PTSD Update

Posted: March 28, 2012 in Uncategorized

There seems to be growing evidence supporting a suspicion that The Retired Enlisted Association (TREA) and some other veteran service organizations (VSOs) have been holding- that DoD has been using the diagnosis of a “personality disorder” to deny a member of the military benefits. “Personality disorder” is a preexisting condition according to the Pentagon. Members of the military discharged with this finding are not entitled to retirement or disability benefits. Since 2001 over 31,000 service members have been discharged due to “personality disorder.” The disorder results in inflexible badly adaptive behavior that may “impair performance and relationships.” Many organizations believe that the Pentagon has been using this diagnosis to get rid of those they think are troublemakers or to save money instead of diagnosing PTSD.
Recently an Army ombudsman wrote that a doctor at Madigan Army Hospital said that a PTSD diagnosis cost the government $1.5 million and that his colleagues should be good stewards of tax money. After this report came out 14 service members who had their PTSD diagnosis reversed were examined again- this time at the new Walter Reed National Military Medical Center in Bethesda, Md. Six were reinstated. Then on 28 FEB while testifying before the Senate Budget Committee Secretary of Defense was asked about the Madigan controversy by Senator Patty Murray (D-WA). The Secretary responded:” I was very concerned when I got the report about what happened at Madigan. I think it reflects the fact that frankly we have not learned how to effectively deal with that, and we have to. We need to make sure we have the psychiatrists, the psychologists, and the medical people who can make these evaluations because these are real problems" [Source: TREA News for the Enlisted 2 Mar 2012 ++]


Tacoma-area Army psychiatrists who made the final determination on soldiers’ post-traumatic stress disorder diagnoses at Madigan Army Medical Center had a stellar national reputation until they fell under scrutiny this year. They once identified false claims made by a soldier who lied about killing an innocent Iraqi girl in a ploy to gain a PTSD diagnosis, according to internal memos obtained by The News Tribune. It turned out the soldier had never deployed. They also were known to diagnose PTSD in soldiers who had been given clean bills of health from other clinicians – the opposite of what the forensic psychiatry team members are accused of doing now. “Quite frankly, they have an extensive track record for effectively diagnosing PTSD in hundreds if not thousands of active-duty military and Reserve personnel over the past several years without issue, and their success is unparalleled,” former Madigan commander retired Col. Jerome Penner told reporters. He led the hospital until March 2011.
In at least three separate investigations. The Army and elected leaders want to know whether the team adjusted behavioral health diagnoses for the right reasons, or whether it shortchanged service members who should get full PTSD benefits. Forensic psychiatrists at Walter Reed Military Medical Center in Maryland have overturned six Madigan diagnoses from last year, and the Army has invited more soldiers to come forward and seek new opinions. Washington Democrats Sen. Patty Murray and Rep. Norm Dicks want to know if the Madigan doctors limited PTSD diagnoses in a misguided effort to save money. Their fears are rooted in fall presentations by Madigan’s Dr. William Keppler in which he urged colleagues to be good stewards of taxpayer dollars. Keppler told them a single PTSD diagnosis could cost as much as $1.5 million over time. Careers are on the line. Madigan commander Col. Dallas Homas is on administrative leave. Keppler is barred from working with patients. Another forensic psychiatrist resigned, citing her concern that “all the investigations are a charade as the outcome has been predetermined.” I find that I can no longer work in a system that requires me to sacrifice my professional and moral principles to political expediency,” Dr. Juliana Ellis-Billingsley wrote 23 FEB.
Since the inquiries began, the Army has invited every soldier whose behavioral health diagnosis was changed at Madigan to get another review of their cases at Walter Reed. Madigan last year identified 17 soldiers who disagreed with their final diagnoses, according to multiple sources who spoke on condition of anonymity. They were invited in January to have their cases reviewed. Six had their PTSD diagnoses reinstated. Three opted not to take the Walter Reed review and eight had the Madigan results upheld. A Madigan source speaking on condition of anonymity because of the pending investigation said the forensic psychiatrists diagnosed 44 cases of PTSD among soldiers whose records initially indicated they were healthy during the same period in 2011 from which the 17 contested cases were pulled. Behavioral health diagnoses are important to former service members not only for their understanding of how they can seek treatment for war-related trauma, but also because they determine the level of disability benefits soldiers will receive for the rest of their lives. A PTSD diagnosis ensures soldiers will receive a lifetime disability rating of at least 50 percent. A veteran with no children rated as 50 percent disabled because of PTSD would receive about $800 a month, while a veteran with no children and a diagnosis of 100 percent disabled by PTSD would receive $3,000 a month, according to Department of Veterans Affairs benefit scales.
The Rand Corp. in 2008 estimated that about 20 percent of combat veterans would show signs of post-traumatic stress or major depression. About one in seven Iraq and Afghanistan veterans have sought treatment for PTSD at VA hospitals. Sen. Murray in an interview said she has discussed with Army Surgeon General Lt. Gen. Patricia Horoho whether the military could be diagnosing PTSD improperly. Murray is the chairwoman of the Senate Veterans Affairs Committee, and her views are shaped by experiences caring for Vietnam veterans at the Seattle VA. She has pressed for answers at Madigan, and last week she learned from Defense Secretary Leon Panetta that the Pentagon would conduct a broader review of how the military diagnoses PTSD. “I think it’s important to err on the side of the diagnosis that gives them the treatment they need,” Murray said. The Army has not yet said how many soldiers who passed through Madigan are challenging their diagnoses. Madigan in 2010 diagnosed 1,418 patients with PTSD, acute stress disorder and anxiety disorder – three common behavioral-health conditions that can be related to combat. Of the three, only PTSD is singled out for a guaranteed disability rating and accompanying pension. Over the past two years, the hospital diagnosed 1,699 soldiers with PTSD. So far, the public has been supportive of growing programs for PTSD and combat trauma. In January, the GAO reported the Defense Department spent $2.7 billion on PTSD and traumatic brain injury programs between 2007 and 2010. The report said the Pentagon had not explained clearly if these programs were successful or redundant.
The reviews at Walter Reed are done with service members face-to-face. It’s not clear if Madigan’s forensic psychiatrists always met soldiers in personal interviews. Horoho told a House subcommittee that the Madigan team sometimes made decisions “administratively” based on case files. Madigan sources said those cases were rare and tended to happen when clinicians from the Department of Veterans Affairs reached different conclusions from active-duty Army doctors. That can happen because retiring soldiers might begin the process of registering for VA benefits before they leave the service. Some Madigan doctors apparently were skeptical of the VA diagnoses, which were sometimes conducted by private contractors with less experience working with the military, according to one memo. In some cases, Madigan psychiatrists found candidates for medical retirements who lied about deployments or who posted information on social media web sites that contradicted what they told clinicians. Madigan forensic psychiatrists were expected to carry out personality tests to determine whether a patient was misleading a clinician. They were to interview patients and ensure that commanders had verified the soldier’s deployment history, according to a summaries of their standards.
One test used by the Madigan doctors was the Minnesota Personality Inventory, which helps psychologists assess whether someone is exaggerating or downplaying symptoms. In the civilian world, the test is often used in civil court cases in which plaintiffs seek financial damages for traumatic events. It’s used to a varying extent by the military and by the VA in assessing a service member’s disability. Forensic psychologist Steve Rubenzer in 2006 published a study in which he wrote that front-line clinicians often do not suspect that their patients have financial motives for seeking PTSD diagnoses. His study on malingering in personal injury cases was cited by Madigan doctors in memos they wrote to commanders after the Army surgeon general launched the latest investigations. “Clinicians may not know that a patient has (motivation to mislead a psychiatrist for financial gain), often do not suspect the possibility of malingering, and typically lack the training or tools to assess malingering even if they suspect it. Not surprisingly, they rarely find it.” Rubenzer wrote six years ago in a passage cited by a Madigan doctor.
Rubenzer said that common notions of PTSD have changed since the Vietnam War; many civilians expect most soldiers will be debilitated in combat, and that those experiences would prevent them from holding down steady work outside of the military. “Those are two huge leaps,” he said. Memos obtained by The News Tribune showed Madigan doctors were bristling at suggestions that they slanted their diagnoses to cut costs. “There has been no pressure by command to limit disability awards to soldiers, just a desire on the part of Madigan psychiatrists and psychologists to produce the most accurate description of soldiers current medical condition,” Madigan medical retirement board physician Dr. Paul Whittaker wrote in a Feb. 16 memo to commanders. Another doctor who once supervised Madigan’s psychiatry department felt his peers were being pilloried for doing the jobs they were asked to do by their commanders. “My perception is that they are getting punished in the media at a minimum for doing their best in making the right diagnosis,” former Madigan Chief of Psychiatry Col. Kris Peterson wrote Feb. 6. “It is dismaying.” [Source: The Olympian Adam Ashton | Posted 3 Mar 2012 ++]

