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United States. Congress. House. Committee on Veter.

Viewpoints on Veterans Affairs and related issues : hearing before the Subcommittee on Oversight and Investigations of the Committee on Veterans' Affairs, House of Representatives, One Hundred Third Congress, second session, May 4, 1994 online

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Online LibraryUnited States. Congress. House. Committee on VeterViewpoints on Veterans Affairs and related issues : hearing before the Subcommittee on Oversight and Investigations of the Committee on Veterans' Affairs, House of Representatives, One Hundred Third Congress, second session, May 4, 1994 → online text (page 8 of 23)
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developed the following:

• CHLORACNE — an acne-like
eruption of comedones, cysts,
and pustules that usually in-
volves the malar area of the face.
It may appear on any area of the
body except the palms of the
hands and the soles of the feet.
When such eruptions occur in
the groin or the eyelids, chlor-
acne is the likely diagnosis.' His-
tologically, chloracne is far dif-
ferent from acne vulgaris.
Hallmarks of chloracne are:

• acanthosis

• absence of the sebaceous
glands in the dermis

• paucity of inflammatory cells

• squamous metaplasia of the
pilosebaceous glands

• phrynoderma (hyperkeratosis
of the hair follicles)



• hyperpigmentation and hy-
pertrichosis (usually in the
temporal areas of the face and
the dorsum of the fingers)'
NEURASTHENIA — a syn-
drome of generalized fatigue,
headaches, insomnia, irritabil-
ity, sleep disturbances, and loss
of initiative. A latency period of
several months to years may oc-
cur with this svndrome.
PERIPHERAL NEUROPATHY
— characterized by numbness
and weakness in the toes and
fingers with decreased- nerve
conduction velocity."
HEPATIC DYSFUNCTION —
characterized by hypertrophy of
the endoplasmic reticulum.
PORPHYRINURIA AND POR-
PHYRIA CUTANEA TARDA —
A cascading sequence of pro-
gressive porphyrinuria in ex-
posed individuals beginning
with asymptomatic copropor-
phyrinuria and progressing to
porphryria cutanea tarda (in-
creased uroporphyrin) has been
described. Usually uroporphy-
rins are increased due to the in-
duction of delta aminolevulinic
acid synthetase which catalyzes
and converts glycine and suc-
cinyl CoA to form delta amino-
levulinic acid."

HYPERTRIGLYCERIDEMIA —
resulting from induction of car-
bamyl acid phosphatase and in-
hibition of lipoprotein lipase. '



and iiii.k
B.) .Skin ol pitlj.

lypii-nl f;/l.'i'i
C) Cr



Mh/.,



D.J Cr




65



It is very important that the health
care professionai secure a detailed
medical histon,' and perform a thor-
ough physical examination.

• History should include compre-
hensive occupational, social and
family components.

• Entire skin surface should be in-
spected for lesions.

• Peripheral neuropathy should be
tested for using a tuning fork
(128CPSI. Vibratory sensation
may be the earliest loss in a pe-
ripheral neuropathy.

• Temperature sensation, pro-
prioception and sensitivity to
light pain (pin prick) in both up-
per and lower extremities
should be determined.

• The following tests should be
considered if clinically indi-
cated:

• Hepatic — SGPT, SCOT, alka-
line phosphatase, total biliru-
bin, 5'nucleotidase, and
gamma glutamyl transferase.
Hepatitis A antibody. Hepati-



tis B core and surface antigen
and antibody should be done
if SGPT/OT and bili are abnor-
mal.

• Neurological — EEC sleep
and waking with nasopharyn-
geal leads, EMG with nerve
conduction velocities of the
upper and lower extremities
and somatsensory evoked po-
tentials of the upper and
lower extremities.

• Hematological — CBC, quan-
titative immunoglobulins
with T-cell function.

• Rheumatological — sed rate,
ANA. anti-DNA, Rheumatoid
facto, VDRL.

• 24-hour urine for copropor-
phyrin. uroporphyrin, inter-
mediate porphyrin, porpho-
bilinogen, and delta
aminolevulinic acid.

