crew: department of defense: department of the army: regarding ptsd diagnosis: 6/30/2011 - release...

8/6/2019 CREW: Department of Defense: Department of the Army: Regarding PTSD Diagnosis: 6/30/2011 - Release Pgs 242…

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REPLY TO

ATTENTIONOF

MCHE-JA

DEPARTMENT OF THE ARMYBROOKE ARMY MEDICAL CENTER

3851 ROGER BROOKE DRIVE

FORT SAM HOUSTON, TEXAS 78234-6200

29 July2008

MEMORANDUM FOR Commander, Great Plains Regional Medical Command, Fort Sam

Houston, TX 78234

SUBJECT: Legal Review- AR 15-6 Investigation ofEACH Department ofBehavioral Health

and Medical Evaluation Board

2. I have determined the following:

l(b)(5)

b. The Investigation is procedurally d e f i ~ · : ' . ! P - . J . J . . L _ U l i l . " - " " . l l l l ~ - " - ' - ' L U . d L U . < J . . I . l . i : ) _ - - " " - " - " - ' - ' - n L U o " ' - ' t , _ L n l l J r o L L J n c u . e r . . . . . _ l . _ _ . v ' - - ~ sworn as directed by the Appointing Authority. (b)(S)

lb)(5)

I

I

Pa


http://slidepdf.com/reader/full/crew-department-of-defense-department-of-the-army-regarding-ptsd-diagnosis 2/92FOIA Release 43

MCHE-DBM 28 July 2008

MEMORANDUM FOR BG JAMES K. GILMAN, COMMANDING, GREAT PLAINS REGIONAL

MEDICAL COMMAND, FORT SAM HOUSTON, TX 78234

SUBJECT: Executive Summary, 15-61nvestigation, Evans Army Community Hospital

1. This memo summarizes the findings of the investigation directed by BG Gilman under

authority of AR 15-6 to investigate an allegation that there has been institutional pressure to

compel Evans Army Community Hospital (EACH) behavioral health providers to improperly

change diagnoses, and that considerations other than established clinical criteria and judgment

have been used to affix diagnoses. The investigation was directed to examine whether there

has been organizational pressure from command or leadership at the MEDCOM or hospital

level to include the EACH command and staff, Behavioral Health department, or MEB staff.

2. Findings.

a. Finding 1: This investigation does not find deliberate institutional or organizational

pressure on EACH behavioral health providers to improperly make or change clinical diagnoses

or to render incorrect or inaccurate diagnoses pursuant to clinical or medical board evaluations.

b. Finding 2: This invest igation does not find that any level of MEDCOM command, EACH

command and staff, or the EACH MEB staff and leadership have attempted to coerce or

otherwise influence the outcome of clinical evaluations conducted by EACH behavioral health

providers pursuant to clinical or medical board evaluations.

c. Finding 3: This investigation finds evidence of potential systemic pressures inherent inArmy physical disability evaluation processes that may influence MEDCOM behavioral health

providers in the course of conducting PTSD disability evaluations. These potential pressures

may lead providers to avoid making a diagnosis of PTSD on medical boards contrary to their

clinical judgment.

3. Recommendation: The existence, extent, and strength of the potential systemic pressures

indentified in Finding 3 could not be well ascertained within the scope of this investigation.

Review at additional Army military treatment facilities is recommended to determine if systemic

processes related to PTSD disability evaluations exert undue pressure on MEDCOM behavioral

health providers to avoid entering a diagnosis of PTSD on an MEB contrary to their clinical

judgment.

c (_ >=- L~ R U C E E. CROWCOL, MS

Investigating Officer

Pa



["},

SECTION VI - AUTHENTICATION (para 3-17, AR 15-6)

THIS REPORT OF PROCEEDINGS IS COMPLETE AND ACCURATE. (If any voting member or the recorder fails to sign here or in Section VII below.indicate the reason in the space where his signature should appear.)

1I~ O ~ C E : . CROW

(Recorder) (Investigating Officer) (President)

(Member) (Member}

(Member) (Member)

SECTION VII • MINORITY REPORT (para 3-/3, AR 15-6)

To the extent indicated in Inclosure , the undersigned do( es) not concur in the findings and recommendations of the board.(In the inclosure, identifY by number ~ c h finding and/or recommendation in which the dissenting member(s) do(es) not concur. State thereasons for disagreement. Additional/substitute findings and/or recommendations may be included in the inclosure.)

(Member) (Member)

SECTION VUI- ACTION BY APPOINTING AUTHORITY (para 1-3 11.Rl5-6)

The findin_ill! and recommendations of t h e ~ n v e s t i g a t i n g o f f i c e ! } ( ~ are (..... "'' 0' .• ~ p p r o v e d with following exceptions/

SubstifutiolJ§]> (If he appointing authori(Y returns (fie prOCeedingS tO the inVeStigating officer Or board for JUF l f leT jJ .0

S Or

corrective action, attach that correspondence (or a summary, if oral) as a numbered inclosure.)

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Page 4 of4 pages, DA Form 1574, Mar83USAPAV1.20



the MEB section was not 'coercive'. He mentions in his sworn statement one other case

where he fell pressure from a dissatisfied patient to add a PTSD diagnosis which he did' ~ b ) ( 6 ) -

In the audio recordind(b)(6) 'mplies to his patient that he claims to have given

him a diagnosisof

Anxiety Disorder NOSin

response to an unspecified source orsources of pressure. During i n t e r v i e ~ ( b ) ( 6 ) described systemic pressures

associated with medical board evaluations that were voiced by other providers as welland are inherent in several processes of the disability system. These processes may

pressure behavioral health providers to avoid using a diagnosis of PTSD and to use an

Anxiety Disorder diagnosis instead.

MEB's require considerable time to complete but receive disproportionately low RVU

credit. Providers were being encouraged to gain more RVU's and to do more boards.

There was a pressure to get more of these done as quickly as possible. The

understanding of providers at EACH was that PTSD boards took longer to do, were

more complicated and more likely to be returned. Their personal experience seemed to

validate this as they saw more boards returned for collaborating evidence in the form of

the commander's letter needing to be reconciled or reviewed. Providers sought to doboards as quickly as possible and with a lower likelihood of them being returned. Talkamongst the staff was that an anxiety disorder NOS diagnosis was likely to be quicker

and be done when you sent it forward.

