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10.1192/bjp.183.4.314Access the most recent version at doi:
2003 183: 314-322 The British Journal of Psychiatry
S. WESSELY, C. UNWIN, M. HOTOPF, L. HULL, K. ISMAIL, V. NICOLAOU and A. DAVID
Persian Gulf War of 1991
Stability of recall of military hazards over time: Evidence from the
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BackgroundBackground War time tr aumaticWar time tr aumatic
events are related to subsequenteven ts ar e relat ed to subsequen t
psy cholog ical and ph y sica l health, bu tpsychological and physical health, but
quant ify i ng the association is problematic.quantifying the association is problematic.
Memory changes over time and isMemory changes over ti me and is
influenced by psychological status.influenced by psychological status.
AimsAims To use a lar ge, two-stag e cohortTo u se a larg e , two-stage cohort
study of members ofthe UKarmed forcesstudyof members ofthe UK armed forces
to study changes in recal l of both traumaticto studychangesinrecall of bothtraumatic
and ‘toxic’ hazards.and ‘toxic’ hazards.
MethodMethod Aquestionnaire-based follow-A questionnai re-based fol low-
up study assessed 2370 UKmilitaryup stu d y assessed 2370 UK mi litary
pe rsonnel , repeat ing ear lie r q uest i onspe rsonnel , repea tin g ear li e r quest i ons
about exposureto militaryhazards.about exposure to militaryhazards.
ResultsResults TheThe kk statistics for reporti ng ofsta t isti cs for report i ng of
hazards were good for some exposures,haza rds were g ood fo r som e exposures ,
but very low for others.Gu lf vet eransbut very low for others.Gulf veterans
report ed more expos ures over ti me (noreported more exposures over time (no
s ign ificant rise i n the Bosnia cohort).In thes ign ificant rise in the Bosnia cohort).In the
Gulf cohort on l y, repo rt ing newGulf coho rt only, r eporti n g new
exposures was associated with worseningexposures was associated withworsening
heal t h percep tion , and f o r g e ttin ghealth percepti on, an d forge tti ng
prev ious l y reported expos ur es wi thpreviousl y report ed exposures w ith
im proved perception.We fou nd noi mpro ved percepti on.We f ound no
associ a tion be tween ph ysi cal health ,associ a tion between ph y sica l health,
psychological morbidity or post-traumaticpsychological morbidity or post-traumatic
st r ess di so r der sy m ptoms andstress disorder symptoms and
endorsement or non-endorsemen t ofendorsem ent or non-endorseme nt of
expos ures.exposures.
ConclusionsConclusions Reporti ng of mi l i taryReporting of military
hazards after a conflict isnot static, and ishazards after a conflictis not static, andis
associat ed wi th current self-ratedassociated with current self-rated
pe rcep tion of hea lth . Sel f-report ofpe rcep tion of hea lth . Sel f-report of
exposures associated wi th media publ ici tyexposures associated wi th med ia publ ici ty
needs to be treated with caution.needs to be treated with caution.
Declaration of interestDeclaration of interest N one .None.
F u ndin g detail ed in A cknowledg e m ents .F u ndi ng detail ed in A c k no wledg e me nts .
It is known that there is an associationIt is known that there is an association
between traumatic event reporting andbetween traumatic event reporting and
negative health outcomes, particularlynegative health outcomes, particularly
post-traumatic stress disorder (PTSD)post-traumatic stress disorder (PTSD)
(Kaylor(Kaylor et alet al, 1987; Brewin, 1987; Brewin et alet al, 2000)., 2000).
However, establishing the nature and mag-However, establishing the nature and mag-
nitude of this association has been difficult,nitude of this association has been difficult,
resulting in very different estimates. Mostresulting in very different estimates. Most
studies of the link between adversity andstudies of the link between adversity and
health are cross-sectional and rely onhealth are cross-sectional and rely on
retrospective accounts of events andretrospective accounts of events and
circumstances. There is consensus thatcircumstances. There is consensus that
retrospectively recalled accounts of traumaretrospectively recalled accounts of trauma
are problematic, and potentially subject toare problematic, and potentially subject to
a variety of recall biases, but there is no con-a variety of recall biases, but there is no con-
sensus as to either the size of the problem orsensus as to either the size of the problem or
its implications (McFarlane, 1988).its implications (McFarlane, 1988).
Several studies have looked at the re-Several studies have looked at the re-
lationship between retrospective recall oflationship between retrospective recall of
exposures at several time points and theirexposures at several time points and their
relationship to health outcomes, mainlyrelationship to health outcomes, mainly
PTSD. We have conducted a large-scalePTSD. We have conducted a large-scale
longitudinal study of the health of UK mili-longitudinal study of the health of UK mili-
tary personnel, based on three cohorts:tary personnel, based on three cohorts:
those who saw service in the 1991 Persianthose who saw service in the 1991 Persian
Gulf conflict, those who were deployed onGulf conflict, those who were deployed on
peacekeeping operations in Bosnia betweenpeacekeeping operations in Bosnia between
1991 and 1997, and those who were in the1991 and 1997, and those who were in the
forces at the time of the 1991 Gulf conflictforces at the time of the 1991 Gulf conflict
but were not deployed (Unwinbut were not deployed (Unwin et alet al , 1999)., 1999).
We now report on the results of a follow-upWe now report on the results of a follow-up
study, in which the same questions aboutstudy, in which the same questions about
specific military exposures related to thespecific military exposures related to the
deployments on which the respondentsdeployments on which the respondents
had served were asked again. In this paperhad served were asked again. In this paper
we examine the consistency of reportingwe examine the consistency of reporting
of military traumas and hazards over theof military traumas and hazards over the
period. We also look at the predictors ofperiod. We also look at the predictors of
any observed change in recall of traumaticany observed change in recall of traumatic
events. In particular, we test the hypothesisevents. In particular, we test the hypothesis
that psychological distress prospectively in-that psychological distress prospectively in-
creases the recall of traumatic events andcreases the recall of traumatic events and
hazards over time. This study is unique inhazards over time. This study is unique in
that it permits the comparison of exposurethat it permits the comparison of exposure
consistency for both the Gulf War and theconsistency for both the Gulf War and the
Bosnia deployments. We are thus able toBosnia deployments. We are thus able to
compare the recall of military exposurescompare the recall of military exposures
relevant to both fighting and peacekeeping.relevant to both fighting and peacekeeping.
METHODMETHOD
A follow-up descriptive study examined theA follow-up descriptive study examined the
health status of a stratified sample of parti-health status of a stratified sample of parti-
cipants who had completed the first phasecipants who had completed the first phase
of the King’s College London epidemio-of the King’s College London epidemio-
logical health survey of military personnellogical health survey of military personnel
(Unwin(Unwin et alet al, 1999). The original study, 1999). The original study
took place in 1997, which was 6 years aftertook place in 1997, which was 6 years after
the end of the Gulf War, and 5 years afterthe end of the Gulf War, and 5 years after
the start of the Bosnia deployment. Thisthe start of the Bosnia deployment. This
survey was succeeded by a series of detailedsurvey was succeeded by a series of detailed
clinical case–control studies (stage 2: Davidclinical case–control studies (stage 2: David
et alet al, 2002; Higgins, 2002; Higgins et alet al, 2002; Sharief, 2002; Sharief et alet al,,
2002). The follow-up study, stage 3, took2002). The follow-up study, stage 3, took
place in 2000 and 2001, approximately 3place in 2000 and 2001, approximately 3
years later. During the follow-up study,years later. During the follow-up study,
participants were asked again about speci-participants were asked again about speci-
fic military exposures related to the deploy-fic military exposures related to the deploy-
ments on which they had served. In thisments on which they had served. In this
paper we compare responses between thepaper we compare responses between the
two large epidemiological surveys of thetwo large epidemiological surveys of the
same personnel at stage 1 and stage 3.same personnel at stage 1 and stage 3.
ParticipantsParticipants
The target group was a stratified sample ofThe target group was a stratified sample of
the cohort who completed the stage 1the cohort who completed the stage 1
Health Survey of Military PersonnelHealth Survey of Military Personnel
((nn¼8195). This cohort consisted of three8195). This cohort consisted of three
groups: personnel who served in the Persiangroups: personnel who served in the Persian
Gulf region between 1 September 1990 andGulf region between 1 September 1990 and
30 June 1991 (the Gulf Cohort); personnel30 June 1991 (the Gulf Cohort); personnel
who had served in Bosnia between 1 Aprilwho had served in Bosnia between 1 April
1992 and 6 February 1997 (the Bosnia co-1992 and 6 February 1997 (the Bosnia co-
hort); and personnel who were serving inhort); and personnel who were serving in
the armed forces on 1 January 1991 butthe armed forces on 1 January 1991 but
who were not deployed to the Gulf conflictwho were not deployed to the Gulf conflict
(the Era cohort). Special forces were ex-(the Era cohort). Special forces were ex-
cluded for security reasons. Two strati-cluded for security reasons. Two strati-
fication variables were used: fatigue andfication variables were used: fatigue and
gender.gender.