  1. mdworthen says:

    Thank you for your thorough, balanced review of the Madigan Army psychiatrists situation.

    It’s so easy to jump to the conclusion that the forensic psychiatry team arbitrarily and cynically changed diagnoses out of a desire to “play God” and deny what they see as overly expensive compensation benefits.

    But, despite strident declarations from certain politicians, we really don’t have a clue yet about what actually happened. I suspect the answer is more complex than what the critics would have us believe. The forensic psychiatrists might have made some mistakes; treating clinicians might have made some mistakes; the Walter Reed psychiatrists might have made some mistakes; etc.

    A forensic evaluation of PTSD is not an easy task, even for experienced forensic psychiatrists and psychologists. There is no blood test for the disorder. It is easy to exaggerate or feign the symptoms–you can find the PTSD diagnostic criteria all over the Internet along with advice on how to present oneself for a PTSD examination, e.g., don’t shower or shave for a few days, stay up all night before the exam, wear old clothing.

    Probably even more important than feigning is the phenomenon of “false attribution” in which a service member or veteran who served in a combat role later develops anxiety and/or depressive symptoms. In an effort to understand why they have started to feel bad, they begin to wonder if their combat experiences might have caused their current psychological symptoms. With so much attention paid to PTSD in the media these days, it’s understandable that such a person might begin to consider such a connection. After all, they experienced some combat stress, possibly even experiences anyone would consider traumatic; they learn about PTSD and how the disorder is often caused by combat stress or trauma; they are currently experiencing symptoms that are right there on the PTSD diagnostic criteria lists, e.g., irritability, emotional detachment or numbing, insomnia; and so they begin to believe that they have PTSD when there might actually be no connection between their combat experiences and their current symptoms at all (there a dozens of things that can cause anxiety or depression, e.g., genetics, thyroid problems, marital stress, sleep disorders, unemployment, etc.).

    Thus, the service member or veteran falsely attributes their current psychological difficulties to their military experience and they become convinced they have PTSD. It is important to point out that this is a completely innocent process. The individual is *not* lying or even exaggerating. They have simply made a faulty causal connection between past experience and current symptoms–something that happens all the time with all sorts of folks (military and civilian) suffering from a wide variety of problems.

    Identifying “false attribution” cases is one of the challenging tasks the forensic psychiatrist must undertake when evaluating a service member who has claimed PTSD disability and is seeking compensation benefits.

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