rifle back out of the swamp or the desert without
10 oiling it and cleaning it and changing the filters, and
11 you need to do the same thing for the human mind.
12 You need to give the people a chance to work
13 these things through, preferably with their peers, the
14 people who went through it together, and giving them the
15 opportunity to do that, helps resolve a lot of the
16 misunderstandings that people have, helps them ventilate
17 and often clarify a lot of their anger, resentment,
18 guilt, other deep emotions that they're keeping bottled
19 up and think they're the only person that's feelings
20 this, and finally enables them to achieve closure, to put
21 I behind them and say okay, that part of my life is over,
22 I can now go on with the next.
23 DR. HAMBURG: This gives us some sense of
24 learning from our experience, including our mistakes,
25 and trying to apply to the next round of our activities,
182 1 the lessons we've learned from the previous ones.
2 Let me just say a word. We've run out of time.
3 Let's say a word about the ways in which the panel, our
4 committee would hope to make use of this information.
5 We are very, very grateful to the people who
6 made presentations, those of you who have come and
7 participated and made comments, those of you who have
8 just been patiently sitting through this, as well as the
9 committee members and the staff. It's a joint effort.
10 One thing that we hope to do as we move toward
11 closure at the end of this year is to draw together the
12 existing information and make a kind of synthesis of what
13 is known, what is the existing knowledge and skill with
14 respect to these problems, the problems of the present
15 Gulf War illnesses altogether, but specifically now I'm
16 talking about the stress related problems.
17 We need to get the information on the stress
18 and illness drawn together in a way that is credible,
19 because it is carefully done, science based to the extent
20 possible, and it is intelligible. It's explained to the
21 American people in a way that is not just too technical
22 or full or jargon and beyond comprehension, so an
23 intelligible, credible synthesis of existing knowledge
24 about stress and illness, in a way that it can help
25 current veterans.
183 1 Secondly, we want to think of ways to stimulate
2 research relevant to the Persian Gulf War difficulties.
3 For example, there are a number of things that came up
4 today between the morning and the afternoon sessions that
5 suggest links between basic and clinical research.
6 We need to be more deliberate. I think all of
7 my colleagues would agree on that, from what we've
8 experienced so far, more deliberate and systematic about
9 connecting basic and clinical research so that each can
10 stimulate the other.
11 But there are profound advances in the basic
12 sciences occurring and we need to see to it that those
13 are put to use to the maximum extent possible for the
14 benefit of the clinical problems being experienced by the
15 vets and others in the country.
16 Furthermore, as we've seen today, there are a
17 lot of potential connections between medical sciences and
18 behavioral sciences. They overlap and those connections
19 also need to be strengthened in a very deliberate and
20 explicit way, so we're going to say some things about
21 science policy for the nation that I believe will be
22 helpful to current and future veterans, that may well
23 have much broader significance than that.
24 We have a very dynamic scientific community,
25 probably the most creative the world has ever seen,
184 1 certainly the largest, but yet there are some connections
2 that are not adequately made at the present time that
3 have been highlighted by today's discussion.
4 Then we have to do what we can to foster public
5 understanding. There has been some public interest in
6 this committee. No doubt that is due in part to the fact
7 that the President launched it and the First Lady
8 launched it, but we have to speak to the public, not just
9 to the professionals in the field or to the veterans, but
10 to the public at large to understand the issues of stress
11 and illness and of the Persian Gulf War health problems
12 altogether, veterans generally, and we're going to try to
13 do that so that in all of these ways we hope that we can
14 help the current veterans, but also speak to the problems
15 of veterans of the future engagements like Bosnia and
17 And finally, we want to say some things about
18 implications of all this for supporting adequate service.
19 We want the public to understand what's necessary, what
20 constitutes an adequate service, and ways of building
21 support for such services as may be necessary.
22 So we have a lot to do as a committee between
23 now and the end of this year. We have roughly half the 24 year to sort of go underwater and swim as far as we can.
25 I thank all of you for the help you've given us
185 1 and we'll try to be responsible in pursuing the leads
2 that have arisen today.
3 The meeting is adjourned.
4 (Proceedings concluded at 3:40 p.m.)