We were primarily interested in exam-We were primarily interested in exam-
ining the health of Gulf veterans. At stageining the health of Gulf veterans. At stage
1, fatigue, along with being strongly asso-1, fatigue, along with being strongly asso-
ciated with other health outcomes mea-ciated with other health outcomes mea-
sured, was one of the most consistentlysured, was one of the most consistently
reported symptoms in Gulf veterans, andreported symptoms in Gulf veterans, and
was ourwas our a prioria priori principal outcome mea-principal outcome mea-
sure, and the basis for the stratified samplesure, and the basis for the stratified sample
strategy. In order to ensure that the moststrategy. In order to ensure that the most
severely ill were well represented, all maleseverely ill were well represented, all male
veterans with a fatigue score of 9 or moreveterans with a fatigue score of 9 or more
(511 Gulf, 115 Bosnia and 120 Era were in-(511 Gulf, 115 Bosnia and 120 Era were in-
cluded). A 1:2 sample of male Gulf veteranscluded). A 1:2 sample of male Gulf veterans
with mid-range fatigue scores of 4–8 (484with mid-range fatigue scores of 4–8 (484
veterans) along with all Bosnia veteransveterans) along with all Bosnia veterans
((nn¼333) and Era veterans (333) and Era veterans (nn¼364) scoring364) scoring
in this range were selected. Finally, a 1:8in this range were selected. Finally, a 1:8
sample of veterans with fatigue scores lesssample of veterans with fatigue scores less
314314
BRITISH JOURNAL OF PSYCHIATRYBRITISH JOURNAL OF PSYCHIATRY (2003), 183, 314^322(2003), 183, 314^322
Stability of recall of military hazards over timeStability of recall of military hazards over time
Evidence from the Pers ian Gulf War of 1991Evidence from the Pers ian Gulf War of 199 1
S. WESSELY, C. UNWIN, M. HOTOPF, L. HULL, K. ISMAIL, V. NICOLAOUS. WESSELY, C. UNWIN, M. HOTOPF, L. HULL, K. ISMAIL, V. NICOLAOU
and A. DAVIDand A. DAVID
R E C A L L O F M IL I TA RY H A Z A R D SRECALL OF MILITARY HAZARDS
than 4 was selected in order to representthan 4 was selected in order to represent
asymptomatic individuals (250 in eachasymptomatic individuals (250 in each
group). All female veterans who completedgroup). All female veterans who completed
the stage 1 questionnaire (the stage 1 questionnaire (nn¼648) were648) were
contacted, as women were oversampled incontacted, as women were oversampled in
the original cohort. This also allowed usthe original cohort. This also allowed us
to look for any gender differences into look for any gender differences in
follow-up variables. The total sample sizefollow-up variables. The total sample size
was 3322.was 3322.
Ethical approvals were obtained for allEthical approvals were obtained for all
stages of the study. All respondents at stagestages of the study. All respondents at stage
1 gave signed consent to later follow-up.1 gave signed consent to later follow-up.
QuestionnaireQuestionnaire
The questionnaire mainly replicated theThe questionnaire mainly replicated the
measures used at stage 1, including demo-measures used at stage 1, including demo-
graphic details (age, gender, marital andgraphic details (age, gender, marital and
educational status, alcohol and smokingeducational status, alcohol and smoking
habits), chronic fatigue scale, medicalhabits), chronic fatigue scale, medical
symptoms (50 items), self-reported medicalsymptoms (50 items), self-reported medical
disorders (39 items), the 12-item Generaldisorders (39 items), the 12-item General
Health Questionnaire (Goldberg, 1972),Health Questionnaire (Goldberg, 1972),
and the 36-item Medical Outcomes Studyand the 36-item Medical Outcomes Study
Short Form (SF-36) sub-scales for physicalShort Form (SF-36) sub-scales for physical
health, health perception and functionalhealth, health perception and functional
capacity (Stewartcapacity (Stewart et alet al , 1988)., 1988).
As detailed in the original study reportAs detailed in the original study report
(Unwin(Unwin et alet al, 1999) we created a brief mea-, 1999) we created a brief mea-
sure labelled ‘post-traumatic stress reac-sure labelled ‘post-traumatic stress reac-
tion’ (PTSR). This was embedded in thetion’ (PTSR). This was embedded in the
wider questionnaire because we did notwider questionnaire because we did not
wish to have an overt PTSD scale, givenwish to have an overt PTSD scale, given
the social context of ‘Gulf War syndrome’the social context of ‘Gulf War syndrome’
at the time among the UK service com-at the time among the UK service com-
munity and also because of the need to keepmunity and also because of the need to keep
measures to a minimum. Full details of thismeasures to a minimum. Full details of this
are contained elsewhere, but in essence itare contained elsewhere, but in essence it
consisted of four simple stem questions cov-consisted of four simple stem questions cov-
ering the basic psychopathological featuresering the basic psychopathological features
of PTSD (Unwinof PTSD (Unwin et alet al, 1999)., 1999).
Military exposure history was investi-Military exposure history was investi-
gated using the same checklist as at stagegated using the same checklist as at stage
1, again tailored for the appropriate de-1, again tailored for the appropriate de-
ployment. In practice this meant that theployment. In practice this meant that the
Bosnia and Era groups were not askedBosnia and Era groups were not asked
about the following exposures specific toabout the following exposures specific to
the Gulf War: smoke from oil-well fires;the Gulf War: smoke from oil-well fires;
mustard gas or other blistering agents; hav-mustard gas or other blistering agents; hav-
ing a Scud missile explode in the air or oning a Scud missile explode in the air or on
the ground within 1 mile; hearing chemicalthe ground within 1 mile; hearing chemical
alarms sounding; and chemical/nerve gasalarms sounding; and chemical/nerve gas
attack. The questionnaires were tailored ac-attack. The questionnaires were tailored ac-
cording to whether the participant was stillcording to whether the participant was still
in service or not, as ascertained at stage 1.in service or not, as ascertained at stage 1.
AnalysesAnal yses
The reliability of the responses for each ex-The reliability of the responses for each ex-
posure at the two time points was quanti-posure at the two time points was quanti-
fied by the kappa statistic, which is afied by the kappa statistic, which is a
measure of the degree of non-randommeasure of the degree of non-random
agreement between measurements of theagreement between measurements of the
same categorical variable. If the measure-same categorical variable. If the measure-
ments agree more often than expected byments agree more often than expected by
chance,chance, kk is positive; if agreement is com-is positive; if agreement is com-
plete,plete, kk is 1; if they disagree more oftenis 1; if they disagree more often
than expected by chance,than expected by chance, kk is negativeis negative
(Last, 1995). A paired(Last, 1995). A paired tt-test was used to-test was used to
examine the number of endorsed exposuresexamine the number of endorsed exposures
at the two time points.at the two time points.
We followed the same analytical ap-We followed the same analytical ap-
proach to exposure measurements overproach to exposure measurements over
two time points as Southwicktwo time points as Southwick et alet al (1997).(1997).
For each of the exposures asked about,For each of the exposures asked about,
variables were created indicating whethervariables were created indicating whether
the exposure was:the exposure was:
(a)(a) always endorsed at both time pointsalways endorsed at both time points
(YY);(YY);
(b)(b) never endorsed at either time pointnever endorsed at either time point
(NN);(NN);
(c)(c) endorsed at time 1 but no longerendorsed at time 1 but no longer
endorsed at time 2, i.e. no longerendorsed at time 2, i.e. no longer
endorsed (YN);endorsed (YN);
(d)(d) not endorsed at time 1, later to benot endorsed at time 1, later to be
endorsed, i.e. newly endorsed (NY).endorsed, i.e. newly endorsed (NY).
Risk factors for number of newly endorsedRisk factors for number of newly endorsed
and no longer endorsed exposures were ex-and no longer endorsed exposures were ex-
plored by examining their median andplored by examining their median and
interquartile range (IQR). Change in healthinterquartile range (IQR). Change in health
status was examined by creating a changestatus was examined by creating a change
variable (stage 3 minus stage 1) for eachvariable (stage 3 minus stage 1) for each
health outcome. This was then used as thehealth outcome. This was then used as the
dependent variable when exploring the ef-dependent variable when exploring the ef-
fect of newly endorsed and no longer en-fect of newly endorsed and no longer en-
dorsed exposures on health reporting overdorsed exposures on health reporting over
time. The data were analysed using thetime. The data were analysed using the
Statistical Package for the Social Sciences,Statistical Package for the Social Sciences,
version 10 for Windows.version 10 for Windows.
RESULTSRESULTS
Address information was not available forAddress information was not available for
13 of the original participants. Valid13 of the original participants. Valid
responses were obtained from 2370 (72%)responses were obtained from 2370 (72%)
participants: 907 Gulf (response rateparticipants: 907 Gulf (response rate
73.0%), 638 Bosnia (70.2%), 643 Era73.0%), 638 Bosnia (70.2%), 643 Era
(69.5%) and 182 Bosnia and Gulf(69.5%) and 182 Bosnia and Gulf
(78.4%). There were 246 (7.4%) refusers.(78.4%). There were 246 (7.4%) refusers.
Owing to the absence of an accurate ad-Owing to the absence of an accurate ad-
dress, 259 (7.8%) never received the ques-dress, 259 (7.8%) never received the ques-
tionnaire, despite three mailing attempts,tionnaire, despite three mailing attempts,
giving a true rate of 78% (Gulf 79%; Bosniagiving a true rate of 78% (Gulf 79%; Bosnia
77%; Era 6.0%; Bosnia and Gulf 82%). For77%; Era 6.0%; Bosnia and Gulf 82%). For
the purpose of analysis participants whothe purpose of analysis participants who
had been deployed to both the Gulf andhad been deployed to both the Gulf and
Bosnia were combined with the Gulf-onlyBosnia were combined with the Gulf-only
group, as in previous analyses of this cohortgroup, as in previous analyses of this cohort
(Unwin(Unwin et alet al, 1999, 2002; Ismail, 1999, 2002; Ismail et alet al , 2000;, 2000;
ReidReid et alet al, 2001). Table 1 gives the distri-, 2001). Table 1 gives the distri-
bution of demographic variables in thebution of demographic variables in the
two study cohorts.two study cohorts.