• Stool specimen for ova and
parasites, total eosinophil
count.



EVALUATION

OF PATIENTS

EXPOSED TO DIOXIN



TREATMENT



TREATMENT

Treatment is still largely focused on
an amelioration of symptoms. Cur-
rently, investigation centers around
the efficacy of certain vitamins along
with special diets, plasmapheresis,
and the administration of the bile salt
binders (such as cholestyramine) to
rid the body of dioxin. " These tech-
niques, although interesting, have not
been scientifically validated.

Vitamin A. administered topically
and systemically. has been used along
with dermabrasion to treat stubborn
chloracne. The condition generally is
resistant to the usual anti-acne regi-
men of tetracycline and ultraviolet
light. The anti-acne drug Accutane
(isotretinoin), a vitamin A derivative,
may be efficacious in treating chlor-
acne but more testing is needed.

To assure proper guidance and fol-



low up in treatment of neurasthenia,
appropriate therapy should be per-
formed by mental health professionals
familiar with the entity, but especially
with the special problems of the Viet-
nam veterans.

In evaluating and treating these vet-
erans, it must be emphasized that
many of the diagnostic procedures de-
scribed are costly and many insurance
carriers will not cover the cost of diag-
nostic tests or treatment for injuries
and illnesses resulting from war expe-
rience. However, a recent court deci-
sion may prove beneficial to many
Vietnam veterans in the treatment of
tliese service-related conditions.

On May 8, 1989, a California federal
judge, Thelton E. Henderson, ruled
that the Veterans Administration has
imposed "an impermissibly demand-



66








CONTINUING RESEARCH



ing test" on veterans seeking assis-
tance in the treatment of ailments re-
sulting from the defoliant. Agent Or-
ange. In his ruling. Judge Henderson
directed the government to reexamine
the issue and "to reurite the regula-
tions governing claims for disability
compensation to those who claim they
have developed medical problems due
to their exposure to Agent Orange in
Vietnam." On May 11 , the U.S. Depart-
ment of Veteran Affairs announced
that they would not appeal Judge
Henderson's decisions and revised
regulations would be published as soon
as possible for review and comment. '-'
The Nehmer Decision, along with
other legislation (specifically The
Agent Orange Act of 1991). provided
TREATMENT (continued) that Soft Tissue Sarcoma be recog-
nized for compensation. This inclu-
sion was added to existing regulations
for Non Hodgkin's Lymphoma and
Chloracne.

The U.S. Department of Veterans
PSYCHOLOGICAL Affairs has also decided to award pre-

PROBLEMS sumptive compensation to veterans

CONTINUING RESEARCH

Animal studies on the toxicity of
dioxin (TCDD) have involved mon-
keys, rats. mice, rabbits, hamsters,
and guinea pigs. These animal studies
confirm that TCDD is a very toxic sub-
stance. In fact, it was printed in a 1986
article in SCIENCE that TCDD was
"one of the most toxic man-made
compounds known." ' However, sus-
ceptibility or sensitivity to dioxin var-
ies considerably from one species to
another For example, relatively small
doses cause death, cancer, and birth
defects in guinea pigs. Yet. in ham-
sters, TCDD is only slightly toxic. Hu-
mans, however, are not subjected to
controlled experiments and the extent
to which dioxin is toxic to humans is a
matter of significant controversy.

No immediate human deaths from



with Peripheral Neuropathy. There are
two limitations with this: (1) the vet-
eran cannot have been exposed to an-
other chemical substance known to
cause the condition and (2) confound-
ing factors (things that may themselves
have caused peripheral neuropathy,
such as age and whether the veteran is
a diabetic alcoholic or suffers from
Gullian-Barre syndrome) will be taken
into account.

