You are here

Chronic Multisymptom Illness S025

Last amended 
9 March 2020
Current RMA Instruments
Reasonable Hypothesis SOP3 of 2020
Balance of Probabilities SOP4 of 2020
Changes from previous Instruments

SOP Bulletin 213

Brief description

This SOP arose from an investigation into 'Gulf War syndrome'.  The RMA concluded that 'Gulf War syndrome' is not a particular disease or injury, but that there is an illness, that can be characterised as a disease for the purposes of SOPs, that can apply broadly to veterans of the Gulf War and also to anyone else with VEA or MRCA service.  That illness has been labelled by the RMA as chronic multisymptom illness, and defined as per the SOP definition.  Chronic multisymptom illness is not a condition that is well known or understood by the broader medical community and so is not well recognised as being a disease in the conventional sense.

The RMA definition corresponds with the working definition that was developed by the US Institute of Medicine, for the purposes of research and treatment evaluation, for chronic medically unexplained symptoms that are reported by Gulf War veterans, but that are also common in civilians and other groups of service personnel.

The symptom sets potentially covered by this condition come from the following list:- fatigue, feeling depressed, difficulty remembering or concentrating, feeling moody, feeling anxious, trouble finding words, difficulty sleeping, joint pain, joint stiffness and muscle pain.  The symptoms need to result in distress and significant disruption of functioning.  See the SOP definition for further details.  Similar symptom sets may occur in psychiatric disorders, brain pathology, terminal cancers, immunodeficiency disorders, cardiac disease, respiratory disease, blood disease, rheumatological disorders and chronic fatigue syndrome.

Confirming the diagnosis  

This diagnosis is complex.  For the diagnosis to be made, on the balance or probabilities, the symptoms should not be better explained by another disease or injury and the criteria in the RMA SOP definition need to be met.  One of the SOP definition requirements is that the diagnosis be made by a specialist physician or psychiatrist.

A business line is available that details the steps that should be taken to investigate claims. 

Additional diagnoses that may be covered by SOP

Gulf war syndrome – 'Gulf War syndrome' is not a disease or injury for the purposes of the VEA (or MRCA).  A claim for Gulf War syndrome should be rejected on that basis, but such a claim should also be investigated to see if there is any other diagnosis that may be made.  In that situation a diagnosis of chronic multisymptom illness may warrant investigation. 

Conditions not covered by SOP and that would generally not be compatible with a diagnosis of chronic multisymptom illness
  • Blood or haematological disorder
  • Cardiac pathology
  • Chronic fatigue syndrome
  • Chronic liver failure
  • Chronic renal failure
  • Conversion disorder (functional neurological symptom disorder) 
  • Dementia
  • Dysthymic disorder
  • Factitious disorder 
  • Fibromyalgia
  • Generalised anxiety disorder
  • Hypochondriasis
  • Illness anxiety disorder
  • Organic brain pathology
  • Other psychiatric disorders such as major depressive disorder which manifest with somatic symptoms. 
  • Other specified somatic symptom and related disorder 
  • Pain disorder with psychological factors
  • Pain disorder with psychological factors and a general medical condition
  • Respiratory pathology
  • Rheumatoid arthritis; Systemic lupus erythematosus; Ankylosing spondylitis; Psoriatic arthropathy
  • Sleep disorder - including obstructive sleep apnoea, narcolepsy
  • Somatic symptom disorder
  • Somatisation disorder
  • Systemic malignancy
  • Undifferentiated somatoform disorder
  • Unspecified somatic symptoms and related disorder
Clinical onset

The clinical onset will be when the required level of symptoms/features necessary to meet the diagnostic criteria were first fulfilled.  This may be some time after any symptoms first developed - i.e., if initially some symptoms were present, but they were insufficient in quantity or severity to meet the diagnostic criteria, then the condition had not had its clinical onset at that point.  The definition criteria require a minimum symptom duration of six months. Confirmation of the diagnosis can only occur once that duration requirement has been met, but the clinical onset can then be retrospectively assessed as being at the start of the period from when the required symptoms/features were first present.

Clinical worsening

The only SOP worsening factor is for inability to obtain appropriate clinical management.  There is a lack of evidence to support any particular treatment as being effective in modifying the course of the illness. Treatments options may include: use of serotonin reuptake inhibitors; cognitive behavioural therapy; and mindfulness-based stress therapy.