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Somatoform-Spectrum Diagnoses Among Medically Evacuated “Operation Enduring Freedom” and “Operation Iraqi Freedom” Personnel
Somatoform-Spectrum Diagnoses Among Medically Evacuated “Operation Enduring Freedom” and “Operation Iraqi Freedom” Personnel JAMES R. RUNDELL, M.D.
Ten percent of military medical evacuees from military operations in Iraq and Afghanistan are psychiatric referrals. Three percent of these psychiatric patients had somatoform-spectrum disorders (SSDs). Potential reasons for this low rate include lower stigma for other types of psychiatric presentations and the possibilities that SSD patients have not yet emerged in clinical settings or are managed in deployment environments. SSD patients, compared with other veterans, are more likely to be enlisted-rank, younger, and an ethnic minority. They are more likely to have non-combat deployment stressors and past psychiatric histories than combat-specific stressors and family problems at home. (Psychosomatics 2007; 48:149–153)
A
n association between participation in a war and somatization has long been recognized.1–4 During and after the 1991 Gulf War, unexplained physical symptoms were common and received a great deal of public attention.5–7 Although deployment to the 1991 Persian Gulf War was not associated with excess rates of hospitalization in a 5-year period after deployment,8 when posttraumatic stress disorder (PTSD) or other psychiatric disorder was diagnosed in Gulf War veterans, there was an increase in self-reported health problems.1,2,9 For example, Engel et al. reported that Gulf War veterans had significantly different rates of endorsing physical symptoms, depending on PTSD diagnosis. Veterans diagnosed with PTSD endorsed an average of 6.7 physical symptoms; those with a nonPTSD psychological condition endorsed 5.3; those with medical illness endorsed 4.3; and a group rated as “healthy” endorsed 1.2.10 Unexplained physical symptoms among 1991 Gulf War veterans was associated with significant morbidity, including occupational disability, as measured by lost workdays.11,12 Between the time Operation Enduring Freedom (OEF [United States military operations in Afghanistan]) and Operation Iraqi Freedom (OIF [United States military operations in Iraq]) began, through July 2004, over 12,000 Psychosomatics 48:2, March-April 2007
medical, surgical, and psychiatric medical evacuees from the theaters of operation have been sent to Landstuhl Regional Medical Center (LRMC) in Germany. LRMC is the largest U.S. military medical facility overseas, and it received virtually all evacuees leaving OEF and OIF during the reference period. A total of 1,294 of those patients were seen by the Psychiatry Service; 1,182 patients were seen by the Psychiatry Outpatient or Inpatient Services, and 112 were seen by the Consultation–Liaison Service. While at LRMC, patients are stabilized and treated for acute problems; length of stay is generally kept under 1 week. Patients who respond to acute treatment return to duty in OEF or OIF. Patients who need ongoing care or rehabilitation are sent from LRMC to military medical facilities in the United States. LRMC’s Mental Health Division maintains clinical records of each OEF and OIF psychiatric patient seen. All OEF/OIF psychiatric patients seen at LRMC have had Received December 14, 2005; revised March 3, 2006; accepted March 14, 2006. From the Dept. of Psychiatry and Psychology; Mayo Clinic/ West, Rochester, MN. Send correspondence and reprint requests to James R. Rundell, M.D., Dept. of Psychiatry and Psychology; Mayo Clinic/ West 11, 200 First Street SW, Rochester, MN 55905. e-mail: rundell. [email protected] Copyright 䉷 2007 The Academy of Psychosomatic Medicine
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149
Somatoform Disorder in Middle East Wars some clinical management attempted before medical evacuation to LRMC, the nature of which depends on resources available at the OEF or OIF locations. All patients are seen by a board-certified psychiatrist at LRMC and are evaluated according to a standard clinical data collection format. The aims of this study were 1) to determine the frequency of somatoform-spectrum diagnoses (SSD [somatoform disorders, psychological factors affecting physical condition, or suspected malingering]) among OEF and OIF personnel medically evacuated to LRMC seen by the Psychiatry Service; 2) to compare demographic characteristics of LRMC SSD patients to all OEF/OIF personnel returned from duty; and 3) to determine whether there are clinical patterns in this SSD patient population that can improve prediction, identification, and management of these disorders in the future. METHOD We reviewed records of 1,294 consecutive OEF/OIF patients evaluated by Psychiatry at LRMC between November 4, 2001, and July 30, 2004. Patients who received a diagnosis of a DSM-IV-TR SSD (N⳱30) were compared with 213,408 OEF and OIF veterans returned from deployments to those theaters of