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. 09/11/2018

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 09/11/2018

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. 09/11/2018

Sources War pension files, which contain detailed information about servicemen’s military and medical histories, often from enlistment until death, were the primary source. 09/11/2018

200 cases of Disordered Action of the Heart (DAH) Subjects Studied Boer War: 200 cases of Disordered Action of the Heart (DAH) 200 cases of rheumatism DAH is Disordered Action of the Heart, an illness characterised by rapid or irregular heartbeat, shortness of breath and chest pain in the absence of organic lesion. Cases of rheumatism were without any objective signs such as inflammation or joint swelling. Cases were selected from all surviving Boer War pension files, which are held at the Public Record Office, London. We extracted consecutive files in proportion to their alphabetical distribution by surname. 09/11/2018

167 cases of exposure to gas 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 These cases were randomly selected from all surviving World War One pension files archived at the Public Record Office. The holding represents a 2% sample based on London and South East England. The neurasthenia cases included examples of shell shock as the term was discouraged by military medical authorities from 1917 onwards. Any cases exposed to gas which had lasting physical damage, were excluded. Every case of DAH and neurasthenia in nurses was included. 09/11/2018

200 cases of psychoneurosis 67 cases of effort syndrome World War Two cases 200 cases of psychoneurosis 67 cases of effort syndrome 100 cases of non-ulcer dyspepsia The 200 cases of psychoneurosis (the equivalent term for neurasthenia/shell shock) were randomly selected from all surviving World War Two pension files. Cases of effort syndrome were rare because the diagnosis had been discredited and all examples found were included. Cases on non-ulcer dyspepsia were also comparatively rare and all examples found were included. 09/11/2018

Gulf War cases 400 cases of Gulf-related illness randomly selected from the Medical Assessment Programme The 400 anonymised cases of Gulf-related illness were randomly selected from the records of the Gulf Veterans’ Medical Assessment Programme funded by the Ministry of Defence. 09/11/2018

Data collection To collect data in a standardised manner, a form recorded: Serviceman’s biographical details Military record 94 possible symptoms Results of medical investigations Explanations for illness Military conduct 09/11/2018

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. 09/11/2018

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). 09/11/2018

Results We found three clusters of post-combat syndromes: Cluster One - a debility syndrome Cluster Two – a somatic syndrome Cluster Three – a neuropsychiatric syndrome 09/11/2018

Debility Cluster (n=847) characterised by: Fatigue, difficulty completing tasks, shortness of breath and weakness. With the exception of anxiety, psychological and cognitive symptoms were notably absent. 09/11/2018

(n=434) characterised by: Somatic Cluster (n=434) characterised by: Rapid heartbeat, shortness of breath, fatigue and dizziness. A symptom cluster indicative of a functional cardiac syndrome. 09/11/2018

Neuropsychiatric Cluster (n=575) characterised by: Fatigue, headaches, depression, anxiety and difficulty sleeping. This cluster is represented by a range of somatic and psychological symptoms. 09/11/2018

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. 09/11/2018

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. 09/11/2018

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. 09/11/2018

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. 09/11/2018

Servicemen’s 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. 09/11/2018

Servicemen’s 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. 09/11/2018

Servicemen’s 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. 09/11/2018

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 09/11/2018

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. See also: KC Hyams, FS Wignall, R Roswell (1996), War syndromes and their evaluation: from the US Civil War to the Persian Gulf War, Annals of Internal Medicine 125: 398-405. 09/11/2018