NORTH ATLANTIC TREATY SCIENCE AND TECHNOLOGY ORGANIZATION ORGANIZATION AC/323(HFM-175)TP/717 www.sto.nato.int STO TECHNICAL REPORT TR-HFM-175 Medically Unexplained Physical Symptoms in Military Health (Symptômes physiques médicalement inexpliqués dans la santé militaire) Final Report of the Research and Technology Group HFM-175. Published December 2017 Distribution and Availability on Back Cover NORTH ATLANTIC TREATY SCIENCE AND TECHNOLOGY ORGANIZATION ORGANIZATION AC/323(HFM-175)TP/717 www.sto.nato.int STO TECHNICAL REPORT TR-HFM-175 Medically Unexplained Physical Symptoms in Military Health (Symptômes physiques médicalement inexpliqués dans la santé militaire) Final Report of the Research and Technology Group HFM-175. The NATO Science and Technology Organization Science & Technology (S&T) in the NATO context is defined as the selective and rigorous generation and application of state-of-the-art, validated knowledge for defence and security purposes. S&T activities embrace scientific research, technology development, transition, application and field-testing, experimentation and a range of related scientific activities that include systems engineering, operational research and analysis, synthesis, integration and validation of knowledge derived through the scientific method. In NATO, S&T is addressed using different business models, namely a collaborative business model where NATO provides a forum where NATO Nations and partner Nations elect to use their national resources to define, conduct and promote cooperative research and information exchange, and secondly an in-house delivery business model where S&T activities are conducted in a NATO dedicated executive body, having its own personnel, capabilities and infrastructure. The mission of the NATO Science & Technology Organization (STO) is to help position the Nations’ and NATO’s S&T investments as a strategic enabler of the knowledge and technology advantage for the defence and security posture of NATO Nations and partner Nations, by conducting and promoting S&T activities that augment and leverage the capabilities and programmes of the Alliance, of the NATO Nations and the partner Nations, in support of NATO’s objectives, and contributing to NATO’s ability to enable and influence security and defence related capability development and threat mitigation in NATO Nations and partner Nations, in accordance with NATO policies. The total spectrum of this collaborative effort is addressed by six Technical Panels who manage a wide range of scientific research activities, a Group specialising in modelling and simulation, plus a Committee dedicated to supporting the information management needs of the organization. • AVT Applied Vehicle Technology Panel • HFM Human Factors and Medicine Panel • IST Information Systems Technology Panel • NMSG NATO Modelling and Simulation Group • SAS System Analysis and Studies Panel • SCI Systems Concepts and Integration Panel • SET Sensors and Electronics Technology Panel These Panels and Group are the power-house of the collaborative model and are made up of national representatives as well as recognised world-class scientists, engineers and information specialists. In addition to providing critical technical oversight, they also provide a communication link to military users and other NATO bodies. The scientific and technological work is carried out by Technical Teams, created under one or more of these eight bodies, for specific research activities which have a defined duration. These research activities can take a variety of forms, including Task Groups, Workshops, Symposia, Specialists’ Meetings, Lecture Series and Technical Courses. The content of this publication has been reproduced directly from material supplied by STO or the authors. Published December 2017 Copyright © STO/NATO 2017 All Rights Reserved ISBN 978-92-837-2042-3 Single copies of this publication or of a part of it may be made for individual use only by those organisations or individuals in NATO Nations defined by the limitation notice printed on the front cover. The approval of the STO Information Management Systems Branch is required for more than one copy to be made or an extract included in another publication. Requests to do so should be sent to the address on the back cover. ii STO-TR-HFM-175 Table of Contents Page List of Figures and Tables viii List of Acronyms ix HFM-175 Membership List xi Executive Summary and Synthèse ES-1 Chapter 1 – Historical Perspective 1-1 1.1 Introduction 1-1 1.2 Lack of Symptom Specificity and the Problems for Diagnosis 1-2 1.3 Functional Syndromes 1-3 1.4 References 1-4 Chapter 2 – The No-Man’s Land of Post-Deployment Syndromes: 2-1 The Current Attempts to Capture this Territory and the Uncertainties About mTBI Abstract 2-1 2.1 Introduction 2-1 2.2 The Threat of Current War 2-2 2.3 The Current Problem 2-3 2.4 mTBI – A Recurring Post-Deployment Syndrome? 