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Bioterrorism Summaries from Annual Session 2002

Course Title: Recognizing and Treating the Psychological Effects of Terrorism
Section: Disaster Preparedness
Faculty Member: Lt. Col. Charles C. Engel, MD, MPH, MC, USA
Date/Time: April 11, 2002, 4:00-5:30 p.m.
Course Number: MTP 132
Reporter: Shannon Donovan, MA

Introduction

Terrorist and wartime events produce chronic symptoms and related disability in patients involved in the events. These symptoms are difficult to treat and cause mistrust and disagreements among patients, providers, and the medical community. Use of diagnostic tests and medical treatment should be conservative and aim to foster a trusting and enduring relationship between the patient and physician. Referral to a mental health provider should be explored early.

Clinical Questions

  • What clinical presentations are expected to follow terrorist events?

  • What are the psychosocial consequences of terrorist events?

  • How can primary care physicians mitigate the psychosocial consequences of a terrorist attack?

Key Clinical Points

  • Terrorist or wartime events produce a variety of medically unexplained physical symptoms and distress syndromes. Putative causes of this overall increase in physical symptoms range from low-level chemical exposures to psychological causes.

  • The primary care physician should use physical symptoms, especially those that are unexplained, as a marker for undetected psychiatric disorders.

  • Distress in the acute aftermath of war or terrorist events is normal. What distinguishes persons in need of care for distress is how well they are functioning, and physicians' efforts should focus on increasing functioning.

  • Acute psychiatric disorders after a terrorist event include direct effects of centrally acting toxins, panic disorder, acute stress disorder, and medically unexplained contagion. Physically injured or medically ill patients are at the highest risk of these disorders. Acute psychosocial concerns include fear of the unknown; uncertainty about the future; conflicts over whether to help others or help oneself and one's own family; loss of social order; sensory experiences, such as false alarms and the smell and sight of dead bodies; and controversial decisions regarding quarantine and other restrictions of basic human rights.

  • Chronic sequelae of a terrorist attack may be the major source of morbidity. These sequelae include chronic unexplained symptoms, post-traumatic stress disorder (PTSD) and other anxiety disorders, depressive disorders, and substance use disorders.

  • Clinician awareness and skill is critical when communicating about uncertain health risks in the aftermath of terrorist attack. Sources of risk distortion include risk descriptions (clinician-related), risk interpretations (patient-related), and risk debates (context-related). For example, in the context of news media distortion, increased population anxiety over unexplained physical symptoms can affect the general health perceptions, and it can increase the likelihood of disagreement in the patient-physician relationship.

  • Patient-physician trust is even more important after terrorism than in usual care, because high levels of patient trust in the clinician can mitigate the impact of disagreements over health risks and chronic unexplained symptoms. In addition, after a terrorist attack, people are vulnerable to feelings of betrayal and mistrust. Most important to fostering trust is conveying compassion and empathy. Research shows that patients estimate the technical competence of their physician largely based on how compassionate and empathic they perceive the physician to be.

  • To mitigate the impact of patient-physician disagreements over unexplained physical symptoms after terrorist attack, it is best to allow the patient an "interpretive space." In other words, the patient be allowed to keep their beliefs regarding the causes of unexplained symptoms. Unnecessarily overpowering their interpretation of cause will iatrogenically damage the physician-patient relationship. More important to successful outcome than changing the patient's belief about the cause of their symptoms is to address misconceptions regarding appropriate treatment.

  • A stepped approach to communication with patients about terrorism-related risks is helpful. Patients with recognized diseases are the least intensive step. These patients receive usual disease-related education such as prognosis, disease self-management, and therapeutic options. Although diagnosed diseases may be catastrophic, patients are usually satisfied that physicians have "done their job" and trust and rapport is relatively easy to attain. The next step up involves the asymptomatic concerned patient. These patients seek care to ask questions and are often mistrustful about future risk of illness. The third step up involves unexplained symptoms after a basic primary care evaluation. In this situation, the presence of "mysterious illness" and associated uncertainty compounds patient mistrust and dampens rapport. The fourth step involves patients with chronic unexplained symptoms with associated loss of functioning. Especially after a terrorist attack, these patients will be mistrustful and dissatisfied with their care. Physician frustration increases the volatility of the situation. Each of these clinical situations requires increasing efforts to build trust and rapport between the patient and physician.