Vietnam veterans also have an op-
portunity to become claimants in a
separate legal action that was filed and
settled out of court in 1984. There is a
payment program for veterans that have
diseases associated with exposure to
Agent Orange. A survivor benefit is
also available if a veteran died as a
result of diseases associated with ex-
posure. The payment program can be
contacted via telephone at 1-800-225-
4712. The address is:

The Agent Orange

Veteran Payment Program

P.O. Box lio

Hartford, CT 06104



TCDD exposure have been reported
following industrial accidents.
Follow-up studies of exposed people
have been contradictory in their find-
ings on the contribution of dioxins to
mortality and morbidity in humans.
For example, studies done by the
American Medical Association, the
Centers for Disease Control (CDC), the
Veterans Administration and others
did not find conclusive evidence that
dioxin was a carcinogen or teratogen
in humans. There is some evidence
that dioxin exposure depresses immu-
nity and can result in cancer'"'

These studies and other conflicting
reports render it impossible to provide
a definitive scientific analysis of the
effects of Agent Orange on humans.



PSYCHOLOGICAL PROBLEMS

It has long been understood that ser-
vice in a war-zone carries both psy-
chological and physical risks. The in-
cidence of war wounds following
service in a war-zone has been well
documented. In the past, diagnoses
such as shell shock, battle fatigue, and
traumatic neurosis have been used for



the continuing psychological and
emotional damage following trau-
matic war-zone experiences. Follow-
ing the Vietnam conflict, such reac-
tions were labeled post-Vietnam
syndrome and delayed stress reaction.
Today the appropriate. (Jiagnosis for
the enduring psycHological sequelae



67



of traumatic war-zone experiences is
post-traumatic stress disorder (PTSD).

The recently completed National
Vietnam Veterans Readjustment Study
(NVVRS) was a four-year. $10 million
Congressionally-mandated effort
which studied the readjustment of
comparable groups of male and female
Vietnam veterans. non-Vietnam vet-
erans (served elsewhere during the
same period) and civilians. The study
concludes that the majority of Viet-
nam veterans have successfully re-
entered civilian life with few psycho-
logical problems. A significant
minority, however, continue to expe-
rience psychological problems.

Approximately 829.000 of 3.1 mil-
lion Vietnam veterans currently ex-
hibit clinically-significant stress reac-
tion symptoms which may warrant
professional attention. Among male
Vietnam veterans, 15%. or 479.000.
meet the current diagnostic criteria for
PTSD. while another 11%. or
350.000. suffer from some PTSD
symptomatology. Among female \'iet-



nam veterans. 8,5%. or 610 of the
7.200 women who served in South-
east Asia, currently have diagnosable
PTSD. while another 8%. or 560. suf-
fer from some PTSD symptomatology.
These rates are dramatically higher
than those found in the non-Vietnam
veterans and civilians. The lifetime
prevalence of PTSD in Vietnam vet-
erans is estimated at 31% for males
and 27% for females.

Those most likely to develop PTSD
are veterans who experienced the war-
zone trauma. Of these. Hispanic and
black veterans are more likely to have
mental health and life adjustment
problems. A particularly tragic find-
ing was that the occurrence of PTSD
had a significant negative impact on
the spouses, children, and others liv-
ing with the veteran. Finally, the
study found that many Vietnam vet-
erans suffering from PTSD have never
used or have discontined using men-
tal health services."



PSYCHOLOGICAL
PROBLEMS (contin ued)

POST-TRAUMATIC
STRESS DISORDER



I
I



POST-TRAUMATIC STRESS DISORDER



Poor readjustment following trau-
matization can indicate the presence
of a variety of psychological condi-
tions. The most severe nonpsychotic
condition resulting from traumatiza-
tion is post-traumatic stress disorder
(PTSD). PTSD is classified in the
American Psychiatric Association's
DIAGNOSTIC AND STATISTICAL
MANUAL OF MENTAL DISORDERS
(DSM-III) as an anxiety disorder in
which "the essential feature is the de-
velopment of characteristic symptoms
following a psychologically traumatic
event that is generally outside the
range of human experience." "

The components of PTSD are
mostly subjective complaints voiced
by the patient or his family. Objective
findings are minimal and the diagno-
sis becomes clear only through accu-



rate history taking. It is important for
the physician to interview close fam-
ily members because the patient char-
acteristically is an inept scrutinizer of
his or her own feelings and behavior.
PTSD is characterized by: '

• A recognized, definitive stress
evoking incident such as a
bombing, an explosion, battle or
incarceration under inhumane
conditions. The incident would
evoke significant symptoms of
distress in almost anyone.

