OBSERVATIONS ON POSTTRAUMATIC STRESS DISORDER AND MILITARY SERVICE
John A. Fairbank, Ph.D.
Associate Professor of Medical Psychology,
Co-Director of the UCLA–Duke University National Center for Child Traumatic Stress
Duke University Medical Center
Member, Committee on Veterans’ Compensation for Posttraumatic Stress Disorder
Institute of Medicine and National Research Council
The National Academies
Committee on Oversight and Government Reform
U.S. House of Representatives
May 24, 2007
Good morning, Mr. Chairman and members of the Committee. My name is John Fairbank and I am Associate Professor of Medical Psychology in the Department of Psychiatry and Behavioral Sciences at Duke University Medical Center and Co-Director of the National Center for Child Traumatic Stress. I want to thank you for the opportunity to testify on behalf of the members of the Committee on Veterans’ Compensation for Posttraumatic Stress Disorder. The committee was convened under the auspices of the National Research Council and the Institute of Medicine. These institutions are operating arms of the National Academy of Sciences, which was chartered by Congress in 1863 to advise the government on matters of science and technology. The work of the committee was requested by the Department of Veterans Affairs (VA), which provided funding for the effort.
Our committee recently completed a report entitled PTSD Compensation and Military Service that addresses topics under discussion in this hearing. I’m pleased to be here today to present a few of the conclusions of that report and to share with you some observations drawn from my experience as a VA psychologist and as a researcher on PTSD and veterans’ health.
I’d like to begin with some background information on posttraumatic stress disorder. PTSD, in brief, is a psychiatric disorder that can develop in a person who experiences, witnesses, or is confronted with a traumatic event, often one that is life-threatening. It is characterized by a cluster of symptoms that include:
• reexperiencing—specifically, intrusive recollections of a traumatic event, often through flashbacks or nightmares;
• avoidance or numbing—efforts to avoid anything associated with the trauma and a general numbing of emotions; and
• hyperarousal—often manifested by difficulty in sleeping and concentrating and by irritability.
PTSD is one of an interrelated and overlapping set of possible mental health responses to combat exposures and other traumas encountered in military service. While the term “posttraumatic stress disorder” has only been part of the lexicon since the 1980’s, the symptoms associated with it have been reported for centuries. In the U.S., expressions including shell shock, combat fatigue, and gross stress reaction have been used to label what is now called PTSD.
I was asked to address whether there has been adequate preparation for the men and women returning home from Operation Iraqi Freedom and Operation Enduring Freedom (OIF/OEF). Our committee’s report makes several recommendations relevant to this question. Specifically, the committee’s review of the scientific literature and VA’s current compensation and pension practices identified areas where changes might result in more consistent and accurate ratings for disability associated with PTSD.
There are two primary steps in the disability compensation process for veterans. The first of these is a compensation and pension, or C&P, examination. These examinations are conducted by VA clinicians or outside professionals who meet certain education and licensing requirements. Testimony presented to the committee indicated that clinicians often feel pressured to severely constrain the time that they devote to conducting a PTSD C&P examination—to as little as 20 minutes—even though the best practice manual for the exams specifies a protocol that can take three hours or more to properly complete. The committee believes that the key to proper administration of VA’s PTSD compensation program is a thorough C&P clinical examination conducted by an experienced mental health professional. Many of the problems and issues with the current process can be addressed by consistently allocating and applying the time and resources needed for a thorough examination. The committee recommended that a system-wide training program be implemented for the clinicians who conduct these exams in order to promote uniform and consistent evaluations.
The second primary step in the compensation process for veterans is a rating of the level of disability associated with service-connected disorders identified in the clinical examination. This rating is performed by a VA employee using the information gathered in the C&P exam. The committee’s review of these VA ratings practices found that the criteria used to evaluate the level of disability resulting from service-connected PTSD were, at best, crude and overly general. It recommended that new criteria be developed and applied that specifically address PTSD symptoms and that are firmly grounded in the standards set out in the Diagnostic and Statistical Manual of Mental Disorders used by mental health professionals. As part of this effort, the committee suggested that VA take a broader and more comprehensive view of what constitutes PTSD disability. In the current scheme, occupational impairment drives the determination of the rating level.