Another pressure described by staff involved an effort to reduce the number of

administrative separations at Ft. Carson due to previous criticism about excessive

"chapter" separations that resulted in media and congressional scrutiny. In essence

providers determined if a Soldier had deployed they would support a medical board in

lieu of an administrative separation regardless if an administrative separation was

supportable. This seemed to correlate with an increased number of MEB's being doneand a pressure to be more liberal with making a boardable psychiatric diagnosis. This

pressure was cited by multiple providers as being 'beyond local, it was Congress and themedia' and 'Monday morning quarterbacking' was felt to be pervasive.

One concern noted by providers was a pressure they perceived to be placed on Soldiers

by their commanders. There were statements from multiple providers that Commanders

were discouraging Soldiers from accessing behavioral health care. One provider noted

"green tab leaders, from platoon sergeants to battalion commanders, were increasingly

frustrated with providers when their subordinate Soldiers were classified as nondeployable or in need of an MEB. They believed manv of these individuals wereembellishing their symptoms in order not to deploy." (b)(6) • These may be the

same leaders who are asked to provide a Commander's letter to validate a Soldier'sPTSD event as well as a Commanders duty performance statement regarding a

Soldier's level of functioning. This information is used by the PEB to adjudicate level ofdisability and it would be concerning if psychiatric medical boards put a Soldier in an

adversarial relationship with his or her command.

8. Recommendations. This investigation directly addressed whether there are

deliberate institutional or organizational pressures from leaders or persons in authoritythat improperly impact on the diagnosing practice of behavioral health providers at

Evans Army Community Hospital. As described in detail above. the evidence obtained

8

Pag



in this investigation does not support this conclusion and further investigation into this

matter does not appear warranted. What could not be fully addressed in this

investigation was whether systemic pressures of MEB evaluations identified at EACH

are experienced among other MTF staffs. ·1n order to determine the existence, extent,and strength of potential systemic pressures across MEDCOM, additional review would

be required.

a. Recommendation 1. Review at additional Army military treatment facilities isrecommended to determine if evaluation processes under proponency of MEDCOM

(MEB) and/or Human Resources Command (PEB/PDA) pursuant to PTSD disability

evaluations, exert improper pressure on MEDCOM behavioral health providers that

discourages them from entering a diagnosis of PTSD on an MEB contrary to their clinicaljudgment. Such a review could involve a representative sample of MTF's and include

methods such as provider/staff surveys, sensing sessions, interviews, and data calls for

metrics sensitive to variance from an expected rate of PTSD diagnosis on finaladjudicated physical evaluation boards.

b. Recommendation 2.Recommended actions for EACH:

1} Education and training: Providers who are to do MEB should have a targetedtraining for conducting these challenging evaluations. Many of the active duty

psychiatrists have had training through residency programs and are experienced with

MEB's. At EACH the former or current active duty providers could devise a trainingprogram for those providers who have not had experience or formal training in the past.

Part of this training should include a vision statement or philosophy of doing MEB's. This

should include that there are no pressures to diagnose outside of what the facts,evidence and history of the Soldier indicate should be the diagnosis. Additional trainingwitb regards to the PEB conducting staff assistance visits, or MTF providers visiting thePEB could facilitate better understand by MTF providers of the PEB process.

2} Local quality control metrics should be employed to monitor trends associatedwith MEB's returned from the PEB. Metrics such as the number returned and reasons

for the returns can help providers appropriately address recurring problems. This should

be in the context of providing a quality product and not as a 'pressure' to change a

diagnosis.

c r - > ~ LBRUCE E. CROWCOL, MS

Investigating OfficerClinical PsychologistChief, Department of Behavioral

MedicineBrooke Army Medical Center

9

Pag



SAMR

DEPARTMENT OF THE ARMYOFFICE OF THE ASSISTANT SECRETARY

MANPOWER AND RESERVE AFFAIRS111 ARMY PENTAGON

WASHINGTON, DC 20310.0111

MAR : 1 2011

MEMORANDUM FOR UNDER SECRETARY OF DEFENSE (PERSONNEL & READINESS)

SUBJECT: Army Personality Disorder Separation Compliance Report for Fiscal Year 10

1. On September 10, 2010 the Under Secretary of Defense directed the Army to examinecompliance with DoD I 1332.14, personality disorder (PO) separations for fiscal year (FY) 1o. In

addition, the Army was directed to provide the total number of PO separations sinceSeptember 11, 2001 including those who had served in Imminent Danger Pay Areas. InFY201 0, 365 enlisted Soldiers were separated for PD. The Army r e v i e ~ e d 14 percent of therecords in order to satisfy the requirements set by USD (P&R). Since September 11, 2001 a

total of 7,440 enlisted Soldiers have been separated for PO and 1,759 of them servecUnImminent Danger Pay Areas.

2. The cases reviewed were in compliance with the requirements set forth by DoD. The Armyis taking additional steps to ensure units and leaders are aware of and complying with DoD andArmy separation and medical screening policies, and that those cases.requiring review andendorsement by the Office of the Surgeon General (OTSG) are being properly forwarded.Detailed analysis may be found In the enclosed report.

3. In addition to the FY10 compliance report, the Army was directed to provide the total numberof Soldiers who have deployed in support of a contingency operation since September 11 , 2001,who were later administratively separated for personality disorder, without completing theenhance screening requirements for Post-Traumatic Stress Disorder and Traumatic Brain Injuryimplemented on August 28, 2008 In 0001 1332.14. Between September 11, 2001 and August28, 2008 a total of 1 453 enlisted Soldiers were administratively separated from the Army for

personality disorder who had also deployed to an area designated as an Imminent Danger PayArea. The Army is presently obtaining current mailing addresses In order to send lettersinforming them of the process to correct their discharge characterization, and how to obtain a

mental health assessment through the Department of Veterans Affairs. Once letters have beenmailed, the Army will proVide the final names to the Department of Veterans Affairs as directed.

4. My secretariat point of contact for this action Is COL Tracl E. Crawford. She can be reachedat (703) 692·1296 or by email at: [email protected].

