INDEX

A

Accidental death, 237247

primary studies, 237241, 245247

PTSD and, 242243

secondary studies, 241242

ACR. See American College of Rheumatology

ACTH. See Adrenocorticotrophic hormone, corticotropin

Adrenocorticotrophic hormone (ACTH). See Corticotropin

Afghanistan. See Operation Enduring Freedom

Age, and PTSD, 88

Agent Orange, 115, 117119, 127, 201, 214, 216, 218, 318

Air Force cohorts, 136, 147, 149, 161, 251253

Alcohol abuse or dependence, 8, 55, 57, 83, 86, 89, 144145, 150, 158163, 224, 238, 243, 250251, 289, 291, 319

Alcohol Use Disorder Identification Test (AUDIT), 158, 161162

Allostasis, 5455

Allostatic load and overload, 4950, 5456

Alternate Family Violence Measure, 289

American College of Rheumatology (ACR), 222, 226227, 255

American Indian veterans. See Race and ethnicity

American Psychiatric Association (APA), 76, 85

Amygdala, importance in stress response, 5153, 5758, 6061, 65, 98100

Animal studies, 1819, 5859, 9697

Anticipation of deployment to a war zone, a deployment–related stressor, 36

Antisocial personality disorder, 145, 161, 284, 289, 300, 306

Anxiety disorders, 2, 7, 12, 30, 35, 51, 53, 84, 86, 8889, 91, 100, 144157, 193, 253, 257, 308309, 319.

See also Generalized anxiety disorder

Anxiety Sensitivity Index (ASI), 149

APA. See American Psychiatric Association

Army cohorts, 34, 79, 118, 125126, 142144, 147, 158, 167, 229, 237, 241, 253, 287

female, 38

ASI. See Anxiety Sensitivity Index

Assault. See Sexual assault and harassment

Assessment of the strength of evidence, 2526

biologic plausibility, 26

consistency of association, 26

dose–response relationship, 25

specificity of association, 26

strength of an association, 25

temporal relationship, 25



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INDEX A Accidental death, 237–247 primary studies, 237–241, 245–247 PTSD and, 242–243 secondary studies, 241–242 ACR. See American College of Rheumatology ACTH. See Adrenocorticotrophic hormone, corticotropin Adrenocorticotrophic hormone (ACTH). See Corticotropin Afghanistan. See Operation Enduring Freedom Age, and PTSD, 88 Agent Orange, 115, 117–119, 127, 201, 214, 216, 218, 318 Air Force cohorts, 136, 147, 149, 161, 251–253 Alcohol abuse or dependence, 8, 55, 57, 83, 86, 89, 144–145, 150, 158–163, 224, 238, 243, 250– 251, 289, 291, 319 Alcohol Use Disorder Identification Test (AUDIT), 158, 161–162 Allostasis, 54–55 Allostatic load and overload, 49–50, 54–56 Alternate Family Violence Measure, 289 American College of Rheumatology (ACR), 222, 226–227, 255 American Indian veterans. See Race and ethnicity American Psychiatric Association (APA), 76, 85 Amygdala, importance in stress response, 51–53, 57–58, 60–61, 65, 98–100 Animal studies, 18–19, 58–59, 96–97 Anticipation of deployment to a war zone, a deployment–related stressor, 36 Antisocial personality disorder, 145, 161, 284, 289, 300, 306 Anxiety disorders, 2, 7, 12, 30, 35, 51, 53, 84, 86, 88–89, 91, 100, 144–157, 193, 253, 257, 308– 309, 319. See also Generalized anxiety disorder Anxiety Sensitivity Index (ASI), 149 APA. See American Psychiatric Association Army cohorts, 34, 79, 118, 125–126, 142–144, 147, 158, 167, 229, 237, 241, 253, 287 female, 38 ASI. See Anxiety Sensitivity Index Assault. See Sexual assault and harassment Assessment of the strength of evidence, 25–26 biologic plausibility, 26 consistency of association, 26 dose–response relationship, 25 specificity of association, 26 strength of an association, 25 temporal relationship, 25 323