operation between January 7, 2002, and June 23, 2004. Comparison parameters were military unit type, military rank, age, gender, and ethnic group. The following clinical information was available for LRMC OEF/OIF SSD patients: psychiatric diagnoses, somatoform symptom(s), stressors, and psychiatric predispositions. Comparative data were analyzed with chi-square tests unless cell size was ⱕ5, in which case Fisher’s exact test was used. Level of statistical significance was set at pⱕ0.05. RESULTS Table 1 summarizes demographic information for the 30 SSD patients and the 213,408 returned OEF/OIF veterans. Compared with all returned OEF/OIF veterans, LRMCevacuated patients with SSD were significantly more likely to be enlisted (96% versus 86%), under age 30 (68% versus 46%), and African American (18% versus 14%) or Hispanic (11% versus 6%). Although there were more SSD patients in the National Guard or Reserves (34% versus 26%), and there were more women than men (19% versus 10%), these differences were not statistically significant. SSD patients were most likely to be evacuated early in their deployments. More than 80% of patients were 150
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evacuated during the first 6 months, compared with only 17% during the second 6 months of deployment. In general, OEF/OIF deployments are at least 1 year for Army service-members. Service-members with less than 5 years of military experience comprise the majority of psychiatric evacuees. A large majority of LRMC SSD patients (83%) served in the U.S. Army; this proportion reflects the overall deployment patterns in terms of service proportions. Most patients are evacuated from Iraq, although almost 20% are evacuated from Afghanistan/OEF, sometimes referred to as “the forgotten war.” At LRMC, 55% of SSD patients are managed as outpatients and 45% as psychiatric inpatients. No LRMC SSD psychiatric evacuees were returned to duty in OIF or OEF. Thirty percent were transferred to a U.S. military hospital for ongoing care or rehabilitation; 70% were returned to their home base and home unit for further outpatient clinical management and administrative disposition. Thirty patients (2.8% of LRMC OEF/OIF patients seen by Psychiatry) received an SSD diagnosis. The SSD diagnoses were conversion disorder (N⳱19; 63.3%), pain disorder (N⳱1; 3.3%), undifferentiated somatoform disorder (N⳱1; 3.3%), psychological factors affecting physical condition (N⳱7; 23.3%), and suspected malingering (N⳱2; 6.7%). Table 2 summarizes clinical information about the 30 SSD patients. The most common presenting somatoform symptoms were headaches, pseudoseizures, and shaking. Most (22 of 30) SSD patients had additional psychiatric diagnoses reported (Table 2), most frequently, adjustment disorder and major depressive disorder. Table 2 also lists the most frequently recorded stressors and predispositions among SSD patients. Deploymentrelated stressors (46.7%) and past or family psychiatric history (43.3%) were the most frequent, more commonly recorded than traditional concerns such as past history of a traumatic event, combat exposure, and family problems back home. Examples of deployment-related stressors are stressful living conditions, weather extremes, interpersonal difficulties with supervisors or peers, and sleep deprivation. DISCUSSION SSDs are diagnosed uncommonly among OEF/OIF patients seen by the Psychiatry Service immediately upon medical evacuation from the theater of operations. There are a number of potential reasons for the low recorded rate of SSDs. First, stigma may be decreased for psychiatric symptom-reporting, as compared with previous wars, alPsychosomatics 48:2, March-April 2007
Rundell though this has not been objectively demonstrated. However, in the U.S. military services during the past 10 years, prevention of mental health problems has received unprecedented attention. For example, suicide rates are monitored closely by commanders, who are, to some extent, held accountable for suicides that occur in their units. If stigma is less for psychiatric symptom-reporting, there might be less somatization. Second, there may be rapid symptom resolution once a patient is out of harm’s way. It is the experience of LRMC psychiatrists that psychiatric evacuees, once out of the combat zone, begin to reconstitute in ways that prevent assimilation back into the operations zone. Examples of creature comforts that reinforce this reconstitution are real beds, hot food, phone cards, personal attention, expanded Internet access, TV, restaurants, and freedom from threat of personal injury. Third, SSDs may be effectively managed in the theater and not medically evacuated. There is a robust mental health presence in the theater; if a patient is evacuated, he or she has already had significant mental health intervention at a level of care not available for other specialties. Fourth, it is possible that there are more SSD patients among medical-surgical evacuees, but psychiatric consulTABLE 1.