Encl- ~ ~ - ..1-

THOMAS R. LAMONTAssistant Secretary of the Army

(Manpower and Reserve Affairs)



Army Personality Disorder Separation

Compliance Report for FV 2010

Background:In 2007, The Government Accounting Office (GAO) reported that the MilitaryDepartments were not fully compliant with DoD personality disorder (PD)

separation guidance (DoDI1332.14)1• As a result, the Under Secretary of

Defense for Personnel and Readiness (USD (P&R)) requested that all ServiceSecretaries review personality disorder separation files to determine compliance

and address any identified issues. In January 2009, the Army was directed to

provide a report on compliance for PO separations occurring in FY2008 and

FY2009. While Improvements towards compliance had occurred, it wasdetermined that compliance reporting should continue through FY2012 for allServices. In addition to the FY201 0 compliance report, the Army was directed to

provide the total number of PO separations since September 11 , 2001 includingthose who had served in imminent danger pay areas. This report Is a review of

the FY2010 PD separation records.

To ensure continued compliance with the DoDI and 10 U.S.C § 1177, the Army

Surgeon General (OTSG) I Commanding General, United States Army Medical

Command (USAMEDCOM), issued guidance on June 9, 2010 to all RegionalMedical Commands outlining screening requirements for Post-Traumatic StressDisorder (PTSD) and Traumatic Brain Injury (TBI) for all Soldiers considered foradministrative separation who require a mental status evaluation, have beendeployed, and who have been diagnosed as experiencing PTSD or TBI or who .

otherwise reasonably allege the influence of such a condition in support of OUSD(P&R) Directive-Type Memorandum (DTM) 10-022, issued later on August 30,

2010. In addition, the Army completed policy updates to AR 635-200 on April 27,2010 and has completed additional policy revisions for clarification to be

published in the next update of AR 635·200. Furthermore, on February 22, 2011,

the OTSG/CG, USAMEDCOM issued updated policy guidance to all RegionalMedical Commands regarding required review and endorsement by OTSG ofseparation actions for PO and other designated physical ormental conditionswhen the member had been deployed to an imminent danger pay area. The

Army is also currently drafting an All Army Activities (ALAAACT) messagereiterating Army policy concerning required screening requirements for PO and

other administrative separations to ensure compliance with OTSGIMEDCOM

policy memo 11·01 0.

1 •Additional Efforts Needed to Ensure Compliance with Personality Disorder SeparationRequirements." GA0·09-31 released October 31,2008.

ASA M&RA (MP) FOUO!LIMDIS 1



The Office of the Deputy Assistant Secretary of the Army for Military Personnel(DASA-MP) coordinated with both Human Resources Command (HRC) and

(OTSG) to cqmplete the FY201 0 report.

PO Separations Since September, 2001

Sep2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Total

TotalSeparations 42 731 972 959 1018 1071 1066 641 575 365 7440

DeploymentExperience 1 55 143 214 191 302 336 211 157 149 1759

Methods:Collection of Da.ta:

In order to obtain losses from the Army due to PO In FY1 0, the Army queried the

·· Army's loss files by Separation Program Designator Code (SPD) for bothparagraph 5·13 (Personality Disorder for Soldiers with less than 24 months ofservice) and 5-17 (Other Designated Physical or Mental Conditions). Because

Soldiers can be separated for multiple reasons under paragraph 5-17

(Adjustment Disorder, Personality Disorder for Soldiers with 24 or more monthsof service, enuresis, sleepwalking, dyslexia, severe nightmares, claustrophobia,transsexualism/gender transformation, and other disorders manifestingdisturbances of perception, thinking, emotional control or behavior) losses underparagraph 5·17 were then sent to OTSG to Identify those separated based upona primary diagnosis of PD. In FY1 0, the Army administratively separated 365

enlisted Soldiers for Personality Disorder pursuant to AR 635·200, paragraph 5-

13 and 5·17 of which a total of 149 enlisted Soldiers had deployed to animminent danger pay area. 14% of all Personality Disorder records were

reviewed for compliance (e.g., 51 files).

Data Analysis:

The Military Personnel Office developed a spreadsheet to collect the dataneeded to detennlne compliance. Patient identification was redacted by usingonly the last 4 digits of the Soldier's social security number as a record ID.Records were reviewed for the presences of the following documents: (1) ServiceMember received formal counseling and was afforded adequate opportunity toimprove his/her behavior prior to being separated on the basis of PD; (2) ServiceMember's PO diagnosis was made by a psychiatrist or Ph.D. level psychologist;

{3) The PO diagnosis included a statement or judgment from the psychiatrist orPh.D. level psychologist that the Service Member's disorder was so severe thatthe Service Member's ability to function effectively in the military environmentwas significantly impaired; (4) Service Member received written notification of his/

ASA M&RA (MP) FOUO/LIMDIS 2



her impending separation based on PO diagnoses; (5) Service Member wasadvised that the diagnosis of a PO does not qualify as a disability. For ServiceMembers separated on the basis of a PO who served in imminent danger payareas: {1) Service Member's PO diagnosis was corroborated by a peerpsychiatrist or Ph.D. level psychologist or higher level mental level professional;

(2) Service Member's PO diagnosis addressed PTSO or other mental illness comorbidity. (Note: In accordance with 00011332.14, paragraph 3.a. (8)(d),unless found fit for duty by the disability evaluation system, a separation for PO isnot authorized if Service- related PTSD is also diagnosed.); (3) ServiceMember's PD diagnosis was endorsed by The Surgeon General of the MilitaryDepartment concerned prior to discharged.

Each of the required compliance areas was scored as either present (receiving a1) or absent in the record (receiving a 0}. To be counted as present in the

record, a stand-alone document had to be found. Only the actual supportingdocumentation was counted. All records were reviewed twice to ensure that no

data was missed.

Findings:DocumentDiion required for all PO Separations files: In FY10, there were 365

total enlisted separations from the United States Army due to a clinical diagnosisof personality disorder. The Army reviewed 14% of these records, exceeding the10% requirement set by USO (P&R).

Adciitiona! Criteria for SeiVice Members 1 ~ v h o served in an Imminent Danger Pay

Arr:;a: OTSG reviewed personality disorder separation packets between 01 Oct09 and 30 Sep 10 and found that they were consistent with the requirements set

forth by DoD meeting 100% compliance.

