THE INSTITUTE OF MEDICINE AND NATIONAL RESEARCH COUNCIL REPORT PTSD COMPENSATION AND MILITARY SERVICE
FINDINGS REGARDING THE EVALUATION OF TRAUMATIC EXPOSURES AND MALINGERING IN VETERANS SEEKING PTSD OMPENSATION
Dean G. Kilpatrick, Ph.D.
Distinguished University Professor
Director, National Crime Victims Research and Treatment Center
Medical University of South Carolina
Member, Committee on Veterans’ Compensation for Posttraumatic Stress Disorder
Institute of Medicine and National Research Council
The National Academies
Committee on Veterans’ Affairs
Subcommittee on Disability Assistance and Memorial Affairs
U.S. House of Representatives
March 24, 2009
Good afternoon, Mr. Chairman, Mr. Ranking Member, and members of the Committee. My name is Dean Kilpatrick and I am Distinguished University Professor in the Department of Psychiatry and Behavioral Sciences and Director of the National Crime Victims Research and Treatment Center at the Medical University of South Carolina. Thank you for the opportunity to testify on behalf of the members of the Committee on Veterans’ Compensation for Posttraumatic Stress Disorder. This committee was convened under the auspices of the National Research Council and the Institute of Medicine of the National Academy of Sciences. Our committee’s work—which was conducted between March 2006 and July 2007—was requested by the Department of Veterans Affairs, which provided funding for the effort.
In June 2007, our committee completed its report, entitled PTSD Compensation and Military Service. I am pleased to be here today to share with you some of the content of that report, the knowledge I’ve gained as a clinical psychologist and researcher on traumatic stress, and my experience as someone who previously served as a clinician at the VA.
I will briefly address four issues in this testimony:
- the evaluation of traumatic exposures for VA compensation and pension purposes,
- the reliability and completeness of military records for evaluation of exposure to stressors,
- what studies say about malingering in the veterans population, and
- the means that mental health professionals use to detect malingering.
Evaluation of traumatic exposures for VA compensation and pension purposes
VA compensation and pension (C&P) examinations for PTSD consist of a review of medical history; evaluations of mental status and of social and occupational function; a diagnostic examination, which may include psychological testing; and an assessment of the exposure to traumatic events that occurred during military service.
To help focus the examination, the Veterans Benefits Administration (VBA) provides examiners with worksheets that set forth what an assessment should cover. These worksheets are designed to ensure that a rating specialist receives all the information necessary to rate a claim.
The PTSD worksheet provides guidance on the elements of a claimant’s military history that should be documented. These include Military Occupational Specialty (MOS), combat wounds sustained, citations or medals received, and a clear description of the “specific stressor event(s) the veteran considered to be particularly traumatic, particularly if the stressor is a type of personal assault, including sexual assault, [providing] information, with examples, if possible.” The worksheet notes:
…Service connection for post-traumatic stress disorder (PTSD) requires medical evidence establishing a diagnosis of the condition that conforms to the diagnostic criteria of DSM-IV, credible supporting evidence that the claimed in-service stressor actually occurred, and a link, established by medical evidence, between current symptomatology and the claimed in-service stressor. It is the responsibility of the examiner to indicate the traumatic stressor leading to PTSD, if he or she makes the diagnosis of PTSD.
A diagnosis of PTSD cannot be adequately documented or ruled out without obtaining a detailed military history and reviewing the claims folder. This means that initial review of the folder prior to examination, the history and examination itself, and the dictation for an examination initially establishing PTSD will often require more time than for examinations of other disorders. Ninety minutes to two hours on an initial exam is normal. (emphasis added)
A Best Practice Manual developed by VA practitioners also offers guidance on assessing trauma exposure, and recommends tests that can be administered to help elicit information. The Manual states that “[i]nitial PTSD compensation and pension evaluations typically require up to three hours to complete, but complex cases may demand additional time.” It estimates that 30 minutes of that time would be used for records review and an additional 20 minutes for orientation to the interview, review of the military history, and conduct of the trauma assessment.
Notwithstanding this guidance, 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—sometimes to as little as 20 minutes.
The reliability and completeness of military records for evaluation of exposure to stressors
VA’s statutory “duty to assist” includes helping veterans gather evidence to support their claims, including the provision of VA records and facilitation of requests for information from the Department of Defense (DoD) and other sources. Military personnel records—which document duty stations and assignments, MOS, citations, medals, and related administrative information—are valued in this regard because they are perceived as unbiased evidence that can corroborate or refute claimants’ accounts. One study reviewed by the committee found that less than half of treatment-seeking Vietnam veterans reporting combat involvement had objective evidence of combat exposure documented in their publicly available military personnel records. It concluded that a “meaningful” number of treatment-seekers “may be exaggerating or misrepresenting their involvement [and combat exposure] in Vietnam and, by inference, they attributed this to “the disability benefit incentive” and compensation-seeking.