The mean number of reported expo-The mean number of reported expo-
sures significantly increased over time forsures significantly increased over time for
the Gulf cohort (Table 2), but the increasethe Gulf cohort (Table 2), but the increase
in the Bosnia cohort was modest and non-in the Bosnia cohort was modest and non-
significant. The Pearson correlation betweensignificant. The Pearson correlation between
the number of reported events at both timethe number of reported events at both time
points was low for both the Gulf cohortpoints was low for both the Gulf cohort
315315
Ta b l e 1Ta b l e 1 De mographic variab les for the Gulf andDemographic variables for the Gulf and
Bosnia cohortsBosnia cohorts
GulfGulf BosniaBosnia
nn (%)(%) nn (%)(%)
GenderGender
MaleMale 900900 (82.6)(82.6) 477477 (74.8)(74.8)
FemaleFemale 189189 (17.4)(17 .4) 161161 (25.2)(25.2)
Age (y ears)Age (y ears)
Under 29Under 29 0000194194 (30.4)(30.4)
30^3430^34 325325 (29.8)(29.8) 221221 (34.6)(34.6)
35^3935^39 321321 (29.5)(29.5) 109109 (17.1)(17 . 1)
40^ 4440^ 44 224224 (20.6)(20.6) 7272 (11 .3)(1 1.3)
Over 45Over 45 21 9219 (20.1)(20.1) 4242 (6.6)(6.6)
Marital stat usMarital stat us
MarriedMarried 726726 (67. 1 )(67.1) 358358 (56.8)(56. 8)
Living with partnerLivin g with partner 108108 (10.0)(10.0) 6464 (10.2)(10.2)
Never marriedN e ve r married 1 22122 (11.3)(11.3) 133133 (21. 1)(21.1)
SeparatedSeparated 5353 (4.9)(4.9) 2929 (4.6)(4.6)
DivorcedDivorced 6969 (6.4)(6.4) 4646 (7.3)(7.3)
WidowedWidow ed 44(0.4)(0.4) 0000
Alcohol use (units/week)Alcohol use (units/week)
NoneN one 1 51151 (14.0)(14.0) 4848 (7.6)(7.6)
1^31^3 271271 (25.1)(25.1) 149149 (23.6)(23.6)
4^104^10 33133 1 (30.6)(30.6) 199199 (31.5)(31.5)
11^2011^20 197197 (18.2)(18.2) 142142 (22.5)(22.5)
21^3021^30 9999 (9.2)(9.2) 6363 (10.0)(10.0)
30+30+ 3131 (2.9)(2.9) 3030 (4.8)(4.8)
Ta b l e 2Ta b l e 2 Changes in mean number of exposuresChanges in mean number of exposures
over time reported by the Gulf and Bosnia cohortsover time reported by the Gulf and Bosnia cohorts
StageStage ExposuresExposures
(mean)(mean)
nnttrr
GulfGulf
1110.710.7 10891089
775.7**5.7** 0.66**0.66**
3311.511.5 10891089
BosniaBosnia
117.17.1 820820
771.071.07
{{
0.57**0.57**
337.37.3 820820
****PP550.01;0.01 ;
{{
PP¼0.29.0.29.
WESSELY ET ALWESSELY ET AL
316316
Ta b l e 3Ta b l e 3 Frequency of recall categories for each exposure in the Gulf and Bosnia cohortsFrequency of recall categories for each exposure in the Gulf and Bosnia cohorts
Recall categoryRecall category
11
YYYY YNYN NNNN NYNY
nn (%)(%) nn (%)(%) nn (%)(%) nn (%)(%) kk
GulfGulf
Smoke from oil-well firesSmoke from oil-well fires 698698 (70.8)(70.8) 2323 (2.3)(2.3) 208208 (21.1)(21.1) 57 (5.8)57 (5.8) 0.790.79
Handled POWHandled POW 461461 (46.8)(46.8) 5959 (6.0)(6.0) 382382 (38.8)(38.8) 83 (8.4)83 (8.4) 0.7 10.71
Small arms fireSmall arms fire 165165 (16.8)(16.8) 4040 (4.1)(4.1 ) 708708 (72. 0)(72.0) 70 (7.1)70 (7.1) 0.680.68
Scud missile exploding within 1 mileScud missile explod ing within 1 mile 241241 (25.2)(25.2) 6666 (6.9)(6.9) 574574 (60.0)(60.0) 74 (7.7)7 4 (7 .7) 0.670.67
Dismembered bodiesDismembered bodies 543543 (54. 9)(54.9) 9090 (9.1)(9.1) 280280 (28.3)(28.3) 76 (7.7)76 (7.7) 0.640.64
Burning rubbish/faecesBurning rubbish/faeces 501501 (51.7)(51 .7) 8181 (8.4)(8.4) 286286 (29.5)(29 .5) 101 (10.4)101 (10.4) 0 .610.61
Maimed sold iersMaimed soldiers 405405 (41.1)(41. 1 ) 8585 (8.6)(8.6) 382382 (38.7)(38.7) 114 (11.6)114 (11.6) 0.600.60
Diesel/petrochemical fuel on skinDiesel/petrochemical fuel on skin 451451 (46.8)(46.8) 8080 (8.3)(8.3) 318318 (33.0)(33.0) 113 (11.7)113 (11.7) 0.590.59
Witnessed an y one dyingWitnessed anyone dying 1 31131 (13.2)(13.2) 5858 (5.8)(5.8) 712712 (71.5)(71.5) 94 (9.4)94 (9.4) 0.540.54
Dead animalsDead animals 260260 (26.4)(26.4) 104104 ( 10.6)(10.6) 496496 (50.4)(50.4) 124 (12.6)124 (12.6) 0.510.51
Combat-related injuryCombat-related injury 3838 (3.8)(3.8) 2828 (2.8)(2.8) 899899 (89.8)(89.8) 36 (3.6)36 (3.6) 0.510.51
NBC suitsNBC suits 817817 (83.2)(83.2) 3939 (4.0)(4.0) 6262 (6.3)(6.3) 64 (6.5)64 (6.5) 0.490.49
Heard chemi cal alarms soundingHeard chem ical alarms sounding 677677 (69.8)(69.8) 6767 (6.9)(6.9) 124124 (12.8)(12.8) 102 (10.5)102 (10.5) 0.490.49
Depleted uraniumDepleted uranium 8787 (10.2)(10.2) 1818 (2.1)(2.1) 632632 (74. 0)(74.0) 117 (13.7)117 ( 13.7) 0.480.48
Chemical/nerve gas attackChemi cal/nerv e gas attac k 5454 (6.2)(6.2) 2828 (3.2)(3.2) 718718 (82.7)(82.7) 66 (7.6)66 (7.6) 0.480.48
Other paints/sol ve ntsOther paints/solvents 396396 (4 1.9)(41.9) 8282 (8.7)(8.7) 290290 (30.7)(30.7) 176 (18.6)1 76 (18.6) 0.450.45
Pesticides on clothing/beddingPesticides on clothing/bedding 251251 (26.6)(26.6) 8484 (8.9)(8.9) 440440 (46.7)(46.7) 166 (17.6)166 (1 7.6) 0.450.45
Food contaminated with smokeFood contaminated with smoke 139139 (1 5.0)(15.0) 7272 (7.8)(7.8) 588588 (63.4)(63.4) 127 (13.7)127 (13.7) 0.440.44
Art illery close byArtillery close by 179179 (18.3)(18.3) 9797 (9.9)(9.9) 566566 (57.8)(57.8) 136 (13.9)136 (13.9) 0.440.44
Personal pesticid esP ersonal pesticides 5 1 8518 (54.5)(54.5) 8383 (8.7)(8.7) 189189 (1 9 .9)(19.9) 160 (16.8)1 60 (1 6.8) 0.420.42
Local foodLocal food 448448 (47.3)(47.3) 124124 (13.1)(13. 1) 236236 (24. 9)(24.9) 139 (14.7)1 39 (1 4.7) 0.420.42
Exhaust from heaters/generatorsExhaust from heat ers/generators 623623 (64.3)(64.3) 6363 (6.5)(6.5) 128128 (13.2)(13.2) 155 (16.0)155 (16.0) 0.400.40
Diesel/petrochemical fumesDiese l/petrochemi cal fumes 690690 (71.7)(71.7) 5555 (5.7)(5.7) 9393 (9.7)(9.7) 124 (12.9)124 (12.9) 0.400.40
Heat illnessHeat illness 1 1 0110 (11.1)(1 1. 1) 1 15115 (11.6)(11.6) 678678 (68.5)(68.5) 87 (8.8)87 (8.8) 0.390.39
CARC paintCARC paint 16 3163 (1 7 .7)(17 .7) 6161 (6.6)(6.6) 500500 (54.2)(54.2) 198 (21.5)198 (21.5) 0.370.37
Bathed in local pond/riverBathed in local pond/river 2727 (2.7)(2.7) 3838 (3.8)(3.8) 885885 (89.3)(89.3) 40 (4.0)40 (4.0) 0.370.37
Bathed in/drank local waterBathed in/drank local water 5757 (6.0)(6.0) 5757 (6.0)(6.0) 753753 (78. 9)(78.9) 87 (9.1)87 (9.1) 0.360.36
Mustard gasMustard gas 22 (0.2)(0.2) 1212 (1.3)(1.3) 876876 (95.5)(95.5) 25 (2.7)25 (2.7) 0.080.08
BosniaBosnia
Small arms fireSmall arms fire 234234 (34.7)(34.7) 5757 (8.4)(8.4) 311311 (46.1)(46. 1 ) 73 (10.8)73 (10 .8) 0.6 10.61
Witnessed an y one dyingWitnessed anyone dying 8585 (12.5)(12.5) 2828 (4.1)(4. 1 ) 508508 (74.6)(74.6) 60 (8.8)60 (8.8) 0.580.58
Art illery close byArtillery close by 127127 (18.6)(18.6) 5050 (7.3)(7.3) 440440 (64.5)(64.5) 65 (9.5)65 (9.5) 0.570.57
Dismembered bodiesDismembered bodies 193193 (28.5)(28.5) 6666 (9.7)(9.7) 337337 (49 .8)(49.8) 81 (12.0)81 (12.0) 0.550.55
Maimed sold iersMaimed soldiers 147147 (21.7)(21.7) 5757 (8.4)(8.4) 390390 (57.5)(57.5) 84 (12.4)84 (12.4) 0.520.52
Diesel/petrochemical fuel on skinDiesel/petrochemical fuel on skin 308308 (45.9)(45.9) 5959 (8.8)(8.8) 202202 (30.1)(30.1) 102 (15.2)102 (15.2) 0.510.51
Bathed in local pond/riverBathed in local pond/river 8989 (13.2)(13.2) 6060 (8.9)(8.9) 462462 (68.5)(68.5) 63 (9.3)63 (9.3) 0.470.47
Heat illnessHeat illness 4949 (7.2)(7.2) 5151 (7.5)(7.5) 540540 (79.3)(79.3) 41 (6.0)41 (6.0) 0.440.44
Dead animalsDead animals 235235 (34.8)(34.8) 6767 (9.9)(9.9) 246246 (36.4)(36.4) 128 (18.9)128 (18.9) 0.430.43
Bathed in/drank local waterBathed in/drank local water 4141 (6.1)(6.1) 4040 (5.9)(5.9) 545545 (81 . 0)(81.0) 47 (7.0)47 (7.0) 0.410.41
Burning rubbish/faecesBurning rubbish/faeces 274274 (41.0)(41.0) 100100 (14.9)(14.9) 198198 (29.6)(29.6) 97 (14.5)97 (14.5) 0.400.40
