This chapter summarizes the Board's observations concerning stress as a contributing factor in the symptoms of Gulf War undiagnosed illnesses. The Board concludes that stress is likely a primary cause of illness in at least some Gulf War veterans and a likely secondary factor in potentiating other causative agents in producing undiagnosed illnesses among some Gulf War veterans. It is worth repeating, as stated earlier, that the Board recognizes that veterans suffering from undiagnosed illnesses, even if caused by deployment stress, have real medical problems that pose a significant disruption in their lives.

Stress, as it pertains to military deployments, can be defined as the real or perceived imbalance between environmental demands and an individual's capacity to adapt to these requirements. Many scientific studies have established unequivocally that stress can have significant physiological and psychological impact in the human body, contributing to considerable physical illnesses in some patients.

During the Gulf War, deployment stressors varied with any of the following factors: "type of primary duty (engaged in combat, combat support, flight-line support, nonflight support, or multiple duties); traumatic events of combat (came under fire, suffered SCUD attacks or was in ground combat, saw casualties, or suffered injuries that required medical attention); perception of a threat (belief that BW or CW were being used against them); prophylactic treatment for nerve gas exposure (PB); chemical hazards (direct contact with smoke or crude oil from oil well fires in Kuwait, use of insect repellent on a regular basis); adverse working conditions (spent more than 8 hours sandbagging or digging holes in the sand, walked or hiked in the sand); family issues (changed marital status, family member experienced significant health events such as birth of a child, death, hospitalization, severe illness, or miscarriage); and period of deployment."¹ In addition, adverse environmental conditions and harsh living conditions contributed to the stresses of deployment.

Stress should not and cannot be ignored as a potential causative factor for some individuals who exhibit physical illness symptoms following deployment, combat, or combat support operations. There is an unfortunate reluctance on the part of the American public, some members of Congress, and especially among some members of the veterans community to recognize the impact that stress can have on an individual. In fact, during a recent congressional hearing on research into the Gulf War, a prominent individual included in his public testimony a ridicule of the notion that stress played any role in Gulf War illnesses, referring to the head of OSAGWI as being the "captain of the stress team." In addition, many veterans become incensed when they perceive that government officials or scientists attribute their suffering as being "all in their head." These attitudes stem from a misunderstanding of the very real physiological and biochemical impact that stress can have on the human body. Stress can lead to genuine illnesses. No physician or researcher familiar with the effects of stress minimizes the suffering that patients often exhibit. The symptoms are indeed real; they are not imagined and they are not "all in the head." In this regard, the Board concurs with the characterization of stress set forth in the RAND study on stress in the Gulf War:

Recently, Dr. Harold C. Sox, the chairman of the distinguished Institute of Medicine panel commissioned to review possible Gulf War exposures, stated that the panel of experts wished that Congress had included psychological stress in the list of exposures they should examine. Congress specifically excluded stress as a potential causative factor for review. The Board concurs with Dr. Sox and recommends that combat stress be investigated by the Institute of Medicine with the same academic and scientific rigor that was used to evaluate chemical and/or biological hazards in the war.

The PAC Final Report findings were: 1) data from the clinical programs and epidemiological studies indicate stress-related disorders are common components of Gulf War veterans' illnesses, and 2) stigmatization of psychosomatic illness seriously interferes with some veterans seeking care. These findings have created considerable controversy. Many U.S. veterans felt the conclusion that stress could contribute to Gulf War illnesses was neglectful on the part of anyone or any organization that embraced that finding, especially DoD, VA, and the PAC. The Board disagrees with that characterization and strongly recommends that those who dispute the possibility of stress as a contributing factor to physical illness review the voluminous published literature on the subject. Veterans can join forces with the scientific community by giving fair consideration to these scientific observations. Regardless of whether a proposed causative factor is unpopular and/or misunderstood by some veterans, servicemembers, members of Congress, or the general public, policymakers and health care providers should not ignore their duty to these veterans and servicemembers by summarily dismissing potential treatment options or research opportunities that could expand our knowledge of human physiology and improve veterans' health.