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324 GULF WAR AND HEALTH AUDIT. See Alcohol Use Disorder Identification Test Auditory-Verbal Learning Test, 169 Australian troops, 79–80, 88–89, 91–92, 123–124, 134, 146, 150, 152, 163, 180, 185, 199, 216, 231–233, 248–249, 253, 256, 287, 318 Autoimmune diseases, 63, 137, 217–218 B Barsky Amplification Scale, 149 Bed nucleus of the stria terminalis (BNST), 51–53, 61 Bias, in identifying and evaluating the literature, 24 Biologic plausibility, in assessing the strength of evidence, 26 Birth defects, 12 and miscarriage, 229–231 primary studies, 229–231 secondary studies, 231 Birth Defects Monitoring Programs, 229 Black veterans. See Race and ethnicity Blood lipids, 193 concentrations of, 188 BMI. See Body-mass index BNST. See Bed nucleus of the stria terminalis Body-mass index (BMI), 61–62, 138, 188–189 Brain function, 60–61 and anxiety and fear, 61 and memory and cognition, 60–61 in stress response, 60–61 Brain-gut axis and IBS, 64–65, 204 in stress response, 64–66 Brain-imaging techniques, 60 Brain’s role in stress response, 50–56, 60–61 allostatic load and overload, 54–56 gastrointestinal (GI) and brain-gut axis, 64–66 hypothalamus-pituitary-adrenal axis, 53–54 importance of the amygdala, 51–53 reticular activating system, 51 Brief Life Stress Questionnaire, 224 Brief Symptom Inventory, 151 British troops. See United Kingdom troops C C-reactive protein, 58, 64 CAGE scale, 158 California Verbal Learning Test (CVLT), 168–169 Canadian troops, 36, 79, 123, 136, 148, 162, 176, 225, 248, 250, 318

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INDEX 325 Cancer, 117–132 all cancers, 118–125 Gulf War, 120–123 PTSD and, 125–126 skin cancer, 124–125 testicular cancer, 123–124 Vietnam War, 118–120 CAPS. See Clinician-Administered PTSD Scale Cardiovascular diseases, 183–196 blood lipid concentrations, 188 cardiovascular symptoms, 183–184, 191–192 heart disease, 186–187 hypertension, 184–186, 189–190 PTSD and, 188–193 Cardiovascular reactivity, PTSD and, 190–191 Cardiovascular system, in stress response, 63–64 Career Development Study (CDS), 285–286 Case-control studies, 21–22 Casualty Information System, 239 Categories of association, 4–5, 26–28. See also Summary of findings regarding the association between deployment to a war zone and specific health and psychosocial effects in identifying and evaluating the literature, 26–28 inadequate/insufficient evidence to determine whether an association exists, 5, 27 limited but suggestive evidence of an association, 4, 27 limited/suggestive evidence of no association, 5, 28 sufficient evidence of a causal relationship, 4, 27 sufficient evidence of an association, 4, 27 CCEP. See Comprehensive Clinical Evaluation Program CDC. See Centers for Disease Control and Prevention CDS. See Career Development Study Centers for Disease Control and Prevention (CDC), 118, 124, 127, 133, 142–143, 158, 168, 174– 177, 185, 187, 193, 237, 248, 251–253 Central nervous system (CNS), 53, 59, 65–66, 207, 210, 225 CES. See Combat Exposure Scale CFS. See Chronic fatigue syndrome Chalder fatigue scale, 176 CHD. See Coronary heart disease Chemical stressors, deployment-related, 39 Child Behavior Checklist, 285, 293 Childhood Physical Punishment Scale, 293 Children, psychosocial effects of parents’ deployment on, 285–286, 291–293 Children’s Depression Inventory, 292 Chronic fatigue syndrome (CFS), 86–87, 174–178, 253 case definition of, 174 primary studies, 175