Food contaminated with smokeFood contaminated with smoke 4141 (6.1)(6.1) 2626 (3.9)(3.9) 537537 (79.8)(79.8) 69 (10.3)69 (10 .3) 0.390.39
Local foodLocal food 362362 (54.1)(54 .1) 7272 (10.8)(10.8) 127127 (19.0)(19.0) 108 (16.1)108 (16.1 ) 0.390.39
Other paints/sol ve ntsOther paints/solvents 255255 (38 .1)(38.1) 6666 (9.9)(9.9) 191191 (28.5)(28.5) 158 (23.6)1 58 (23.6) 0.340.34
Handled POWHandled POW 1 16116 (17.3)(17 .3) 7878 (11.7)(11.7) 363363 (54.3)(54.3) 112 (16.7)112 ( 1 6 .7) 0 .340.34
Exhaust from heaters/generatorsExhaust from heaters/generators 458458 (68.0)(68.0) 5555 (8.2)(8.2) 6464 (9.5)(9.5) 97 (14.4)97 (1 4.4) 0.320.32
Pesticides on clothing/beddingPesticides on clothing/bed ding 8282 (1 2.3)(12.3) 5050 (7.5)( 7.5) 405405 (60.8)(60.8) 127 (19.1)127 (19. 1) 0.310.31
Diesel/petrochemical fumesDiese l/petrochemi cal fumes 434434 (64.5)(64.5) 4848 (7.1)(7.1) 6969 (10.3)(10.3) 120 (17 .8)1 20 (17.8) 0.300.30
(continued)(continued)
R E C A L L O F M IL I TA RY H A Z A R D SRECALL OF MILITARY HAZARDS
and Bosnia cohort (and Bosnia cohort (rr¼ 0.66 and 0.57 respec-0.66 and 0.57 respec-
tively). Table 3 shows the percentage re-tively). Table 3 shows the percentage re-
sponses of YY, NN, YN and NY, alongsponses of YY, NN, YN and NY, along
with thewith the kk values, for each of the variablesvalues, for each of the variables
in the questionnaires given to the Gulfin the questionnaires given to the Gulf
and Bosnia cohorts. In the Gulf cohort theand Bosnia cohorts. In the Gulf cohort the
most reliably recalled exposures were:most reliably recalled exposures were:
smoke from oil-well fires (smoke from oil-well fires (kk¼0.79);0.79);
handled prisoners of war (handled prisoners of war (kk¼0.71); small0.71); small
arms fire (arms fire (kk¼0.68); Scud missile exploding0.68); Scud missile exploding
within 1 mile (within 1 mile (kk¼0.67); and seeing dis-0.67); and seeing dis-
membered bodies (membered bodies (kk¼0.64). For the Bosnia0.64). For the Bosnia
cohort the most reliably recalled exposurescohort the most reliably recalled exposures
were: small arms fire (were: small arms fire (kk¼0.61); witnessing0.61); witnessing
anyone dying (anyone dying (kk¼0.58); artillery close by0.58); artillery close by
((kk¼0.57); seeing dismembered bodies0.57); seeing dismembered bodies
((kk¼0.55); and diesel or petrochemical fuel0.55); and diesel or petrochemical fuel
on skin. For the 24 exposures common toon skin. For the 24 exposures common to
the two cohorts, the Gulf cohort had higherthe two cohorts, the Gulf cohort had higher
kk values for all except 4 (bathed in/drankvalues for all except 4 (bathed in/drank
local water; bathed in local pond/river; heatlocal water; bathed in local pond/river; heat
illness; and witnessed anyone dying).illness; and witnessed anyone dying).
On average the Gulf cohort had moreOn average the Gulf cohort had more
newly endorsed (NY) than no longernewly endorsed (NY) than no longer
endorsed (YN) exposures (meanendorsed (YN) exposures (mean
NYNY¼2.90, s.d.2.90, s.d.¼ 2.39; mean YN2.39; mean YN¼ 1.80,1.80,
s.d.s.d.¼1.75), a pattern repeated in the Bosnia1.75), a pattern repeated in the Bosnia
cohort (mean NYcohort (mean NY¼ 2.89, s.d.2.89, s.d.¼2.36; mean2.36; mean
YNYN¼1.74, s.d.1.74, s.d.¼1.78) and indicating an1.78) and indicating an
overall rise in the number of exposures re-overall rise in the number of exposures re-
called over time (Table 4). Table 5 givescalled over time (Table 4). Table 5 gives
the risk factors for numbers of newly en-the risk factors for numbers of newly en-
dorsed and no longer endorsed exposures.dorsed and no longer endorsed exposures.
For the number of no longer endorsedFor the number of no longer endorsed
items, the most significant risk factor wasitems, the most significant risk factor was
serving status, with those in service havingserving status, with those in service having
a higher median value for no longer en-a higher median value for no longer en-
dorsed exposures than those not in service.dorsed exposures than those not in service.
This pattern held for both the Gulf andThis pattern held for both the Gulf and
Bosnia cohorts. For the newly endorsed ex-Bosnia cohorts. For the newly endorsed ex-
posures over time, being male and youngerposures over time, being male and younger
were associated with higher median valueswere associated with higher median values
for both the Gulf and Bosnia cohorts,for both the Gulf and Bosnia cohorts,
whereas living with a partner was asso-whereas living with a partner was asso-
ciated with a higher median value in theciated with a higher median value in the
Bosnia cohort only.Bosnia cohort only.
Table 6 shows the mean changes inTable 6 shows the mean changes in
health outcomes for the Bosnia and Gulfhealth outcomes for the Bosnia and Gulf
cohorts and their association with newlycohorts and their association with newly
endorsed or no longer endorsed exposures.endorsed or no longer endorsed exposures.
For the purpose of these analyses, the noFor the purpose of these analyses, the no
longer endorsed (YN) and newly endorsedlonger endorsed (YN) and newly endorsed
(NY) exposure recall variables have been(NY) exposure recall variables have been
recoded to combine the tailed distributionrecoded to combine the tailed distribution
into one group. There was a pattern of in-into one group. There was a pattern of in-
creased (i.e. improved) health perceptioncreased (i.e. improved) health perception
and increased no longer endorsed (i.e. for-and increased no longer endorsed (i.e. for-
gotten) exposures over time in the Gulfgotten) exposures over time in the Gulf
cohort, which was not replicated in thecohort, which was not replicated in the
Bosnia cohort. Conversely, there was aBosnia cohort. Conversely, there was a
pattern of worsening health perceptionpattern of worsening health perception
and increasing new endorsement of expo-and increasing new endorsement of expo-
sure variables over time in the Gulf cohortsure variables over time in the Gulf cohort
but not the Bosnia cohort. There was nobut not the Bosnia cohort. There was no
discernible pattern of association betweendiscernible pattern of association between
317317
Ta b l e 3Ta b l e 3 (continued)(continued)
Recall categoryRecall category
11
YYYY YNYN NNNN NYNY
nn (%)(%) nn (%)(%) nn (%)(%) nn (%)(%) kk
BosniaBosnia (continued)(continued)
Personal pesticidesPersonal pest icides 206206 (31.0)(31.0) 7777 (11.6)(1 1 .6) 217217 (32.7)(32.7) 163 (24.5)163 (24.5) 0.290.29
Combat-related injuryCombat-related injury 1414 (2.0)(2.0) 2727 (4.0)(4. 0) 596596 (87.3)(87.3) 46 (6.7)46 (6.7) 0.220.22
CARC paintCARC paint 1818 (2.7)(2.7) 3131 (4.7)(4.7) 538538 (81.5)(81.5) 73 (11.1)73 (1 1. 1) 0.180. 18
NBC suitsNBC suits 33(0.4)(0.4) 1313 (1.9)(1.9) 606606 (90.6)(90.6) 47 (7.0)47 (7.0) 0.060.06
Deplet ed ura ni u mDepleted uran ium 11(0.0)(0.0) 1010 (0.5)(0.5) 618618 (98.4)(98.4) 17 (0.8)17 (0.8) 0.050.05
CA R C, chem ical age nt resistant coating; N BC, nuclear , biological and chemical; POW, prisoners of war.CARC, chemical agentresistantcoating; NBC, nuclear, biological and chemical; POW, prisoners of war.
1. YY, endorsed at both time points; NN, not endorsed at either time point;YN, no longer endorsed; NY, not endorsed at time1, endorsed at time 2.1. YY, endorsed at both time points; NN, not endorsed at either time point;YN, no longer endorsed; NY, not endorsed at time1, endorsed at time 2.
2. Denominator used for percentages is total2. De nominator used for pe r ce ntages is total nn for each e x posure.fo r ea ch e xposure .