Discussion:While the cases reviewed were consistent with the requirements set forth byDoD, the Army is taking additional steps to ensure units and leaders are aware ofand complying with DoD and Army separation and medical screening policies,primarily that those cases requiring review and endorsement by OTSG are beingproperly forwarded.

Corrective Plan of Action:The United States Army will continue to educate the field regarding screeningrequirements including higher level review at the level of the Office of TheSurgeon General, when required, and is publishing revisions to AR 635-200 toclarify these requirements. The Army also plans to publish an All Army Activitiesmessage (ALARACT) as well as a senior leadership 'sends' message to leadersasking for their assistance to ensure compliance.

ASA M&RA (MP) FOUO/LIMOIS 3



The Army is also exploring options to enable the internal Army tracking of allseparations under AR 635-200, paragraph, 5-17, Other Designated Physical orMental Conditions. Reasons for separation under paragraph 5-17 (adjustmentdisorder, personality disorder for members with 24 or more months of active

service, chronic airsickness, chronic seasickness, enuresis, sleepwalking,dyslexia, severe nightmares, etc.) are all categorized under a SeparationProgram Designator (SPD) code broadly assigned to all paragraph 5-17separations. Because of this, the only way to analyze trends that may theninfluence changes in policy, is to individually examine each 5-17 separation file toaccount for the actual reason for separation which is very time consuming andmanpower intensive.

Service Members Deployed in Support of a Contingency

Operation Since September 11, 2001 and Later Administratively

Separated for Personality Disorder:

In addition to the FY2010 compliance report, the Army was directed to providethe total number of Service members who have deployed in support of acontingency operation l:!ince September 11 , 2001 who were later administrativelyseparated for a personality disorder, regardless of years of service, withoutcompleting the enhanced screening requirements for Post-Traumatic StressDisorder (PTSD) and Traumatic Brain Injury (TBI) Implemented on August 28,2008 in DODI1332.14.

Between the period of September 11, 2001 and August 28, 2008 a total of 1 453enlisted Soldiers were administratively separated from the Army for personalitydisorder who had also deployed to an area designated as an Imminent DangerPay Area. The Army is utilizing the template letter provided by OSD, with slightmodifications, to contact and inform these former members of the process to

correct their discharge characterization process and how to obtain a mentalhealth assessment through the Department of Veterans Affairs. The Army ispresently obtaining current mailing addresses and identifying any of thesemembers who may now be deceased. Once letters have been mailed to each ofthese former members, the final names will be forwarded to the Department ofVeterans Affairs as directed.

ASA M&RA (MP) FOUO/LIMDIS 4



DEPARTMENT OF THE ARMYOFFIC{: cy niE:As$1$TAz'JTS&:f:l.E1lll..l:{'(! : l A N ? O ' ' I ' I f i ! . " \ ~ A H t i ' P . : E s ! f f i V E A . i : F A ! t i s

1 1 Mi'!f PE'ilTAGdli .W A S H l ' f i G T t ~ . i:l'c W11)..¢f11

MEMORANDl;JMFORTHE UNDER SECRETARY OF DEFENSE, PERSONNELAND Rf.=jiJDINESS ·

SUBJECT: Administrative Se;paratlon of Stildiers with Post Traumatic Stress Disorder(PTSD) or ·rraumatic Brain Injury (T8l)

1. As requested, thls letter proVfdes Information to addrass the concer,ns of SenEJtors BOI1d1Grassley, 8rownbaci( and Leahy. The Army Is dedlcatad to ensuring that all Soldiers \\1thphysical and mental conditions caused by wartime servioo receive the care they d$SSf\ri:l.

The enclosure otitilnes me numbar ofSotd!eis discharged In Fiscal Years 200S..2010 fc,iPersonality Disorder, Adjustment Disorder, and Other Physical or MentalCdnditiotrs, and

how many have,deplqyed to an Imminent Danger Pay Area. Pleas,e realize that there arecomplexities lhvolved beyond the numelic.al data, and that the Amly has taken actlons'toensure these So!diem were appropriately :screened for PTSD and TBi.

2. In 2008 and 2007, public cbncsm l!las raised that moroeSoJdiers ret1,1mlng trom combattours had been discharged from the military for Personality Disorders$ but were .suhs,s;quently suffering from PTSD or TBI refated io thelr combatexperiences. The ArmyIssued policies to address mase concerns, and fmplemented the requirement for higher 'level review of administrative separations for Pe-rsonality Disorder at Office of The Surge\lnGeneral and scre&•lng for PTSD and TBI. TI1s Army also lssued guidance outliningprocectures forPTSO and TB! screening forat! Soldiers ct::insldere\:1 for admlnlstrstlv'eseparation vtho require<! a mental status evaluation, or who had been deptoyoo to anlmiliinant Danger Pay Area.

3. In at.Cordanee \VltlrOSD gt)idancer the Army·Is c a n d u g t l r ~ g · a reView ofat east'10pef<ient .ofall PersonalityGlrordar saparatlonsforflscaLyear 2010. Adqitlonally;.\>ie arelidentifying Soldiers who. ¢eplpy€ld to r;tn tmmi.nal'\t DangerPay Area wf1o ·were s e p a r ~ t e i H o r P ~ r s p n a l i t y Pisordersinoo.20011n <>rderto Inform them Of the process to correct t.rye1r

discharge characteriiatlcn and how to obtaln mental health assessment through theDepartment ofVeterans Affa1rs.

4. _MyPOC for this action isJ(b)(6)

. ·-HI'

Encl

· f 7 t f r u 1 > ~ -w..·· ~ · .·, , • , ····-·· '

.'d-,. ' ' ' ·.. ' ' "'- '

TH 'ii/M R. MONT ~ O t e ' j ? . . 7 . . : · ~ A t secretary of the Army

·npower and Reserve Affairs)



INFORMATION PAPER

SAMR-MP25 October 2010

SUBJECT: Screening of Personality and Adjustment Disorder Discharges

1. References:

a. Letter from Senator Bond et al. to Secretary Gates, 15 October 2010.

b. Department of Defense Instruction 1332.14, Enlisted Administrative Separations,28 August 2008.

c. Memorandum, USD-PR, subject: Continued Compliance Reporting onPersonality Disorder (PD) Separations, 10 September 2010.

d. Army Regulation 635-200, Active Duty Enlisted Separations, Rapid ActionRevision Issue Date: 27 April 2010. ·

e. OTSG/MEDCOM Policy Memo 09-056, Guidance for Administrative Separation

for Personality Disorder (PD) or other Behavioral Conditions, 22 July 2009.

f. OTSG/MEDCOM Policy Memo 10-040, Screening Requirements for PostTraumatic Stress Disorder (PTSD) and mild Traumatic Brain Injury (mTBI) for

Administrative Separations of Soldiers, 9 July 2010.