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326 GULF WAR AND HEALTH PTSD and, 176–177 secondary studies, 175–176 Chronic obstructive pulmonary disease (COPD), 197, 201 Chronic stress, 6, 13, 15, 52–57 brain function, 60–61 cardiovascular system, 63–64 endocrine system, 61–62 gastrointestinal system and brain-gut axis, 64–66 and health, 59–66 immune and inflammatory responses, 62–63 Chronic widespread pain (CWP), 222–228, 255–257. See also Fibromyalgia primary studies, 222–224 PTSD and, 226, 256–257 secondary studies, 224–226 Chronicity of stressors, 57 CIDI. See Composite International Diagnostic Interview Clinical features, of PTSD, 76–77 Clinician-Administered PTSD Scale (CAPS), 76, 138, 226, 291, 309 CNS. See Central nervous system Cognition, 60–61 Cohort studies, 20–21 Combat exposure, 28, 33–34, 42, 81 and PTSD risk, 88, 90, 92–93 Combat Exposure Index, 145 Combat Exposure Scale (CES), 117, 224, 253, 305, 317 Expanded, 146, 224 Committee on Gulf War and Health: Physiologic, Psychologic, and Psychosocial Effects of Deployment-Related Stress, approach to its charge, 2–3, 14–15 interpretation of its charge, 2, 13–14 Comorbidity, and PTSD, 78, 84–85 Composite International Diagnostic Interview (CIDI), 23, 76, 142, 147 Comprehensive Clinical Evaluation Program (CCEP), 181, 223 Conclusions, 317–320 about cancer, 126–127 about cardiovascular diseases, 193–194 about chronic fatigue syndrome, 177 about chronic stress and health, 66 about deployment-related stressors, 43 about digestive system disorders, 209–210 about employment, 309–310 about endocrine diseases, 139–140 about fibromyalgia and chronic widespread pain, 226–227 about gastrointestinal (GI) effects, 209–210 about homelessness, 301–302 about incarceration, 306

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INDEX 327 about marital and family conflict, 293–294 about neurobehavioral and neurocognitive effects, 170 about neurobiology, 100 about psychiatric disorders, 152 about reproductive effects, 233 about respiratory system diseases, 200–201 about skin disorders, 218–219 about sleep disturbances, 182 about substance-use disorders, 162–163 about suicide and accidental death, 243–244 about symptom reporting, 257–258 quality of the studies, 317–318 summary of, 7–9, 318–320 Conflict Tactics Scale (CTS), 287–288 Confounding factors, 21 in identifying and evaluating the literature, 24 Consistency of association, in assessing the strength of evidence, 26 Continuous Performance Test, 169 Controllability, modifying the stress response, 59 COPD. See Chronic obstructive pulmonary disease Coping strategies, and PTSD, 89–90 Coronary heart disease (CHD). See Heart Disease Corticotropin, 52–53, 58, 64, 96 Corticotropin-releasing hormone (CRH), 52–53, 58, 64, 96–98, 208 Cortisol, 53–54, 58–61, 96–97, 100 Course, of PTSD, 81–84 CRH. See Corticotrophin-releasing hormone Cross-sectional studies, 22 CTS. See Conflict Tactics Scale CVLT. See California Verbal Learning Test CWP. See Chronic widespread pain Cytokines, 54, 62 D Da Costa syndrome, 183 Danish troops, 41, 167, 188, 198, 215, 232–233, 248–249, 318 Demographics of military populations, 12–13 Department of Defense (DoD) Mental Health Advisory Team, 241, 283 Solider and Marine Well-Being Survey, 34 Task Force on Domestic Violence, 287 Deployment-related stressors, 2, 5–6, 13, 31–47, 115 anticipation of deployment to a war zone, 36–37 conclusions, 43 environmental and chemical stressors, 39 impacts on families and children, 292–293

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328 GULF WAR AND HEALTH living conditions, 38 military sexual assault and harassment, 37–38 noncombat stressors, 35 peacekeepers, 40–41 Reserve and National Guard troops, 39–40 stressors during combat, 32–35 women, 41–43 Depressive disorders, 51, 55–56, 91–92, 142–157, 193, 257, 319. See also Major depressive disorder; Psychiatric Disorders Developmental history, and PTSD, 88–89 Diabetes, 133–135 primary studies, 133 secondary studies, 134–135 Diagnosis, of PTSD, 76–77 Diagnostic and Statistical Manual of Mental Disorders (DSM), 7, 76–77, 81, 84–85, 142, 158, 256 diagnostic criteria for PTSD, 77 Diagnostic Interview Schedule (DIS), 142, 217, 242 Digestive system disorders, 204–213 primary studies, 205–206 PTSD and, 208–209 secondary studies, 207–208 DIS. See Diagnostic Interview Schedule Disability, and PTSD, 85–86 DoD. See Department of Defense Dose-response relationship, in assessing the strength of evidence, 4, 25 of cancer and PTSD, 125 of combat and PTSD, 92, 94 of early life stress and PTSD, 58 of exposure to war-zone stressors and PTSD, 144, 150 of sex and PTSD, 87 of skin disorders and PTSD, 216 Drug abuse or dependence, 8, 84, 86, 158–163, 238–239, 243, 251, 320 DSM. See Diagnostic and Statistical Manual of Mental Disorders E Early-life stress modifying the stress response, 58 and PTSD, 88–89 Employment, 308–311 Endocrine diseases, 133–141 diabetes, 133–135 obesity, 138–139 PTSD and, 137–138 thyroid disease, 135–137