tations were not generated at LRMC. LRMC is an acutecare facility, with a short length of stay. Two percent of hospitalized medical-surgical OEF/OIF patients received psychiatric consultations; only one patient received an SSD diagnosis from the inpatient consultation service. It is possible that patients without acute, correctable conditions were evacuated further, to military medical facilities in the United States, for ongoing evaluation and care of unexplained physical symptoms. There could be also SSD patients who do not come to LRMC who have not reached a stage of medical evaluation suggesting an SSD. For example, there is mandatory postdeployment medical and mental health screening, but this does not occur until a service-member has returned to his or her home base. Finally, it is possible that somatoform symptoms and SSDs are longer-term sequelae and have not yet developed in vulnerable patients. After the 1991 Gulf War, 40% of physical symptoms reported by veterans had a latency period exceeding 1 year after their return.3 The finding that 1991 Gulf War veterans with PTSD reported physical symptoms six times more often than healthy 1991 Gulf War veterans also lends support to this possibility.10 It will be important to follow the longitudinal course of OEF and OIF veterans. OEF and OIF are unique in the
Demographic Data in OEF and OIF Somatoform-Spectrum Disorder (SSD) Patients Seen by the Psychiatry Service at Landstuhl Regional Medical Center (LRMC), Versus All Returning OEF and OIF Personnel SSD
N Dates seen at LRMC Ethnicity Caucasian African American Hispanic Others Unknown Unit type Active duty Reserve/Guard Rank Enlisted Officer Age, years 18–20 21–30 31–40 ⬎40 Unknown Gender Men Women Total
30 Nov. 4, 2001–Jul. 30, 2004 N⳱30 17 7 6 0 0 N⳱30 18 12 N⳱30 30 0 N⳱30 7 10 7 6 0 N⳱30 24 6 30
%
56.7 23.3 20 0 0 60 40 100 0 23.3 33.3 23.3 20 0 80 20 100
Returned OIF/OEF Veterans
%
214,408 (78.6% OIF) Jan. 7, 2002–Jun. 23, 2004 N⳱214,408 154,365 28,733 11,613 10,555 9,142 N⳱214,408 155,089 55,319 N⳱214,408 184,487 29,921 N⳱214,408 1,085 98,174 58,810 55,119 1,220
0.5 45.8 27.4 25.7 0.6
191,971 21,840 213,811
89.5 10.1 99.6
v2
p
15.788
0.001
2.932
0.087
4.889
0.017
351.923
⬍0.001
3.178
0.118
72 13.4 5.4 4.9 4.3 74.2 25.8 86 14
OEF: Operation Enduring Freedom; OIF: Operation Iraqi Freedom.
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Somatoform Disorder in Middle East Wars degree to which individuals exposed to the combat environment must return on future deployments, sometimes multiple times. Re-exposure to traumatic events and the anticipation of that re-exposure may yet result in somatization and unexplained physical symptoms. There are a number of stressors and predispositions reported by the SSD patients. The two most common are deployment-related stressors (e.g., conflict with peers or
TABLE 2.
supervisors, living conditions) and past psychiatric history. Interestingly, stressors related to the day-to-day deployment environment were reported more frequently than combat exposure stressors and family problems back home. This may have treatment and management implications; interventions aimed at addressing deployment stressors instead of only focusing on traditional issues such as combat exposure and family stressors may help prevent
Clinical Presentations in Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) Somatoform-Spectrum Disorder (SSD) Patients Seen by the Psychiatry Service at Landstuhl Regional Medical Center
Somatoform Symptoms
Nⴔ30 Patients
%
Chest pain Headaches Limb numbness Memory problems Non-epileptic seizures Hearing loss Vision loss Unresponsiveness Syncope-like complaints Tremor/shaking Shortness of breath Suicidal ideation Total SSD Diagnoses or Conditions Conversion disorder Pain disorder Undifferentiated somatoform disorder Psychological factors affecting medical condition Suspected malingering Additional Psychiatric Diagnoses Adjustment disorder Major depressive disorder Dysthymic disorder Generalized anxiety disorder Panic disorder Posttraumatic stress disorder Anxiety disorder, NOS Obsessive-compulsive disorder Alcohol use disorder Personality disorder Total Stressors and Predispositions Deployment-related stressors Combat-related stressor Job dissatisfaction Family problems at home Distress about detainee treatment Friend killed Physical injury or medical problem Similar symptom before deployment Legal problems Past history of traumatic event Past or family psychiatric history Total
2 8 1 1 5 1 2 2 3 4 1 2 32 Nⴔ30 Patients 19 1 1 7 2 Nⴔ30 Patients 8 3 1 1 1 1 2 1 2 2 22 Nⴔ30 Patients 14 2 6 6 1 1 4 3 3 2 13 55
6.7 26.7 3.3 3.3 16.7 3.3 6.7 6.7 10 13.3 3.3 6.7 % 63.3 3.3 3.3 23.3 6.7 % 26.7 10 3.3 3.3 3.3 3.3 6.7 3.3 6.7 6.7 % 46.7 6.7 20 20 3.3 3.3 13.3 10 10 6.7 43.3