  • Avoid early presumptive diagnostic labels for chronic unexplained physical symptoms to avoid fostering the sick role in patients and to provide time to negotiate an appropriate label. In particular, avoid the temptation to quickly label unexplained symptoms after a terrorist attack as a manifestation of PTSD. Not all distress after trauma is a manifestation of PTSD per se. In addition, many patients with unexplained physical symptoms will resent a PTSD label.

  • Aggressive symptomatic interventions for chronic symptoms after a terrorist attack should be avoided unless the patient has a well-defined condition for which the intervention in question is clearly indicated.

  • Diagnostic testing for chronic unexplained symptoms after terrorist attack should be used judiciously, since testing for chronic symptoms is often of low yield and keeps the patient in a passive mindset, waiting on the physician for an answer to problems instead of actively participating in his or her care.

  • Sedative-hypnotics and anxiolytic medications may bolster function and often have value in the acute aftermath of a traumatic event. However, long-term use of central nervous system depressants (e.g., anxiolytics, sedative-hypnotics, and muscle relaxants) and opioid analgesics are habit forming and reduce functioning and are therefore relatively contraindicated for chronic symptoms after a terrorist attack.

  • Mental health consultation is less stigmatized in the acute aftermath of a terrorist attack than in the chronic stages. Most people will see emotional symptoms immediately after a serious trauma as a normal occurrence. Later, however, stigma for post-traumatic symptoms will grow as memories of the impact from the original trauma become more obscure. For chronic unexplained physical symptoms after a terrorist attack, it is best to discuss consultation with patients early in the episode of care, soon after it is suspected that the medical workup will have a low yield. This early mention of mental health consultation can be used to determine whether the patient is open to psychosocial interventions for unexplained physical symptoms. If the patient is open to psychosocial care, mental health consultation may be discussed in greater detail. If the patient deflects or rejects consultation, this can be revisited later as indicated. Mental health consultation is best done using a provider that the physician knows well who understands psychosocial sequelae of trauma including the conservative medical management of chronic unexplained symptoms.

  • Good basic primary care of post-attack patients includes brief physical examination at every visit while exploring new patient health concerns and patient explanations for symptoms, conservative diagnostic testing, evaluation of symptoms and their impact on activity and health behaviors, routine scheduled appointments to follow patients nonacutely, avoidance of prescribing rest, and consistent rather than as-needed dosing of necessary medications.

Background & Discussion

Much of what we know about the health effects of traumatic exposures was learned in military settings. The symptoms experienced by Gulf War veterans, including breathlessness, fatigue, irritability, headache, insomnia, and paresthesias, have been described in the medical literature after every war since the U.S. Civil War. These symptoms were investigated extensively after they were described in World War I combatants, but then as now, no definitive cause could be established. Speculated causes of symptoms after both wars ranged widely from low-level chemical exposures to psychological causes. A summary of the literature in the years after the Gulf War found that poorly understood war syndromes have been associated with armed conflict since the U.S. Civil War. Therefore, it appears that the consequences of war and related traumatic events such as terrorism include unexplained physical symptoms. Literature on unexplained physical symptoms in general suggest that they are a key clinical indicator of unrecognized but treatable distress and mental illness in primary care patients.

Health Problems after War or Terrorist Attacks

Distress in the acute aftermath of war or terrorist events is a normal phenomenon. Even preparation for a war may result in low-level erratic behaviors. What distinguishes persons in need of care for distress is whether they are functioning well. For patients in need of treatment, physicians should focus on maximizing function rather than extinguishing distress per se. Direct effects of exposure to some chemical agents (e.g., 3-quinuclidinyl benzilate, also known as "QNB" or "BZ") or their antidotes (e.g., anticholinergics or diazepam) can resemble acute psychiatric reactions. Persons who are physically wounded in an event are at increased risk for long-term psychological effects. Therefore, it is not a dichotomous situation in which some people need medical attention and others need psychosocial attention.