However, this conclusion is not supported by other research that the committee examined, calling into question whether the information available in the military personnel files is always adequate to evaluate trauma exposure. The National Archives and Research Administration, the nation’s conservator of the military personnel records, offers the following caveat for users of these data: “Detailed information about the veteran’s participation in military battles and engagements is NOT contained in the record”. Studies indicate, instead, that broad-based research into other indicators of the likelihood of having experienced traumatic stressors has value. This may be especially important in cases of PTSD related to sexual assault. Available information suggests that female veterans are less likely to receive service connection for PTSD and that this is a consequence of the relative difficulty of substantiating exposure to noncombat traumatic stressors like military sexual assault.
The committee concluded that the most effective strategy for dealing with problems with self-reports of traumatic exposure is to ensure that a comprehensive, consistent, and rigorous process is used throughout the VA to verify veteran-reported evidence.
What studies say about malingering in the veterans population
The committee noted that assessment of malingering is a high stakes issue because it is as devastating to falsely accuse a veteran of malingering as it is unfair to other veterans to miss malingered cases. The most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) defines malingering as “the intentional production of false or grossly exaggerated physical or psychological symptoms motivated by external incentives . . . such as obtaining financial compensation”.
Combat veterans who are evaluated for PTSD frequently exhibit elevations across various assessment measures, including elevations on tests used to detect symptom overreporting. Concerns have thus been raised regarding the accuracy of veterans’ accounts of their psychological functioning, which in turn poses significant challenges for diagnostic assessment and treatment. While some research and commentary suggests that this pattern may reflect, at least in part, symptom overreporting by a subset of veterans who are motivated by possible receipt of financial compensation, access to treatment, and other incentives, the committee found that literature examining the relationship between compensation seeking and reported levels of psychopathology has in fact yielded mixed results.
The committee’s review of the literature concluded that, while misrepresentation of combat involvement and trauma exposure undoubtedly does happen among veterans seeking treatment and compensation for PTSD, the evidence currently available is insufficient to establish how prevalent such misrepresentations are and how much effect they have on the ultimate outcome of disability claims. Further, while some veterans do drop out of mental-health treatment once they obtain service-connected disability compensation for PTSD, the currently available data suggest that this concern may not apply to the majority of veterans who seek and obtain such awards. Although more research is needed, the committee concluded that the preponderance of evidence does not support the notion that receiving compensation for PTSD makes veterans less likely to make treatment gains or acknowledge improvement from treatment.
The means that mental health professionals use to detect malingering
Although there is a need for a reliable, valid way to detect malingering, experts agree that there is no magic bullet or gold standard for doing so. Several investigators have used scales from such tests as the Minnesota Multiphasic Personality Inventory (MMPI) and MMPI-2 to indirectly infer the possibility of malingering, and the Best Practice Manual notes that they are useful in identifying the test-taking style of veterans and in assessing service-connected PTSD status. However, these measures have clear limitations and should not be used as the sole basis for assessing whether a veteran is malingering with respect to PTSD status. The committee concluded that, in the absence of a definitive measure, the most effective way to detect inappropriate PTSD claims is to require a consistent and comprehensive state-of-the-art examination and assessment that allows the time to conduct appropriate testing in those specific circumstances where the examining clinician believes it would inform the assessment.
Our committee also reached a series of other findings and recommendations regarding the conduct of VA’s compensation and pension system for PTSD that are detailed in the body of our report. The National Academies previously provided the subcommittee with copies of this report and would happy to fulfill any additional requests for it.
Thank you for your attention. I’m happy to answer your questions.
Publications referenced in this testimony
American Psychiatric Association. 2000. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Washington DC: APA.
Frueh BC, Elhai JD, Grubaugh AL, Monnier J, Kashdan TB, Sauvageot JA, Hamner MB, Burkett BG, Arana GW. 2005. Documented combat exposure of U.S. veterans seeking treatment for combat-related post-traumatic stress disorder. British Journal of Psychiatry 186(6):467–472.
Institute of Medicine. 2007. PTSD Compensation and Military Service. Washington, DC: National Academies Press. [Online]. Available: http://www.nap.edu/catalog.php?record_id=11870 [accessed 20 March 2009].
U.S. National Archives and Records Administration. 2009. Military Service Records and Official Military Personnel Files. [Online]. Available: http://www.archives.gov/veterans/military-service-records/ [accessed 20 March 2009].
Watson P, McFall M, McBrine C, Schnurr PP, Friedman MJ, Keane T, Hamblen JL. 2002. Best Practice Manual for Posttraumatic Stress Disorder (PTSD) Compensation and Pension Examinations. [Online]. Available: http://www.avapl.org/pub/PTSD%20Manual%20final%206.pdf [accessed 20 March 2009].
An archived webcast and transcript of the hearing can be found on the House Veterans' Affairs Committee's Web site.