A recent RAND Corporation publication³ commissioned by OSAGWI reviewed stress as it pertains to the Gulf War. It included a review of the scientific literature on stress (301 reference citations), focusing on three sources of evidence: 1) general, non-Gulf War-related studies concerning the link between stress and health problems; 2) available data concerning stresses faced by deployed personnel in the Persian Gulf; and 3) empirical studies bearing directly on the link between stress and health problems experienced by Gulf War veterans. The RAND review concluded: "Although the general scientific literature has implicated stress exposure as a contributing factor in various well-defined conditions, including some health problems experienced by Gulf War veterans, few problems or symptoms are uniquely characteristic of stress exposure.... In sum, the possibility that stress may have either contributed to or exacerbated the health problems of some registry participants (and, by extrapolation, some Gulf War veterans) can neither be ruled out nor proven based upon currently published descriptive registry data."⁴ A separate but companion RAND study by David H. Marlowe concluded "...the stress of combat or simply deploying to the theatre of war can have both immediate and long-term physical and psychological consequences. These consequences are similar throughout the history of warfare even though the nature of warfare has changed dramatically. Stress is likely to affect and be affected by many factors synergistically which implicitly leads to the conclusion that it is unlikely that a single independent cause exists for the undiagnosed symptoms of some Gulf War Veterans.... [T]his paper argues that the search for a single cause of undiagnosed illness is simplistic and, ultimately, doomed to fail. In the area of stress-related concerns, a series of complex and interacting factors are a more likely source of these symptoms. The presentation of psychological pain in the form of physical symptoms is a common event, far more widespread than many realize. Moreover, the undiagnosed illnesses pertaining to service in the Gulf may have been shaped by the culture, which in turn can shape the nature and interpretation of symptoms by the veterans. To be most helpful to the veterans who are suffering from these symptoms, the issue of complexity must be addressed and not abandoned in a search for a single cause."⁵

In 1994, the U.S. Army, recognizing the deleterious effects that stress can have on deployed and deployable personnel, published a detailed set of manuals on combat and stress. This initiative matched that of the Canadian government, which, after concluding that stress played a major role in the post-Gulf War illnesses experienced by many of its troops, developed effective stress control programs for its forces. In 1999, the Department of Defense codified its stress program by issuing DoD Directive 6490.5, Combat Stress Control (CSC) Programs. The purpose of this directive was to "establish policy and assign responsibility ... for developing CSC programs within the Military Services, the Combatant Commands and Joint Service Operations; [and to] ensure appropriate prevention and management of Combat Stress Reaction casualties to preserve mission effectiveness and warfighting, and to minimize the short- and long-term adverse effects of combat on the physical, psychological, intellectual, and social health of service members." Operationally, this directive has been put into effect for U.S. forces in Bosnia and Kosovo, who have had in-country combat stress control services for deployed members.

In June 2000, DoD conducted a senior leadership conference that focused entirely on stress. More than 150 senior personnel from each of the military services, the Unified Combatant Commands, the Joint Staff, and other interested federal government representatives attended the conference. The Undersecretary of Defense for Personnel and Readiness provided opening and closing remarks for the conference and took ownership of future DoD action on conference recommendations. The conference provided two days of factual, anecdotal, and sometimes emotional presentations that demonstrated the unambiguous role of stress in military operations. Categories and subcategories of operational stress, combat stress, deployment stress, the factors that create and influence stress, separation from families, threat of NBC warfare, fear of injury or death, boredom, periods of anxiety, hostile physical environment, and ethics were all topics for presentation and discussion.

The Board commends DoD for these initiatives and recommends that the newly formed OSAGWIMRMD maintain a close working relationship with the policy development offices at the Department level and the implementing offices for CSC programs at the Service level. The efforts of the Special Assistant should be inclusive and cognizant of the role that stress plays in deployment-related matters. The Board also recommends that the Special Assistant be included in all CSC policy matters, to include implementation of the CSC program and any proposed modifications.

The Board finds that:

• Stress was a likely contributor to the symptoms of undiagnosed illnesses in at least some Gulf War veterans.
• Stress can have a major influence on the health of military personnel.
• DoD has adequately complied with the PAC recommendation in its Final Report concerning stress, stress awareness, and program(s) that address stress.

The Board recommends that:

• DoD and the military services continue to recognize stress and stress amelioration as core concepts for a fit and healthy force.
• The military services incorporate stress awareness and stress training into enlisted and officer training schools and professional development courses.
• The military services heighten and incorporate institutional awareness of this subject into the annual training requirements of the military services-e.g., in the annual U.S. Army mobilization requirements training and comparable training in the other services.
• DoD examine the peer-reviewed scientific literature and conduct appropriate research on stress to enhance deployment health, military health programs, and general military training programs.

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