2. On 15 October 2010, Senators Bond, Grassley, Brown back and Leahy wrote to

Secretary Gates expressing their concerns about screening of Personality andAdjustment Disorder discharges. They requested data on the number of Soldiersdischarged under Chapters 5-13 and 5-17 and the number of those that have deployed.

OSD further requested information regarding actions taken, or underway; to ensure that

Service members who deployed to an Imminent Danger Pay area, who were diagnosedwith either Adjustment Disorder, Personality Disorder, or Other Designated Physical orMental Condition and were discharged in Fiscal Years 2008-2010 did not have Post

Traumatic Stress Disorder (PTSD) or Traumatic Brain Injury (TBI). Actions taken orunderway include:

a. In 2006 and 2007, public concern was raised that the Army was discharging

some Soldiers returning from combat for personality disorder who were also sufferingfrom PTSD and/or TBI related to their combat experiences. To address these concerns,the United States Army Medical Command (MEDCOM) issued policy in August 2007 to

their Regional Medical Commands directing Office of the Surgeon General (OTSG)higher level review of administrative separations based upon a diagnosis of personalitydisorder including whether or not PTSD, TBI and/or other co-morbid mental illness may

have been a significant contributing factor to the diagnosis. In May 2008, MEDCOM

1



SAMR-MPSUBJECT: Screening of Personality and Adjustment Disorder Discharges

issued additional policy requiring PTSD and TBI screening prior to Soldiers beingconsidered for administrative separation.

b. In August 2008, the Department of Defense (DoD) mandated similarrequirements (DoDI1332.14) regarding separations on the basis of a personalitydisorder to include:

(1) A Psychiatrist or PhD-level Psychologist must diagnose the personalitydisorder.

(2) A peer or higher-level mental health professional must corroborate thediagnosis.

(3) Diagnosis must be endorsed by the Surgeon General of the MilitaryDepartment concerned.

(4) The diagnosis must consider whether PTSD, TBI and/or other co-morbidmental illness may have been a significant contributing factor to the diagnosis.

c. In February 2009, Army policy was updated implementing the above DoDrequirements.

d. On 25 July 2010, pursuant to the provisions mandated by section 512 of PublicLaw 111-84, National Defense Authorization Act for Fiscal Year 2010 and 10 U.S.C.§1177 and 1553, the Under Secretary of Defense for Personnel&Readiness issued

policy via Directive Type Memorandum 10-022, requiring a medical exam evaluation forPost-Traumatic Stress Disorder (PTSD) or Traumatic Brain Injury (TBI) prior toadministratively separating Service members, under conditions other than honorable,who had deployed overseas in support of a contingency operation during the previous24 months. On 30 Aug 10, the Assistant Secretary of the Army for Manpower &Reserve Affairs responc;led to OUSD (P&R) that OTSG Policy Memorandum 10-040,dated 9 June 2010, included procedures ensuring compliance with requirementspromulgated in OUSD DTM 10-022.

e. OTSG Policy Memorandum 10-040, outlines procedures for PTSD and TBIscreening for all Soldiers considered for administrative separation who require a mental

status evaluation, or who have been deployed overseas in support of a contingencyoperation, and who are diagnosed by a physician, clinical psychologist, or psychiatristas experiencing PTSD or TBI or who otherwise reasonably allege, based on theirservice while deployed, the influence of such a condition. OTSG Policy Memorandum09-056 provides guidance for administrative separation for Personality Disorder andother behavioral conditions. A revision of the that policy, currently in staffing, will

2




require review and endorsement of all Soldiers who have deployed that are being

processed under Chapter 5-17.

f. In accordance with OSD guidance, the Army is conducting a review of at least 10

percent of all Personality Disorder separations for fiscal year 2010. Additionally, we arecurrently identifying Soldiers separated for Personality Disorder in order to inform themof the process to correct their discharge characterization and how to obtain mentalhealth assessment through the Department of Veterans Affairs.

4. Social Security Numbers of Soldiers with Chapter 5-13 and Chapter 5-17 dischargesfor fiscal years 2008,2009, and 2010 were obtained from the Total Army PersonnelDatabase. These records were then forwarded to the Patient Administration Systems

and Biostatistics Activity to identify those Soldiers with a diagnosis of PersonalityDisorder or Adjustment Disorder. They were also forwarded to the PersonnelContingency Cell to determine if the Soldier had deployed. Comparison of thesedatabases yielded the following information:

a. Number of Adjustment Disorder (AD) discharges (Chapter 5-17).

(1) FYOB 2,032

{2) FY09 2,427

(3) FY1 0 2,033

b. Number of AD discharges who had deployed to an Imminent Danger Pay (IDP)area.

(1) FYOB 346

(2) FY09 475

(3) FY10 767

c. Number of Personality Disorder {PO) discharges (Chapter 5-13 < 24 monthsof

service; Chapter 5-17 with 24or

more monthsof

service).

(1) FYOB 641

(2) FY09 575

(3) FY10 365

3




d. Number of PD discharges who had deployed to an IDP area.

(1) FY08 211

(2) FY09 157

(3) FY1 0 149

e. Number of Condition, Not Disability discharges (Chapter 5-17 minus PDsw/24 or more months of service).

(1) FY08 3,654

(2) FY09 3,501

(3) FY10 3,154

f. Number of Condition, Not a Disability discharges who had deployed to an

IDP area.

(1) FY08 724

(2) FY09 561

(2) FY1 0 1,003

4



PRESENTATION DOCUMENTATION FORM

As a requirement of the accrediting bodies of the Office ofthe Surgeon General, the following information regarding yourpresentation is a prerequisite for approval of continuing education credits. NOTE: One form per lecture if different topics.

