Sunday, September 10, 2006
Post Traumatic Stress Disorder (PTSD) and Treatment
Author: Tom Berger
Article:Distinguished members of the Subcommittee on PTSD of the GulfWar & Stress: Health Project, Vietnam Veterans of America (VVA)thanks you for the opportunity to present for the record ourviews on the current state of clinical diagnoses and thedisability compensation claims process as accorded our nation'sveterans suffering from PTSD.
* First, Vietnam Veterans of America applauds this Committee forits obvious concern about the mental health care of our troopsand veterans.
VVA cautions, however, that providing the appropriate PTSDclinical diagnoses and services to assist these women and menrequires both an understanding of the stresses and stressors towhich they have been exposed and the willingness to commit thefinancial and personnel resources necessary to help theseveterans cope and perhaps eventually recover. Evidenceoverwhelmingly supports the need for early intervention andtreatment of PTSD and related mental health disorders not onlyfor active duty troops and veterans but for their families aswell. We must accept that only through early intervention andtreatment can we hope for the recovery of our troops andveterans from the mental health diseases caused by the trauma ofwar.
But as Dr. William Winkenwerder, Assistant Secretary of Defensefor Health Affairs observed in his testimony before the HouseSubcommittee on Military Personnel in October 2005, "no one whogoes to war remains unchanged." There is no longer any doubtthat the combat experiences of veterans can and often do causemental health injuries that can be just as debilitating asphysical wounds. If left untreated, post-traumatic stressdisorder and other psychological traumas can affect combatveterans to the point that, over time, even their dailyfunctions become seriously impaired. This places them at higherrisk for self-medication and abuse with alcohol and drugs,domestic violence, unemployment & underemployment, homelessness,incarceration, suicide, and even medical morbidities such ascardiovascular diseases and cancer (1).No one really knows how many of our troops in Iraq andAfghanistan have been or will be affected by their wartimeexperiences; despite the early intervention by psychologicalpersonnel,
no one really knows how serious their emotional andmental problems will become. However, recent reports havesuggested that troops returning from service in Afghanistan andIraq are suffering mental health problems at a rate higher thanthe levels seen in Vietnam War veterans (2, 3, and 4). In fact,VVA has no reason to believe that the rate of veterans of thiswar having their lives significantly disrupted at some point intheir lifetime by PTSD will be any less than the 37 percentestimated for Vietnam veterans by the National Vietnam VeteransReadjustment Study (NVVRS) conducted some 20 years ago.
Since 1980, when the American Psychiatric Association (APA)added PTSD to the third edition of its "Diagnostic andStatistical Manual of Mental Disorders (DSM-III)" classification scheme, a great deal of attention has been devoted to thedevelopment of instruments for assessing PTSD [see Keane et al.,(5)], as well as to psychotherapy and pharmacotherapy PTSDtreatment modalities [see Foa et al., (6) and the NationalCenter for PTSD's Fact Sheets (7)]. Under intense pressure fromVietnam veterans and their Congressional supporters, theDepartment of Veterans Affairs subsequently developed a uniquerange of mental health diagnoses and care services to assistveterans with managing or even overcoming the most troubling ofthe symptoms associated with PTSD, and the VA disability,compensation, pension, and benefits system was amended toprovide appropriate financial redress for the debilitatingeffects of PTSD or other mental health disability compensationclaims related to military service. But the adjudication of PTSDclaims continues to be a complex, constantly evolving exercise affected by regulations, legislation, and the latest medical research.
Often the VA orders a compensation examination by a VA clinicianor contractor to establish proof of a service-connected PTSDdisability. However, by the outset of the "Global War onTerrorism", Congressional investigations and G.A.O. reportsnoted that the VA was experiencing a chronic and growing claimsback log which it has had little success in reducing.
Because of reductions in staff at both the Veterans BenefitsAdministration (VBA) and the Veterans Health Administration(VHA) -- mental health staff in particular -- and other keyorganizational capacities in general since 1996, too manyclinicians and adjudicators (mis)-placed an emphasis onproductivity rather than quality or accuracy and believed thatthey must see clients quickly, even if their examinations didnot yield accurate clinical data or the correct information uponwhich to adjudicate the claim. Veterans' complaints of 15-minuteor 30-minute examinations that were by the very nature of theprocess grossly inadequate to the point of being malfeasant(with strong pressure to continue these unconscionablepractices) became commonplace. Many incorrect diagnoses haveundoubtedly occurred as a result.
