BMJ 2002;324:321 ( 9 February )

Papers

Post-combat syndromes from the Boer war to the Gulf war: a cluster analysis of their nature and attribution

Edgar Jones, reader, ^a Robert Hodgins-Vermaas, research assistant, ^a Helen McCartney, lecturer, ^b Brian Everitt, professor, ^c Charlotte Beech, research assistant, ^a Denise Poynter, research assistant, ^a Ian Palmer, professor, ^d Kenneth Hyams, chief consultant, ^e Simon Wessely, professor. ^a

^a Department of Psychological Medicine, Guy's, King's, and St Thomas's School of Medicine, London SE5 8AZ, ^b King's College London at the Joint Services Command and Staff College, Watchfield, ^c Institute of Psychiatry, London, ^d Royal Defence Medical College, Fort Blockhouse, Gosport, ^e Office of Public Health and Environmental Hazards, Department of Veterans Affairs, Washington DC, USA

Correspondence to: E Jones E.Jones{at}hogarth7.demon.co.uk

Objectives: To discover whether post-combat syndromes have existed after modern wars and what relation they bear to each other.
Design: Review of medical and military records of servicemen and cluster analysis of symptoms.
Data sources: Records for 1856 veterans randomly selected from war pension files awarded from 1872 and from the Medical Assessment Programme for Gulf war veterans.
Main outcome measures: Characteristic patterns of symptom clusters and their relation to dependent variables including war, diagnosis, predisposing physical illness, and exposure to combat; and servicemen's changing attributions for post-combat disorders.
Results: Three varieties of post-combat disorder were identifieda debility syndrome (associated with the 19th and early 20th centuries), somatic syndrome (related primarily to the first world war), and a neuropsychiatric syndrome (associated with the second world war and the Gulf conflict). The era in which the war occurred was overwhelmingly the best predictor of cluster membership.
Conclusions: All modern wars have been associated with a syndrome characterised by unexplained medical symptoms. The form that these assume, the terms used to describe them, and the explanations offered by servicemen and doctors seem to be influenced by advances in medical science, changes in the nature of warfare, and underlying cultural forces.

What is already known on this topic Service in the Gulf war is associated with an increased rate of reported symptoms and worsening subjective health Post-combat syndromes have been described after most modern conflicts from the US civil war onwards What this study adds There seems to be no single post-combat syndrome but a number of variations on a theme The ever changing form of post-combat syndromes seems to be related to advances in medical understanding, the developing nature of warfare, and cultural undercurrents Because reported symptoms are subject to bias and changing emphasis related to advances in medical science or the discovery of new diseases, the characterisation of individual syndromes has to be treated with caution Attributions by servicemen are generally consistent with symptom characteristics, though there seems to be a growing reluctance to consider the stress of military service as a cause

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