Under the committee’s suggested framework, the psychosocial and occupational aspects of functional impairment would be separately evaluated, and the claimant would be rated on the dimension on which he or she is more affected. The committee believes that the emphasis on occupational impairment in the current criteria unduly penalizes veterans who may be capable of working, but who are significantly symptomatic or impaired in other dimensions, and it may thus serve as a disincentive to both work and recovery.
Determining ratings for mental disabilities in general and for PTSD specifically is more difficult than for many other disorders because of the inherently subjective nature of symptom reporting. In order to promote more accurate, consistent, and uniform PTSD disability ratings, the committee recommended that VA establish a certification program for raters who deal with PTSD claims, with the training to support it, as well as periodic recertification. The committee believes that rater certification will foster greater confidence in ratings decisions and in the decision-making process.
Earlier in my career, I was a co-principal investigator for the National Vietnam Veterans Readjustment Study—the NVVRS—and served as a VA staff psychologist, working primarily with Vietnam War combat veterans. I was asked to comment on what the lessons of Vietnam tell us about today and how my experience provides perspective on this issue. I’d like to make clear at the outset that the committee’s report did not directly address this topic and that these are my own observations.
Nearly 25 years ago, in response to unanswered questions about Vietnam veterans’ postwar adjustment, the Congress enacted Public Law 98-160, which in part directed the VA to arrange for an independent, scientific study of the adjustment of Vietnam veterans. The intent of the study was to provide an empirical basis for the formulation of policy related to veterans’ psychosocial health, especially PTSD. Findings from the National Vietnam Veterans Readjustment Study were first presented to Congress in 1988. Because of its important scientific strengths—including the comprehensive assessment of its subjects using psychological tests with well-established psychometric properties—NVVRS findings have been an important part of the empirical foundation of federal policy related to war veterans.
In the NVVRS paper entitled “Problems in the Families of Male Vietnam Veterans with Posttraumatic Stress Disorder”, published in the Journal of Consulting and Clinical Psychology in 1992, my colleagues and I reported that families of veterans with PTSD were more likely to suffer domestic violence than the families of veterans without PTSD. In addition, the study found that children of the veterans with PTSD manifested significantly higher levels of behavioral and emotional problems than children of veterans without PTSD, and that more than one third of veterans with PTSD had a child with behavioral or emotional problems.
In my opinion, this NVVRS finding of multiple severe problems in the families of veterans with PTSD—made 15 years after the end of the Vietnam War—has important implications for today’s service men and women returning from OIF/OEF. Specifically, our Vietnam-era findings suggest that a significant number of current members of our Armed Forces will need access to effective treatments for war-related PTSD and its co-morbid conditions; similarly, their spouses and children will need access to trauma-informed treatments and services. A hard lesson learned from our nation’s response to Vietnam veterans is that we do not want to delay doing our best to prevent war-related PTSD from wreaking havoc on the futures of our OIF/OEF veterans and their families.
As a psychologist at the VA Medical Center in Jackson, Mississippi from 1979 to 1987, I had the good fortune to work with and learn from scores of Vietnam veterans receiving psychological services for PTSD and other mental health problems. An enduring—and distressing—memory of working with these veterans was trying to help them and their spouses process and recover from the shock, disappointment, anger and sense of betrayal that so often accompanied denial of benefits or compensation for the psychological and emotional toll that war-zone stress had taken on their lives in the form of PTSD. More often than not, a profound sense of unfairness lay at the heart of their reactions. The PTSD C&P evaluation and disability ratings process has improved considerably since the late 1980s, but, as the PTSD Compensation and Military Service report suggests, much more may be done to enhance confidence in PTSD compensation ratings decisions and ultimately to improve this process for veterans returning from combat and for their families.
Thank you for your attention. I will be happy to answer your questions.