Gulf War Syndrome: Respiratory and Psychiatric Distress in a Gulf War Veteran

Soon after the return of the last U.S. troops from the Middle East in 1991, veterans began to report unexplained health concerns that did not fit established diagnoses. These concerns included respiratory, gastrointestinal, dermatological, musculoskeletal, and neurological symptoms (1). Gulf War syndrome or chronic multisymptom illness is a heterogeneous group of somatic and psychological symptoms with no identifiable explanation experienced by combat veterans of the 1990–1991 Gulf War. Participants in the Gulf War were subjected to numerous unique exposures, which have been regarded as potential causative or contributing agents to these symptoms (Table 1). These exposures included chemical warfare agents released during destruction of Iraqi facilities, pesticides, prophylactic medications, vaccinations, and oil well fires set by Iraqi troops as they fled Kuwait (2).

We present a case of a patient who met criteria for chronic multisymptom illness (3). The patient's preestablished psychiatric history, respiratory symptoms with a largely normal work-up, and exposures during the Gulf War merit further discussion and exploration of Gulf War syndrome.

Case

"Ms. LL" is a 67-year-old African-American female Gulf War veteran with a psychiatric history of sexual trauma, posttraumatic stress disorder (PTSD), generalized anxiety disorder, and major depressive disorder. She had a medical history of severe respiratory symptoms. She initially presented to her family medicine physician with a primary concern of progressive shortness of breath. During the course of the evaluation, she admitted to suicidal ideation for the past 2 weeks. She was placed on an involuntary hold and transferred to a veterans' facility for further evaluation and treatment. Her initial psychiatric evaluation revealed that she had felt depressed since 1991, following her return from the Gulf War. She reported reexperiencing her time in the war, as well as visions of "black spirits" that coincided with the severity of her mood symptoms. Additionally, she reported a history of sexual trauma, both in the military and earlier as a young adult. She said that frustration and fear surrounding her worsening respiratory symptoms contributed to the increase in severity of her depression, and she had become suicidal.

Ms. LL had an outpatient psychiatrist and at the time was prescribed venlafaxine 150 mg daily, zolpidem 0.5 mg nightly, and clonazepam 0.5 mg twice daily. Due to concern for risk of respiratory depression in association with benzodiazepine use in combination with her already impaired respiratory function, she had been implored by her psychiatrist to stop the zolpidem and clonazepam but had not yet weaned herself off. She lived at home with her husband, had two grown children, and attended church regularly. She reported occasional cannabis use and denied alcohol use. Her daughter noted that the patient's respiratory symptoms had been disabling for the patient and a mystery for everyone in the family. She also reported that these episodes "spiraled out of control quickly" and that Ms. LL had "always been a worrier."

The patient described a significant history of trauma. She reported being kidnapped in her early 20s and taken to another state, where she suffered a series of repeated sexual and physical assaults. She escaped only after she surreptitiously contacted her family using an intermediary whom she met during a chance encounter. No charges were filed for these events, she had not reported any trauma-related symptoms afterwards, and she had not engaged in any psychiatric care.

After Ms. LL's escape and return home, she completed nursing school and joined the Navy reserves. She served one tour during the Gulf War. During this time, she reported receiving multiple vaccinations but had no exposure to burning oil wells or chemical weapons. While on tour, she was sexually assaulted by another sailor. Although the incident was reported at the time to a chaplain, no charges were filed. Following her deployment, she reported significant trauma-related symptoms, including flashbacks, hypervigilance, anxiety, and depression stemming from both her military service and military sexual trauma. Frustrated by these experiences, she attempted suicide in 1993 by jumping from a bridge, but she survived and established care with a PTSD and military sexual trauma clinic in another state. The patient reported significant improvement with psychiatric care, but eventually she returned to her home state and was lost to psychiatric follow-up for about 10 years. She reported that things were going well during this time.

Although she achieved stability in her mental health, the patient began to develop a set of respiratory symptoms that defied diagnostic explanation. She underwent extensive diagnostic evaluation, including pulmonary function tests, allergen testing, laryngoscopy for vocal cord dysfunction, bronchoscopy and bronchoalveolar lavage, evaluation with speech and language pathology, and manometry—all of which were negative for organic pathology.