NOS: not otherwise specified
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Rundell evacuations and help prevent SSDs. In most SSD patients, additional psychiatric disorders will also need to be addressed. This study is a unique look at a group of patients at an important juncture: immediately after evacuation from a war theater. Since virtually all patients came through this single hospital after evacuation and received evaluations according to a single process, it is a valuable population for scientific study. Before evacuation, they were seen in numerous locations, with different evaluative procedures, and after return to duty or to the United States, they are seen in many different military and civilian settings, with varying evaluative mechanisms and data recording tools. The unique setting at LRMC aids in assessment of interpretability and validity of the findings. This study also has important limitations. First, data are retrospective and collected according to a suggested outline, rather than according to a structured diagnostic interview. Second, the number of SSD patients is small. Third, data collection was at a specific point in time; correlation with currently unavailable longitudinal data and data from preevacuation and postevacuation would improve the interpretability and context of the findings.
Fourth, all conflicts are different, and it is difficult to compare rates of various disorders between them. Even within this analysis, patients from OEF may differ from OIF patients because these operations differ from each other in personal danger risk and degree of political support. CONCLUSION SSDs are uncommonly diagnosed among patients evacuated from the combat theater. This is an unexpected finding, given the clinical experience after the 1991 Gulf War. It will be important to see whether veterans begin to have more unexplained physical problems over time. Interventions that focus on improving deployment stressors may play a role in preventing and mitigating SSDs. A presentation based on this article won the DLIN/ Fischer Clinical Research Award at the 2005 Annual Meeting of The Academy of Psychosomatic Medicine. At the time this work was performed, the author was a federal government employee. The views expressed in this article are the author’s, and do not reflect the views of the U.S. Army or the U.S. Dept. of Defense.
References
1. Ford JD, Campbell KA, Storzbach D, et al: Posttraumatic stress symptomatology is associated with unexplained illness attributed to Persian Gulf War military service. Psychosom Med 2001; 63: 842–849 2. Storzbach D, Campbell KA, Binder LM, et al: Psychological differences between veterans with and without Gulf War unexplained symptoms. Psychosom Med 2000; 62:726–735 3. Kroenke K, Koslowe P, Roy M: Symptoms in 18,495 Persian Gulf War veterans: latency of onset and lack of association with selfreported exposures. J Occup Environ Med 1999; 40:520–528 4. Binder LM, Storzbach D, Campbell KA, et al: Comparison of MMPI-2 profiles of Gulf War veterans with epileptic and nonepileptic seizure patients. Assessment 2000; 7:73–78 5. Joseph SC: A comprehensive clinical evaluation of 20,000. Persian Gulf War veterans: Comprehensive Clinical Evaluation Program Evaluation Team. Mil Med 1997; 162:149–155 6. Lyle-Stuart JA, Murray KM, Ursano RJ, et al: The Department of Defense’s Persian Gulf War Registry, Year 2000: an examination of veterans’ health status. Mil Med 2002; 167:121–128 7. Roy MJ, Koslowe PA, Kroenke K, et al: Signs, symptoms, and ill-
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defined conditions in Persian Gulf War veterans: findings from the comprehensive clinical evaluation program. Psychosom Med 1998; 60:663–668 8. Knoke JD, Gray GC: Hospitalization for unexplained illnesses among U.S. veterans of the Persian Gulf War. Emerg Infect Dis 1998; 4:211–219 9. Wagner AW, Wolfe J, Rotnitsky A, et al: An investigation of posttraumatic stress disorder on physical health. J Trauma Stress 2000; 13:41–55 10. Engel CC Jr, Liu X, McCarthy BD, et al: Relationship of physical symptoms to posttraumatic stress disorder among veterans seeking care for Gulf War-related health concerns. Psychosom Med 2000; 62:739–745 11. Engel CC Jr, Ursano RJ, Magruder C, et al: Psychological conditions diagnosed among veterans seeking Department of Defense care for Gulf War-related health concerns. J Occup Environ Med 1999; 41:384–392 12. Lange G, Tiersky L, DeLuca J, et al: Psychiatric diagnoses in Gulf War veterans with fatiguing illness. Psychiatry Res 1999; 89:39– 48
