JULY 23, 1996

9:30 A.M.


Pesidential Advisory Committee Members:

Doctor Joyce Lashof, Chairperson

Doctor Davis Hamburg

Doctor John Baldeschwieler

Michael Kowalok

Thomas Cross

Holly Gwinn

Joseph Cassells

Nicole Stern

Kelly Brix


Speaker Page

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

3 panel.

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

11 that.

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

16 craft.

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 to

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

13 know.

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

18 places.

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

6 physician.

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

9 forth?

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

10 of.

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

4 Iraq.

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

13 America.

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

23 veteran.

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

24 solutions.

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

6 to?

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

17 boats.

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

5 bag.

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

9 know.

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

16 questions?

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 in

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

7 veterans.

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

23 determined.

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

11 for.

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 of

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

2 questions?

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

9 drank.

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

4 Registry.

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

16 important.

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.

16 (Break.)

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

20 life.

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

19 weight.

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

24 experiences.

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

11 process.

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

7 formation.

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

24 satisfaction.

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

11 traumatic.

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

18 high.

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

12 treatment.

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

14 Harvard.

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

23 active.

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

10 body.

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

15 established.

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

10 well.

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

14 hormones.

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

3 system.

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

8 noradrenalin.

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

22 catecholamines.

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

18 knows.

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

3 reactions.

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

15 well.

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

19 life.

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

8 inflammation.

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

19 inflammation.

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

18 speculation.

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

11 longitudinally.

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

12 time?

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

18 processes.

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

21 it.

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

15 further.

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

24 volume?

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

10 controls.

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 on


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.

19 (Lunch.)

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

5 us.

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

13 forces.

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

11 population.

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

8 groups.

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

19 caution.

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

13 expect.

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

22 overwhelmed.

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

5 years.

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

13 studies.

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

5 traumatized.

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

25 like.

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

23 controls.

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

23 intrude.

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

17 veterans.

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

8 1940's.

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

14 veterans.

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

24 controls.

25 We similarly did what's called a Yohimbine

122 1 challenge study where he used Yohimbine and alpha two

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

18 problems.

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

8 two.

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

16 folks.

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

23 War.

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

14 diagnoses.

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 of

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 at

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

5 unchanged.

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

13 evaluation.

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

21 necessarily.

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

5 right?

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

18 condition.

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

12 disease.

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

6 states.

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

15 status.

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

23 women.

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

12 relatively.

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

16 cohort.

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-

14 3.

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

19 data.

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

7 information.

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

13 PTSD.

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

5 abuse.

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

23 PTSD.

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

5 veterans.

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

14 asked?

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

11 interview?

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

6 front.

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

16 cohesion.

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

16 troops.

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

4 situation.

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 a

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

12 employment.

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

20 Research.

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

5 specialists.

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

15 expertise.

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

3 teams.

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

21 Bosnia.

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

17 personnel.

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

19 to.

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

13 briefing.

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.

21 Anybody?

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

23 commanders?

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

16 beyond.

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.)