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INDEX 329 Endocrine system in stress response, 61–62 insulin resistance and glucose intolerance, 62 obesity, 61–62 Environmental stressors, 6, 39, 49, 197 Epidemiologic studies, 7, 17–22 case-control studies, 21–22 cohort studies, 20–21 cross-sectional studies, 22 Ethnicity. See Race and ethnicity Evaluation criteria, 3–4 primary studies, 3 secondary, or support, studies, 4 Evaluation of the literature, 17–29 Evidence, assessment of the strength of, 25–26 Evidence types, 18–22 animal studies, 18–19 epidemiologic studies, 19–22 F Fear conditioning, in the neurobiology of PTSD, 97–98 Fertility difficulties, 231–232 primary studies, 231–232 secondary studies, 232 Fibromyalgia and chronic widespread pain, 222–228 primary studies, 222–224 PTSD and, 226 secondary studies, 224–226 “Fight or flight” stress response, 6, 14, 49, 51–52, 54 G GAD. See Generalized anxiety disorder Gastrointestinal (GI) effects, 204–213, 251 primary studies, 205–206 PTSD and, 208–209 secondary studies, 207–208 in stress response, 64–66 General symptoms and signs, 248–250, 259 PTSD and reporting of, 250–251 Generalized anxiety disorder (GAD), 144–152, 169, 180 Genes, modifying the stress response, 56–58 GI. See Gastrointestinal (GI) effects Glucocorticoids, 60 receptors of, 53–54, 96 Glucose intolerance, 62 Graves disease, 137, 139. See also Endocrine diseases; Thyroid disease

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330 GULF WAR AND HEALTH Graves registration, 13, 35 Grooved Pegboard Test, 169 Gulf War, 1, 5, 32, 35, 38–43, 79, 82–83, 88–89, 92, 115, 120–121, 125–127, 318 demographics, 12–13 living conditions, 37–38 prevalence of PTSD in, 79, 82–83, 87–88 Gulf War Health Registry, 253 Gulf War illness, 122, 179, 205, 224. See also Unexplained illness H Harassment. See Sexual assault and harassment Hardiness, and PTSD, 89–90 Hawaiian Vietnam Veterans Project (HVVP), 87 Health effects, 115–260 assessment of as an inclusion criterion, 23 cancer, 117–132 cardiovascular diseases, 183–196 chronic fatigue syndrome, 174–178 digestive system disorders, 204–213 endocrine diseases, 133–141 fibromyalgia and chronic widespread pain, 222–228 gastrointestinal effects, 204–213 neurobehavioral and neurocognitive effects, 167–173 organization of chapter, 115–117 psychiatric disorders, 142–157 reproductive effects, 229–236 respiratory system diseases, 197–203 skin disorders, 214–221 sleep disturbances, 179–182 substance-use disorders, 158–166 suicide and accidental death, 237–247 symptom reporting, 248–260 Heart disease, 183–184, 186–187, 189, 192–194 primary studies, 186–187 secondary studies, 187 Heart rate, PTSD and, 63, 188–191 Hispanic veterans. See Race and ethnicity Hodgkin’s lymphoma, 118–119 Homeless Chronically Mentally Ill Veterans Program, 300 Homelessness, 299–303 primary studies, 299–300 secondary studies, 300–301 Homeostasis, 54 HPA. See Hypothalamus-pituitary-adrenal axis HVVP. See Hawaiian Vietnam Veterans Project Hypertension, 183–186

