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Post-combat disorders from the Boer War to the Gulf Conflict: their nature and attribution

Post-combat disorders from the Boer War to the Gulf Conflict: their nature and attribution. Dr Edgar Jones, Reader in the History of Medicine and Psychiatry, GKT School of Medicine, London. Learning and Performance Objectives. To understand more about the nature of post-combat disorders

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Post-combat disorders from the Boer War to the Gulf Conflict: their nature and attribution

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  1. Post-combat disorders from the Boer War to the Gulf Conflict: their nature and attribution Dr Edgar Jones, Reader in the History of Medicine and Psychiatry, GKT School of Medicine, London.

  2. Learning and Performance Objectives • To understand more about the nature of post-combat disorders • To identify common patterns in their presentation • To relate them to the changing nature of warfare and advances in medical science

  3. Definition Post-combat disorders are characterised by a range of medically unexplained symptoms that are both somatic and psychological. They are distressing and debilitating disorders which often prevent sufferers from completing tasks. Symptoms commonly become chronic and difficult to treat.

  4. Sources War pension files, which contain detailed information about servicemen’s military and medical histories, often from enlistment until death, were the primary source.

  5. Subjects Studied Boer War: 200 cases of Disordered Action of the Heart (DAH) 200 cases of rheumatism

  6. World War One cases 200 cases of DAH 200 cases of neurasthenia 167 cases of exposure to gas Nurses: 24 cases of DAH and 49 cases of neurasthenia

  7. World War Two cases 200 cases of psychoneurosis 67 cases of effort syndrome 100 cases of non-ulcer dyspepsia

  8. Gulf War cases 400 cases of Gulf-related illness randomly selected from the Medical Assessment Programme

  9. Data collection To collect data in a standardised manner, a form recorded: • Serviceman’s biographical details • Military record • 94 possible symptoms • Results of medical investigations • Explanations for illness • Military conduct

  10. Common symptoms The 15 most common symptoms reported included: Difficulty completing tasks, fatigue, shortness of breath, persistent anxiety, weakness, rapid heartbeat, headaches, difficulty sleeping, tremor, dizziness, depression, pains in joints, changes in weight, irritability and memory loss.

  11. Statistical Analysis The dataset with 1,856 subjects and 25 variables was subjected to cluster analysis (a k-means algorithm to cluster the data, and the gap statistic was used to determine the most appropriate number of groups).

  12. Results We found three clusters of post-combat syndromes: • Cluster One - a debility syndrome • Cluster Two – a somatic syndrome • Cluster Three – a neuropsychiatric syndrome

  13. Debility Cluster (n=847) characterised by: Fatigue, difficulty completing tasks, shortness of breath and weakness. With the exception of anxiety, psychological and cognitive symptoms were notably absent.

  14. Somatic Cluster (n=434) characterised by: Rapid heartbeat, shortness of breath, fatigue and dizziness. A symptom cluster indicative of a functional cardiac syndrome.

  15. Neuropsychiatric Cluster (n=575) characterised by: Fatigue, headaches, depression, anxiety and difficulty sleeping. This cluster is represented by a range of somatic and psychological symptoms.

  16. Predicting cluster membership Cluster membership was found to be most closely correlated with individual wars. This implied that there is an important temporal element running through these post-combat syndromes.

  17. Debility Cluster 74% of the servicemen in this cluster had fought in wars conducted before 1918. Only 76 (9%) were WW2 veterans, and 146 (17%) were Gulf War veterans.

  18. Somatic Cluster WW1 veterans represented 49% of its membership. Only 83 (19%) of WW2 veterans and 38 (9%) of Gulf War veterans were found in this cluster.

  19. Neuropsychiatric Cluster Over half of the Gulf veterans (54%) fell into this cluster, together with 57% of all WW2 veterans. Only 21% of WW1 veterans were in this group.

  20. Servicemen’s attributions Debility Cluster: 61% believed that their symptoms were related to a physical illness physical injury or strain, effect of climate or a toxic exposure.

  21. Servicemen’s attributions Somatic Cluster: 68% of those who believed that physical illness, injury, climate or toxic exposure were the cause of their symptoms fell into this cluster, and only 13% of those who believed it was the result of the stress of service.

  22. Servicemen’s attributions Neuropsychiatric Cluster: 143 (64%) of those who believed that the stress of military service was the cause of their symptoms were found in this group. Only 23 (12%) of the 186 who believed they had a physical illness were in this group.

  23. Conclusions • There seems to be no single post-combat syndrome but variations on a theme. • Variations are related to the changing hazards of war and advances in medical science. • Attributions by servicemen are generally consistent with symptom clusters

  24. References E Jones, R Hodgins Vermaas, H McCartney, B Everitt, C Beech, D Poynter, I Palmer K Hyams, S Wessely (2002), Post-combat syndromes from the Boer War to the Gulf War: a cluster analysis of their nature and attribution, BMJ 324: 321-24.

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