AP: Raising Traumatic Stress Malingering, VA Disability Claim Fraud Fears

Here we go again. Fears of PTSD malingering and VA claim fraud bobbed to the surface this weekend in a piece by Allen G. Breed, AP:

Moved by a huge tide of troops returning from Iraq and Afghanistan with post-traumatic stress, Congress has pressured the Department of Veterans Affairs to settle their disability claims — quickly, humanely, and mostly in the vets' favor.

The problem: The system is dysfunctional, an open invitation to fraud. And the VA has proposed changes that could make deception even easier.

PTSD's real but invisible scars can mark clerks and cooks just as easily as they can infantrymen fighting a faceless enemy in these wars without front lines. The VA is seeking to ease the burden of proof to ensure that their claims are processed swiftly.

But at the same time, some undeserving vets have learned how to game the system, profitably working the levers of sympathy for the wounded and obligation to the troops, and exploiting the sheer difficulty of nailing a surefire diagnosis of a condition that is notoriously hard to define.

"The threshold has been lowered. The question is how many people will take advantage of that," said Dr. Dan G. Blazer, a Duke University psychiatrist who has worked with the military on PTSD issues. PTSD, he adds, is "among the easiest (psychiatric) conditions to feign."

Mark Rogers, a longtime claims specialist with the Veterans Benefits Administration, agrees. "I could get 100 percent disability compensation for PTSD for any (honorably discharged) veteran who's willing to lie," said Rogers, a Vietnam-era vet who is now retired. "I just tell him what to say and where to go."

The only problem with this, of course, are the reams of past years' studies showing quite the opposite. Two that come immediately to mind:

• In 2007, Navy Times reported: "In 2001, 10 percent of soldiers going through the medical retirement process received permanent disability benefits. In 2005, with two wars raging, that percentage dropped to 3 percent, according to the Government Accountability Office. Reservists dropped from 16 percent to 5 percent."
  
  
• Also in 2007, US News & World Report found the military to be downgrading disability ratings, reporting: "Since 2000, 92.7 percent of the disability ratings handed out by PEBs have been 20 percent or lower... Moreover, fewer veterans have received ratings of 30 percent or more since America went to war in Afghanistan and Iraq... As of 2006, for example, 87,000 disabled retirees were on the list of those exceeding the 30 percent threshold; in 2000, there were 102,000 recipients."

Then again, maybe PTSD diagnoses shouldn't be taken seriously.

Breed, in a companion AP piece getting a bit less buzz but championing the same cause, reports "the fact that, as a constellation of self-reported symptoms, PTSD is very subjective."

Apparently, biological changes in the brain aren't objective, either.

Everyone agrees that each case of malingering or fraud should be penalized and stopped, no matter if that claim is being filed with the VA or a civilian's private insurance company. Unfortunately, this AP piece appears to do more to spread distrust and blame the veteran than anything else. Not surprisingly, the push-back has begun.

Reaction to DoD Decision Against Awarding Purple Heart to Veterans with Combat PTSD

This week's news that the Purple Heart will not be considered for those coping with the psychological wounds of war has gotten a reaction from many quarters. The military decoration is awarded for "being wounded or killed in any action against an enemy of the United States or as a result of an act of any such enemy or opposing armed forces."

Through August 2008, 2,743 OEF and 33,923 OIF veterans have received the distinguished medal (of ~1.7 million given out since its modern inception in 1932; more Purple Heart history), which brings with it "enhanced benefits, including exemptions from co-payments for veterans hospital and outpatient care and gives them higher priority in scheduling appointments."

In extended, a selection of some of the debate on the matter. These are lengthy and multiple pieces, but are quite enlightening to read through if you have the time. The issue touches upon a slew of concerns dealing with our positions on tradition, progress, science, psychology, honor, equity -- all well worth examining.

Female Iraq Vet Faces Life in Prison for Frontline Self-Inflicted Gunshot Wound

Another stunner from the Washington Post:

In a nondescript conference room at Walter Reed Army Medical Center, 1st Lt. Elizabeth Whiteside listened last week as an Army prosecutor outlined the criminal case against her. The charges: attempting suicide and endangering the life of another soldier while serving in Iraq.

Her hands trembled as Maj. Stefan Wolfe, the prosecutor, argued that Whiteside, now a psychiatric outpatient at Walter Reed, should be court-martialed. After seven years of exemplary service, the Army reservist faces the possibility of life in prison if she is tried and convicted.