2-5 2.5 Neuraesthenic Neuroses and Somatic Post-Deployment Syndromes 2-6 2.6 The Challenge of Overlapping Clinical Syndromes 2-7 2.6.1 Illness Attributions and Beliefs 2-8 2.6.2 Medically Classified Syndromes / Functional Syndromes 2-9 2.6.3 Psychiatric Classification of Somatic and Pain Syndromes 2-9 2.6.4 Physical Symptoms in Psychiatric Illness 2-10 2.6.5 Impact of Compensation Systems 2-10 2.7 The Current Controversy 2-10 2.7.1 Allostasis: A Shared Mechanism of Disease 2-11 2.8 Conclusion 2-11 2.9 References 2-12 Chapter 3 – Allostatic Load Review 3-1 3.1 Introduction 3-1 3.2 Related Constructs of Sensitization and Kindling 3-1 3.3 Stress and Potential Risk Factors 3-2 3.4 Measuring Allostatic Load 3-3 STO-TR-HFM-175 iii 3.5 Developing an Allostatic Load Score 3-4 3.6 Associations of Interest 3-5 3.7 Resilience 3-6 3.8 References 3-6 Chapter 4 – The Long-Term Costs of Traumatic Stress: Intertwined 4-1 Physical and Psychological Consequences Abstract 4-1 4.1 Introduction 4-1 4.2 The Relationship Between Acute Stress Disorder and PTSD 4-2 4.3 Delayed Onset PTSD 4-2 4.4 The Enduring Impact of Traumatic Memory 4-3 4.5 Triggering and Sensitization 4-3 4.6 Physical Morbidity Associated with Traumatic Stress 4-5 4.7 PTSD and Psychosomatic Syndromes 4-5 4.8 The Relationship Between Hypertension and PTSD 4-6 4.9 Hyperlipidaemia 4-6 4.10 The Relationship Between Obesity and PTSD 4-7 4.11 The Relationship Between PTSD Symptoms and Coronary Heart Disease 4-7 4.12 Clinical Implications 4-8 4.13 Treatment Implications 4-8 4.14 Conclusion 4-9 4.15 Acknowledgements 4-9 4.16 References 4-9 Chapter 5 – Issues and Challenges in Diagnosis of Mild Traumatic 5-1 Brain Injury in Military Settings: Implications for Clinical Practice Abstract 5-1 5.1 Introduction 5-1 5.2 Issues Related to Causation of Loss of Awareness and Memory 5-2 5.3 Issues Relating to Post-Concussive Symptoms 5-2 5.4 Issues Related to Neuroimaging, Neuropsychological Assessment and 5-3 Concussion 5.5 Multi-Faceted Overlap with PTSD 5-4 5.6 Implications for Research and Policy 5-4 5.7 Prevalence Estimates for Concussion/mTBI and Post-Concussive 5-5 Symptoms 5.8 Implications for Treatment 5-5 5.9 Recommendations 5-6 5.10 Conclusion 5-7 5.11 Acknowledgements 5-7 5.12 References 5-7 iv STO-TR-HFM-175 Chapter 6 – Stress-Related Musculoskeletal Pain 6-1 Abstract 6-1 6.1 Introduction 6-1 6.2 The Nature of Stress 6-2 6.3 Stress and Adaptation to Life Events 6-3 6.4 Traumatic Events and Musculoskeletal Pain 6-4 6.5 Epidemiological Evidence 6-5 6.6 Diagnostic Overlap with Chronic Pain Disorders 6-6 6.7 Shared Neurobiology 6-8 6.8 The Interactive Relationship 6-8 6.8.1 How Does Stress Lead to Pain − Research Agenda 6-9 6.8.2 Practice Points 6-10 6.9 Summary 6-12 6.10 Acknowledgements 6-12 6.11 References 6-12 Chapter 7 – Explanatory and Pragmatic Perspectives Regarding 7-1 Idiopathic Physical Symptoms and Related Syndromes Abstract 7-1 7.1 Introduction 7-1 7.2 Idiopathy, Explanation and Pragmatism 7-2 7.3 Idiopathy, Somatization, and Causation 7-3 7.4 Idiopathies and Diagnostic Labels 7-6 7.5 Idiopathies and Treatment Research 7-7 7.6 Discussion 7-9 7.7 Disclosures 7-9 7.8 Acknowledgement 7-10 7.9 References 7-10 Chapter 8 – Development of a Day Treatment Program for Medically 8-1 Unexplained Physical Symptoms (MUPS) in the Dutch Army Abstract 8-1 8.1 Background 8-1 8.2 Clinical Challenges 8-3 8.3 Case Reports 8-3 8.3.1 Case 1 8-3 8.3.2 Case 2 8-4 8.4 Research in Dutch Cohorts 8-5 8.5 Symptom Presentations 8-5 8.6 Development of Blended Care Program 8-6 8.7 Outpatient Day Treatment Program 8-7 8.7.1 Assessment 8-8 8.7.2 Treatment 8-9 STO-TR-HFM-175 v 8.7.2.1 Specialized Physical Therapy 8-9 8.7.2.2 CBT According to the ‘Model of Causes’ 8-9 8.7.2.3 Psychomotor Therapy 8-9 8.7.2.4 Psychoeducation 8-9 8.7.2.5 VIP 8-10 8.8 Therapeutic Course 8-10 8.8.1 Case 1 8-10 8.8.2 Case 2 8-10 8.9 Conclusion 8-11 8.10 References 8-13 Chapter 9 – MUPS in Military Setting: An Organisational Perspective 9-1 9.1 Introduction 9-1 9.2 Organisational Concerns 9-2 9.2.1 Health 9-2 9.2.2 Performance 9-3 9.3 Conclusion and Recommendations 9-5 9.4 References 9-5 Chapter 10 – Multi-Disciplinary Treatment of Persistent Symptoms 10-1 After Gulf War Service 10.1 Persistent Post-Deployment Physical Symptoms: The Need for Innovative 10-1 Health Care 10.2 Brief History of the Gulf War Health Center’s Specialized Care Program 10-3 10.3 The Gulf War Health Center’s Health Care Continuum 10-4 10.4 The Mission, Objectives, and Description of the Specialized Care Program 10-4 10.5 The Roles of Program Providers – The General Internist 10-7 10.5.1 The Health Psychologist 10-8 10.5.2