Terrorist attacks or war events can provoke acute onset of psychiatric disorders, such as panic disorder. Panic disorder is characterized by frequent and disabling panic attacks. Symptoms of a panic attack consist of psychological symptoms, such as a sense of impending doom, and clusters of physical symptoms, such as tremors and chest discomfort, and may often resemble acute myocardial infarction at presentation. Not surprisingly, patients who experience panic attacks, and their evaluating physicians, often interpret that attacks as a medical emergency rather than a condition requiring psychiatric referral. Acute stress disorder may also involve panic attacks. Acute stress disorder represents the early phases of post-traumatic stress disorder (PTSD) and may be the closest condition in the current Diagnostic and Statistical Manual of Mental Disorders to battle fatigue or combat stress, labels the military has traditionally assigned to the acute psychosocial consequences of war. In the condition sometimes called medically unexplained contagion or mass hysteria, groups of people develop symptoms in response to a sensory stimulus (e.g., a smell in the air) or triggering event that is mistaken for a poisoning or toxic exposure. These events can be extremely disruptive to organizations, yet after testing, the cause of the resulting symptoms cannot be determined.

Acute psychosocial concerns include fear of the unknown; uncertainty about the future; conflicts over whether to help others or help oneself and one's family; breakdown of the social order; disorienting sensory experiences, such as false alarms and the smell and sight of dead bodies; and socially divisive decisions involving restrictions of individual rights. False chemical alarms created distress among many troops during the Gulf War and led to subsequent perceptions that large numbers were exposed to chemical agents. Heightened security measures implemented by the airlines after the terrorist attacks of 11 September 2001 have since precipitated many false alarms, leading to heightened public anxiety and distress as well as potentially unconstructive expenditures of time, energy, and resources. In the case of a biological attack, quarantine of exposed persons is possible, depending on the biological agent used. The logistics, stigma, and loss of human rights associated with quarantine may create unanticipated societal divisions and strife.

Even though the acute circumstances surrounding a terrorist attack quickly captures our collective imagination, the chronic sequelae of these events may be the greatest source of societal morbidity. These issues now face communities in New York, New Jersey, Florida, and Washington, D.C. Chronic sequelae are simultaneously similar to and unique from symptoms and syndromes seen in regular primary care practice. The syndromes are similar to usual practice, but the severity, prevalence, and burden of these syndromes will be greater after a terrorist attack. Chronic depression is common, as are chronic unexplained physical symptoms and disabling health anxiety. In the years immediately following the Vietnam War, it was believed that nearly all traumatized persons experienced a single syndrome, post-traumatic stress disorder (PTSD), which involved nightmares, difficulty sleeping, avoidance of people and situations reminiscent of the past trauma, and aggressive impulses. In the past 25 years, researchers have learned that only a minority of persons who experience traumatizing events experience PTSD and that the symptoms and health effects associated with these traumas go well beyond the narrow case criteria for PTSD. Another frequent downstream effect of PTSD is substance misuse.

The primary care physician should use physical symptoms, especially those that are unexplained, as a marker for unrecognized and treatable distress and psychiatric disorders. Many patients seen in primary care have poorly explained physical symptom syndromes, and these symptom syndromes may occupy more than half of the primary care physician's time. Examples of such syndromes include the temporomandibular joint syndrome, fibromyalgia, chronic fatigue syndrome, chronic Lyme disease, most cases of low back pain, and the patellofemoral syndrome. Data on treatment and risk factors reveal that these syndromes may be more alike than different. Often, physicians think of symptoms as only important to the extent that they represent clues to underlying disease. Consequently, physicians may "back burner" medically unexplained symptoms or minimize their impact on patients. However, a large empirical literature suggests that the morbidity associated with chronic unexplained symptoms ranges from psychosocial distress to marked decreases in function.

