Dizziness, Vertigo, and Mental Health Comorbidity in Gulf War Veterans

Abstract

Background:

Gulf War Illness (GWI) is a chronic condition involving symptoms across multiple body systems. Previous research has implicated the vestibular system as a potential underlying factor in the symptoms experienced by veterans with GWI, due in part to exposure to potentially ototoxic chemicals and events.

Purpose:

To characterize the presence of vertigo and dizziness symptoms in a sample of veterans with GWI using validated self-report instruments, accounting for mental health comorbidities.

Research Design:

This is a case series, follow-up, prospective interview of clinical veterans; results presented are purely descriptive.

Study Sample:

Our sample of 50 veterans was a follow-up to a case series of clinical Gulf War veterans evaluated at the War Related Illness and Injury Study Center.

Data Collection and Analysis:

Veterans participated in a 70-min phone interview where the following questionnaires were administered: Vertigo Symptom Scale (VSS), Patient Health Questionnaire (depression scale), Patient Health Questionnaire (somatization scale), Beck Anxiety Inventory, Posttraumatic Stress Disorder (PTSD) Checklist, Defense and Veterans Brain Injury Center Traumatic Brain Injury Questionnaire, and GWI (Kansas) Questionnaire. We used descriptive (mean/median, standard deviation, interquartile range, and percentage) statistics to describe our sample and illuminate possible relationships between measures.

Results:

Our primary finding is a substantial report of vertigo symptoms in our sample, according to the VSS. Ninety percent of participants scored above the VSS threshold (>12), suggesting “severe dizziness.” The most commonly endorsed symptom on the VSS was “headache or pressure in the head.”

Conclusions:

We conclude that there is significant burden of vertigo symptoms in veterans with GWI, suggesting a need for objective tests of vestibular function in this population. Furthermore, the relationship between symptoms of vertigo and dizziness, vestibular function, and PTSD warrants further exploration using objective measures.

Key Words

dizziness - Gulf War Illness - posttraumatic stress disorder - vertigo - veterans

This material is the result of work supported with resources and the use of facilities at the East Orange New Jersey VA medical facility.

The results of this paper have not been previously presented in any form.

The authors declare that the following work was conducted in the absence of any commercial or financial relationships that could be construed as potential conflict of interest.

The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.