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Ten percent of military medical evacuees from military operations in Iraq and Afghanistan are psychiatric referrals. Three percent of these psychiatric patients had somatoform-spectrum disorders (SSDs). Potential reasons for this low rate include lower stigma for other types of psychiatric presentations and the possibilities that SSD patients have not yet emerged in clinical settings or are managed in deployment environments. SSD patients, compared with other veterans, are more likely to be enlisted-rank, younger, and an ethnic minority. They are more likely to have non-combat deployment stressors and past psychiatric histories than combat-specific stressors and family problems at home. (Psychosomatics 2007; 48:149–153)
A
n association between participation in a war and somatization has long been recognized.1–4 During and after the 1991 Gulf War, unexplained physical symptoms were common and received a great deal of public attention.5–7 Although deployment to the 1991 Persian Gulf War was not associated with excess rates of hospitalization in a 5-year period after deployment,8 when posttraumatic stress disorder (PTSD) or other psychiatric disorder was diagnosed in Gulf War veterans, there was an increase in self-reported health problems.1,2,9 For example, Engel et al. reported that Gulf War veterans had significantly different rates of endorsing physical symptoms, depending on PTSD diagnosis. Veterans diagnosed with PTSD endorsed an average of 6.7 physical symptoms; those with a nonPTSD psychological condition endorsed 5.3; those with medical illness endorsed 4.3; and a group rated as “healthy” endorsed 1.2.10 Unexplained physical symptoms among 1991 Gulf War veterans was associated with significant morbidity, including occupational disability, as measured by lost workdays.11,12 Between the time Operation Enduring Freedom (OEF [United States military operations in Afghanistan]) and Operation Iraqi Freedom (OIF [United States military operations in Iraq]) began, through July 2004, over 12,000 Psychosomatics 48:2, March-April 2007
medical, surgical, and psychiatric medical evacuees from the theaters of operation have been sent to Landstuhl Regional Medical Center (LRMC) in Germany. LRMC is the largest U.S. military medical facility overseas, and it received virtually all evacuees leaving OEF and OIF during the reference period. A total of 1,294 of those patients were seen by the Psychiatry Service; 1,182 patients were seen by the Psychiatry Outpatient or Inpatient Services, and 112 were seen by the Consultation–Liaison Service. While at LRMC, patients are stabilized and treated for acute problems; length of stay is generally kept under 1 week. Patients who respond to acute treatment return to duty in OEF or OIF. Patients who need ongoing care or rehabilitation are sent from LRMC to military medical facilities in the United States. LRMC’s Mental Health Division maintains clinical records of each OEF and OIF psychiatric patient seen. All OEF/OIF psychiatric patients seen at LRMC have had Received December 14, 2005; revised March 3, 2006; accepted March 14, 2006. From the Dept. of Psychiatry and Psychology; Mayo Clinic/ West, Rochester, MN. Send correspondence and reprint requests to James R. Rundell, M.D., Dept. of Psychiatry and Psychology; Mayo Clinic/ West 11, 200 First Street SW, Rochester, MN 55905. e-mail: rundell. [email protected] Copyright 䉷 2007 The Academy of Psychosomatic Medicine
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149
Somatoform Disorder in Middle East Wars some clinical management attempted before medical evacuation to LRMC, the nature of which depends on resources available at the OEF or OIF locations. All patients are seen by a board-certified psychiatrist at LRMC and are evaluated according to a standard clinical data collection format. The aims of this study were 1) to determine the frequency of somatoform-spectrum diagnoses (SSD [somatoform disorders, psychological factors affecting physical condition, or suspected malingering]) among OEF and OIF personnel medically evacuated to LRMC seen by the Psychiatry Service; 2) to compare demographic characteristics of LRMC SSD patients to all OEF/OIF personnel returned from duty; and 3) to determine whether there are clinical patterns in this SSD patient population that can improve prediction, identification, and management of these disorders in the future. METHOD We reviewed records of 1,294 consecutive OEF/OIF patients evaluated by Psychiatry at LRMC between November 4, 2001, and July 30, 2004. Patients who received a diagnosis of a DSM-IV-TR SSD (N⳱30) were compared with 213,408 OEF and OIF veterans returned from deployments to those theaters of operation between January 7, 2002, and June 23, 2004. Comparison parameters were military unit type, military rank, age, gender, and ethnic group. The following clinical information was available for LRMC OEF/OIF SSD patients: psychiatric