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INDEX 331 primary studies, 184–185 PTSD and, 189–190 secondary studies, 185–186 Hypothalamus-pituitary-adrenal (HPA) axis, 50, 53–54, 58, 65, 96–97, 218 alterations in the neurobiology of PTSD, 96–97 in stress response, 53–54 I IBS. See Irritable bowel syndrome ICD. See International Statistical Classification of Diseases and Related Health Problems Immune responses, in stress response, 62–63 Inadequate/insufficient evidence to determine whether an association exists, 5, 9, 27, 320 Incarceration, 304–307 Inclusion criteria, 23 health-effect assessment, 23 in identifying and evaluating the literature, 23 methodologic rigor, 23 primary studies, 23 secondary studies, 23 Inflammatory responses, in stress response, 62–63 Insulin resistance, 62 International Statistical Classification of Diseases and Related Health Problems (ICD), 115, 122, 136, 149, 186, 193, 238, 243–244, 248, 251, 254 Intimate partner violence, 287–291 primary studies, 288–290 secondary studies, 290–291 Iowa Persian Gulf Study Group cohort, 42, 122, 125, 148–149, 159, 200, 217, 223–225, 248, 254, 304 Iraq. See Operation Iraqi Freedom Irritable bowel syndrome (IBS), 64–65, 204–213 K Korean War, 3, 7, 14, 17, 31, 84, 91, 100, 117, 126, 137, 139, 181, 192, 194, 208, 210, 218–219, 249–250, 300, 318 prevalence of PTSD in, 80–81 L Limitations of veteran studies, 5, 217–218 in identifying and evaluating the literature, 28 Limited but suggestive evidence of an association, 4, 8, 27, 319–320 Limited/suggestive evidence of no association, 5, 9, 28, 320 Liver cancer, primary, 118–119 Living conditions, as deployment-related stressors, 38

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332 GULF WAR AND HEALTH M Magnetic resonance imaging (MRI), 99 Major depressive disorder (MDD), 7, 76, 84–86, 91–92, 96, 142–157, 189, 226, 243, 253, 309 Marine cohorts, 34, 79, 119, 253 Marital and family conflict, 283–298 deployment impacts on families and children, 291–293 intimate partner violence, 287–291 primary studies, 284–286 secondary studies, 286–287 MDD. See Major depressive disorder Memory, 53, 60–61, 167–169, 248–249 Mental Health Advisory Team (MHAT), DoD, 31, 34–35, 92, 241, 283 Meta-analysis, 18, 91, 98, 190, 193, 255, 258 Methodologic rigor, as an inclusion criterion, 23 MHAT. See Mental Health Advisory Team MI. See Myocardial infarction Military sexual assault and harassment, 37–38 Military status, and PTSD, 91 Minnesota Multiphasic Personality Inventory (MMPI), 137, 189, 256 Miscarriage primary studies, 229–231 secondary studies, 231 Mississippi Scale for Combat-Related PTSD, 81, 180, 189, 191–192, 309 MMPI. See Minnesota Multiphasic Personality Inventory Modifiers of the stress response, 56–59 controllability, 59 early-life stress, 58 genes, 56–58 Motor-vehicle accidents, 238–241 MRI. See Magnetic resonance imaging Multisymptom-based medical conditions, 2, 12, 251–254 Myocardial infarction (MI), 58, 189, 193 N NART. See National Adult Reading Test Nasal cancer, 118–119 Nasopharyngeal cancer, 118–119 National Adult Reading Test (NART), 167 National Child Abuse and Neglect Data System, 293 National Comorbidity Survey (NCS), 78, 83–84, 158–161, 189, 290, 309 National Crime Victimization Survey, 287 National Death Index, 123, 237–238, 240 National Family Violence Re-Survey, 287

