GULF WAR ILLNESS

1 War Related ILLNESS and Injury Study Center WRIISC post -Deployment Health Services, Patient Care Services Department of Veterans Affairs G U L F WA R I L L N E SS. A G U I D E F O R V E T E R A N H E A LT H C A R E P R O V I D E R S. W H AT I S G U L F WA R I L L N E S S? W H AT A R E T H E. gulf War ILLNESS (GWI) is a P O S S I B L E C AU S E S O F IN CLINICAL PRACTICE, term that refers to a group of G U L F WA R I L L N E S S? the first questions a unexplained or ill-defined chronic Despite much research, the causes provider needs to ask is symptoms found in Veterans of GWI remain unclear. A number about the Veteran's military deployed to the Persian gulf of possible causes of GWI include: and deployment history during Operation Desert Storm/ Immune dysfunction including specific locations Operation Desert Shield (1990- Nerve dysfunction and times of deployment 1991).

2 GWI falls under the umbrella Mitochondrial dysfunction and possible exposures of chronic multisystem ILLNESS A genetic and of concern. Providers can (CMI). Understanding GWI and environmental suggest further evaluation effectively evaluating, diagnosing, exposure interaction with an environmental and managing associated health clinician or expert health concerns and medically During deployment, many service in occupational and unexplained conditions are members encountered a variety of environmental exposures critical components of delivering different exposures that may place if they have specific optimal care to affected Veterans. them at risk for adverse health exposure concerns. A. effects. Exposures specific for GWV directory of Environmental W H AT A R E T H E S Y M P T O M S include pyridostigmine bromide Health Coordinators O F G U L F WA R I L L N E S S?

3 Tablets (taken as a preventative is available here: Symptoms of GWI vary; there is measure), burning oil well fires, not a single consistent pattern and the Anthrax Vaccination. of symptoms. This may make There have been no clear or it challenging for healthcare consistent links found between providers to recognize and specific exposures and GWI. If a treat it. The most common Veteran is concerned about the symptoms of GWI include: possible relationship between D E FI N I N G G U L F WA R I L L N E SS. Fatigue their symptoms and deployment In 2015, the Institute of Medicine Muscle and joint pain exposure, it may be worthwhile (now the National Academy of Cognitive trouble to conduct a comprehensive Medicine) met to discuss the Skin rashes exposure assessment (see side bar). evidence supporting various GWI.

4 Abdominal discomfort/ case definitions. Two definitions While several mental health bowel changes were recommended for research conditions are often comorbid Headaches purposes. These definitions can with GWI, GWI is not considered Shortness of breath also inform clinical encounters with a mental health condition Sleep disturbances Veterans to determine if a Veteran nor is GWI considered to be meets criteria for a GWI diagnosis. Several studies showed that a result of malingering. about one-third of gulf War The CDC Definition is considered Veterans (GWV) have GWI. the more sensitive of the two For more information, contact 800-248-8005 | 1. War Related ILLNESS and Injury Study Center WRIISC post -Deployment Health Services, Patient Care Services Department of Veterans Affairs definitions and includes: At least one symptom (of at W H AT I S T H E T R E AT M E N T F O R.)

5 Least 6 months duration) from at least two categories: G U L F WA R I L L N E S S? Fatigue GWI falls under a broader umbrella term for a Musculoskeletal constellation of chronic, unexplained symptoms Mood and Cognition referred to as CMI and therefore treatment is similar. CMI is an umbrella term which conditions include: The Kansas Definition is the more specific and includes: Moderately severe or multiple Myalgic Encephalomyelitis/Chronic Fatigue symptoms in 3 of 6 complexes: Syndrome (Systemic Exertion Intolerance Fatigue/Sleep problems Disease) (ME/CFS (SEID)) , a condition of long- Pain symptoms term and severe fatigue and post -exertional Neurologic/Cognitive/Mood malaise that is not relieved by rest and is Gastrointestinal problems not directly caused by other conditions. Respiratory problems Fibromyalgia, a condition characterized by Skin problems widespread muscle pain.