diagnoses, somatoform symptom(s), stressors, and psychiatric predispositions. Comparative data were analyzed with chi-square tests unless cell size was ⱕ5, in which case Fisher’s exact test was used. Level of statistical significance was set at pⱕ0.05. RESULTS Table 1 summarizes demographic information for the 30 SSD patients and the 213,408 returned OEF/OIF veterans. Compared with all returned OEF/OIF veterans, LRMCevacuated patients with SSD were significantly more likely to be enlisted (96% versus 86%), under age 30 (68% versus 46%), and African American (18% versus 14%) or Hispanic (11% versus 6%). Although there were more SSD patients in the National Guard or Reserves (34% versus 26%), and there were more women than men (19% versus 10%), these differences were not statistically significant. SSD patients were most likely to be evacuated early in their deployments. More than 80% of patients were 150
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evacuated during the first 6 months, compared with only 17% during the second 6 months of deployment. In general, OEF/OIF deployments are at least 1 year for Army service-members. Service-members with less than 5 years of military experience comprise the majority of psychiatric evacuees. A large majority of LRMC SSD patients (83%) served in the U.S. Army; this proportion reflects the overall deployment patterns in terms of service proportions. Most patients are evacuated from Iraq, although almost 20% are evacuated from Afghanistan/OEF, sometimes referred to as “the forgotten war.” At LRMC, 55% of SSD patients are managed as outpatients and 45% as psychiatric inpatients. No LRMC SSD psychiatric evacuees were returned to duty in OIF or OEF. Thirty percent were transferred to a U.S. military hospital for ongoing care or rehabilitation; 70% were returned to their home base and home unit for further outpatient clinical management and administrative disposition. Thirty patients (2.8% of LRMC OEF/OIF patients seen by Psychiatry) received an SSD diagnosis. The SSD diagnoses were conversion disorder (N⳱19; 63.3%), pain disorder (N⳱1; 3.3%), undifferentiated somatoform disorder (N⳱1; 3.3%), psychological factors affecting physical condition (N⳱7; 23.3%), and suspected malingering (N⳱2; 6.7%). Table 2 summarizes clinical information about the 30 SSD patients. The most common presenting somatoform symptoms were headaches, pseudoseizures, and shaking. Most (22 of 30) SSD patients had additional psychiatric diagnoses reported (Table 2), most frequently, adjustment disorder and major depressive disorder. Table 2 also lists the most frequently recorded stressors and predispositions among SSD patients. Deploymentrelated stressors (46.7%) and past or family psychiatric history (43.3%) were the most frequent, more commonly recorded than traditional concerns such as past history of a traumatic event, combat exposure, and family problems back home. Examples of deployment-related stressors are stressful living conditions, weather extremes, interpersonal difficulties with supervisors or peers, and sleep deprivation. DISCUSSION SSDs are diagnosed uncommonly among OEF/OIF patients seen by the Psychiatry Service immediately upon medical evacuation from the theater of operations. There are a number of potential reasons for the low recorded rate of SSDs. First, stigma may be decreased for psychiatric symptom-reporting, as compared with previous wars, alPsychosomatics 48:2, March-April 2007
Rundell though this has not been objectively demonstrated. However, in the U.S. military services during the past 10 years, prevention of mental health problems has received unprecedented attention. For example, suicide rates are monitored closely by commanders, who are, to some extent, held accountable for suicides that occur in their units. If stigma is less for psychiatric symptom-reporting, there might be less somatization. Second, there may be rapid symptom resolution once a patient is out of harm’s way. It is the experience of LRMC psychiatrists that psychiatric evacuees, once out of the combat zone, begin to reconstitute in ways that prevent assimilation back into the operations zone. Examples of creature comforts that reinforce this reconstitution are real beds, hot food, phone cards, personal attention, expanded Internet access, TV, restaurants, and freedom from threat of personal injury. Third, SSDs may be effectively managed in the theater and not medically evacuated. There is a robust mental health presence in the theater; if a patient is evacuated, he or she has already had significant mental health intervention at a level of care not available for other specialties. Fourth, it is possible that there are more SSD patients among medical-surgical evacuees, but psychiatric consulTABLE 1.