Ta b l e 4Ta b l e 4 Frequencyof newly endorsed (‘no to yes’) and no longer endorsed (‘yes to no’) exposure recall in theFrequency of newly endorsed (‘no to yes’) and no longer endorsed (‘yes to no’) exposure recall in the
Gulf and Bosnia cohortsGulf and Bosnia cohorts
Num ber of changesNumber of changes G u lfGulf BosniaBosnia
Yes to noYes to no No to yesNo to yes Yes to noYes to no No to yesNo to yes
nn (%)(%) nn (%)(%) nn (%)(%) nn (%)(%)
00 260260 (25.8)(25.8) 131131 (13.0)(13.0) 195195 (28.4)(28.4) 9393 ( 1 3 .6)(13.6)
11261261 (25.9)(25.9) 204204 (20.3)(20.3) 177177 (25.8)(25.8) 123123 (17.9)(17 .9)
22 209209 (20.8)(20.8) 183183 ( 18.2)(18.2) 142142 (20.7)(20.7) 145145 (21.1)(21.1)
33118118 (11.7)(1 1.7) 151151 (15.0)(15.0) 7070 (10.2)(10.2) 100100 (1 4.6)(14.6)
448989 (8.8)(8.8) 123123 (12.2)(12.2) 4646 (6.7)(6.7) 7979 (11.5)(1 1.5)
553333 (3.3)(3.3) 8686 (8.5)(8.5) 2727 (3.9)(3.9) 5858 (8.5)(8.5)
662020 (2.0)(2.0) 4646 (4.6)(4.6) 1414 (2.0)(2.0) 2828 (4.1)(4.1 )
7766(0.6)(0.6) 3232 (3.2)(3.2) 77(1.0)(1.0) 2121 (3.1)(3.1)
8866(0.6)(0.6) 2424 (2.4)(2.4) 44(0.6)(0.6) 1919 (2.8)(2.8)
9911(0.1)(0.1) 1010 (0.4)(0.4) 22(0.3)(0.3) 1212 (1.7)(1 .7)
1010 22 (0.2)(0.2) 88(0.8)(0.8) 22(0.3)(0.3) 11(0.1)(0.1)
1111 ^^33(0.3)(0.3) ^^55(0.7)(0.7)
1212 ^^11(0.1)(0.1) ^^11(0.1)(0.1)
1313 ^^11(0.1)(0.1) ^^11(0.1)(0.1)
1414 ^^11(0.1)(0.1) ^^^^
1515 ^^22 (0.2)(0.2) ^^^^
1616 11(0.1)(0.1) ^^^^^^
WESSELY ET ALWESSELY ET AL
physical health, psychological morbidity orphysical health, psychological morbidity or
PTSD symptoms (PTSR) and endorsementPTSD symptoms (PTSR) and endorsement
or non-endorsement of exposures, foror non-endorsement of exposures, for
either the Gulf or the Bosnia cohort. Theseeither the Gulf or the Bosnia cohort. These
analyses were repeated for the Gulf co-analyses were repeated for the Gulf co-
hort, omitting the five Gulf-specifichort, omitting the five Gulf-specific
exposures (smoke from oil-well fires;exposures (smoke from oil-well fires;
mustard gas or other blistering agents;mustard gas or other blistering agents;
having a Scud missile explode in the airhaving a Scud missile explode in the air
or on the ground within 1 mile; chemi-or on the ground within 1 mile; chemi-
cal/nerve gas attack; and hearing chemicalcal/nerve gas attack; and hearing chemical
alarms sounding), with no difference inalarms sounding), with no difference in
findings (Table 7).findings (Table 7).
Table 8 shows the regression analysesTable 8 shows the regression analyses
results for the effects of newly endorsedresults for the effects of newly endorsed
(‘newly remembered’) and no longer(‘newly remembered’) and no longer
endorsed (‘forgotten’) exposures onendorsed (‘forgotten’) exposures on
health, controlling for age, gender andhealth, controlling for age, gender and
number of endorsed exposures at stagenumber of endorsed exposures at stage
1. For the Gulf cohort, the total of newly1. For the Gulf cohort, the total of newly
endorsed exposures was associated with aendorsed exposures was associated with a
reduction in health perception and in-reduction in health perception and in-
creased psychological morbidity, whereascreased psychological morbidity, whereas
the total of no longer endorsed exposuresthe total of no longer endorsed exposures
was significantly associated with improvedwas significantly associated with improved
health perception. This pattern was nothealth perception. This pattern was not
replicated in the Bosnia cohort (data notreplicated in the Bosnia cohort (data not
shown).shown).
DIS CUSS IONDISCUSS ION
We already know that there is poor agree-We already know that there is poor agree-
ment between reporting of military eventsment between reporting of military events
and contemporaneous records of the sameand contemporaneous records of the same
events (Keaneevents (Keane et alet al, 1989). In an ideal, 1989). In an ideal
world we would have objective, indepen-world we would have objective, indepen-
dent, contemporary records of exposuresdent, contemporary records of exposures
and hazards, but this is rarely (if ever) poss-and hazards, but this is rarely (if ever) poss-
ible, given the ‘friction’ of war, and theible, given the ‘friction’ of war, and the
impossibility of monitoring all hazards,impossibility of monitoring all hazards,
both known and unknown, at the time.both known and unknown, at the time.
For that reason it is likely that self-reportFor that reason it is likely that self-report
of hazards and exposures will continue toof hazards and exposures will continue to
be the basis of the assessment of the conse-be the basis of the assessment of the conse-
quences of war and military deploymentsquences of war and military deployments
for the foreseeable future.for the foreseeable future.
RoemerRoemer et alet al (1998) documented con-(1998) documented con-
sistent increases in reports of exposure tosistent increases in reports of exposure to
seven specific war-related stressors overseven specific war-related stressors over
time in a sample of 460 service personneltime in a sample of 460 service personnel
deployed to Somalia in a peacekeepingdeployed to Somalia in a peacekeeping
operation. These men and women wereoperation. These men and women were
assessed in the first year after their return,assessed in the first year after their return,
and then 1–3 years later. At the secondand then 1–3 years later. At the second
assessment PTSD symptoms uniquely con-assessment PTSD symptoms uniquely con-
tributed to reported exposure scores.tributed to reported exposure scores.
SouthwickSouthwick et alet al (1997) administered on(1997) administered on
two occasions a 19-item war zone expo-two occasions a 19-item war zone expo-
sure questionnaire and the Mississippisure questionnaire and the Mississippi
Scale for Combat Related PTSD to 59Scale for Combat Related PTSD to 59
members of the National Guard whomembers of the National Guard who
had been activated for Gulf War duty.had been activated for Gulf War duty.
They analysed the extent that recall andThey analysed the extent that recall and
forgetting of exposures altered over time,forgetting of exposures altered over time,
and found that the number of ‘no’ toand found that the number of ‘no’ to
‘yes’ changes was significantly and posi-‘yes’ changes was significantly and posi-
tively related to PTSD symptom severitytively related to PTSD symptom severity
at the later assessment. In contrast,at the later assessment. In contrast,
Bramsen and colleagues, in a study ofBramsen and colleagues, in a study of
Dutch peacekeepers, did not find eitherDutch peacekeepers, did not find either
an increase in reported items over time,an increase in reported items over time,
or an association between number ofor an association between number of
changes between the first and secondchanges between the first and second
assessments and symptoms of PTSDassessments and symptoms of PTSD
(Bramsen(Bramsen et alet al, 2001). Meanwhile, other, 2001). Meanwhile, other
researchers have used the experience ofresearchers have used the experience of
the Gulf War to study consistency ofthe Gulf War to study consistency of
318318
Ta b l e 5Ta b l e 5 Association between demographic factors and exposure change variables (YN, no longer endorsed; NY, newly endorsed)Association between demographic factors and exposure change variables (YN, no longer endorsed; NY, newly endorsed)
GulfGulf BosniaBosnia
YNYN NYNY YNYN NYNY
nn MedianMedian IQRIQR PP MedianMedian IQRIQR PPnn MedianMedian IQRIQR PP MedianMed ian IQRIQR PP
GenderGender 0.350.35
11
0.020.02
11
0. 1 70. 1 7
11
550.010.01
11
MaleMale 839839 1. 01.0 3.003.00 3.03.0 3.003.00 552552 1.01.0 3.003.00 3.03.0 3.003.00
FemaleFemale 167167 1.01.0 3.003.00 2.02.0 3. 003.00 134134 1.01.0 2.002.00 2. 02.0 2.002.00
Age (y ears)Age (years) 0. 1 20.1 2
22
0.010.01
22
0.900.90
22
550.010.01
22
Under 29Under 29 00^^^^^^^^168168 1.01.0 2.002.00 3.03.0 3.003.00
30^3430^34 306306 1.01.0 3.003.00 3.03.0 3.003.00 272272 1.01.0 3.003.00 2.02.0 3.003.00
35^3935^39 299299 1.01.0 2.002.00 3.03.0 3.003.00 117117 2.02.0 3.003.00 2.02.0 3.003.00
40^4440 ^ 44 206206 1.01.0 2.002.00 2.02.0 3.003.00 8787 1.01.0 1.001.00 2.02.0 3.003.00
Over 45Over 45 195195 2.02.0 2.002.00 2.02.0 3.003.00 4242 1.51.5 3.003.00 2.02.0 3.253.25
Marital statusMarital status 0.670.67
22
0.090.09
22
0.550.55
22
0.040.04
22
MarriedMarried 667667 1.01.0 3.003.00 2.02.0 3.003.00 407407 1.01.0 3.003.00 2.002.00 3.003.00
Livi n g with part ne rLiv in g wit h partne r 1 05105 2.02.0 2.002.00 3.03.0 4.004.00 7 676 1.01.0 2.002.00 3.03.0 3.003.00
Never marriedNever married 112112 1.01.0 2.002.00 2.02.0 3.003.00 118118 1.01.0 2.002.00 2.02.0 4.004.00
SeparatedSeparated 5050 2.02.0 2.002.00 3.03.0 4.004.00 3232 1 .01.0 1.001.00 2.02.0 2.752.75
DivorcedDivorced 6161 2.02.0 2.502.50 3.03.0 3.003.00 4444 1.01.0 3.003.00 2.02.0 3.003.00
Widow edWidowed 441.51.5 2.502.50 3.03.0 4.254.25 00^^^^^^^^
Serving statusServing stat us 0.030.03
11
0.410.41
11
0.000.00
11
0.680.68
11
Still servingStill serv ing 347347 2.02.0 2.002.00 3.03.0 3.003.00 416416 2.02.0 3.003.00 2.02.0 3.003.00
Not servi ngNot serving 642642 1.01.0 2.002.00 2.02.0 3.003.00 251251 1 . 01.0 2.002.00 2.02.0 3.003.00
IQR, interquartile range.IQR, interquartile range.