A problematic consequence of a terrorist attack is resulting levels of physical health anxiety leading to inappropriate health care use and excessive diagnostic examinations, as well-meaning physicians dutifully attempt to rule out virtually every possible exposure-related cause of a patient's symptoms. Outside the context of war or terrorist attack, chronic unexplained symptom syndromes create dissatisfaction with care among patients and frustration with the patient among primary care physicians. Physicians lose credibility with their patients if they appear to have trouble explaining patients' symptoms. After a terrorist attack, patients will act out their mistrust for their physician by seeking "heroes," (i.e., physicians claiming to know the true causes of these symptoms and who offer superficially impressive or seemingly innovative therapies). Affected patients often see these individuals as heroes because they offer firm explanations and aggressive treatment. However, such heroes usually offer untested therapies that target unproven etiologies. Heroes often emerge to prey on vulnerable populations of ill persons after a terrorist attack, appear to act on pure motives while typically seeking surreptitious gains, and very often do more harm than good.

Aftermath of Traumatic Events

Recent history suggests an escalating and repetitive cycle involving health concerns after hazardous military duties and putative environmental exposures. We have identified key contextual factors characteristic of this cycle. The cycle begins with some inciting event (e.g., war, terrorist attack, peacekeeping mission, or putative environmental exposure), after which symptoms and concerns emerge with the passage of time. Because the symptoms go unexplained, mistrust and suspicion toward large institutions arise. Debate ensues at multiple levels (e.g., scientific, political, news media, and advocacy groups) about potential causes, and subsequent investigations yield inconclusive results. For example, the Canadian equivalent of the U.S. Department of Defense investigated peacekeepers sent to Croatia who were ill and worried about contact with red soil that many feared was contaminated. Detailed investigation did not reveal a definitive illness or cause. Similarly, many U.S. military personnel who received the mandatory anthrax vaccination later expressed concerns about its long-term health effects.

This cycle has been observed in civilian communities as well. For example, following the 1992 crash of an El Al commercial airliner a residential area of Amsterdam, many residents fell ill. Putative causes of symptoms among the residents included depleted uranium (found in small quantities in the tailfin of the plane), an improbable theory that a weapons-grade nerve agent may have been hidden in the belly of the aircraft, and occult infections due to intracellular bacteria called mycoplasmas. Extensive governmental investigations turned up no definitive illness or cause. The nuclear accident at Three Mile Island raised legitimate concerns about cancer and other ailments that were never supported in empirical studies, and the sinking of the Exxon Valdez with its associated oil spill has recently been reported in the news media to have resulted in a wide array of unexplained symptoms and symptom syndromes among local Alaskan residents. After the events of September 11, prescriptions of psychoactive medications, especially sleep medications, increased and physicians anecdotally observed a increase in pain complaints among patients. A "World Trade Center syndrome" has emerged to describe ailments of people near the site of the New York terrorist attacks. Even exposures to mail that was irradiated to protect postal workers and others from anthrax spores have raised health concerns that some workers attribute to the irradiation process.

The social legacy of terrorist attacks include, therefore, persistent and divisive arguments over the legitimacy, severity, and causes of symptoms, who is to blame for symptoms, who has been victimized, and who shall offer reparations to whom for those symptoms. As observed after September 11, the short-term effect of a terrorist attack is to unite communities. However, the long-term health legacy of these events is to fracture existing social unity. Because mistrust of institutions develops, the physician-patient relationship is compromised, and in this contentious climate it becomes difficult to build trust with and provide good care to affected patients.

These and other contextual factors can profoundly affect the public's perception of personal risk and vulnerability to illness. Public discussion and regular news media attention may adversely affect the general health of the population by increasing anxiety about symptoms. For example, a recent poll of the public showed that 9% of persons felt that they or their family were likely to contract anthrax in next 12 months. Although the level of uncertainty associated with estimates is high, most experts would agree that this perceived risk appears to be much greater than the actual risk.

