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Tuesday, January 16, 2007

Personality Disorder -- Or Combat PTSD?

A recent post on the fact that 22,000 OEF/OIF troops have been discharged with personality disorder -- the same diagnosis given to Steven Green, the soldier charged with raping an Iraqi girl and then killing her and her family in Al Mahmudiyah -- stimulated quite a bit of interest. One of the questions raised: Are troops being given personality discharges in place of a diagnosis of combat-related PTSD?

Click on 'Article Link' below tags for more...

First a bit more on the Green case via Newsweek:

Green's case has helped to spur a closer look at the Army's standards for recruitment and training. Green enlisted and passed basic training at a time when the Army was under terrific pressure to bring in new soldiers and had relaxed its entry requirements. In 2005, about the time Green was accepted, the Army raised the limit on the so-called Category 4 recruits it would allow, the designation for soldiers with the lowest scores on its aptitude test. (Green's score is not known.) The Army has also been handing out more waivers—including case-by-case exceptions for criminal offenses—which increased by 3 percent last year. Basic training has slipped as well. In years past, basic was geared to "wash out" those unfit for the stresses of military life. Now it has been reformulated to keep as many recruits as possible. "What you're seeing is the reverse of what made the Army so effective," says Sen. Jack Reed of the Armed Services Committee. ...

The most recent washout numbers show a dramatic decline in standards: currently only 7.6 percent of new recruits fail to get through their first six months of service, down from 18.1 percent in May 2005, according to the latest Army figures. "That's a heck of a drop," says Leo Daugherty, the Army's command historian at Fort Knox. "The young man who got in [Green] should never have gotten in the Army. He slipped through the system." The Army says it has adapted basic training to lessons learned in Iraq and Afghanistan, and helps soldiers to improve their weaknesses. "We will get rid of those individuals who have no business being a soldier," says Col. Kevin Shwedo, director of operations, plans and training for Army Accessions Command. "We're not going to quit on a soldier when they're trainable. That's a big difference."

How about quitting on soldiers who do not appear to have had serious behavioral problems prior to enlistment but are now suffering from combat PTSD following their deployment to a war zone? Does the military stick with them?

From the Austin American-Statesman:

Soldiers suffering from the stress of combat in Iraq are being misdiagnosed by military doctors as having a personality disorder, lawyers and psychologists say, which allows them to be quickly and honorably discharged but stigmatizes them with a label that is hard to dislodge and can hurt them financially.

Though accurate for some, experts say, the personality disorder label has been used as a catch-all diagnosis to discharge personnel who may no longer meet military standards, are engaging in problematic behavior or suffer from more serious mental disorders. For returning veterans, the diagnosis can make it harder to obtain adequate mental health treatment if they must first show they have another problem, such as post-traumatic stress disorder. "It's an absolute disgrace to military medicine," said Bridgette Wilson, a former Army medic who is now an attorney in San Diego serving mainly military clients. "I see it over and over again, the dramatic misuse of personality disorder diagnosis. It's a fairly slick and efficient way to move some bodies through."

And stories coming out of Fort Carson, Colo., are far from comforting:

A government worker at Fort Carson in Colorado who has access to personnel records and who spoke on condition on anonymity for fear of losing his job said Army psychologists there have diagnosed some soldiers with a personality disorder after a single evaluation lasting 10 minutes to 20 minutes. Several soldiers at Fort Carson interviewed by Cox Newspapers said they have been given or offered the diagnosis in a handful of meetings lasting less than an hour.

The personality disorder diagnosis can result in a soldier getting an honorable discharge within days, which can be appealing for many returning from Iraq. The timing of many of the discharges, in some cases within months after soldiers have returned, appears to violate the military's rules, which say a personality disorder diagnosis should not be made if a soldier is experiencing "combat exhaustion or other acute situational maladjustments."

Personality Disorder is defined as "a deeply ingrained, abnormal behavior pattern that appears during childhood or adolescence." While a combat-related diagnosis for PTSD requires the military to invest in the continuing care of the veteran, a diagnosis of Personality Disorder does not.

A review of four soldiers' medical records at Fort Carson and records from a soldier at another post show that they were diagnosed with post-traumatic stress disorder before or after their discharge.Recommending a discharge on the basis of a personality disorder is a faster process than discharging someone for mental health problems of another nature. It requires only one military psychologist's finding, and the paperwork usually takes only a couple of days.