1. Mann ^Whitney1. Mann ^ Whitney UU test for rankdifference.test for rank difference.
2. Kruskal^Wallis test for rank difference.2. Kruskal^Wallis test for rankdifference.
R E C A L L O F M IL I TA RY H A Z A R D SRECALL OF MILITARY HAZARDS
reports of hazardous ‘toxic’ exposuresreports of hazardous ‘toxic’ exposures
over time (McCauleyover time (McCauley et alet al, 1999; Wolfe, 1999; Wolfe
et alet al, 2002), but these studies did not, 2002), but these studies did not
consider the influence of psychologicalconsider the influence of psychological
variables on changing patterns of recall.variables on changing patterns of recall.
We now consider two major findings.We now consider two major findings.
The first relates to the stability of recall ofThe first relates to the stability of recall of
military hazards, and the second concernsmilitary hazards, and the second concerns
the direction of any observed changes andthe direction of any observed changes and
the influence of psychosocial factors onthe influence of psychosocial factors on
those changes.those changes.
Stability of recallStability of recall
There was relatively low agreement forThere was relatively low agreement for
reporting of war exposures over time, asreporting of war exposures over time, as
shown by the majority of exposures hav-shown by the majority of exposures hav-
ing aing a kk under 0.6. In general our findingsunder 0.6. In general our findings
are very similar to those of the only studyare very similar to those of the only study
that used a similar design to look at con-that used a similar design to look at con-
sistency of recall in smaller numbers ofsistency of recall in smaller numbers of
US Gulf War veterans (McCauleyUS Gulf War veterans (McCauley et alet al,,
1999). When the questions that we asked1999). When the questions that we asked
were almost identical to those asked inwere almost identical to those asked in
the US survey, the consistency of recallthe US survey, the consistency of recall
was likewise similar. Hence, in both stu-was likewise similar. Hence, in both stu-
dies, reporting exposure to smoke fromdies, reporting exposure to smoke from
oil fires was associated with good reliabil-oil fires was associated with good reliabil-
ity, hearing Scuds detonate was also rea-ity, hearing Scuds detonate was also rea-
sonably reliable, being aware of chemicalsonably reliable, being aware of chemical
alarms sounding was moderately reliablealarms sounding was moderately reliable
as was believing oneself exposed to chemi-as was believing oneself exposed to chemi-
cal attack, whereas reporting drinkingcal attack, whereas reporting drinking
local water, exposure to chemical agentlocal water, exposure to chemical agent
resistant coating (CARC) paint and expo-resistant coating (CARC) paint and expo-
sure to depleted uranium was very unreli-sure to depleted uranium was very unreli-
able in both studies. The recall ofable in both studies. The recall of
depleted uranium exposure is particularlydepleted uranium exposure is particularly
problematic in the Bosnia cohort, indi-problematic in the Bosnia cohort, indi-
cated by the lowestcated by the lowest kk value (0.05).value (0.05).
Perhaps this is a reflection of the enor-Perhaps this is a reflection of the enor-
mous publicity given to reports of cancersmous publicity given to reports of cancers
occurring in peacekeepers from severaloccurring in peacekeepers from several
European nations that happened betweenEuropean nations that happened between
the two phases of our study. Likewise,the two phases of our study. Likewise,
chemical exposures such as CARC paint,chemical exposures such as CARC paint,
other paints/solvents and pesticides onother paints/solvents and pesticides on
clothing/bedding were associated withclothing/bedding were associated with
the greatest number of ‘no’ to ‘yes’the greatest number of ‘no’ to ‘yes’
changes (increased recall) in both Gulfchanges (increased recall) in both Gulf
and Bosnia cohorts, and correspondinglyand Bosnia cohorts, and correspondingly
lowlow kk values. There has also been intensevalues. There has also been intense
media concern over all these exposures inmedia concern over all these exposures in
the British press in the past decade, in-the British press in the past decade, in-
cluding, but not restricted to, the militarycluding, but not restricted to, the military
context.context.
Change in recal l over timeChange in recall over time
Looking now at the general pattern ofLooking now at the general pattern of
change, previous studies have shown thatchange, previous studies have shown that
the mean number of events reported overthe mean number of events reported over
time can either increase (Southwicktime can either increase (Southwick et alet al,,
1997; Roemer1997; Roemer et alet al, 1998; King, 1998; King et alet al,,
2000) or stay the same (Bramsen2000) or stay the same (Bramsen et alet al,,
2001). Our study produced an increase2001). Our study produced an increase
in the number of events reported overin the number of events reported over
time in the Gulf cohort, but no significanttime in the Gulf cohort, but no significant
increase in the Bosnia cohort. What thisincrease in the Bosnia cohort. What this
illustrates is the importance of notillustrates is the importance of not
assuming that all conflicts are the sameassuming that all conflicts are the same
in terms of their social and psychologicalin terms of their social and psychological
impact. Results in our peacekeeping co-impact. Results in our peacekeeping co-
hort are similar to those of Bramsen andhort are similar to those of Bramsen and
colleagues looking at Dutch peacekeepers,colleagues looking at Dutch peacekeepers,
and our Gulf results, although differentand our Gulf results, although different
319319
Ta b l e 6Ta b l e 6 Mean change in health outcomes c ategorised by no longer endorsed and newly endorsed exposuresMean change in health outcomes categorised by no longer endorsed and newly endorsed exposures
for the Bosnia and G ulf cohortfor the Bosnia and Gulf cohort
HealthHealth
perceptionper ce ption
11
Physi cal healthPhysi cal health
11
GHQGHQ
22
PTSRPTSR
33
MeanMean (s.d.)(s.d.) MeanMean (s.d.)(s.d.) MeanMean (s.d.)(s.d.) MeanMean (s.d.)(s.d.)
GulfGulf
TotalTotal 0.80.8 (20.90)(20.90) 771.71.7 (16.00)(16.00) 770.80.8 (5.65)(5.65) 770.20.2 (1.42)(1.42)
No longer endorsed (YN)No longer endorsed (YN)
00 770.90.9 (20.71)(20.71) 773.23.2 (17.42)(17.42) 770.70.7 (6.1 2)(6.12) 0.0080.008 (1.39)(1.39)
110.60.6 (2 1 .83)(21.83) 771.21.2 (14.54)(14.54) 770. 90.9 (5.75)(5.75) 770.20.2 (1.49)(1.49)
220.20.2 (20.40)(20.40) 771.21.2 (14.67)(1 4.67) 771.01.0 (5.17)(5 .17) 770.30.3 (1 .34)(1.34)
331.21.2 (20.01)(20.01) 772.52.5 (14.12)(14.1 2) 770.40.4 (5.03)(5.03) 770.20.2 (1.33)(1.33)
4or54or5 1.61.6 (20.32)(20.32) 0.60.6 (1 9 .72)(19.72) 771.51.5 (5.64)(5.64) 770.50.5 (1.46)(1.46)
6+6+ 1 3 .813.8 (19.96)(19.96) 772.32.3 (13.3 1)(13.3 1) 0.00.0 (6.06)(6.06) 770.40.4 (1.44)(1.44)
PP
44
0.010.01 0.330.3 3 0.670.67 0.010.01
Newly endorsed (NY)Newly endorsed (NY)
003.83.8 (22.82)(22.82) 772.12.1 (15.92)(15.92) 771.91.9 (5.29)(5.29) 770.40.4 (1.31)(1 .31)
112.32.3 (20.94)(20.94) 770.030.03 (15.58)(15.58) 77 0.90.9 (5.23)(5.23) 770.40.4 (1.38)(1.38)
222.472.47 (19. 07)(19.07) 771.71.7 (14.92)(14.92) 771.51.5 (5.03)(5.03) 770.40.4 (1.51)(1 .5 1)
33 771.161.16 (22.54)(22.54) 772.22.2 (18.97)(18.97) 770.50.5 (6.34)(6.34) 770.010.01 (1.43)(1.43)
4or54or5 771.271.27 (18.86)(18.86) 772.12.1 (15.20)(15.20) 0.0040.004 (5.90)(5.90) 0.050.05 (1 .33)(1.33)
6+6+ 771.551.55 (22.04)(22.04) 772.62.6 ( 15.60)(15.60) 77 0.60.6 (6 .01)(6.01) 770.020.02 (1.50)(1.50)
PP
44
550.010.01 0. 1 40. 1 4 0.010.01 550.010.01
BosniaB osnia
TotalTotal 772.072.07 (22.56)(22.56) 772.972.97 ( 15.76)(15.76) 770.70.7 (5.99)(5.99) 0.040.04 (1 .6)(1.6)
No longer endorsed (YN)No longer endorsed (YN)
00 771.81.8 (22.27)(22.27) 775. 15.1 (18.09)(18.09) 770.40.4 (6.02)(6.02) 0.30.3 (1.64)(1.64)
11 772.12.1 (22.20)(22.20) 773.13.1 (15.36)(15.36) 770.70.7 (6. 1 3)(6.13) 0.040.04 (1.63)(1.63)
22 772.22.2 (22.47)(22.47) 0.70.7 (1 3 . 1 9)(13. 19) 771.21.2 (6.34)(6.34) 770.10. 1 (1.33)(1.33)
33 770.70.7 (24.1 9)(24.19) 773.43.4 (14.66)(14.66) 771.11. 1 (5. 15)(5 .15) 770.30.3 (1.70)(1.70)
4or54or5 774.44.4 (21.50)(21.50) 773. 13. 1 (15.12)(15.1 2) 770.0070.007 (5.25)(5.25) 0.20.2 (1.61)(1.61)
6+6+ 770.50.5 (26.74)(26.74) 2.52.5 (15.40)(15.40) 772.12.1 (6.94)(6.94) 770.70.7 (1.87)(1.87)
PP
44
0.560.56 0.030.03 0. 110.11 0.010.01
Newly endorsed (NY)Newly endorsed (NY)
000.70.7 (20.56)(20.56) 770.50.5 (13 .79)(13.79) 771.31.3 (4.64)(4.64) 770.30.3 (1.59)(1.59)
111.51.5 (22.98)(22.98) 773.03.0 (16.20)(16.20) 770.60.6 (5.74)(5.74) 770.050.05 (1.5 3)(1.53)
22 774. 14.1 (21.03)(21.03) 771.61.6 (12.32)(12.32) 770.80.8 (6.07)(6.07) 770.030.03 (1.48)(1.48)
33 775.75.7 (24.83)(24.83) 773.63.6 (17.57)(17 .57) 770.60.6 (5.83)(5.83) 0.20.2 (1.57)(1.57)
4or54or5 774.44.4 (22.08)(22.08) 774. 94.9 (18.29)(18.29) 770.50.5 (6.28)(6.28) 0.20.2 (1 .62)(1.62)
6+6+ 1 .41.4 (23.49)(23.49) 773.93.9 (15.74)(15.74) 770.70.7 (7.24)(7.24) 0.20.2 (1.89)(1.89)
PP
44
0. 1 70.17 0.310.3 1 0.210.2 1 0.050.05
1. Positive value indicates improvementin health.1. Pos itive val ue ind icates improvement in health.
2. General Health Questionnaire (GHQ): positive value indicates increase in psychological morbidity.2. General Health Questionnaire (GHQ): positive value indicates increase in psychological morbidity.