• Recurrent experiencing of this
event as evidenced by at least
one of the following;

• Recurrent and intrusive recol-
lections of the event.

• Recurrent dreams of the
event.

• Sudden acting or feeling as if



68



POST-TRAUMATIC
STRESS DISORDER
(continued)

PTSD - PHYSICAL
SYMPTOMS

DIFFERENTIAL

DIAGNOSIS

AND COMORBIDITY



the traumatic event were re-
curring.

• Intense psychological distress
at exposure to events that sym-
bolize or resemble an aspect of
the event.

• Persistent avoidance of stimuli
associated v\/ith the trauma or
numbing of general responsive-
ness (not present before the
trauma), as indicated by at least
three of the following:

• Efforts to avoid thoughts or
feelings associated with the
trauma.

• Efforts to avoid activities or
situations that arouse recol-
lections of the trauma.

• Inability to recall an impor-
tant aspect of the trauma
(psychogenic amnesia).

• Markedly diminished interest
in significant activities.

• Feeling of detachment or es-
trangement from others.

• Restricted range of affect, e.g.
unable to have loving feelings.

PTSD - PHYSICAL SYMPTOMS

Although PTSD is classified as a
psychological disorder, recent studies
indicate a link between PTSD and cer-
tain physical health problems.

Studies conducted at the VA Medi-
cal Center in Menlo Park, California,
and at the Olin E. Teague Veterans'
Center in Temple, Texas, showed that
the majority of veterans diagnosed as
suffering from PTSD also had identi-
fied medical problems. ' Among the
most serious illnesses discovered in
PTSD patients were:

• The entire range of hypertensive
cardiovascular disease.

• Gastrointestinal disorders - in-
cluding esophageal pain and re-
gurgitation, stomach pain, ul-



• Sense of a foreshortened fu-
ture,

• Persistent symptoms of increased
arousal (not previously present),
as indicated by at least two of the
following;

• Difficulty falling or staying
asleep.

• Irritability or outbursts of an-
ger.

• Difficulty concentrating.

• Hyper vigilance.

• Exaggerated startle response,

• Physiologic reactivity upon
exposure to events that sym-
bolize or resemble an aspect of
the traumatic event,

• Duration of the disturbance
symptoms of at least one month.

Many Vietnam veterans are also bur-
dened by tremendous guilt about some
aspect of their service. At this point,
they are experiencing either a chronic
type of PTSD or the delayed onset
variety where the symptoms develop
after a symptom-free period which can
last years,™



cers, dumping syndrome, and a
wide range of digestive prob-
lems. In addition, there may be
problems with constipation, di-
arrhea and rectal bleeding.
• Musculoskeletal disorders.
Since the manifestation of physical
ailments becomes apparent long be-
fore the associated psychological
symptoms of PTSD are severe, it is the
primary care physician who plays a
vital role in the early diagnosis of
PTSD. Once diagnosed, the primary
care physician and mental health spe-
cialist can work together to attack the
physical symptoms and associated
psychological problems.



DIFFERENTIAL DIAGNOSIS AND COMORBIDITY

The accurate differential diagnosis experiences and current symptomatol-

of war-related PTSD can be difficult ogy. In fact, he may resist the idea that

for a number of reasons. today's suffering had its genesis 20

First, the veteran does not always years ago. Many times the connection

make a connection between war-zone is made only after significant amounts



69



of psychotherapy.

Second, the veteran may not be an
accurate reporter of his past and cur-
rent problems. Denial and or distor-
tion may take place. Many times oth-
ers who live with the veteran can
augment self-reported facts and help
clarify the history and symptom pic-
ture.