Title and Date of Presentation:

PTSD Disability Determination: Expectations and RealityN!>mP nUnstJ:n.ctnr!

(b)(6) ITime Allocated for presentation: !l!!!!!!:

Teaching Methods to be Used (Check all that apply) : Discussion Slides Overhead Panel PresentationSmall Group Interaction Other, please specify

Brief Narrative Description: Provide 3 • 5 sentences regarding your presentation. This narrative should answer the questions"What will health providers, either nurses or physicians, learn from this presentation that will enhance their professionalknowledge, skills and/or abilities?" and "How will this be accomplished?"

Initiating a Medical Evaluation Board (MEB) for a soldier with combat-related PTSD is a complicated and time-intensiveprocedure that relies on appropriate documentation in both mental health and non-mental health levels of the system. Untilrecently, the Physical Disability Agency (PDA) has issued few guidelines as to what they need in an MEB, and have neverissued guidelines pertaining to what they do NOT need. An unstated component in the system is that disability compensationoften depends on how much work the psychiatrist puts into the MEB. This presentation will provide an overview of how the

Physical Disability Evaluation System (PDES) determines disability compensation and what is considered "ideal" for an MEB.

113 adjudicated PTSD case files were reviewed to contrast the "ideal" with the "reality"of

what a typical Army psychiatristdocuments in MEBs.

Objectives: Must provide 3 objectives. Utilize verbs that are clearly behavioral and measurable, such as describe, discuss,explain, recite, etc. Do not use terms such as understand better, have a clear appreciation for, etc.

• Describe the system for documenting and adjudicating cases of PTSD disability

• Summarize symptoms or dysfunctions that affect disability determination based on a chart review of 113 cases

• Establish realistic guidelines for psychiatrists in documenting PTSD cases for disability adjudication

Content Outline: Provide a basic outline with major headings. This outline should correspond to your objective(s). If youwish to provide a more detailed outline for note taking, you should use an additional piece of paper. A comprehe11sive outli11eis required prior to the presentation in a camera-ready format, aUowinlf room for note·takinlf

I. The Current Burden of combat-related PTSD in the ArmyA. EpidemiologyB. Costs

II. Overview of the Physical Disability Evaluation System (PDES)A. Guiding regulationsB. VASRD rating system

1. Monetary values and corresponding disease severityc. The Medical Evaluation Board (MEB)D. The Physical Evaluation Board (PEB)E. U.S. Army Physical Disability Agency (USAPDA)

II. Ideals for a psychiatrist documenting PTSD disabilityA. Documentation of symptomsB. Commanders' statementsc. Occupational dysfunction in the military and civilian environments

III. Case review of 113 PEB packets and adjudicated casesA. Statistics on how much compensation is given out at the varying disability levelsB. Statistics on what symptoms were documented by psychiatrists for the MEB

c. Statistics on what types of occupational dysfunctions were documented by psychiatrists for the MEBD. Statistics on how much collateral information was included in MEBsE. Associations between content of he MEBs and the fmal disability determinationF. Conclusions concerning which factors do and do NOT play a role in determining disabilityG. Conclusions concerning the objectivity and subjectivity of the systemH. Recommendations to mental health providers for achieving the best outcome for their disabled patients



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F OI A

R

el eas eP age2 5 9

Objectives

• Describe the system for documen

adjudicating cases of PTSD disab

• Summarize symptoms or dysfunc

affect disability determination basechart review of 113 cases

• Establish realistic guidelines for

psychiatrists· in documenting PTS

for disability adjudication



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F OI A

R

el eas eP age2 6 1

Step #1 -- MEB

• Medical Evaluation Board (MEB)

performed by a psychiatrist "When

soldier reaches maximum benefit

medical care for a condition whichrender the soldier unfit for further

service soldiers shall be referred f

evaluation within 1 year of the dia

their medical condition."



F OI A

R

el eas eP age2 6 2

Step #1 -- MEB

• The soldier may or may not be ra

meeting medical retention standa

• The MEB is documented on pape

Narrative Summary, or NARSUM)• The NARSUM and other docume

submitted to the PEBLO.

• The PEBLO forwards the packet t

PEB.



F OI A

R

el eas eP age2 6 3

Step #2 -- PEB

• Physical Evaluation Board (PES) eval

MEB and decides whether the soldier

duty or not.

• Once determined unfit, the PES is req

law to rate the disability using the Vete

Affairs Schedule for Rating Disabilities

• Ratings can range from 0 to 100 perce

in increments of 10.

• 3 PEBs exist



F OI A

R

el eas eP age2 6 4

Step #3 -- USAPDA

• U.S. Army Physical Disability Age

(USAPDA, or simply PDA)

• Manages and provides appellate

for the Army's disability system.• Headquartered at Walter Reed.

• Oversees the three PEBs.



F OI A

R

el eas eP age2 6 5

Step #4 -- APDAB

• If the PDA changes the findings o

PEB and the soldier non-concurs

submits a rebuttal, the case is forw

to the U.S. Army Physical DisabiliAppeal Board (APDAB)



F OI A

R

el eas eP age2 6 6

Fitness for Duty

The standard for determining fitness is w

medical condition precludes the soldie

reasonably performing the duties of his

office, grade, rank, or rating.

• There is no requirement that a soldier

able to perform in every condition or u

circumstance.

• Deployability may be used as factor



F OI A

R

el eas eP age2 6 7

Disposition

• Those found unfit for duty have fo

possible dispositions:

1 separation without benefits

2. separation with severance pay

3. temporary duty retirement list (T

4. permanent duty retirement list (



F OI A

R

el eas eP age2 6 8

Factors Affecting Dispos

• whether the soldier can perform in h

MOS;

· • the rating percentage;• the stability of the disabling conditio

• and years of active service in the ca

existing conditions.