In 2017 and 2019, her symptoms were severe enough to require admission to an intensive care unit with mechanical ventilator support. She described symptoms of chest tightness, an inability to cough up thick mucus, and frustration regarding her negative pulmonary work-up. She reported that she was fearful for her own well-being and described many of her fellow Gulf War veterans who had died as a result of similar symptoms since returning from the war. She stated at this time that an unknown outside provider had diagnosed her with "Gulf War illness."

Discussion

The National Health Survey of Gulf War Veterans and Their Families and the Follow-Up Study of Gulf War and Gulf Era Veterans are the largest longitudinal population-based cohort studies of this patient population. Surveys in 1995, 2005, and 2013 compared veterans deployed to the Gulf War with those who were on duty between September 1990 and May 1991 but not deployed (4, 5). Results indicated a higher prevalence of numerous unexplained health issues and poor overall health in deployed veterans, compared with their nondeployed counterparts (6). Gulf War veterans consistently reported higher rates of nearly all symptoms examined, including but not limited to neuralgia, gastritis, chronic obstructive pulmonary disease, and asthma (7).

The mechanism of this syndrome, dubbed "Gulf War syndrome" in the literature and press, continues to be poorly understood. Current research has focused on the unique chemical and toxic exposures faced by soldiers in the war. Risk factors that have been studied most extensively include pesticides, pyridostigmine bromide, sarin, vaccines, depleted uranium, and oil well fires (1, 8). This has proved challenging to study epidemiologically because of the lack of accurate record keeping, difficulty modeling these exposures, and potential confounding effects (8, 9). Comparisons between the symptoms of Gulf War syndrome and other toxicant-induced syndromes suggest either a chronic direct neurotoxic effect or a toxicant-induced loss of tolerance (i.e., autoimmune) as a possible mechanism (8). At present, the best-linked exposures are pesticides and pyridostigmine bromide. Notably, psychiatric disorders such as PTSD are not significant risk factors for the syndrome, although they may be comorbid (8). The preferred Department of Veterans Affairs term for the syndrome is chronic multisymptom illness, and several diagnostic criteria have been proposed (Table 1) (10, 11). To date, there are no universally accepted therapies (3).

Although Ms. LL's exposures were limited, the chronicity of her symptomatology in association with her history of Gulf War deployment allowed for consideration of Gulf War syndrome as a diagnosis. In her case, diagnostic criteria were met (3) (Table 1), but an alternative psychiatric diagnosis, such as a somatic symptom, panic, or a trauma-related disorder, could not be ruled out. It is possible that she had both Gulf War syndrome and the psychiatric conditions, which could have synergistically contributed to the severity of her illness. Ms. LL's case illustrates the difficulty of making a definitive diagnosis in this patient population, which often has a history of multiple exposures and complex trauma. However, the severity of her respiratory illness, requiring multiple intensive care admissions, argues against a purely psychiatric etiology. Furthermore, it was noted that she reacted positively to the use of Gulf War syndrome as her primary diagnosis.

During her psychiatric hospitalization, she was stabilized on venlafaxine 150 mg daily, and clonazepam and zolpidem were discontinued. She was noted to have several episodes of shortness of breath but improved after instruction in a mindfulness technique, which she stated helped her to control her symptoms. After stabilization, she was discharged with plans to follow up with her outpatient psychiatrist.

Conclusions

This case described a 67-year-old Gulf War veteran with a history of generalized anxiety disorder, major depression, and PTSD, who presented with suicidal ideation in the setting of a poorly understood respiratory illness. For any veteran with a history of service during the Gulf War who has unexplained medical ailments, chronic multisymptom illness should be considered as a unifying diagnosis. The heterogeneity of diagnostic criteria and presence of a history of complex trauma complicates both psychiatric and medical treatment. Careful consideration and validation of the patient's history and experience can engender a productive therapeutic alliance, and treatment of underlying psychological factors may aid in treatment of somatic symptoms.

Key Points/Clinical Pearls