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INDEX 333 National Guard troops, 13, 32, 35, 39–40, 79, 83, 122, 124, 146, 148, 159–160, 176–177, 224– 225, 251–252. See also Reservists deployment-related stressors for, 39–40 National Health Interview Surveys, 242 National Health Survey of Gulf War Era Veterans and Their Families, 38, 133, 147, 175, 185, 198, 206, 215, 222 National Law Center on Homelessness and Poverty, 299 National Survey of Homeless Assistance Providers, 300 National Survey of the Vietnam Generation (NSVG), 143, 284–285, 288–290, 308 National Vietnam Veterans Readjustment Study (NVVRS), 33, 78, 80, 84–85, 87–88, 92, 117, 143–144, 158–159, 162, 180, 182, 251, 284–285, 288, 291, 293–294, 299, 305, 308–309, 318 Naval Mobile Construction Battalions (Seabees), 134, 136, 148, 175, 179, 184–185, 198–200, 205, 209 Navy cohorts, 43, 91, 147, 179, 253 NCS. See National Comorbidity Survey Neurobehavioral and neurocognitive effects, 167–173 primary studies, 167–168 PTSD and, 168–170 secondary studies, 168 Neurobiology of PTSD, 94–100 fear conditioning, 97–98 HPA-axis alterations, 96–97 neuroimaging studies, 99–100 sleep disturbances, 98–99 startle reflex, 98 sympathetic nervous system alterations, 94–96 Neurocognition Deployment Health Study, 167 Neuroimaging studies, in the neurobiology of PTSD, 99–100 NHL. See Non-Hodgkin’s lymphoma Non-Hodgkin’s lymphoma (NHL), 118–119, 126–127 Noncombat stressors, deployment-related, 2, 13, 31, 35 Normative Aging Study, 80, 90, 189, 192, 250, 318 NSVG. See National Survey of the Vietnam Generation NVVRS. See National Vietnam Veterans Readjustment Study O Obesity, 61–62, 138–139 Obsessive-compulsive disorder, 145–147 OEF. See Operation Enduring Freedom OIF. See Operation Iraqi Freedom Operation Desert Shield, 11, 13, 32 Operation Desert Storm, 1, 11, 13, 32 Operation Enduring Freedom (OEF), 1–3, 6–7, 11–14, 28, 31, 33, 39, 40, 43, 88, 93, 100, 150– 151, 248, 255, 258, 283 prevalence of PTSD in, 79

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334 GULF WAR AND HEALTH Operation Iraqi Freedom (OIF), 1–3, 6–7, 11–14, 28, 31–35, 38–40, 43, 79, 88, 94, 100, 150– 151, 167, 191, 208, 241, 243, 248, 255, 257–258, 283 prevalence of PTSD in, 79 P Panic disorder, 84, 95, 97, 145–149 Parental Problems Index (PPI), 285 PB. See Pyridostigmine bromide PDHA. See Postdeployment health assessment Peacekeepers, deployment-related stressors for, 35, 40–41 and health effects, 162, 167, 170, 180, 188, 215, 232–233, 249–250 and psychosocial effects, 287, 290 Persian Gulf War Veterans Act, 1, 12 Phobias, 146–148, 150 Physical injury, and PTSD, 93–94 Postdeployment health assessment (PDHA), 150–151 Posttraumatic stress disorder (PTSD), 2–3, 5–8, 12, 15, 18, 23, 28, 31, 35, 43, 51, 59–60, 75– 113, 116, 118, 137–140, 142–152, 159, 162, 168–170, 176–183, 188–194, 205, 208–210, 249–250, 283–294, 299, 304–305, 308–309, 317–319 and cancer, 125–126, 132 and cardiovascular disease, 192–193 and cardiovascular reactivity, 190–191 and cardiovascular symptoms, 191–192 and chronic fatigue syndrome, 176–177 and chronic pain, 256–257 and comorbidity, 84–85 conclusions, 100 course of, 81–84 diagnosis and clinical features, 76–77 and digestive system disorders, 208–209 and disability, 85–86 and endocrine diseases, 137–139 and fibromyalgia and chronic widespread pain, 226 and gastrointestinal effects, 208–209 and general symptom reporting, 250–251 and heart rate, 188–189 and hypertension, 189–190 and neurobehavioral and neurocognitive effects, 168–170 and neurobiology, 94–100 and prevalence, 78–81 and reproductive effects, 233 and respiratory system diseases, 200 risk and protective factors for, 86–94 and skin disorders, 216–218 and sleep disturbances, 180–182 and substance-use disorders, 162

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INDEX 335 and suicide and accidental death, 242–243 and unexplained illness, 254–255 PPI. See Parental Problems Index Prevalence of PTSD, 78–83 in the Gulf War, 79 in the Korean War, 80–81 in Operation Enduring Freedom and Operation Iraqi Freedom, 79 in U.S. military populations, estimated, 82–83 in the Vietnam War, 80 in World War II, 80–81 Proinflammatory cytokines, 54, 62 Propranolol, 95–96 Protective factors for PTSD. See Risk and protective factors Psychiatric disorders, 142–157. See also Posttraumatic stress disorder; Substance-use disorders primary studies, 142–147 secondary studies, 148–151 Psychiatric history, and PTSD, 89 Psychosocial effects, 8, 283–319 employment, 308–311 families and children, 291–293 homelessness, 299–303 incarceration, 304–307 intimate partner violence, 287–291 marital and family conflict, 283–298 PTSD. See Posttraumatic stress disorder Pyridostigmine bromide (PB), 39 R Race and ethnicity, and PTSD, 87–88, 305 Random error, in identifying and evaluating the literature, 24–25 Rapid-eye-movement (REM) sleep, 51, 98–99, 181 RAS. See Reticular activating system rCBF. See Regional cerebral blood flow Recommendations, 321 Regional cerebral blood flow (rCBF), 99 REM. See Rapid-eye-movement sleep Reproductive effects, 229–236 birth defects and miscarriage, 229–231 fertility difficulties, 231–232 PTSD and, 233 sexual dysfunction, 232–233 Reservists, 11, 31, 39–40. See also National Guard troops deployment-related stressors for, 39–40 Respiratory system diseases, 197–203 primary studies, 197–199