tations were not generated at LRMC. LRMC is an acutecare facility, with a short length of stay. Two percent of hospitalized medical-surgical OEF/OIF patients received psychiatric consultations; only one patient received an SSD diagnosis from the inpatient consultation service. It is possible that patients without acute, correctable conditions were evacuated further, to military medical facilities in the United States, for ongoing evaluation and care of unexplained physical symptoms. There could be also SSD patients who do not come to LRMC who have not reached a stage of medical evaluation suggesting an SSD. For example, there is mandatory postdeployment medical and mental health screening, but this does not occur until a service-member has returned to his or her home base. Finally, it is possible that somatoform symptoms and SSDs are longer-term sequelae and have not yet developed in vulnerable patients. After the 1991 Gulf War, 40% of physical symptoms reported by veterans had a latency period exceeding 1 year after their return.3 The finding that 1991 Gulf War veterans with PTSD reported physical symptoms six times more often than healthy 1991 Gulf War veterans also lends support to this possibility.10 It will be important to follow the longitudinal course of OEF and OIF veterans. OEF and OIF are unique in the
Demographic Data in OEF and OIF Somatoform-Spectrum Disorder (SSD) Patients Seen by the Psychiatry Service at Landstuhl Regional Medical Center (LRMC), Versus All Returning OEF and OIF Personnel SSD
N Dates seen at LRMC Ethnicity Caucasian African American Hispanic Others Unknown Unit type Active duty Reserve/Guard Rank Enlisted Officer Age, years 18–20 21–30 31–40 ⬎40 Unknown Gender Men Women Total
30 Nov. 4, 2001–Jul. 30, 2004 N⳱30 17 7 6 0 0 N⳱30 18 12 N⳱30 30 0 N⳱30 7 10 7 6 0 N⳱30 24 6 30
%
56.7 23.3 20 0 0 60 40 100 0 23.3 33.3 23.3 20 0 80 20 100
Returned OIF/OEF Veterans
%
214,408 (78.6% OIF) Jan. 7, 2002–Jun. 23, 2004 N⳱214,408 154,365 28,733 11,613 10,555 9,142 N⳱214,408 155,089 55,319 N⳱214,408 184,487 29,921 N⳱214,408 1,085 98,174 58,810 55,119 1,220
0.5 45.8 27.4 25.7 0.6
191,971 21,840 213,811
89.5 10.1 99.6
v2
p
15.788
0.001
2.932
0.087
4.889
0.017
351.923
⬍0.001
3.178
0.118
72 13.4 5.4 4.9 4.3 74.2 25.8 86 14
OEF: Operation Enduring Freedom; OIF: Operation Iraqi Freedom.
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Somatoform Disorder in Middle East Wars degree to which individuals exposed to the combat environment must return on future deployments, sometimes multiple times. Re-exposure to traumatic events and the anticipation of that re-exposure may yet result in somatization and unexplained physical symptoms. There are a number of stressors and predispositions reported by the SSD patients. The two most common are deployment-related stressors (e.g., conflict with peers or
TABLE 2.
supervisors, living conditions) and past psychiatric history. Interestingly, stressors related to the day-to-day deployment environment were reported more frequently than combat exposure stressors and family problems back home. This may have treatment and management implications; interventions aimed at addressing deployment stressors instead of only focusing on traditional issues such as combat exposure and family stressors may help prevent
Clinical Presentations in Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) Somatoform-Spectrum Disorder (SSD) Patients Seen by the Psychiatry Service at Landstuhl Regional Medical Center
Somatoform Symptoms
Nⴔ30 Patients
%
Chest pain Headaches Limb numbness Memory problems Non-epileptic seizures Hearing loss Vision loss Unresponsiveness Syncope-like complaints Tremor/shaking Shortness of breath Suicidal ideation Total SSD Diagnoses or Conditions Conversion disorder Pain disorder Undifferentiated somatoform disorder Psychological factors affecting medical condition Suspected malingering Additional Psychiatric Diagnoses Adjustment disorder Major depressive disorder Dysthymic disorder Generalized anxiety disorder Panic disorder Posttraumatic stress disorder Anxiety disorder, NOS Obsessive-compulsive disorder Alcohol use disorder Personality disorder Total Stressors and Predispositions Deployment-related stressors Combat-related stressor Job dissatisfaction Family problems at home Distress about detainee treatment Friend killed Physical injury or medical problem Similar symptom before deployment Legal problems Past history of traumatic event Past or family psychiatric history Total
2 8 1 1 5 1 2 2 3 4 1 2 32 Nⴔ30 Patients 19 1 1 7 2 Nⴔ30 Patients 8 3 1 1 1 1 2 1 2 2 22 Nⴔ30 Patients 14 2 6 6 1 1 4 3 3 2 13 55
6.7 26.7 3.3 3.3 16.7 3.3 6.7 6.7 10 13.3 3.3 6.7 % 63.3 3.3 3.3 23.3 6.7 % 26.7 10 3.3 3.3 3.3 3.3 6.7 3.3 6.7 6.7 % 46.7 6.7 20 20 3.3 3.3 13.3 10 10 6.7 43.3
NOS: not otherwise specified
152
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Rundell evacuations and help prevent SSDs. In most SSD patients, additional psychiatric disorders will also need to be addressed. This study is a unique look at a group of patients at an important juncture: immediately after evacuation from a war theater. Since virtually all patients came through this single hospital after evacuation and received evaluations according to a single process, it is a valuable population for scientific study. Before evacuation, they were seen in numerous locations, with different evaluative procedures, and after return to duty or to the United States, they are seen in many different military and civilian settings, with varying evaluative mechanisms and data recording tools. The unique setting at LRMC aids in assessment of interpretability and validity of the findings. This study also has important limitations. First, data are retrospective and collected according to a suggested outline, rather than according to a structured diagnostic interview. Second, the number of SSD patients is small. Third, data collection was at a specific point in time; correlation with currently unavailable longitudinal data and data from preevacuation and postevacuation would improve the interpretability and context of the findings.