3. Post-traumatic stress reaction (PTSR): positive value indicates increase in symptoms.3. Post-traumatic stress reaction (PTSR): positive value indicates increase in symptoms.
4. Non-parametric test for trend.4. Non-parametric test for trend.
WESSELY ET ALWESSELY ET AL
from those in the peacekeepers, arefrom those in the peacekeepers, are
similar to the findings of Southwick andsimilar to the findings of Southwick and
colleagues in US Gulf veterans. On thecolleagues in US Gulf veterans. On the
other hand, neither we nor Bramsenother hand, neither we nor Bramsen etet
alal (2001) are able to confirm the sub-(2001) are able to confirm the sub-
stantial increase in reporting of eventsstantial increase in reporting of events
recorded by Roemerrecorded by Roemer et alet al (1998) in US(1998) in US
peacekeepers in Somalia. However, thepeacekeepers in Somalia. However, the
US operation in Somalia was beset byUS operation in Somalia was beset by
difficulties, and involved rather more thandifficulties, and involved rather more than
peacekeeping, with periods of actualpeacekeeping, with periods of actual
combat.combat.
A second reason why the literature isA second reason why the literature is
not entirely consistent is that previousnot entirely consistent is that previous
studies have been concerned with eitherstudies have been concerned with either
post-traumatic type events and symptoms,post-traumatic type events and symptoms,
or more ‘toxic’ hazards, but rarely withor more ‘toxic’ hazards, but rarely with
both. In our Gulf studies we have alwaysboth. In our Gulf studies we have always
taken a broader view of hazards and expo-taken a broader view of hazards and expo-
sures, incorporating exposures such assures, incorporating exposures such as
vaccinations, smoke from oil fires, depletedvaccinations, smoke from oil fires, depleted
uranium and so on, which are not trau-uranium and so on, which are not trau-
matic in the customary use of the word,matic in the customary use of the word,
but certainly came to prominence afterbut certainly came to prominence after
the 1991 Gulf War. This means thatthe 1991 Gulf War. This means that
we included more measures of thesewe included more measures of these
kinds of hazards than the other studies, butkinds of hazards than the other studies, but
conversely our measure of post-traumaticconversely our measure of post-traumatic
stress symptoms is less sophisticated.stress symptoms is less sophisticated.
Recall of exposures and currentRecall of exposures and current
health per cepti onheal th per cepti on
We found an association between healthWe found an association between health
perception and both increased reportingperception and both increased reporting
and also forgetting of exposures, but thisand also forgetting of exposures, but this
was not true of psychological morbiditywas not true of psychological morbidity
or physical health. This association heldor physical health. This association held
for the Gulf cohort, but not for the Bosniafor the Gulf cohort, but not for the Bosnia
cohort. In general we found that the maincohort. In general we found that the main
pattern of change was of increased report-pattern of change was of increased report-
ing (‘no’ to ‘yes’) rather than forgettinging (‘no’ to ‘yes’) rather than forgetting
(‘yes’ to ‘no’).(‘yes’ to ‘no’).
There may be several explanations forThere may be several explanations for
changes in reporting of an event over time.changes in reporting of an event over time.
The recall of events might simply becomeThe recall of events might simply become
inflated over time; conversely, individualsinflated over time; conversely, individuals
might have underestimated their reportsmight have underestimated their reports
initially and later given more accurateinitially and later given more accurate
appraisals. Over the specific interval of thisappraisals. Over the specific interval of this
study, there was considerable media atten-study, there was considerable media atten-
tion to the Gulf War and its possible healthtion to the Gulf War and its possible health
effects. No doubt this information waseffects. No doubt this information was
incorporated to some lesser or greaterincorporated to some lesser or greater
degree into the participants’ perspectivesdegree into the participants’ perspectives
on their experiences of the war. The acqui-on their experiences of the war. The acqui-
sition of new knowledge, from whateversition of new knowledge, from whatever
source, could explain both types of changessource, could explain both types of changes
in item endorsement: elucidating andin item endorsement: elucidating and
clarifying events and circumstances thatclarifying events and circumstances that
did occur but were not previously knowndid occur but were not previously known
(accounting for ‘no’ to ‘yes’ changes), and(accounting for ‘no’ to ‘yes’ changes), and
delimiting details of experiences previouslydelimiting details of experiences previously
held to be true (accounting for ‘yes’ to ‘no’held to be true (accounting for ‘yes’ to ‘no’
changes). We should also be careful not tochanges). We should also be careful not to
assume that changes in reporting equateassume that changes in reporting equate
with changes in memory – it might be thatwith changes in memory – it might be that
events previously seen as irrelevant andevents previously seen as irrelevant and
not endorsed on a questionnaire have in-not endorsed on a questionnaire have in-
creased in importance and salience overcreased in importance and salience over
time, perhaps because of media coverage,time, perhaps because of media coverage,
rather than being newly remembered. Onrather than being newly remembered. On
the other hand, there is evidence from thisthe other hand, there is evidence from this
study that the reporting of events isstudy that the reporting of events is
influenced by current health perception.influenced by current health perception.
We found an association between changesWe found an association between changes
in endorsement – both positive and nega-in endorsement – both positive and nega-
tive – of hazards, and current healthtive – of hazards, and current health
perception. Remembering more exposuresperception. Remembering more exposures
over time was associated with worseningover time was associated with worsening
perception of health; conversely, improvedperception of health; conversely, improved
perception of health was associated withperception of health was associated with
forgetting previously recalled exposures.forgetting previously recalled exposures.
This pattern held after we had removedThis pattern held after we had removed
exposures specific to the Gulf War fromexposures specific to the Gulf War from
the analysis, indicating that the findingthe analysis, indicating that the finding
was not due to certain key Gulf War expo-was not due to certain key Gulf War expo-
sures that might be strongly associated withsures that might be strongly associated with
health. This finding was not replicated withhealth. This finding was not replicated with
measures of mental health in general, ormeasures of mental health in general, or
PTSD symptoms in particular.PTSD symptoms in particular.
Another important finding is that theAnother important finding is that the
association between health perception andassociation between health perception and
recall or non-recall of hazards and expo-recall or non-recall of hazards and expo-
sures was found in the Gulf cohort butsures was found in the Gulf cohort but
not in the Bosnia cohort. This was not be-not in the Bosnia cohort. This was not be-
cause of a differential effect of exposurescause of a differential effect of exposures
only encountered in the Gulf and also theonly encountered in the Gulf and also the
subject of intense media scrutiny, since re-subject of intense media scrutiny, since re-
moving these Gulf-specific exposures didmoving these Gulf-specific exposures did
not alter the association.not alter the association.
We draw attention to the finding that,We draw attention to the finding that,
contrary to our original predictions, changecontrary to our original predictions, change
in recall of exposures was not associatedin recall of exposures was not associated
with changes in post-traumatic stress symp-with changes in post-traumatic stress symp-
toms, but with health perception. However,toms, but with health perception. However,
this is in keeping with our own nested case–this is in keeping with our own nested case–
control study in which we interviewed bothcontrol study in which we interviewed both
ill and healthy veterans, this time using aill and healthy veterans, this time using a
standardised psychiatric interview to enablestandardised psychiatric interview to enable
us to make firm diagnoses of PTSD, whichus to make firm diagnoses of PTSD, which
was not the case in the epidemiologicalwas not the case in the epidemiological
study. Although psychological morbiditystudy. Although psychological morbidity
was increased, modestly, in the Gulfwas increased, modestly, in the Gulf
320320
Ta b l e 7Ta b l e 7 Mean change in health outcomes categorised by newly endorsed and no longer endorsed exposuresMean change in health outcomes categorised by newly endorsed and no longer endorsed exposures
for generic military exposures in the Gulf cohortfor generic military exposures in the Gulf cohort
HealthHealth
perceptionper ce ption
11
Physi cal healthPhys ical health
11
GHQGHQ
22
PTSRPTSR
33
MeanMean (s.d.)(s.d.) MeanMean (s.d.)(s.d.) MeanMean (s.d.)(s.d.) MeanMean (s.d. )(s.d.)