F OI A

R

el eas eP age2 6 9

Separation without Ben

• The unfitting disability

-existed prior to service (EPTS)

· -was not permanently aggravated by•

serv1ce- and the member has less than 8 yea

active service



F OI A

R

el eas eP age2 7 0

Separation with Severanc

The soldier

- Has less than 20 years of active fed•

serv1ce

- and has a disability rating of less thapercent

-With a 10% rating, the soldier receiv

twelve month's basic pay multiplied

time in service



F OI A

R

el eas eP age2 7 1

Permanent Retirement (P

-The disability is determined permanstable

-and rated at a minimum of 30 perce

-o r the soldier has 20 years of active•serv1ce

- The soldier with a 30% rating will reof their base pay

- OR receive their normal retirement p

(whichever is higher)-There is no "double-dipping" of pay



F OI A

R

el eas eP age2 7 2

Temporary Retirement (T

• Same as PDRL except that the di

not stable for rating purposes,

• Soldier will be re-assessed yearly

monitor for changes in disability (atherefore the disability rating)



F OI A

R

el eas eP age2 7 3

Relevance to PTSD Ca

• Most soldiers get a 10% rating, a

30% rating, and <1% get a 50% ra

• Most junior soldiers will get separa

severance pay• Senior soldiers will be placed on T

• Those separated with severance

still apply to the VA for monthly di

payments



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F OI A

R

el eas eP age2 7 5

PTSD

• One of the few psychiatric conditions f

specific etiology (cause) is believed to

• The "cause," however, is necessary bu

sufficient for the diagnosis.

• Other factors are essential in addition

requisite stressor

• Adjudicators must be cautious in assum

PTSD exists on the basis of only one f



F OI A

R

el eas eP age2 7 6

Guidelines from the PD

• The PDA has released two docum

this subject:

-"Issues in Adjudication of Cases Inv

Posttraumatic Stress Disorder" - Fa-"Guidance for Preparing Psychiatric

on Soldiers Going Through the Phy

Evaluation Board Process" - Fall 20

-Both are written by David T. Armitag

COL(RET)



F OI A

R

el eas eP age2 7 7

The Forensic Standa

• The MEB is akin to a Sanity Boardthe adjudicators are looking for coinformation to support the patient'statements and dispel any questiomalingering or exaggeration for segain (money, separation from the or avoidance of domestic duties).

• The adjudicators at the PDA are o

M.D. and J.D.



F OI A

R

el eas eP age2 7 8

The Traumatic Even

• Exact use of DSM-IV criteria, partin regards to presence of the trauevent and reaction to the event

- Use of collateral information to provevent or the reaction may be used

- Using vague descriptions such as "hto combat situations with fear'' are i

-The reaction may be simply dissoci

-A reaction approximating "disgust" o"nauseating" is not sufficient



F OI A

R

el eas eP age2 7 9

The Traumatic Even

-· Use "common sense" in deciding event is "severe" enough to cause

• Common sense may include the

"reasonable person" test: would oreasonable soldiers in the samecircumstances have had the samereaction?

• Ex: a soldier hearing artillery fire m

away is overwhelmed by fear



F OI A

R

el eas eP age2 8 0

Symptoms

• The PDA does not explicitly state that

criteria for the symptom clusters of re

experiencing, avoidance, and hyperaro

be met. It is implied, however.

• "Double-counting" of symptoms is proh

due to the potential for "pyramiding" of

• "Laundry-lists" of DSM-IV symptoms ar

as carrying little weight



F OI A

R

el eas eP age2 8 1

Collateral Document

• Include any documents you use wNARSUM

• Emails with soldier's unit member

• Personnel records (award citation• Assignment orders

• Medical records

• Police reports/sworn witness state

• Statements by the family



F OI A

R

el eas eP age2 8 2

Impairment

• Spheres of impairment may includ

military work environment, the soc

sphere, and tasks that may be use

civilian occupational world• Military and social impairment do

impact the disability rating unless

be tied into the civilian impairmen



F OI A

R

el eas eP age2 8 3

Military Dysfunction

· • The usu;al reason for initiating the

that the soldier is unfit for duty

• State how he is unfit

• The disability rating is not based military impairment - symptoms m

better outside of military environm

• However, the military impairment

used to extrapolate civilian impai



F OI A

R

el eas eP age2 8 4

Social Impairment

• Social impairment may be used as

symptom to prove the presence o

• Tying it into civilian impairment is

for the adjudicators• Ex. - the soldier cannot work with

due to severe anger or isolating b

•. Ex. - use of alcohol/drugs to self-m

causes stigmatization or legal pro



F OI A

R

el eas eP age2 8 5

Civilian Impairment

• a ~ k . a . "civilian and industrial adap

• Determine if the symptoms will im

aspect of work outside of the milit

• The PDA believes that nightmaresinsomnia rarely impact work perfo

to a significant degree



F OI A

R

el eas eP age2 8 6

Considerations for Civili

Impairment

1. Remember locations, work-like

procedures, and instructions

2. Maintain concentration to compl

in a timely manner

3. Communicate with others about

4. Being civil toward boss or cowor

5. Sustain an ordinary routine with• •

superv1s1on



F OI A

R

el eas eP age2 8 7

Considerations for Civil

Impairment

6. Work with/near others without b

distracted by them

7. Make simple work-related decis

8. Work without excessive rest per

9. Seek help when appropriate

10. Adapt to changes at work

·11. Awarenessof

hazards,use· of

precautions



F OI A

R

el eas eP age2 8 8


Impairment

• Other factors may include:

- Job stability, type of job, schoo

-Time commitment for outpatient

treatment or repeated inpatient (esp. due to suicidality or substa

abuse)

-Non-compliance issues

-Competency to manage finance



F OI A

R

el eas eP age2 8 9


Impairment

• Commander's Performance Statecontains many specifics about wodysfunction..

• The PDA loves this statement• Statements that the soldier cannodue to a profile are useless

- Commander should focus on what sthe soldier doing instead of their nor

• •miSSIOn



F OI A

R

el eas eP age2 9 0

Personality Disorder

• The PDA states that personality t

maladaptive styles should be disc

and their impact on dysfunction n

• There are pros and cons to this a



F OI A

R

el eas eP age2 9 1

Depression and Anxie

• The PDA is looking to see if any o

diagnoses better account for the s

military dysfunction, particularly

adjustment disorders.• For instance, the presence of "tole

combat stress reactions followed

of a new stressor such as impend

divorce or a new, hostile platoon s



F OI A

R

el eas eP age2 9 2

Substance Abuse

• Primary substance abuse by itself

compensable condition

• Substance abuse caused by or

aggravated by PTSD should not reless compensation



F OI A

R

el eas eP age2 9 3

Occupational Therap

• An OT consult may be useful in fin

ways to describe civilian impairme

ability to manage one's finances

• Allen Cognitive Level (ACL) is a wresearched modality, given in 15 m

and is a given to all inpatients on

inpatient wards.