Subsequent VA attempts to address the problem led to significantvariations in disability ratings by region and adjudicators forPTSD-related claims and other mental health disorders. Althoughpost-traumatic stress disorder is a commonly compensatedcondition (i.e., awarded PTSD claims constitute about half ofall awarded claims and about a quarter million veterans arecurrently compensated), it is important to note that PTSD is NOTthe most variably rated disability; there are other disabilitiesfor which ratings differ far more drastically, infectiousdiseases, for example. But this misconception has led toextravagant claims by some that the majority of PTSD-relatedclaims are fraudulent and that a "secret underground networkadvises veterans where to go for the best chance of beingdeclared disabled."
In any case, by 2002 the Department of Veterans Affairs hadprepared a "Best Practice Manual for Posttraumatic StressDisorder (PTSD) Compensation and Pension Examinations" (8)containing scientifically validated assessment instruments forthe diagnostic evaluation of PTSD and guidelines for thedetermination of a service-connected disability for PTSD. Infact, several of the distinguished scientists who co-authoredthis Best Practice Manual sit before us today.
Members of this Subcommittee, however, might be astonished todiscover that by February 2006, the VA not only has issued nodirectives to clinicians and to adjudicators to use the Manual,nor provided any training on this guide, but that even copies ofit are not available to staff throughout the VA, nor to anyoneelse for that matter. VVA has good reason to believe that thereare thousands of hard copies of the Best Practices Manualsitting in a warehouse somewhere, printed with tax dollars fromyou and me, that they refuse to make available.
With that said, VVA offers the following comments specific tothe mental health clinical diagnostic practices currently beingoffered our nation's veterans seeking rightful disabilitycompensation claims for their PTSD suffering --
* VA Central Office must formally direct the distribution anduse of its "Best Practice Manual for Posttraumatic StressDisorder" throughout the VA healthcare system.
The Best Practice Manual includes the following statement onpage 6: "The VHA encourages use of this protocol when examiningveterans for compensation purposes to ensure that a detailedhistory is obtained from the veteran and a comprehensiveevaluation is performed and documented".
An unhurried, scientifically validated diagnostic assessmentmechanism utilizing current DSM-IV checklists must be uniformlyapplied to obtain the correct type of clinical data necessary toprovide accurate PTSD diagnoses. The Best Practice Manualcontains not only a standardized assessment protocol, but alsoincludes appropriately validated diagnostic and psychometricassessment tools and a recommended initial examination time ofat least three hours to perform the series of psychologicalevaluations needed to best decide and rate the claim, along witha 90-minute follow-up examination. And according to the Manual,assessment for PTSD must also include the client's militaryhistory.
* The VA must also provide the resources for appropriate,in-depth training for the VA mental health clinicians, staff andadjudicators to properly and effectively implement the Manual'sprotocol and guidelines.
Training in the use of the "Best Practice Manual" is, in theparlance of today's world, a "no brainer." But adequate trainingis also necessary for looking for, identifying, and assessingPTSD clients within the framework of their particularwar-related trauma and to ensure sensitivity using non-invasivemethods of inquiry, such as motivational interviewing. Inaddition, a staff that is thoroughly knowledgeable with theManual will become familiar with both asking appropriatequestions and recognizing physiological symptoms that may betterassist in accurate diagnoses and effective evaluations.
* The VA mental health leadership in cooperation with theVeterans Benefits Administration must change the way PTSD and other disability claims are adjudicated.
In addition to increasing the number of adjudicators (as well asproviding much better training, competency based testing, andmuch better supervision), VVA proposes a pilot project in whichthe most experienced adjudicators at a VARO "triage" incomingclaims, rather than simply handling them by docket number.Relatively simple claims can then be fast-tracked; there is noreason why a veteran who files a claim along with theappropriate paperwork for, say, tinnitus, cannot be adjudicatedwithin 60 days. Claims that need additional documentation can bereturned to the veteran or the veteran's service officer.Difficult or complicated cases can be routed to the mostexperienced adjudicators. Because the adjudication of PTSDclaims historically seems to have resulted in significantdisparities in adjudication decisions, these might be sent to aspecial group of adjudicators well-trained and well-versed inthe VA's Best Practices Manual. VVA believes this proposedchange can improve productivity as well as morale in both the VAand VBA systems and be welcomed by the veterans community.
* The VA should develop and launch an internal mental healthanti-stigma campaign that focuses on PTSD.
The stigma associated with seeking help for PTSD will notdecrease without a system wide campaign to change perceptionsand attitudes among staff and leadership. Educational programsfor VA mental health staff, veterans and their families shouldbe strongly encouraged, and the programs should present symptomsand descriptions of combat-related PTSD and other mental healthproblems, publicize available resources, encourage veterans tocome forward, and guarantee that seeking assistance for PTSDwithin the VA system will not be held against the individual.
About the author:Tom Berger is a writer for The VVA Veteran, the official voiceof Vietnam Veterans of America, Inc. � An organization charteredby the U.S. Congress. Learn more at www.vva.org
Post Traumatic Stress Disorder (PTSD) and Treatment