A diagnosis of post-traumatic stress disorder, on the other hand, must be handled by a medical review board, which must confirm that the condition stems from combat, a process that usually takes several months.

Dr. Joseph Bobrow, a former chief psychologist at Kaiser Hospital in San Francisco, said a personality disorder is one of the most difficult diagnoses to confirm, particularly when there is cumulative trauma. "I think it's ludicrous to make a diagnosis of personality disorder in a 20- to 40-minute interview," he said. "Even if you do a complete battery of psychological testing and intensive and informed clinical interviews over a week, some of those results can be and are contested in a court of law."

Some of the soldiers at Fort Carson say they had been told by Army psychologists that the Department of Veterans Affairs would take care of them if their troubles persisted. A personality disorder, however, is considered a pre-existing condition, not one related to a soldier's service, and Veterans Affairs can treat but not give disability benefits in these cases.

Many soldiers who sought mental health counseling after returning from Iraq, like former Spc. Donald Schmidt of Chillicothe, Ill., say they learned only after their discharge that they must repay part of their re-enlistment bonus based on the portion of time they did not serve — more than $10,000 in Schmidt's case.

Getting a Personality Disorder discharge also may make finding employment more difficult as employers examine the veteran's records and learn of behavioral problems noted on discharge papers.
In her 13 years in practice, San Diego attorney Wilson said she has seen dozens of Marines from nearby Camp Pendleton and soldiers from other posts separated for a personality disorder when the real reason, in her view, has been to punish a soldier, avoid paying disability benefits for a more serious condition or get rid of someone deemed undesirable.

Though some of her clients have personality disorders, she said, most who received the diagnosis and discharge had minor behavioral problems or were diagnosed with bipolar disorder or severe depression by either military or civilian psychologists. About three-quarters of her clients who have been diagnosed with a personality disorder, she said, weren't given any psychological test. Rather, she said, the diagnosis was based on a roughly 45-minute interview.

One troubling case:

For nearly a year after his return from Iraq in August 2005, former Pvt. Jason Harvey had gone without any follow-up evaluations at Fort Carson after screening positive for possible post-traumatic stress disorder and a traumatic brain injury, his records show.

After a suicide attempt in May, records show that the 23-year-old was diagnosed with depression and post-traumatic stress disorder, but in late June the Army tried to discharge him with a personality disorder. Harvey said he was told by a staff psychologist in a joint meeting with his commander that if he did not agree to an honorable discharge, the commander would pursue a punitive discharge. "They played me like a fiddle," Harvey said, adding he was wrongly told the medical retirement fell under the same category as post-traumatic stress disorder. In fact, it is a nonmedical discharge.

Also at Fort Carson, after two tours in Iraq, Schmidt, 22, told a psychologist he was feeling violent impulses as a result of marital difficulties. The decorated soldier is on guard constantly and "quick to anger" when he had not been that way before, said his mother, Patrice Semtner-Myers. Schmidt said his Army psychologist, Dr. Michael Pantaleo, made the diagnosis after several meetings lasting between 15 and 30 minutes each and never asked him questions about his behavior before joining the Army. Pantaleo did not return calls seeking comment.

Schmidt was discharged "without a dime in his pocket," his mother said. "The soldiers are often too stupid to know what they've done" when they accept the disorder or seek it, Wilson said. "They go out and discover the state police department really isn't interested in someone discharged with a personality disorder or find they have trouble getting security clearances."

Some military psychologists appear to be violating guidelines in the Diagnostic and Statistical Manual of Mental Disorders, the psychiatric manual used by the military. If a soldier complains of mental problems after returning from combat, a personality disorder is supposed to be ruled out for an unspecified amount of time because some of its characteristics, such as problems interacting with others and substance abuse, overlap with some of the hallmarks of post-traumatic stress disorder.

The Pentagon "is not familiar with the rules, or they are choosing to ignore them," said Paul Sullivan, director of programs for Veterans for America, a Washington-based nonprofit.

Every branch deals with these types of discharges differently:

Determination of personality disorder

Medical guidelines for each service:

Army: Requires a psychologist's findings.

Navy: Vague language; not clear that determination must come from a mental health professional or command.

Marines: Similar to Army rules but two forms of documents required. Same doctor must render findings on a Marine's impairment and on written nonmedical evidence to show examples of inability to function in the corps.

Air Force: Alone in requiring oversight where commanders fail to act on appropriate findings. Commander must have decision reviewed by discharge authority.

This is an issue that clearly deserves a closer look.


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