Military psychiatrists at Walter Reed who examined Whiteside, 25, after she recovered from her self-inflicted gun wound diagnosed her with a severe mental disorder, possibly triggered by the stresses of a war zone. But Whiteside's superiors considered her mental illness "an excuse" for criminal conduct, according to documents obtained by The Washington Post.

At the hearing, Wolfe, who had warned Whiteside's lawyer of the risk of using a "psychobabble" defense, pressed a senior psychiatrist at Walter Reed to justify his diagnosis.

"I'm not here to play legal games," Col. George Brandt, chief of Behavioral Health Services in Walter Reed's Department of Psychiatry, responded angrily, according to a recording of the hearing. "I am here out of the genuine concern for a human being that's breaking and that is broken. She has a severe and significant illness. Let's treat her as a human being, for Christ's sake!"

As Combat PTSD Stigma Ebbs, Funding Fight and Political Disillusionment Flow

Today's New York Daily News quotes two highly-decorated veterans appointed to the House Veterans Disability Benefits Commission.

They've spent over two years studying the problems of the Veterans Administration health care system. In discussing their 113 recommendations (released earlier in the month), comments by one of its distinguished members, retired Marine Maj. Gen. James Livingston, brought to focus how far we've come in our work to destigmatize combat PTSD:

They were an unlikely bunch of soldiers to be making the case for the "talking cure" before Congress last week. They once dismissed it as a copout for shirkers and wimps.

"Absolutely, we've gone through a transition" over the years, said retired Marine Maj. Gen. James Livingston, who wears the Medal of Honor from Vietnam. "Now I'm a believer in early intervention" by therapists in the treatment of post-traumatic stress disorder, the diagnosis for what was called battle fatigue or shell shock in wars gone by, Livingston said.

While we've made great inroads (especially considering that a rough, tough guy like Livingston has come full-circle in his attitude towards the psychological wounds of war), the truth is that our changed attitudes are worthless if we don't follow up with the proper response.

PTSD Statistics, WWII to Iraq

See also the comprehensive The War List: OEF/OIF Statistics.

Jack Epstein and Johnny Miller of the San Francisco Chronicle have done a great job of compiling statistics for shell shock, battle fatigue, and today's posttraumatic stress disorder from wars waged from WWII to Iraq.

Click on 'Article Link' below tags for a sample of Iraq stats...

[One note: A few stats are already outdated since this article's publication in June of 2005. Currently, according to the VA, 20,638 OEF/OIF troops have been diagnosed with PTSD.]

From the San Francisco Chronicle:

-- According to a 2005 VA study of 168,528 Iraqi veterans, 20 percent were diagnosed with psychological disorders, including 1,641 with PTSD.

-- In an earlier VA study this year, almost 12,500 of nearly 245,000 veterans visited VA counseling centers for readjustment problems and symptoms of PTSD.

-- The Marines and Army were nearly four times more likely to report PTSD than Navy or Air Force because of their greater exposure to combat situations.

-- Enlisted men were twice as likely as officers to report PTSD.

-- 8 percent to 10 percent of active-duty women and retired military women who served in Iraq suffer from PTSD.

-- Studies show that U.S. women serving in Iraq suffer from more pronounced and debilitating forms of PTSD than their male counterparts.

-- A Defense Department study of combat troops returning from Iraq found 1 in 6 soldiers and Marines acknowledged symptoms of severe depression and PTSD, and 6 in 10 of these same veterans were unlikely to seek help out of fear their commanders and fellow troops would treat them differently.

-- A 2003 study published in the New England Journal of Medicine said about 1 in 6 soldiers returning from Iraq suffered from PTSD. Interviews with those at risk showed that only 23 percent to 40 percent sought professional help, most typically because they feared it would hurt their military careers.

An updated study regarding the mental health of our current combat veterans was published in the Journal of the American Medical Association last month. Additional combat troop data can be found in the March 2006 issue of Esquire magazine, which I summarized here.

[UPDATE May 26, 2006]: The Waterloo/Cedar Falls [IA] Courier does another fine job of reporting on combat PTSD in a companion piece to this weekend's article detailing the unique characteristics of the Iraq war. This latest offering takes us on a quick history tour of PTSD through the years. Although each war has its own flavor, the only thing that's changed as far as the war's emotional aftershocks is what we decide to call the mental burdens placed on its veterans.