The Physician-Patient Relationship

Physicians sometimes do not communicate effectively with patients who have subjective health concerns after potential environmental exposures, such as those occurring during and after a terrorist attack. Physicians try to think objectively and scientifically, but in fact scientific considerations are often misapplied to clinical decisions and are further distorted by emotional and social factors that often shape patients' and clinicians' conclusions about health risk. For example, studies suggest that people blame coerced exposures for illness (e.g., anthrax vaccination) more quickly than voluntary exposures (e.g., overeating or obesity). Blame is also more likely to be assigned to industrial rather than natural causes, unfamiliar rather than familiar causes, and memorable rather than unmemorable events. Addressing these factors requires a high level of patient-provider trust, and development of patient trust of the provider is strongly associated with patient perceptions of the provider's level of compassion and empathy, even more strongly associated with patient trust than are patient estimates of the provider's technical competence. Trust can have calming effect on the patients and create an environment in which health risk communication can be most effective, a consideration that is crucial when seeing patients with chronic health concerns related to a terrorist attack.

Mismanagement of the physician-patient relationship can iatrogenically exacerbate illness after terrorist attack. The relationship may evolve into a "contest" in which the patient has to prove to that she is ill, whereas the physician feels compelled to reassure the patient that she has no physical ailment. The patient experiences this perspective as patronizing and dismissive, and thus escalates her complaints. A humble clinical posture is important for the physician when addressing unexplained symptoms after terrorist attack, since even clinicians tend to disagree over their causes and appropriate management. For example, a study of clinicians caring for Gulf War veterans revealed that internists tended to view "Gulf War illness" as a psychological problem requiring psychological therapies, while mental health providers tended to view it as a medical problem requiring of medical therapies. Hence, an exclusive primary care focus on disease management is not adequate when caring for patients after a terrorist attack.

Care of Patients Who Have Experienced Traumatic Events

Much is known about the technological aspects of medicine, but a large gap exists between existing technologies and the application of those technologies in routine clinical practice involving "real patients with real problems." Our center, Deployment Health Clinical Center in Washington, D.C., has instituted a rehabilitative approach for persons with war or other military-related health concerns. The approach adopts a collaborative care model that focuses on behavioral outcomes rather than strictly biomedical indices. The medical model looks narrowly at the disease-disability relationship and attempt to reduce disability by addressing the disease. There are, however, many other modifiable physical, social, and psychological factors that contribute to disability. In this collaborative model, rapid assessment and curative treatment matter less than regular visits and follow-through on promises: that is, establishment of trust. In the office, the entire practice team needs to be aware of the style of care the physician wishes to cultivate.

A central aspect of collaborative care that is critical when caring for patients with chronic unexplained symptoms after a terrorist attack is the need to negotiate rather than prescribe the cause of illness. When negotiating the cause of illness with the patient, it is useful to allow the patient "interpretive space." Epidemiologists apply a very high test when deciding whether a hypothesized (i.e., plausible or possible) cause is a proven cause. After events such as war and terrorism, we are seldom left with good measures of event-related environmental exposures, and therefore reaching the level of evidence required to prove causality is nearly impossible. On the other end of the spectrum, however, plausible causes (causes that in theory cannot be ruled out) are usually many. We define the interpretive space as the large empirical gap between plausible and proven causes for patients' illnesses, particularly those illnesses that follow events involving potentially important environmental exposures, such as terrorist attack or war. Physicians often want to discourage patients from dwelling on plausible causes and instead promote "stress" as the cause of symptoms for patients with unexplained symptoms. To the patient, "stress" is often viewed as a dismissive and blame-shifting diagnosis. We recommend a more negotiated approach that leaves room for patients' personal explanations for illness as well as room for physicians to bring sound scientific evidence into the dialogue. This collaborative blend of personalized negotiation and science-based medicine may lead to better, more satisfying care for both patient and physician.

Collaborative care is facilitated using a stepped approach to communication with patients about the health effects of a terrorist attack. Patients with recognized disease form the least intensive first step. Regardless of whether disease is related to a traumatic event, its recognition leaves the patient more satisfied with the encounter. The steps then increase in intensity for encounters with patients whose needs were not met in the visit.

