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Appendix D: Gulf War Illnesses and Recognizing New Diseases
Pages 342-365

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From page 342...
... It also points to social factors, including culture and economics, which weigh into decisions about new diseases. HOW NEW DISEASES GAIN RECOGNITION IN MEDICINE Medicine is teeming with examples of new diseases gaining recognition.
From page 343...
... A case definition seeks to formulate criteria that effectively identify and distinguish a new patient population from patient populations with recognized 2What is now diagnosed as chronic fatigue syndrome is strikingly similar to the nineteenth century descriptions of the condition labeled neurasthenia (Wessely et al., 19984. Lyme disease is an infectious disease that has been traced back to a disease characterized at the beginning of the twentieth century (Aronowitz, 1991)
From page 344...
... That is why the prevailing medical convention is to resist the popular label "Gulf War syndrome." When evidence is presented that a case definition is successful at singling out a new patient population from comparison groups, the case definition progresses a step forward: it begins to achieve recognition by the medical establishment as a new syndrome. The term "syndrome" is by convention reserved for a reproducible set or cluster of symptoms, signs, and/or laboratory tests, without known pathology or etiology (Scadding, 19961.
From page 345...
... Impairment of functioning- social, educational, or occupational is considered one of the quintessential criteria for a mental disorder. In its standard manual used for the classification and diagnosis of mental disorders in the United States, the American Psychiatric Association defines a mental disorder as a behavioral or psychological syndrome associated with distress and disability (i.e., impairment of functioning (APA, 1994~.
From page 346...
... Systems of Disease Classification Formal classifications of diseases, disorders, and syndromes are found in the latest modifications of the International Classification' of Diseases (ICD-10) and the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)
From page 347...
... It attempts to infer the existence of something that cannot be observed directly or verified empirically. In the application of factor analysis to Gulf War illnesses, researchers strive to infer, and thereby "define," a potentially new Gulf War syndrome on the basis of the cooccurrence (or associations)
From page 348...
... recognize the social, financial, and political pressures that promote or discourage acceptance of a new category. The authors proffer these criteria to encourage more systematic approaches to defining a new condition from Gulf War symptoms (Wegman et al., 1997~.
From page 349...
... The fundamental question propelling research is to determine whether unexplained illnesses in Gulf War veterans are variants of, or distinct from, similar conditions. This section first describes medically unexplained illnesses and then presents the evidence for overlap between unexplained illnesses in Gulf War veterans and civilian populations.
From page 350...
... In ongoing research, the medically unexplained illnesses most frequently compared with illnesses in Gulf War veterans are fibromyalgia, chronic fatigue syndrome, and multiple chemical sensitivity (for summary descriptions, see Boxes D.1-D.3~. All three are characterized by multisystem somatic complaints, usually pain, headache, and fatigue (Table D.1, Table D.2~.
From page 351...
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From page 353...
... 353 ~ , I: cot an .Cq ~ o ' ~ EM set, O —~ .
From page 354...
... Attempts to systematically study medically unexplained illnesses have been thwarted by problems in case definition and classification of patients (Hyams, 1998~. The problems stem not only from the absence of abnormal physical signs ~2Somatization refers to a group of mental disorders in which mental distress is expressed in terms of physical suffering (APA, 1994~.
From page 355...
... This is referred to as the problem of specificity, and it plagues research on medically unexplained illnesses (Hyams, 1998~. What is now grouped together as "unexplained illnesses" in Gulf War veterans, for example, might comprise heterogeneous illnesses with different etiologies, pathogenesis, and risk factors.
From page 356...
... recommend a dimensional approach that divides patients with unexplained illnesses, not along categorical lines, but according to the number and chronicity of symptoms, associated mood disturbance, patients' attributions for symptoms, and identifiable physiological processes. Evidence for Overlap In past and ongoing research, Gulf War illnesses have been compared with fibromyalgia, chronic fatigue syndrome, and multiple chemical sensitivity (Boxes D.1-D.34.
From page 357...
... The first indication of Gulf War veterans reporting symptoms consistent with these conditions emerged from the DoD and VA registries (Joseph, 1997; Murphy et al., 1999~.~4 The large, well-desi~ed epidemiologic studies summa~4A diagnosis of fibromyalgia was made for 18 percent of 1,150 DoD registry patients referred for rheumatological evaluation of musculoskeletal complaints (Erickson et al., 1998~. The overall frequency of fibromyalgia, chronic fatigue syndrome, and multiple chemical sensitivity in veterans participating in VA and DoD registries has not been published.
From page 358...
... Chemical intolerance and symptom severity scores were significantly greater for all three groups than for controls. The only published study thus far to have examined Gulf War veterans expressly for a diagnosis of multiple chemical sensitivity, as well as for chronic fatigue syndrome and fibromyalgia, was undertaken by Pollet and coworkers (19984.
From page 359...
... Further studies are in progress searching for similarities and differences between Gulf War illnesses and these related conditions (Research Working Group, 1999~. Benefits to Veterans There are several immediate and potential advantages to veterans from investigating relationships between their illnesses and fibromyalgia, chronic fatigue syndrome, and multiple chemical sensitivity.
From page 360...
... Other attributes of medically unexplained illnesses, such as fatigue, pain, and headache, are far more difficult to measure in animal behavior. Multiple chemical sensitivity is one of the few medically unexplained conditions for which an animal model has been developed (Table D
From page 361...
... Still to be answered through more research is whether the symptoms do constitute a syndrome and, if so, whether the syndrome is genuinely new or is a variant form of other conditions, such as chronic fatigue syndrome, fibromyalgia, or multiple chemical sensitivity. This appendix has provided some evidence for overlap between Gulf War illnesses and these three conditions.
From page 362...
... 1999. Prevalence and overlap of chronic fatigue syndrome and fibromyalgia syndrome among 100 new patients with multiple chemical sensitivity syndrome.
From page 363...
... 1997. A comprehensive clinical evaluation of 20,000 Persian Gulf War veterans.
From page 364...
... 1999. A controlled comparison of symptoms and chemical intolerances reported by Gulf War veterans, implant recipients and persons with multiple chemical sensitivity.
From page 365...
... 1994. Multiple chemical sensitivity syndrome: A clinical perspective.


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