From the Courier:

Experts maintain the mental state as it relates to armed conflict likely began when the first human picked up the first stick or stone. Only the name has changed. During the Civil War, soldiers who lost their will or capacity to fight were afflicted with nostalgia, later diagnosed as soldier's heart. The affliction for a time also carried the name Swiss disease, a tribute to soldiers from that country forced into military units.

Society later introduced the concept of railway spine, which evolved from numerous and horrific railroad accidents. The diagnosis was popularized in lawsuits in the 1870s. As the theory evolved, doctors reached a general view that intense fear disturbed a person's nervous system. By the end of the 19th century, traumatic hysteria and traumatic neurasthenia were the accepted terms.

Then came World War I. The global cataclysm advanced the idea of subconscious mental processes, a theory gaining acceptance. During that war, physicians described soldiers as shell shocked. They assigned the diagnosis to those with neurological symptoms but no physical injuries. The term came from the idea exploding shells changed atmospheric pressure near soldiers, harming their nervous systems. Researchers later determined relatively few cases involved exploding ordnance, which only added to the mystery.

World War II provided the concept of combat fatigue. Statistics show one in four casualties in World War II resulted from the mental disorder. In Europe, the U.S. military recorded one combat stress casualty for every three soldiers wounded in action, according to Field Manual FM 6-22.5, which is used and distributed by the U.S. Marine Corps.

But it was the experience of Vietnam which eventually brought about the term posttraumatic stress disorder, recognized in the Diagnostic and Statistical Manual of Mental Disorders in 1980. In 1999, the DOD began to require the use of the term combat stress reaction; later it was changed to combat-operational stress reaction to show how it differed from other forms of trauma-induced PTSD.

Part of the disorder's history includes society's reaction to it. Whether diagnosed with nostalgia, railway spine or shell shock, afflicted soldiers over the years were labeled as malingerers. When he admitted problems about midway through a tour in Iraq, Army veteran Ron DeVoll Jr. of Cedar Falls says supervisors' attitudes changed. "They talked down to me, called me a coward. 'You're supposed to be tough. You're supposed to be a man.' I thought I was," he says.

In the course of seeking help, DeVoll told superiors he was having nightmares. "They said, 'That's normal. You'll get over it.'" The response DeVoll received in 2003 echoes that from earlier eras.

During World War I, Thomas Salmon, a U.S. medical officer, defined the condition as merely an "escape" from intolerable circumstances. At the same time, Fredrick Parsons, commanding officer at a U.S. military hospital, said "a war neurosis which persists is not a creditable disease to have ... as it indicates in practically every case a lack of the soldierly qualities which have distinguished the Allied Armies." He added "no one should be permitted to glorify himself as a case of 'shell shock.'"

During World War I, the British military reportedly executed more than 300 of its own soldiers for cowardice, desertion or insubordination. In today's terms, at least some likely were only demonstrating effects of combat-stress reaction.

In World War II, the British military described some of its soldiers as lacking moral fiber. On the American side, Gen. George Patton severely tarnished his distinguished military career after slapping and yelling at two soldiers. The privates were recuperating in a military hospital in Sicily alongside others with more visible wounds. "Don't admit this yellow bastard," Patton reportedly yelled at a medical officer. "There's nothing the matter with him. I won't have the hospitals cluttered up with these sons of bitches who haven't got the guts to fight."

President Franklin Roosevelt received hundreds of letters about the incident. The majority supported Patton and his actions; some even suggested a promotion was in order. Ultimately, though, Patton was reprimanded, ordered to apologize and relieved of command of the Seventh Army.

One of the best articles I've seen out there on the historical aspect of PTSD. Not surprising that it come from a local media source; they've been cleaning the clocks of the national media coverage on this for quite a while.


Related Posts

• Combat Clips: A Selection of OEF/OIF Veteran Statistics, October 2009
  
• Combat Clips: A Selection of OEF/OIF Veteran Statistics, July 2009
  
• The War List: OEF/OIF Statistics
  
• OEF/OIF Veteran Suicide Toll: Nearly 15% of Overall U.S. Military Casualties Result from Suicide
  
• CBO Stats on OEF/OIF Casualties and Costs
  
• National Veterans Foundation: A Collection of Troop Stats
  
• Iraq War Costs and Casualties Tallied Up
  
• 15 Year Anniversary of Start of first Gulf War, Desert Storm

Malingering as Vet Brain Injury Cases Soar

A brief respite from my post-traumatic stress disorder [PTSD] series to call attention to a somewhat related piece of reporting appearing in Salon today.