TotalTotal 0.70.7 (20.93)(20.93) 771.61.6 (15.71)(15.7 1) 770.80.8 (5.80)(5.80) 770.20.2 (1.44)(1.44)
No longer endorsed (YN)No longer endorsed (YN)
00 770.30.3 (21.23)(21.23) 772.72.7 (1 6.3 2)(16.32) 770.70.7 (6.52)(6.52) 770.020.02 (1.47)(1.47)
110.40.4 (20.88)(20.88) 770.80.8 (15.24)(15.24) 770.70.7 (5.44)(5.44) 770.10.1 (1.45)(1.45)
22 770.30.3 (20.55)(20.55) 770.80.8 (14. 18)(14.18) 770. 90.9 (5.1 8)(5. 18) 770.30.3 (1 .35)(1.35)
332.32.3 (19.71)(19 .71) 772.42.4 (13.7 2)(13.72) 770.80.8 (5.53)(5.53) 770.30.3 (1.30)(1.30)
4or54 or 5 2.12.1 (21.26)(21.26) 771.31.3 (19.88)(19.88) 771.01.0 (5.59)(5.59) 770.60.6 (1.58)(1.58)
6+6+ 18.318.3 (19.30)(19.30) 2.32.3 (10.68)(10.68) 771.61.6 (5.66)(5.66) 770.40.4 (1.09)(1.09)
PP
44
0.010.01 0.380.38 0.470.47 550.010.01
Newly endorsed (NY)Newly endorsed (NY)
002.82.8 (22.25)(22.25) 771.11.1 (14.71)(14.7 1) 771.21.2 (6.07)(6.07) 770.30.3 (1.43)(1.43)
112.02.0 (21.22)(21.22) 770.70.7 (14.99)(14.99) 771.41.4 (5.45)(5.45) 770.40.4 (1.48)(1.48)
221.71.7 (18.64)(18.64) 771.11.1 (15.42)(15.42) 770.60.6 (5.37)(5.37) 770.20.2 (1 .40)(1.40)
33 771.31.3 (21.31)(21.31) 773.33.3 (18.5 1)(18.51) 770.30.3 (5.94)(5.94) 770.10.1 (1.49)(1.49)
4or54or5 771.41.4 (20.07)(20.07) 773.03.0 (16. 18)(16.18) 770.30.3 (6.09)(6.09) 770.050.05 (1.32)(1 .32)
6+6+ 771.71.7 (22.02)(22.02) 771.31.3 (14.91)(14.91) 770.90.9 (6.03)(6.03) 77 0.20.2 (1.52)(1.52)
PP
44
550.010.01 0.060.06 0.1 20. 1 2 0.010.01
1. Positive value indicates improvementin health.1. Positive value indicates improvement in health.
2. General Health Questionnaire (GHQ): positive value indicates increase in psychological morbidity.2. General Health Questionnaire (GHQ): positive value indicates increase in psychological morbidity.
3. Post-traumatic stress reaction (PTSR): positive value indicates increase in symptoms.3. Post-traumatic stress reaction ( PTSR): positive value indicates increase in symptoms.
4. Non-parametric test for trend.4. Non-parametric test for trend.
R E C A L L O F M IL I TA RY H A Z A R D SRECALL OF MILITARY HAZARDS
cohort, this was rarely due to PTSD (Ismailcohort, this was rarely due to PTSD (Ismail
et alet al, 2002). This is unsurprising. The Gulf, 2002). This is unsurprising. The Gulf
War was not particularly traumatic in theWar was not particularly traumatic in the
conventional sense for the coalition forces,conventional sense for the coalition forces,
particularly in the context of past militaryparticularly in the context of past military
campaigns that were associated with highcampaigns that were associated with high
rates of classic war-related psychiatric in-rates of classic war-related psychiatric in-
jury. The perceived hazards of the Gulfjury. The perceived hazards of the Gulf
tended to be those not usually associatedtended to be those not usually associated
with the military setting, and not encapsu-with the military setting, and not encapsu-
lated in the formulations of PTSD. Instead,lated in the formulations of PTSD. Instead,
most revolved around fears of environmen-most revolved around fears of environmen-
tal exposure and contamination. We havetal exposure and contamination. We have
argued elsewhere that the indisputable in-argued elsewhere that the indisputable in-
crease in ill health seen after the Gulf Warcrease in ill health seen after the Gulf War
is better understood as part of the literatureis better understood as part of the literature
on unexplained symptoms and syndromes,on unexplained symptoms and syndromes,
rather than conventional PTSD. This mayrather than conventional PTSD. This may
help to explain why changes in recall ofhelp to explain why changes in recall of
exposures were associated more withexposures were associated more with
changes in health perception than withchanges in health perception than with
symptoms of post-traumatic stress.symptoms of post-traumatic stress.
ACKN O WLEDGEMENTSACKN OWLEDGEMENTS
This study was funded by the US Department ofThi s stud y was funded by the U S Department of
Defense and the UK Medical Research Council.Defense and the UK Med ical Research Council.
Nei t her or gani sa tion has had any in put into the de-Neith e r organi sa tion has had any input in to the de-
sign, conduct, analysis or reporting of the study. Thesign, conduct, analysis or reporting of the study. The
views expressed are the authors’ own.views expressed are the authors’ own.
We thank all the s ervicemen a nd service womenWe th ank all the ser vicemen a nd service women
who gave freely of thei r time.W e also thank Dr Ingewho gave freely of thei r ti me.W e also than k Dr Inge
Bramsen and Professor Ariel Shalev for their helpfulBrams e n and Prof essor A riel S ha l e v f o r their helpful
advice.advice.
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Ta b l e 8Ta b l e 8 Prediction of change in health status and psychological morbidity by newly endorsed and no longer endorsed exposure recall: hierarchical regressionanalysisPrediction of change in health status and psychological morbidity by newly endorsed and no longer endorsed exposure recall: hierarchical regressionanalysis
controlling for age, gender and exposure at time 1 for the Gulf cohortcontrolling for age, gender and exposure at ti me 1 for the Gulf cohort
PredictorsPred ictors RRRR
22
Step 1Step 1 Ste p 2Step 2 Step 3Step 3
BBs.e.s.e. AA BBs.e.s.e. AA BBs.e.s.e. AA
Health perception and newly endorsed (NY)Health perception and newly endorsed (NY)
Step 1Step 1 0.070.07 0.0050.005
AgeAge 770.2 10.2 1 0. 100.10 77 0.07*0.07* 770.200.20 0.010.01 770.07*0.07* 770.250.25 0.100.10 770.08*0.08*
GenderGender 770.220.22 1.771.77 770.000.00 0.1 20.12 1.851.85 0.000.00 770.640.64 1.861.86 770.010.01
Step 2Step 2 0.070.07 0.000.00
Time1exposureTime1exposure 0.0090.009 0. 1 40.1 4 0.020.02 0.0010.001 0.140. 1 4 0.000.00
Step 3Step 3 0.12**0.1 2** 0.010**0.010**
NYNY 770.900.90 0.290.29 770.10**0.10**
Health perce pti on and no long er endorsedHealt h percepti on and no longe r endorsed
exposures (YN)exposures (YN)
Step 1Step 1 0.070.07 0.0050.005
AgeAge 770.2 10.2 1 0. 100.10 77 0.07*0.07* 770.200.20 0.100.10 770.07*0.07* 770.240.24 0.100.10 770.08*0.08*
GenderGender 770.220.22 1.781.78 770.000.00 0. 120. 12 1.851.85 0.000.00 770.300.30 1.841.84 770.000.00
Step 2Step 2 0.070.07 0.0000.000
Time1exposureTime1exposure 0.0090.009 0. 1 40.1 4 0.020.02 770.0080.008 0.1 50. 15 770.020.02
Step 3Step 3 0.13**0.1 3** 0.01 1**0.01 1**
YNYN 1.361.36 0.400.40 0. 11*0. 11*
Psycholog i cal morbid it y and newly endorsedPsychological morbidit y and newly endorsed
exposures (NY)exposures (NY)
Step 1Step 1 0.030.03 0.0010.001
AgeAge 0.010.01 0.030.03 0.010.01 0.0070.007 0.030.03 0.0090.009 0.020.02 0.030.03 0.020.02
GenderGender 0.440.44 0.490.49 0.030.03 0.340.34 0.5 10.51 0.020.02 0.470.47 0.5 10.5 1 0.030.03
Step 2Step 2 0.040.04 0.0020.002
Time1exposureTime1exposure 0.030.03 0.040.04 770.020.02 0.010.01 0.040.04 770.010.01
Step 3Step 3 0.080.08 0.0060.006
NYNY 0.1 60. 16 0.080.08 0.07*0 .07*
**PP550.05; **0.05; **PP550.01 .0.01 .
WESSELY ET ALWESSELY ET AL
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322322
CLINICAL IMPLIC ATIONSCLINICAL IMPLICATIONS
&&
Stabil it y of recall of hazar dous exposu res du rin g mi l itary ope rati ons diffe rsStabil ity of recall of hazardous exposu res d uri ng mi l itary operat ions diffe rs
according to the nature of the exposure ^ those extensively publicised in the mediaaccording to the nature of the exposure ^ those extensively publicised in the media
are parti cul arly prob lemati c.are part icu larl y proble mat i c.
&&
The number of exposures recalled has increased with the passage of time.The number of exposures recalledhas increased with the passage of time.
&&
The total number of hazardous exposures reported may reflect not only actualThe total number of hazardous exposures rep orted mayreflect not only actual
exposures but also current distress.e xposures but also cur rent dist ress.
LIMI TATIONSLIMITATIONS
&&
All military conflicts differ in various ways ^ it cannot be assumed that theseAll military conflicts differ in various ways ^ it cannot be assumed that these
find i ngs ext rapolate bey ond the1 991 Gu lf War.fi ndin gs e xtrapolate beyond t he1991G u lf W ar.
&&
The measurement of self-reported exposures was fairly crude.The measurement of self-reported exposures was fairly crude.
&&
Measurement of post-traumatic symptoms was by self-report and not byMeasurement of post -traumatic symptoms was by self-report and not by
structured interview.structured interview.
S .WESSELY, FRCP, C. U N WIN, MSc, M . H OTOPF, PhD, L. HULL, BSc, K . I SMAIL, MRCP s ych,V. N ICOLAOU, BSc,S.WESSELY , FRCP, C. U NWIN, MSc, M . HO TOPF, PhD , L. HULL, BSc, K. ISMA IL, MRCPsych,V. NIC OLAOU, BSc,
A. D AVID, MD, Kin g’s C entre for M ili tary Heal t h Research ,Ki n g’s College L ond on ,UKA. DAVID, MD, King’s Centre for Military Health Research, King’s College London,UK
Correspondence: Professor S.Wessely, Department of Psychological Medicine,GKT School of Medicine,Correspondence: Professor S.We ssely, D epartment of Psychological Medicine,GKT Scho ol of Medicine,
103 Denmark Hill, London SE5 8 AF,UK. E-mail: s.wessely103 Denmark Hill, London SE5 8AF,UK. E-mail: s. wes sely@@iop.kcl.ac.ukiop.kcl.ac.uk
(First received 15 January 2003, final revision 22 April 2003, accepted 6 May 2003)(First received 15 January 2003, final revision 22 April 2003, accepted 6 May 2003)