Third, many of the symptoms en-
countered in PTSD are not unique to
the disorder and are suggestive of
other illnesses such as depression and
generalized anxiety disorder or panic
disorder. This overlap of symptoms,
bow-ever, should not obscure the fun-
damental biological and psychologi-



cal difference which exist between
these conditions. "

Finally, there is a high rate of com-
orbidity between PTSD and condi-
tions such as major depressive epi-
sodes and other anxiety disorders.
Psychoactive substance use disorders,
most commonly alcohol abuse and de-
pendence, is commonly associated
with PTSD. The NVVRS found a
strong relationship between PTSD and
the likelihood of having other psycho-
logical disorders. Numerous other
studies have also documented the
high degree of comorbidity found in
cases of PTSD.



RELATED PSYCHOLOGICAL DISORDERS



• DEPRESSION— Depression fre-
quentlv accompanies other symptoms
in PTSD and often meets the DSM-III
criteria for depressive disorder. Most
researchers find symptoms of depres-
sion periodically in a variety of post-
traumatic stress disorders. Usually,
the depression is not severe enough to
be diagnosed as primary depression or
major depressive disorder, and it is ac-
companied by anxiety. Symptoms in-
clude feeling sad or blue, being exces-
sively worried or fatigued, feeling
tense, being lonely, having trouble
concentrating, lacking interest in sex-
ual activity and sometimes having sui-
cidal ideation.'

• ANXIETY' — The relationship of
PTSD to other anxiety disorders is not
fully clarified. Both "anxiety" and
"panic" reactions are reported in
PTSD. Several studies report con-
scious fear associated with PTSD and
it is becoming increasingly common
to see studies with significant percent-
ages of patients with PTSD who expe-



rience panic attacks and agoraphobia
with panic attacks. Both objective and
subjective symptoms are associated
with the anxiety state. The individual
may experience a variety of physical
symptoms such as headache, dizzi-
ness, gastrointestinal distress, chest
discomfort, nausea, tremulousness.
and palpitations. The behavioral con-
comitants would include restlessness,
nocturnal dyspnea, irritability, fa-
tigue, insomnia, and distractibility."

• ALCOHOL AND OTHER DRUG
ABUSE — Substance abuse is com-
monly encountered in treating PTSD.
Alcohol and other drugs are used to
reduce anxiety. Over time, the origi-
nal trauma of combat, masked by
chemical use. becomes buried under
layers of subsequent trauma that occur
to heavy alcohol or other drug users -
loss of a spouse, children, friends and/
or a job. Both conditions - PTSD and
substance abuse - must be treated.



DIFFERENTIAL
DIAGNOSIS I
AND COMORBIDITY
(continued) {

RELATED I
PSYCHOLOGICAL
DISORDERS



70



TREATMENT OF
WAR-RELATED STRESS

CONDITIONS

INFECTIOUS DISEASES
PREVALENT IN
SOUTHEAST ASIA



The NVVRS found that Vietnam vet-
erans with PTSD have used physical
and mental health services more than
their non-Vietnam and civilian coun-
terparts. Most of these services have
been provided outside the Veterans
Administration health care system. If
the possibility of war-related PTSD ex-
ists, the best course is referral to men-
tal health professionals who are expe-
rienced in the diagnosis and treatment
of PTSD.

Unfortunately, many mental health
professionals either do not accept the
validity of this diagnosis or are not
skillful in making it. Therefore, refer-
rals should be carefully negotiated to
avoid such individuals. Mental health
professionals in Veterans Administra-
tion facilities should be considered
first. If this is not feasible or if the vet-
eran resists, then other professionals
with PTSD experience should be uti-
lized.

In the case of PTSD. accurate differ-
ential diagnosis is critical because of
the treatment implications, A diagno-
sis of PTSD indicates the need for fo-
cal treatment. The use of experienced
clinicians, therefore, is the course
most likely to result in a definitive di-
agnosis and the formulation of an
effective treatment plan. The occur-



rence of substance abuse or depen-
dence requires that both conditions be
treated either simultaneously or se-
quentially.

Treatment of choice for PTSD is
psychotherapy."' This may be pro-
vided in individual, family or group
sessions by any qualified mental
health professional. Psychotherapy
provides the opportunity to psycho-
logically work through the conflicts
and meanings from traumatic war-
zone experiences and to more fully in-
tegrate these into the veteran's psy-
chological makeup.