6 Other symptoms may include sleep disruption or unrefreshing Symptoms cannot be explained by sleep, headache, and memory problems. another medical condition No condition that would impair Functional gastrointestinal disorders , a ability to report symptoms group of conditions marked by chronic or recurrent symptoms related to any part of the Symptoms must have started gastrointestinal tract. Examples include irritable during or after deployment bowel syndrome (IBS), functional dyspepsia, More recently, VA has formed a working group to and functional abdominal pain syndrome. develop a single, clinical case definition of GWI. Undiagnosed illnesses with symptoms that may include but are not limited to: abnormal Until a single case definition exists, a clinical weight loss, fatigue, cardiovascular disease, diagnosis of GWI should reflect the following: muscle and joint pain, headache, menstrual The diagnosis must refer specifically to disorders , neurological and psychological Veterans deployed to combat theatre problems, skin conditions, respiratory of operations in support of Operation disorders , and sleep disturbances.

7 Desert Shield and Operation Desert Storm, between years 1990-1991. In 2014, the Department of Veterans Affairs and The Veteran's symptoms cannot be better Department of Defense (DoD) released clinical explained by another medical condition, practice guidelines for healthcare providers caring including a psychiatric condition. If the Veteran for Veterans with CMI. These guidelines can be useful has comorbid conditions with overlapping for the evaluation and management of GWI, as well. symptoms, such as post traumatic stress The guidelines outline key steps that providers can Disorder ( ptsd ) or heart disease, GWI can be follow to ensure a systematic approach is followed diagnosed if the symptoms are in excess of that addresses critical factors at each of the major what is expected from the comorbid condition.

8 Decision points. Specifically the Clinical Practice Guidelines emphasizes an ordered sequence of steps The Veteran's symptoms must include of care, decisions to be considered, and action to be at least two or more chronic symptoms taken. More information and answers to frequently in different body systems that occurred asked questions are provided at the links below. during or shortly after the deployment, and persist or regularly occur since then. For more information, contact 800-248-8005 | 2. War Related ILLNESS and Injury Study Center WRIISC post -Deployment Health Services, Patient Care Services Department of Veterans Affairs CMI CPG Algorithm address Veteran concerns so that a shared treatment plan can be put into place. Take a holistic perspective and do not CMI Pocket Card dichotomize Veterans medically unexplained symptoms as simply physiological or psychological symptoms.

9 Often the etiology MI Frequently Asked Questions is more complex and multi-factorial. Learn more about risk mus/CMI_FAQ% communication and its importance in Refer gulf War Veteran patients provider/patient interactions: seeking information on health benefits related to GWI to the Veteran's Benefits Administration Once you determine that a Veteran has GWI, the to check eligibility. There is patient should be treated symptomatically. The focus no International Classification should be on addressing the specific symptoms of Diseases (ICD) code that is of individual Veteran patients and developing recognized automatically for service- management strategies designed to optimize overall connected benefits related to GWI. quality of life. Because they're generally lower risk, P R I N C I P L E S O F C A R E M A N AG E M E N T non-pharmacologic treatments are recommended before considering pharmacological treatment.

10 Several evaluation strategies and diagnostic Non-pharmacologic approaches could include tests may help determine if a Veteran meets recommending a low impact, graded exercise program the criteria for a diagnosis of GWI. During the or a trial of cognitive-behavioral therapy (CBT). CBT. evaluation and diagnosis stages providers does not alter the symptoms directly, but may help should consider the following principles: patients with symptoms lead more productive lives The evaluation must be individualized to the by teaching them active management and coping Veteran's presenting symptoms, concerns, skills. Each Veteran who has symptoms of GWI. and history based on clinical judgment. should receive individualized recommendations Medically explainable causes for the symptoms for specific symptom management, as what works must be considered and appropriately evaluated.