• REFERENCES

• Balaban CD. 2002; Neural substrates linking balance control and anxiety. Physiol Behav 77: 469-475
• Beck AT, Steer RA. 1993. Beck Anxiety Inventory Manual. San Antonio, TX: Psychological Corporation;
• Bierer LM, Ivanov I, Carpenter DM, Wong EW, Golier JA, Tang CY, Yehuda R. 2015; White matter abnormalities in Gulf War veterans with posttraumatic stress disorder: a pilot study. Psychoneuroendocrinology 51: 567-576
• Black DW, Carney CP, Peloso PM, Woolson RF, Schwartz DA, Voelker MD, Barrett DH, Doebbeling BN. 2004; Gulf War veterans with anxiety: prevalence, comorbidity, and risk factors. Epidemiology 15: 135-142
• Blevins CA, Weathers FW, Davis MT, Witte TK, Domino JL. 2015; The posttraumatic stress disorder checklist for DSM-5 (PCL-5): development and initial psychometric evaluation. J Trauma Stress 28: 489-498
• Dhingra SS, Kroenke K, Zack MM, Strine TW, Balluz LS. 2011; PHQ-8 days: a measurement option for DSM-5 major depressive disorder (MDD) severity. Popul Health Metr 9: 11
• Dretsch MN, Williams K, Emmerich T, Crynen G, Ait-Ghezala G, Chaytow H, Mathura V, Crawford FC, Iverson GL. 2016; Brain-derived neurotropic factor polymorphisms, traumatic stress, mild traumatic brain injury, and combat exposure contribute to postdeployment traumatic stress. Brain Behav 6: e00392
• Fiedler N, Kipen H, Natelson B, Ottenweller J. 1996; Chemical sensitivities and the Gulf War: Department of Veterans Affairs Research Center in basic and clinical science studies of environmental hazards. Regul Toxicol Pharmacol 24: S129-S138
• Fife TD, Kalra D. 2015; Persistent vertigo and dizziness after mild traumatic brain injury. Ann N Y Acad Sci 1343: 97-105
• Fong E, Li C, Aslakson R, Agrawal Y. 2015; Systematic review of patient-reported outcome measures in clinical vestibular research. Arch Phys Med Rehabil 96: 357-365
• Fox A, Helmer D, Tseng C, Patrick-DeLuca L, Osinubi OY. 2017; Report of autonomic symptoms in a clinical sample of veterans with Gulf War illness. Mil Med 183: e179-e785
• Fukuda K, Nisenbaum R, Stewart G, Thompson WW, Robin L, Washko RM, Noah DL, Barrett DH, Randall B, Herwaldt BL, Mawle AC, Reeves WC. 1998; Chronic multisymptom illness affecting air force veterans of the Gulf War. J Am Med Assoc 280: 981-988
• Gwini SM, Forbes AB, Sim MR, Kelsall HL. 2016; Multisymptom illness in Gulf War veterans: a systematic review and meta-analysis. J Occup Environ Med 58: 659-667
• Harricharan S, Nicholson AA, Densmore M, Theberge J, McKinnon MC, Neufeld RWJ, Lanius RA. 2017; Sensory overload and imbalance: resting-state vestibular connectivity in PTSD and its dissociative subtype. Neuropsychologia 106: 169-178
• Herdman SJ, Hall CD, Delaune W. 2012; Variables associated with outcome in patients with unilateral vestibular hypofunction. Neurorehabil Neural Repair 26: 151-62
• Hinz A, Ernst J, Glaesmer H, Brahler E, Rauscher FG, Petrowski K, Kocalevent RD. 2017; Frequency of somatic symptoms in the general population: normative values for the patient health questionnaire-15 (PHQ-15). J Psychosom Res 96: 27-31
• Hsu PC, Cheng PW, Young YH. 2015; Ototoxicity from organic solvents assessed by an inner ear test battery. J Vestib Res 25: 177-183
• Julian LJ. 2011; Measures of anxiety: state-trait anxiety inventory (STAI), beck anxiety inventory (BAI), and hospital anxiety and depression scale-anxiety (HADS-A). Arthritis Care Res 63 (11) (Suppl) S467-S472
• Kahraman SS, Arli C, Copoglu US, Kokacya MH, Colak S. 2017; The evaluation of anxiety and panic agarophobia scores in patients with benign paroxysmal positional vertigo on initial presentation and at the follow-up visit. Acta Otolaryngol 137: 485-489
• Kroenke K, Spitzer RL, Williams JB. 2002; The PHQ-15: validity of a new measure for evaluating the severity of somatic symptoms. Psychosom Med 64: 258-266
• Lincoln A, Helmer DA, Schneiderman A, Li M, Copeland HL, Prisco M, Wallin M, Kang HK, Natelson B. 2006; The war-related illness and injury study centers: a resource for deployment-related health concerns. Mil Med 171: 577
• Littlefield PD, Pinto RL, Burrows HL, Brungart DS. 2016; The vestibular effects of repeated low-level blasts. J Neurotrauma 33: 71-81
• McAndrew LM, Phillips LA, Helmer DA, Maestro K, Engel CC, Greenberg LM, Anastasides N, Quigley KS. 2017; High healthcare utilization near the onset of medically unexplained symptoms. J Psychosom Res 98: 98-105
• McKenzie DP, Sim MR, Clarke DM, Forbes AB, Ikin JF, Kelsall HL. 2015; Developing a brief depression screen and identifying associations with comorbid physical and psychological illness in Australian Gulf War veterans. J Psychosom Res 79: 566-573
• Pacella ML, Hruska B, Delahanty DL. 2013; The physical health consequences of PTSD and PTSD symptoms: a meta-analytic review. J Anxiety Disord 27: 33-46
• Radziej K, Schmid G, Dinkel A, Zwergal A, Lahmann C. 2015; Psychological traumatization and adverse life events in patients with organic and functional vestibular symptoms. J Psychosom Res 79: 123-129
• Roland PS, Haley RW, Yellin W, Owens K, Shoup AG. 2000; Vestibular dysfunction in Gulf War syndrome. Otolaryngol Head Neck Surg 122: 319-329
• Schwab KA, Ivins B, Cramer G, Johnson W, Sluss-Tiller M, Kiley K, Lux W, Warden D. 2007; Screening for traumatic brain injury in troops returning from deployment in Afghanistan and Iraq: initial investigation of the usefulness of a short screening tool for traumatic brain injury. J Head Trauma Rehabil 22: 377-389
• Steele L. 2000; Prevalence and patterns of Gulf War illness in Kansas veterans: association of symptoms with characteristics of person, place, and time of military service. Am J Epidemiol 152: 992-1002
• Steele L, Lockridge O, Gerkovich MM, Cook MR, Sastre A. 2015; Butyrylcholinesterase genotype and enzyme activity in relation to Gulf War illness: preliminary evidence of gene-exposure interaction from a case-control study of 1991 Gulf War veterans. Environ Health 14: 4
• Storzbach D, Campbell KA, Binder LM, McCauley L, Anger WK, Rohlman DS, Kovera CA. 2000; Psychological differences between veterans with and without Gulf War unexplained symptoms. Portland environmental hazards research center. Psychosom Med 62: 726-735
• Tigno Jr. TA, Armonda RA, Bell RS, Severson 3rd MA. 2017; The vestibulocochlear bases for wartime posttraumatic stress disorder manifestations. Med Hypotheses 106: 44-56
• Weidt S, Bruehl AB, Straumann D, Hegemann SC, Krautstrunk G, Rufer M. 2014; Health-related quality of life and emotional distress in patients with dizziness: a cross- sectional approach to disentangle their relationship. BMC Health Serv Res 14: 317
• Yardley L, Masson E, Verschuur C, Haacke N, Luxon L. 1992; Symptoms, anxiety and handicap in dizzy patients: development of the vertigo symptom scale. J Psychosom Res 36: 731-741
• Yee MK, Janulewicz PA, Seichepine DR, Sullivan KA, Proctor SP, Krengel MH. 2017; Multiple mild traumatic brain injuries are associated with increased rates of health symptoms and Gulf War illness in a cohort of 1990–1991 Gulf War veterans. Brain Sci 7: E79