Step two involves the care of the asymptomatic but concerned patient. This type of patient seeks care to ask questions but denies current illness. Often, patients have read about possible causes of post-attack health concerns. These patients require rapid reliable information regarding what is known about health consequences of the attack. We have established a Web site, PDHealth.mil, that is specifically designed to offer clinicians the latest scientific and news media information related to the health effects of different military operations, wars, and terrorist attacks. The information on this site may be reviewed together with the patient as time allows, or the patient may be given homework and a return visit to discuss what has been learned during the interim. Anyone may visit the site, and a mechanism exists for leaving comments and suggestions.

Step three involves patients with recent onset of symptoms that remain medically unexplained after an initial but thorough medical diagnostic assessment. Patients whose symptoms are not well explained are at higher risk of complaints and dissatisfaction with their care, frustration with their physician, and post-attack psychosocial problems. Special care should be taken to convey hope, the common nature of unexplained symptoms, the availability of self-help approaches, and the need for a rehabilitative rather than a curative approach to care.

Step four involves patients in whom unexplained symptoms have persisted for many months or years and are associated with significant decrements in functioning. For this group, supervised physical reactivation is usually necessary and intensive multidisciplinary approaches to reactivation and care are needed.

An emphasis of these intensive programs is to embrace the ill individual's own causal model for illness, acknowledge the patient's serious level of illness, and collaborate with the patient and family to develop a long-term symptom management plan. The U.S. Department of Defense and Veterans Administration have developed clinical practice guidelines for post-deployment clinical evaluation and management, and this stepped clinical risk communication approach is used.

In terms of treatment of chronic sequelae of war and terrorism, it is generally true that "less is more." More tests and medicines usually do not help. More care increases the risk of iatrogenic harm through medication side effects and high false-positive rates characteristic of low-yield diagnostic evaluations. Moreover, testing keeps the patient passive by delaying him from actively participating in achieving wellness. In addition, diagnostic labeling can change people's views for the worse by diminishing their sense of health, particularly if the adopted diagnostic label does not lead to specific therapeutic options. Use of somatoform diagnoses is not indicated for people with multiple unexplained symptoms after terrorist attack and other potentially significant environmental exposures; this practice tends to fracture the physician-patient relationship and escalate an iatrogenic patient-physician contest. Rather, unexplained symptoms should be labeled generically until a definitive disease diagnosis can be made or until patient and physician can negotiate a more useful working diagnosis.

Sedative-hypnotics and anxiolytic medications may bolster function and often have value in the acute aftermath of a traumatic event. However, long-term use of central nervous system depressants (e.g., anxiolytics, sedative-hypnotics, and muscle relaxants) and opioid analgesics are habit forming and reduce functioning and are therefore relatively contraindicated for chronic symptoms after a terrorist attack.

A mental health consult should be advised early in the episode of care, when it is suspected that the diagnostic workup will have a low yield. A trial balloon statement can be used to feel out the patient on the issue and revisited later if necessary. If the matter is not raised early, the patient often feels rejected and dismissed when the physician raises the subject after an exhaustive medical assessment. A follow-up visit after psychiatric consult should be scheduled to maintain a healthy physician-patient relationship and reduce patients' concerns about rejection. Referral should be made to a mental health care provider that the physician knows personally and who understands conservative medical management of unexplained symptoms and the impact of traumatic events. Practitioners of consultation liaison psychiatry are often a good choice.

Principles of Care

  • Perform a basic physical examination at every visit. This action validates patient concerns and is reassuring to patients.
  • Perform testing conservatively, giving careful thought to adverse effects and false-positive rates.
  • Try to read patient behaviors as well as listening to their words.
  • Schedule appointments on regular basis, to evaluate patients in a nonacute situation. Visits that occur "as needed" create more stressful patient encounters and reinforce disability and illness behavior.
  • Avoid prescribing rest to patients with such symptoms as back pain; attempt physical reactivation from the start.
  • If medications are needed, prescribe them for consistent dosing to achieve adequate blood levels. Allowing patients to take medications on a symptom-based "as-needed" schedule reinforces disability and illness behavior.

Conclusion

Effective treatment of patients with symptoms after a traumatic event should center on supportive care, regular office visits, and appropriate referrals. In the aftermath of such events, patients' faith in institutions and trust in medical care providers is often shaken; thus, a critical component of quality care is restoration and maintenance of the physician-patient relationship.