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336 GULF WAR AND HEALTH PTSD and, 200 secondary studies, 199–200 Reticular activating system (RAS), in stress response, 51–52 Rey-Osterrieth Complex Figure Drawing Test, 168–169 Risk and protective factors for PTSD, 86–94 age, 88 combat exposure, 92–93 developmental history and early-life stress, 88–89 hardiness, coping strategies, and sense of control, 89–90 physical injury, 93–94 psychiatric history, 89 race and ethnicity, 87–88 sex, 86–87 social support, 91–92 socioeconomic status and military status, 91 Rome Criteria, for functional GI disorders, 204 S Schedule for Affective Disorders and Schizophrenia-Lifetime Version, 243 SCID. See Structured Clinical Interview for DSM Seabee Health Study, 186 Seabees. See Naval Mobile Construction Battalions Self-reports, 4, 23, 28, 33, 41, 79, 116, 120, 122, 124–126, 133–138, 146–150, 167, 175–176, 183–187, 197–201, 205–207, 214–217, 222, 224–226, 229, 231–232, 242, 250–258, 288, 292, 305, 317–318 of sleep disturbance, 179–180 Sense of control, and PTSD, 89–90 Serotonin, 56–59, 94 Sex, and PTSD, 86–87 Sexual assault and harassment, military, 37–38 Sexual dysfunction, 232–233 Shell shock, 75 Skin cancer, 124–125, 131 Skin disorders, 214–221 primary studies, 214–215 PTSD and, 216–218 secondary studies, 215–216 Sleep disturbances, 98–99, 179–182 in the neurobiology of PTSD, 98–99 PTSD and, 180–182 self-reports of, 179–180 Social Isolation Index, 285 Social support, and PTSD, 91–92 Socioeconomic status, and PTSD, 91 Soft-tissue sarcoma, 118–119 Soldier and Marine Well-Being Survey, DoD, 34. See also Mental Health Advisory Team

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INDEX 337 Somatoform pain disorder, 150, 256 Specificity of association, in assessing the strength of evidence, 26 Spouse/Partner Interview, of the National Vietnam Veterans Readjustment Study, 284–285 Standard Family Violence Measure, 289 Startle reflex, in the neurobiology of PTSD, 98 Strength of association, in assessing the strength of evidence, 25 Strength of evidence, assessment of, 25–26 Stress response, 6, 13–14, 49–74 central role of the brain, 50–56 chronic stress and health, 59–66 conclusions, 66 modifiers of the stress response, 56–59 pathways of, 52 physiologic changes during, 50 Stressors experienced by U.S. forces anticipation of deployment to a war zone, 36–37 chronicity of, 56–57 deployment-related, 5–7, 11, 13–15, 31–47 during combat, 32–35 environmental and chemical, 39 living conditions, 38 military sexual assault and harassment, 37–38 noncombat, 35 Structured Clinical Interview for DSM (SCID), 23, 76, 80, 92, 142, 144, 146, 149–150, 181, 189, 191, 284–285, 291, 305 Substance-use disorders, 60, 84, 89, 149, 158–166. See also Alcohol abuse or dependence; Drug abuse or dependence; Psychiatric disorders primary studies, 158–160, 164–166 PTSD and, 162 secondary studies, 160–162 Sufficient evidence of a causal relationship, 4, 8, 27, 319 Sufficient evidence of an association, 4, 8, 27, 319 Suicide, 237–247 ideation, 148, 151 primary studies, 237–241 PTSD and, 242–243 secondary studies, 241–242 Summary of findings regarding the association between deployment to a war zone and specific health and psychosocial effects, 8–9, 319–320 inadequate/insufficient evidence to determine whether an association exists, 9, 320 limited but suggestive evidence of an association, 8, 319–320 limited/suggestive evidence of no association, 9, 320 schematic depiction of, 15 sufficient evidence of a causal relationship, 8, 319 sufficient evidence of an association, 8, 319 Sympathetic nervous system alterations, in the neurobiology of PTSD, 94–96

