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THE FOLLOWING LECTURE HAS BEEN APPROVED FOR ALL STUDENTS BY BIRMINGHAM CITY UNIVERSITY This lecture may contain information, ideas, concepts and discursive anecdotes that may be thought provoking and challenging.

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This lecture may contain information, ideas, concepts and discursive anecdotes that may be thought provoking and challenging

Any issues raised in the lecture may require the viewer to engage in further thought, insight, reflection or critical evaluation

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The Psychology of Gulf War Syndrome

A strange and curious condition caused by an unusual war

Prof. Craig Jackson

Head of Psychology Division


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Headlines of Gulf War




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  • History of Gulf War

  • Aug 1990: Iraq invaded Kuwait

  • Aug 1990 - Jun 1991:

  • Allied Troop Deployment

    • 697,000 by USA

    • 53,000 by United Kingdom

    • 4,500 by Canada

  • Feb 1991:

  • Iraq expelled from Kuwait

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History of Gulf War Symptoms

Within months of end of war some veterans reported symptoms

Some studies tried to identify the key clinical features of ill health in veterans

US Government invited sick veterans to join voluntary medical registries

Many presented with non-specific symptoms


Most common primary diagnoses among 20,000 vets were:

musculoskeletal disorders (18.6%)

psychological conditions (18.3%)

multi-system conditions (17.8%).

No evidence of a unique illness Joseph 1997

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  • History of Gulf War Symptoms

  • Collection of symptoms in soldiers who served in Persian Gulf War (1990-1991)

  • Highly variable

  • Include:

    • Rash

    • Fatigue

    • Muscle pain

    • Joint pain

    • Headache

    • Irritability

    • Depression

    • Sleep disturbance

    • Gastrointestinal problems

    • Respiratory problems

    • Cognitive deficits


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Dilemma of Gulf War Symptoms

The studies demonstrate an increase in reporting of symptoms in veterans who served in the Gulf conflict, compared to those not deployed or who have served elsewhere.

However, similar symptoms were reported in all control groups

No obvious unique collection of symptoms in Gulf War veterans

Data rely on self-reported symptoms, and lend themselves to response biases

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Dilemma of Gulf War Symptoms

Variety and multiplicity of symptoms no consistent pattern exists . . .

. . . Therefore impossible to suggest a common underlying disease process

This makes it unlikely that a single cause will explain ill health in Gulf veterans

No study has found consistent abnormal clinical or laboratory findings among ill Gulf veterans

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  • The Veterans’ Case

  • Military authorities exposed service personnel to unreasonable medical

  • and environmental hazards

  • 2. Military authorities have since failed to

    • generate, record and act on information of relevance to veterans’ illnesses

    • have withheld and destroyed information

    • have distributed misleading information

  • A nd have obstructed enquiries by others.

  • 3. Diagnosis and treatment of illness has been impeded by the unprecedentednature of the medical conditions, but also by the military authorities’ own obstructive behaviour.

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The UK Ministry of Defence

“The Ministry of Defence accepts some veterans have become ill

Many believe this ill health is unusual and directly related to service in the Gulf

UK Gulf veterans report more ill-health than other comparable groups

(Unwin et al 1999)

This is not unique to Gulf veterans as the same symptoms are seen in UK military personnel who did not deploy to the Gulf

Gulf Conflict veterans report having more of the symptoms and are suffering more severely from them

Some veterans have recognised medical conditions, but a large number of non-specific, multi-system, medically unexplained symptoms are also reported”

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Theory #1 Vaccine Overload

The Theory. . .

GW1Vs received at least 17 different

Vaccines: e.g. Pyridostigmine

Established vaccines Poliomyelitis

Yellow fever


Experimental vaccines Anthrax

Botulinum toxoid


MOD says UK troops received 10 types

Adjuvants and viral genomes!

Squalene polymer antibodies Rook & Zumla (1997)

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Theory #1 Vaccine Overload

The Evidence

GWS symptoms X3 more likely in vaccinated vets

GWS in 34% vaccinated vets

12% vaccinated but non-deployed vets

4% in non-vaccinated vets

GWS lowest in troops on ships (21%)

GWS highest in those in Iraq / Kuwait (42%)

Steele 2001

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Theory #1 Vaccine Overload

The Evidence

Compared with troops in Bosnia conflict, and those not deployed in Gulf:

GWVs reported significantly more symptoms:

Twice as likely to have GWS diagnosis

Number of vaccinations increased likelihood of GWS:

Vaccination before conflict less problematic than vaccination during conflict

Ismail 2002

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Theory #1 Vaccine Overload

The Evidence

US Department of Defence (1997)

Initiated Anthrax Vaccination Immunization Program

2.4 Million military personnel

Adverse reactions in personnel were similar to symptoms of GWS

French troops were not exposed to the same cocktail of drugs as British and US service personnel, and have not reported any 'Gulf War Syndrome'

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Theory #2 Depleted Uranium

The Theory. . .

DU – Low-level radioactive material

Nephrotoxic when internalised in large quantities

Amour piercing

Those handling munitions were appropriately protected and no adverse health effects have been reported in these troops

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Theory #2 Depleted Uranium

The Evidence. . .

Elevated incidence of renal dysfunction have not been

observed in personnel exposed to DU during the conflict

MoD is continuing research via an independent oversight


Several major reviews have concluded that it is unlikely

to be implicated in Gulf veterans' illnesses

Three-fold increase in birth defects in Iraq since 1991

The Royal Society 2003

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Theory #3 Oil Fire Smoke

The Theory. . .

After ground war hundreds of oil wells

were set alight

Plumes of smoke across the battlefields

Smoke is known to cause respiratory tract irritation

Personnel involved in tackling the blazes were appropriately protected

Health of individuals working in the proximity of the fires was closely monitored

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Theory #3 Oil Fire Smoke

The Evidence. . .