References

Engel CC Jr. Outbreaks of medically unexplained physical symptoms after military action, terrorist threat, or technological disaster. Mil Med. 2001;166(12 Suppl):47-8. PMID: 11778432

Engel CC Jr, Adkins JA, Cowan D. Caring for medically unexplained physical symptoms following toxic environmental exposures: effects of contested causation. Environ Health Perspect. [In press].

Engel CC Jr, Jaffer A, Adkins J, Sheliga V, Cowan D, Katon WJ. Population-based health care: a model for restoring community health and productivity following terrorist attack. In: Norwood A, Ursano RJ, eds. Individual and Community Responses to Trauma and Disaster: The Structure of Human Chaos. 2nd ed. New York: Cambridge University Press; [In press].

Engel CC Jr, Katon WJ. Population and need-based prevention of unexplained symptoms in the community. In: Institute of Medicine. Strategies to Protect the Health of Deployed U.S. Forces: Medical Surveillance, Record Keeping, and Risk Reduction. Washington, DC: National Academy Press; 1999:173-212.

Engel CC Jr, Kroenke K, Katon WJ. Mental health services in Army primary care: the need for a collaborative health care agenda. Mil Med. 1994;159:203-9. PMID: 8041464

Engel CC Jr, Liu X, Clymer R, Miller RF, Sjoberg T, Shapiro JR. Rehabilitative care of war-related health concerns. J Occup Environ Med. 2000;42:385-90. PMID: 10774507

Engel CC Jr, Liu X, Miller RF, McCarthy BD, Ursano RJ. Relationship of physical symptoms to post-traumatic stress disorder among veterans seeking care for Gulf War-related health concerns. Psychosom Med. 2000;62:739-45. PMID: 11138991

Engel CC Jr, Roy M, Kayanan D, Ursano RJ. Multidisciplinary treatment of persistent symptoms after Gulf War service. Mil Med. 1998;163:202-8. PMID: 9575762

Engel CC Jr, Ursano R, Magruder C, Tartaglione R, Jing Z, Labbate LA, Debakey S. Psychological conditions diagnosed among veterans seeking Department of Defense care for Gulf War-related health concerns. J Occup Environ Med. 1999;41:384-92. PMID: 10337608

Holloway HC, Norwood AE, Fullerton CS, Engel CC Jr, Ursano RJ. The threat of biological weapons. Prophylaxis and mitigation of psychological and social consequences. JAMA. 1997;278:425-7. PMID: 9244335

Hunt SC, Richardson RD, Engel CC Jr. Clinical management of Gulf War veterans with medically unexplained physical symptoms. Mil Med. 2002;167:414-20. PMID: 12053851

Hyams KC, Wignall FS, Roswell R. War syndromes and their evaluation: from the U.S. Civil War to the Persian Gulf War. Ann Intern Med. 1996;125:398-405. PMID: 8702091

Hyams KC, Murphy FM, Wessely S. Responding to chemical, biological, or nuclear terrorism: the indirect and long-term health effects may present the greatest challenge. J Health Polit Policy Law. 2002;27:273-91. PMID: 12043900

Jones E, Hodgins-Vermaas R, McCartney H, Everitt B, Beech C, Poynter D, et al. Post-combat syndromes from the Boer war to the Gulf war: a cluster analysis of their nature and attribution. BMJ. 2002;324:321-4. PMID: 11834557

Richardson RD, Engel CC Jr, McFall M, McKnight K, Boehnlein JK, Hunt SC. Clinician attributions for symptoms and treatment of gulf war-related health concerns. Arch Intern Med. 2001;161:1289-94. PMID: 11371256

Wessely S, Hyams KC, Bartholomew R. Psychological implications of chemical and biological weapons. BMJ. 2001;323:878-9. PMID: 11668118

Wessely S, Nimnuan C, Sharpe M. Functional somatic syndromes: one or many? Lancet. 1999;354:936-9. PMID: 10489969

Recommended Web Sites

U.S. Department of Defense Post-Deployment Health

Centers for Disease Control and Prevention

American Red Cross

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