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338 GULF WAR AND HEALTH Symptom reporting, 248–260 chronic pain, 255–256 general symptoms and signs, 248–250 PTSD and chronic pain, 256–257 PTSD and general symptom reporting, 250–251 PTSD and unexplained illness, 254–255 unexplained illness, 251–254 T T3. See Triiodothyronine T4. See Thyroxine Task Force on Domestic Violence, DoD, 287 Temporal relationship, in assessing the strength of evidence, 25 Test of Memory Malingering (TOMM), 168 Testicular cancer, 123–124, 131 Thyroid disease, 135–137 primary studies, 135–136 secondary studies, 136–137 Thyroid-stimulating hormone (TSH), 133, 135–136, 138–139 Thyrotropin. See Thyroid-stimulating hormone Thyroxine (T4), 135–136, 138 TOMM. See Test of Memory Malingering Trauma. See Posttraumatic stress disorder Triiodothyronine (T3), 135–136, 138 TSH. See Thyroid-stimulating hormone Types of evidence, in identifying and evaluating the literature, 18–22 U UK. See United Kingdom troops UN. See United Nations Unexplained illness, 90, 251–254, 257–260 PTSD and, 254–255 United Kingdom (UK) troops, 36, 75, 79, 121, 123, 135, 167, 175, 180, 184, 214–216, 222, 225– 226, 232–233, 241, 248, 318 United Nations (UN), 40–41, 188, 250 University of Pennsylvania Smell Identification Test, 169–170 V VES. See Vietnam Experience Study VET. See Vietnam-Era Twin Registry Veteran studies, limitations of, 5, 28, 317–318 Veterans Health Study, 137, 192, 217, 251 Veterans Programs Enhancement Act, 1, 12 Vietnam-Era Twin Registry (VET), 134, 145, 159, 163, 191, 207

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INDEX 339 Vietnam Experience Study (VES), 80, 87, 118, 133, 135, 137, 142, 158, 161–162, 168–169, 185, 187, 193, 197, 215–218, 229, 231–233, 237–238, 243, 248, 284, 318 Vietnam War, 6, 13, 31, 33, 35, 40–41, 81, 86, 88, 91–95, 97, 100, 115, 117–120, 127, 139, 162, 194, 201, 210, 214, 216, 218–219, 231, 237–239, 248–250, 256–257, 284, 289–291, 293, 300, 308–309, 318 demographics, 13 prevalence of PTSD in, 80 Violent Behavior Index, 293 W WAIS-R. See Wechsler Adult Intelligence Scale-revised “War neurosis,” 75 WCST. See Wisconsin Card Sorting Test Wechsler Adult Intelligence Scale-revised (WAIS-R), 168–169 Wisconsin Card Sorting Test (WCST), 168–169 Women, 13, 33, 38, 41–43, 137–140, 222, 248 cancer, 117, 120, 123 cardiovascular disease, 186 comorbidity and disability, 84–86 deployment-related stressors for, 41–43 employment, 308 fibromyalgia and chronic pain, PTSD and, 226, 256 gastrointestinal effects, PTSD and, 209 homelessness, 299, 301 marital and family conflict, 284–285, 287–288 prevalence of PTSD in, 78 psychiatric disorders, 144–146, 149 PTSD risk and protective factors, 86–87, 91 reproductive effects, 230–231 respiratory diseases, PTSD and, 200 substance abuse, 158–159, 161–162 suicide and accidental death, 139–140 symptom reporting, PTSD and, 250–251 in the Vietnam war, 80–82 World Health Organization, 78, 158 World Mental Health Survey, 78 World War I, 75, 183 World War II, 7, 13, 31, 33, 41, 75, 83–85, 90–91, 93–94, 137–138, 181, 189, 192, 208, 218– 219, 249–250 prevalence of PTSD in, 80–81 Y Yohimbine, 95

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