For some veterans, pharmacother-
apy is a useful adjunct to the psycho-
logical treatments. Relief from dis-
tressing anxiety and depressive
symptoms can facilitate some vet-
erans' abilities to participate effec-
tively in psychotherapy when their
conditions would otherwise prohibit
it. Medication alone, however, is
never sufficient to alleviate the suffer-
ing found in PTSD " Any medication
must be closely monitored because of
the increased potential for substance
abuse or the possibility of inhibitory
effects on psychotherapy. At this
point, there are no published reports
of controlled studies on the use of
medication in the treatment of PTSD.



INFECTIOUS DISEASES PREVALENT IN SOUTHEAST ASIA



when evaluating patients who
served in Vietnam, it is important to
have some understanding of infec-
tious diseases prevalent in Southeast
Asia. The most common are melioido-
sis, tuberculosis, malaria, and intesti-
nal parasites.
• MELIOIDOSIS — caused by
pseudomonas pseudomallei, an
organism found in the waters
and soil of Southeast Asia. Infec-
tion occurs by inhalation, inges-
tion, or contamination of open
wounds. Melioidosis may
present itself as an acute or



chronic form of pulmonary, sup-
purative, or septicemic disease.

The pulmonary form is most
commonly encountered. It
presents itself as a lower respira-
tory tract infection or mimics tu-
berculosis. Possible symptoms
include fever, productive cough,
weight loss, pleural pain and he-
moptysis. A chest radiograph
frequently reveals upper lobe
nodular infiltrates and a thin-
walled cavity."

The disease may also present
as an acute systemic infection



71



having abrupt onset and fulmi-
nating course. The organism
produces disseminated ab-
scesses following septicemic ep-
isodes, with symptoms depend-
ing on the major site of
involvement. Specifically, the
patient may develop pneumo-
nia, arthritis, hepatitis, menin-
gitis, encephalitis, or osteomy-
elitis. Chest radiographs
commonly show irregular nodu-
lar densities. Abscess may de-
velop in the skin, brain, lung,
myocardium, liver, spleen,
lymph nodes, or the prostate."

Chronic melioidosis recurs as
a necrotizing pneumonia or sys-
tem abscess usually associated
with splenomegaly. Recrudes-
cence has been noted as much as
25 years after exposure.

Host factors may play impor-
tant roles in the reactivation of
the disease. Alcoholic binges,
cirrhosis, burns, malignancy,
trauma, carcinoma, diabetic ke-
toacidosis, or intercurrent ill-
ness which compromises a
host's immune system have
been associated with recrudes-
cence.'

The organism is resistant to
many commonly employed anti-
biotics, but may respond to
chloramphenicol, tetracycline,
rifampin, or trimethoprim-sulfa-
methoxazole. Drugs have been
given in combination for sepsis,
but single drugs have been used
for isolated pulmonary disease.
Third-generation cephalospo-
rins, especially ceftazidime,
may be effective, but experience
with these drugs is limited.

Activation of a latent me-
lioidosis condition should be
considered in any Vietnam vet-
eran presenting with a fever of
undetermined origin. Hemag-
glutination and complement fix-



ation titres are effective in estab-
lishing the diagnosis. Titres of
greater than one to forty suggest-
ing recent or previous infection
have been reported in three to
nine percent of Vietnam vet-
erans."

TUBERCULOSIS — a common
infection in Southeast Asia. Ac-
cording to the Centers for Dis-
ease Control (CDC|, 41 to 50 per-
cent of Indo-Chinese refugees
have positive skin tests for tu-
berculosis with active tuberculo-
sis diagnosed in one to two per-
cent of the cases. Among active
cases, 25 percent of isolates are
resistant to isoniazide. 22 per-
cent to streptomycin, and tfiree


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Online LibraryUnited States. Congress. House. Committee on VeterViewpoints on Veterans Affairs and related issues : hearing before the Subcommittee on Oversight and Investigations of the Committee on Veterans' Affairs, House of Representatives, One Hundred Third Congress, second session, May 4, 1994 → online text (page 8 of 23)
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