Fourth, all conflicts are different, and it is difficult to compare rates of various disorders between them. Even within this analysis, patients from OEF may differ from OIF patients because these operations differ from each other in personal danger risk and degree of political support. CONCLUSION SSDs are uncommonly diagnosed among patients evacuated from the combat theater. This is an unexpected finding, given the clinical experience after the 1991 Gulf War. It will be important to see whether veterans begin to have more unexplained physical problems over time. Interventions that focus on improving deployment stressors may play a role in preventing and mitigating SSDs. A presentation based on this article won the DLIN/ Fischer Clinical Research Award at the 2005 Annual Meeting of The Academy of Psychosomatic Medicine. At the time this work was performed, the author was a federal government employee. The views expressed in this article are the author’s, and do not reflect the views of the U.S. Army or the U.S. Dept. of Defense.
References
1. Ford JD, Campbell KA, Storzbach D, et al: Posttraumatic stress symptomatology is associated with unexplained illness attributed to Persian Gulf War military service. Psychosom Med 2001; 63: 842–849 2. Storzbach D, Campbell KA, Binder LM, et al: Psychological differences between veterans with and without Gulf War unexplained symptoms. Psychosom Med 2000; 62:726–735 3. Kroenke K, Koslowe P, Roy M: Symptoms in 18,495 Persian Gulf War veterans: latency of onset and lack of association with selfreported exposures. J Occup Environ Med 1999; 40:520–528 4. Binder LM, Storzbach D, Campbell KA, et al: Comparison of MMPI-2 profiles of Gulf War veterans with epileptic and nonepileptic seizure patients. Assessment 2000; 7:73–78 5. Joseph SC: A comprehensive clinical evaluation of 20,000. Persian Gulf War veterans: Comprehensive Clinical Evaluation Program Evaluation Team. Mil Med 1997; 162:149–155 6. Lyle-Stuart JA, Murray KM, Ursano RJ, et al: The Department of Defense’s Persian Gulf War Registry, Year 2000: an examination of veterans’ health status. Mil Med 2002; 167:121–128 7. Roy MJ, Koslowe PA, Kroenke K, et al: Signs, symptoms, and ill-
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defined conditions in Persian Gulf War veterans: findings from the comprehensive clinical evaluation program. Psychosom Med 1998; 60:663–668 8. Knoke JD, Gray GC: Hospitalization for unexplained illnesses among U.S. veterans of the Persian Gulf War. Emerg Infect Dis 1998; 4:211–219 9. Wagner AW, Wolfe J, Rotnitsky A, et al: An investigation of posttraumatic stress disorder on physical health. J Trauma Stress 2000; 13:41–55 10. Engel CC Jr, Liu X, McCarthy BD, et al: Relationship of physical symptoms to posttraumatic stress disorder among veterans seeking care for Gulf War-related health concerns. Psychosom Med 2000; 62:739–745 11. Engel CC Jr, Ursano RJ, Magruder C, et al: Psychological conditions diagnosed among veterans seeking Department of Defense care for Gulf War-related health concerns. J Occup Environ Med 1999; 41:384–392 12. Lange G, Tiersky L, DeLuca J, et al: Psychiatric diagnoses in Gulf War veterans with fatiguing illness. Psychiatry Res 1999; 89:39– 48
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