Postcombat disorders from the Boer War to the Gulf Conflict: their nature and attribution

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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.

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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

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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.

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Sources

• War pension files, which contain detailed
  information about servicemens military and
  medical histories, often from enlistment until
  death, were the primary source.

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Subjects Studied

• Boer War
• 200 cases of Disordered Action of the Heart (DAH)
  
• 200 cases of rheumatism

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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

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World War Two cases

• 200 cases of psychoneurosis
• 67 cases of effort syndrome
• 100 cases of non-ulcer dyspepsia

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Gulf War cases

• 400 cases of Gulf-related illness randomly
  selected from the Medical Assessment Programme

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Data collection

• To collect data in a standardised manner, a form
  recorded
• Servicemans biographical details
• Military record
• 94 possible symptoms
• Results of medical investigations
• Explanations for illness
• Military conduct

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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.

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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).

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Results

• We found three clusters of post-combat syndromes
• Cluster One - a debility syndrome
• Cluster Two a somatic syndrome
• Cluster Three a neuropsychiatric syndrome

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Debility Cluster

• (n847) characterised by
• Fatigue, difficulty completing tasks, shortness
  of breath and weakness. With the exception of
  anxiety, psychological and cognitive symptoms
  were notably absent.

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Somatic Cluster

• (n434) characterised by
• Rapid heartbeat, shortness of breath, fatigue and
  dizziness. A symptom cluster indicative of a
  functional cardiac syndrome.

15
Neuropsychiatric Cluster

• (n575) characterised by
• Fatigue, headaches, depression, anxiety and
  difficulty sleeping. This cluster is represented
  by a range of somatic and psychological symptoms.
  

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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.

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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.

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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.

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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.

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Servicemens 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.

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Servicemens 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.

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Servicemens 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.

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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

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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.