More U.S. soldiers than ever are sustaining serious brain injuries in Iraq. But a significant number of them are being misdiagnosed, forced to wait for treatment or even being called liars by the Army.

Being called liars?!

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

Mark Benjamin's Salon piece introduces us to 24-year old Spc. James Wilson. He's a proud soldier who's served two tours in Iraq - including heavy combat in the opening days of the invasion.

In the fall of 2004, his 1st Cavalry Division was mostly fighting in Sadr City, a volatile sector of Baghdad. On Sept. 6, Wilson was manning a .50-caliber machine gun atop a Humvee when a bomb or bombs went off directly under the vehicle, rocking his head forward and slamming it into the machine gun. A fellow soldier told Wilson that his Kevlar helmet had been split open by the impact. The heat from one blast felt like "a hair dryer" on his skin, multiplied "times 20," Wilson later wrote in his diary. To the best of his recollection, the force of the blast also knocked the gun from its mount, smashing it into his leg.

From all outward appearances, he miraculously survived the incident.

Two weeks later, however, he was on his way to Walter Reed Hospital; Wilson's dazed, light-headed symptoms had led Army medics to believe that he was suffering from post-traumatic stress disorder [PTSD]. But the medics turned out to be wrong.

Wilson's symptoms included:

• seizures
  
• short-term memory loss
  
• severe headaches with eye pain
  
• dizzy spells that lead to vomiting

The above symptoms it would seem (when coupled with the documented head injury he'd suffered during the attack) should have clearly been enough for the doctors at Walter Reed to diagnose a case of traumatic brain injury, right? Wrong. A visit to the Pentagon in which Wilson threw up all over Paul Wolfowitz' carpet apparently wasn't enough evidence, either.

Despite Wilson's description of his injury and his symptoms, Walter Reed officials repeatedly questioned his mental state and the authenticity of his combat story. In a June 2005 memorandum from an Army Physical Evaluation Board, some Walter Reed doctors stated that Wilson exhibited "conversion disorder with symptoms of traumatic brain injury." Conversion disorder holds that symptoms such as seizures arise from a psychological conflict rather than a physical disorder.

Col. James F. Babbitt, president of the Physical Evaluation Board, accused Wilson of being a liar. "I believe that the preponderance of the evidence available to the Board supports an alternative diagnosis ... one of malingering," Babbitt wrote in that memo.

Malingering?

Defined: Evading duty or work by pretending to be incapacitated.

Spc. Wilson and his wife, Heidi, weren't going to just roll over and take the malingering charge without a fight. They strongly opposed the diagnosis, and worked vehemently to get the proper medical treatment. The malingering charge also stung this proud veteran. "I want my dignity, pride and respect back," Wilson says. After serving his country, being accused of misleading doctors, he says, "is the worst thing in the world."

Is this the proper care that our soldiers should be receiving upon their return to us? A year spent dealing not only with physically debilitating symptoms, but with the added burden of fighting the very government that sent them to war?

On Dec. 19, 2005, more than a year after he was admitted, Walter Reed finally sent Wilson to a neurological center to be treated for traumatic brain injury. Neuropsychological testing done at Walter Reed on Oct. 11, 2005, led officials to conclude that "there was no indication of malingering."

According to a neurosurgeon with extensive experience treating combat head injuries, an October 2004 MRI of Wilson, combined with a description of his symptoms, showed that he should have been treated for a traumatic brain injury right then. Medical experts say the failure to treat a brain-injury victim promptly could hinder recovery.

Unfortunately, Wilson isn't the only one getting this type of `treatment'.

Salon conducted interviews with other soldiers suffering from brain injuries at Walter Reed. They are as frustrated and anguished by the delays and suggestions that their problems are a result of mental or hereditary illnesses.

Salon also interviewed military doctors and examined medical records and found Walter Reed is swamped with brain-injury cases. " [A] significant number of brain-injury patients are falling through the cracks from a lack of resources, know-how, and even blatant neglect."


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• VFA Releases Report on the Treatment of America's Wounded Warriors
  
• Idaho State University's Free TBI Education Programs
  
• VA: About 6 Percent of OEF/OIF Vets Expected to be Diagnosed with TBI
  
• Combat Traumatic Brain Injury Perplexes Caregivers, Strains VA System
  
• Bob Woodruff Updates on February TBI Story
  
• Hand2Hand Contact Brings Soldiers All the Way Home, Easter Seals Helps Vets with TBI
  
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• Walter Reed Hearings Review and Latest Developments
  
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