Monitoring studies found no evidence of increased levels of toxic gases

Was an increase in the level of fine particulate matter

Gulf veterans have commonly reported respiratory symptoms

Little evidence of pulmonary damage attributable to oil well smoke

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Theory #4 Chemical / Biological Warfare Agents

The Theory. . .

Nerve Gas

Sarin - Cholinesterase Inhibition

VX Headaches, Diarrhoea, Paralysis





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Theory #4 Chemical / Biological Warfare Agents

The Evidence. . .

There is no objective evidence that Iraq utilised any chemical or biological warfare (CBW) capability

Documented that many detection devices alarmed

during the war

Many personnel believed they were under

chemical attack

Frequent false alarms occurred as the devices were

exquisitely sensitive, obtained at the expense of some


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Theory #5 Post Traumatic Stress Disorder

The Theory. . .

Many attribute ill health to post-traumatic stress disorder

12% of all the veterans who attended were suffering from PTSD and somatic symptoms (MoD's Medical Assessment Programme)

Gulf veterans were under considerable stress, not least from the constant threat of chemical and biological weapons

Each conflict is associated with a unique

environment / type of warfare and a unique

combination of physical and psychological

stressors that may contribute to ill health

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Theory #5 Post Traumatic Stress Disorder

The Evidence. . .

Large numbers of veterans suffering from symptoms who do not have psychological dysfunction - suggests that stress alone cannot account for ill health in all veterans

Symptoms in Gulf veterans are similar to those reported after other conflicts (Hyams et al 1997)

The Gulf War cannot compare with previous wars in terms of human casualties and other environmental factors

Impossible to compare research done on different wars owing to changing nature of medicine, technology, and cultural factors

Media reporting in society contributes factors for ill health reporting

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Theory #6 Pesticides / Insecticides

The Theory. . .

Widespread use of pesticides containing organophosphates (Ops) to combat desert pests

Pyridostigmine bromide was given prophylactically as a counter-measure

against chemical attacks

Pyridostigmine reversibly inhibits acetylcholinesterase at the neuromuscular junction and prevents subsequent binding of nerve agents

Causes cholinergic crisis (nerve paralysis)

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Theory #6 Pesticides / Insecticides

The Evidence. . .

The associations between reported exposure to pesticides and measures of ill health showed no significant difference between Gulf and Bosnia & Era veterans (Unwin et al 1999)

Usually gross evidence of toxic effects of high doses of OPs, there were no obvious acute effects in the war theatre

Delayed effects of low-level exposure are not fully understood

Is plausible that there may be some role in veterans' illnesses

The MoD maintains it is unlikely to play a major role, but has commissioned a detailed study into the effects of OPs

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Possible Theories

(Multiple) Vaccines Theory of a combination of stress and vaccinations

Post Traumatic Stress Disorder having effects

Hotopf et al (2000)


Oil Fire Smoke

Chemical/ Biological Agents

Pesticides / Insecticides

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Complications. . .

Military populations generally healthier than civilians (Healthy Warrior effect)

Gulf vets death rates are not higher than non Gulf vets

(including suicide and cancer)

Gulf vets have more accidents than non Gulf vets ! ? !

Over decade after deployment some GV still suffer ill-health

No unique Gulf war syndrome

Only common GV related experience involves “perceptions of ill-health”

GVs symptoms are worse for lower ranks

Huge bias - recalling more exposures, incidents, and inoculations

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  • Health Perceptions of Vets

  • Military populations generally healthier than civilians (Healthy Warrior effect)

  • 17% of UK vets believe they have GWS (Chalder et al 2001)

  • Belief in having GWS linked to:

  • Knowing someone else with GWS

  • Being ill afterwards

  • No longer in military

  • High number of vaccinations before deploy

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Health Perceptions of Vets

Characteristics of Vets responding

To the survey

Chalder et al (2001)

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Health Perceptions of Vets

Relationship between GWS and other outcomes

Chalder et al (2001)

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The Future for GW1 Vets?

Legally, GWS exists - - - - Medically, GWS does not exist

Upto 9000 UK troops (of 53,000 deployed) may have GWS

2800 (approx) UK vets have attended MOD

assessment programme

This number is declining

What of GWII?

Same problems to emerge?

How will any symptom reports be handled?

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The Future for GW1 Vets


Medical recognition wanted

Legal recognition acquired

Care for GWS sufferers

Info dissemination

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Joseph S, and the Comprehensive Clinical Evaluation Program Evaluation Team. A

comprehensive clinical evaluation of 20,000 Persian Gulf War veterans. Milit Med, 162:

149-55, 1997.

Unwin C, Blatchley N, Coker W, et al. Health of UK servicemen who served in the Persian Gulf

War. Lancet 353: 169-78, 1999.

Lee HA, Gabriel R, Bolton JPG, et al. Health status and clinical diagnoses of 3,000 UK Gulf War

veterans. J R Soc Med 95: 491-497, 2002.

Ministry of Defence. Gulf Update. Issue 4. London: MoD, 2002.

Coker WJ. A Review of Gulf War illness. J R Nav Med Serv 82: 141-146, 1996.

Rook G & Zumla A. Gulf War Syndrome: is it due to a systemic shift in cytokine balance towards a

Th2 profile? Lancet 349: 1831-1833,1997.

Hotopf M, David A, Hull L, et al. Role of vaccinations as risk factors for ill health in veterans of the

Gulf War: cross-sectional study. BMJ 320: 1363-1367,2000.

Hyams KC, Wignall FS, Roswell R. War syndromes and their evaluation: from the US Civil War to

the Persian Gulf War. Ann Intern Med 125: 398-405, 1997