The Unexplained Pain of Battle
In virtually all wars there are a number of participants with unexplained symptoms. Such complaints usually involve fatigue, non-specific gastrointestinal complaints, and muscle and joint pain. With the Holidays fast upon us, it is a time to not only thank the men and women who serve, but also an opportunity to wish them the best when they return from the far corners of the earth.
Many readers will recall the unexplained physical symptoms which received quite a bit of media attention during and after the 1991 Gulf War. Interestingly, such somatic complaints were more frequent in those with the diagnosis of posttraumatic stress disorder (PTSD), or other psychological conditions. Unfortunately, these physical complaints have had a consequence which is not trivial: the 1991 Gulf War veterans suffered significant occupational disability (as measured by days absent from the workplace).
A study published last year in the March-April edition of “Psychosomatics” reviewed the records of over 1,200 Iraq and Afghanistan patients evaluated by psychiatrists at Landstuhl Regional Medical Center in Germany, the largest military medical facility outside the United States. A little less than 3% received a diagnosis of a somatoform-spectrum disorder (SSD); of those, 63% were diagnosed with conversion disorder, 3% pain disorder, 3% undifferentiated somatoform disorder, 23% psychological factors affecting physical condition, and 7% were suspected of malingering. One of the most common SSD manifestations was headache.
Interestingly, deployment-related stressors such as stressful living conditions, weather extremes, interpersonal problems with supervisors and peers and sleep deprivation were most associated (approximately 47% of cases) with SSD. Past or family psychiatric history resulted in 43% of SSD cases. Past history of combat exposure, home family problems, and past history of trauma were responsible for a relatively low percentage of SSDs.
So, why are SSDs so uncommon, thus far, among Iraq and Afghanistan veterans? Here are some theories:
- Perhaps there is less of a stigma for today’s veterans; they may feel freer to report psychiatric complaints, thus receiving treatment in a timelier manner compared to past wars. There has been more of an emphasis the last few years on maintaining the mental health of military personnel.
- There may be a rapid resolution of the presenting complaint once the evacuated patient is in a safe environment, out of the combat zone.
- SSDs may be effectively managed while in the combat theater, as there is a strong mental health presence in the combat zones of today.
- Perhaps SSDs and somatic symptoms that become chronic pain complaints are things seen more commonly after many years. It could be that it is too early for the vulnerable patient to develop such symptoms and diagnoses. It should be remembered that after the 1991 Gulf War, 40% of physical symptoms reported by veterans had a latency period that exceeded one year after the return from deployment.
I have a sense that the veterans of today’s wars will be followed closely. And while times have changed, in that there is more of a sensitivity on the part of the military in terms of suicide prevention protocols and the attempts at removing stigma from the seeking of mental health counseling, those who treat today’s veterans must also be vigilant for the new challenges which might arise from a veteran who must undergo repeated deployments to the combat environment. Repeated exposure to traumatic events and the anticipation of those repeat deployments might very well result in heretofore unseen and more virulent psychiatric illness which will almost surely have somatic manifestations.
Take a moment to remember the Veteran this Holiday season. There is a good chance he or she will still be fighting battles long after leaving the service.