F OI A

R

el eas eP age2 9 4

Malingering

• Malingering may be suggested by:

- Recitation of DSM-IV criteria

- Vague descriptions of symptoms such as combat-induced nightmares usually involvas opposed to non-combat PTSD nightma

- Inability to state how PTSD affects their dafunctioning

- Hyperarousal not in evidence

- Reporting static symptoms - PTSD usuall

• A comment concerning the absence of

items may be hel·pful to dispel doubt



F OI A

R

el eas eP age2 9 5

One Word= One Rati

• Possibilities in the civilian and indadaptability section:

. - "Mild" = 1Oo/o

-"Definite" = 30%

- "Considerable" =50%

- "Severe" =70%

-"Total"- 100%

Your opinion may or may not be weig

heavily



F OI A

R

el eas eP age2 9 6

VASRD Classificatio

Full remission at 0 percent.

(a) Symptom free.

(b) No medication.

(c) No medical supervision.

(d) Work record acceptable or bet

(e) Satisfactory social adjustment.



F OI A

R

el eas eP age2 9 7

VASRD Classificatio

Mild at 10 percent.

(a) Displays minimal signs or symptom

probing.

(b) May require medication or psychothespecially during

times of stress.

(c) Adequate job adjustment.

(d) Adequate social adjustment.



F OI A

R

el eas eP age2 9 8

VASRD Classificatio

Definite at 30 percent.

(a) Does not require hospitalization.

(b) Displays some signs or symptomsillness on examination.

(c) Usually requires medication and orpsychotherapy.

(d) Usually there is job instability.

(e) Borderline social adjustment.



F OI A

R

el eas eP age2 9 9

VASRD Classificatio

Considerable at 50 percent.

(a) Intermittent hospitalization.

(b) Overtly displays some signs or sym

mental illness.(c) Requires constant medications or

psychotherapy.

(d) Extreme job instability.

(e) Significant social maladjustment.



F OI A

R

el eas eP age3 0 0

VASRD Classificatio

Severe at 70 percent.

(a) Usually financially mentally competent and capablecooperating in PEB proceedings but occasionallyincompetent.

(b) Usually hospitalized, but often in care of next-of-kin

(c) Actively psychotic, but may have intermittent contareality.(d) Requires supervision approximately 50 percent or

time.

(e) Some potential to be harmful to self or others.(f) Unemployable.(g) M_inimal social adjustment.



F OI A

R

el eas eP age3 0 1

VASRD Classificatio

Total at 100 percent.

(a) Usually mentally incompetent to handle fiaffairs and to participate in PEB proceedings.

(b) Usually hospitalized, rarely in care of nexguardian.

(c) Actively psychotic, totally out of contact w

(d) Requires constant supervision and- care.

(e) Significant potential to be harmful to self o

(f) Unemployable.

(g) Incapable of any social adjustment.



F OI A

R

el eas eP age3 0 2

PTSD that Existed Prior to S

(EPTS)

• Permanent versus temporary se

aggravation.

• Natural progression of the EPTS

condition.• "EPTS, not permanently service-

aggravated" means no benefits w

awarded (this. is less than a Oo/o



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F OI A

R

el eas eP age3 0 4

PTSD

• 1 March 2003 to 8 Aug 2005

- 850 cases with PTSD as a diagnosi

-0% 39 cases

- 10% 549 cases

- 30% 202 cases

-50% 6 cases

- EPTS 54 cases



F OI A

R

el eas eP age3 0 5

Methods

• Reviewed the PDA files of 113 PT

cases between Nov 2004 and Mar

• Data considered by the PDA in the

determination was tabulated, incluNARSUM and collateral informatio

other providers, commanders, cow

and family members

• Internal PDA emails/memos were



F OI A

R

el eas eP age3 0 6

Findings

• Search for any associations betwe

types of data and the amount of d

awarded

• Paint of picture of what types of dcommonly being included· by Army

psychiatrists in their MEBs for PTS



F OI A

R

el eas eP age3 0 7

Collection of Data

• A table of data was collected from

file, including:

• Disability Percentage

• Demographics

• Axis I, II, and Ill



F OI A

R

el eas eP age3 0 8

Collection of Data from

• Nature of Trauma

• DSM-IV PTSD criteria A, B, and C

• Social, Civilian, and Military-speci

dysfunction, and degree of detail• Treatment response

• Other MEB for physical injury

• Psychiatric and trauma history

• Appearance on mental status exa



F OI A

R

el eas eP age3 0 9

Collection of Other Da

• Use of collateral information from

notes, inpatient records

• Use of psychological testing

• Collateral information from family,coworkers, and command

• Verification of the trauma details v

from commanders



F OI A

R

el eas eP age3 1 0

Description of the Popul

• Disability awarded (from Dec 2004March 2005):

• 0% -- two files

• 10% -- 92 files• 30% -- 18 files

• 50% -- 1 file

• 32 files could not be located

• Average of 41 new c a s ~ s per mon



F OI A

R

el eas eP age3 1 1

Axes 1-111• 67% of the files had PTSD as the

Axis I diagnosis

• 25% had one additional Axis I diag

8% had three or more Axis I diagn• 2o/o had an Axis II diagnosis

• 32% received a MEB for a separa

Ill dx



F OI A

R

el eas eP age3 1 2

Input from Other Provid

• Large majority of the files lacked m

documentation other than the MEB



F OI A

R

el eas eP age3 1 3

Nature of the Trauma

• 83% of the MEBs described the tr

The rest did not mention anything

than "soldier was in Iraq"

• 39% of the soldiers suffered physiinjuries from a trauma

• 63% were directly at risk of being

during an incident.



F OI A

R

el eas eP age3 1 4

Nature of the Traum

• 71% described mental trauma from

viewing disturbing sights. More th

listed multiple sights.

• 33°/o of the MEBs described the soresponse to the trauma. Most of t

who received physical injuries wer

knocked unconsciousness simulta



F OI A

R

el eas eP age3 1 5

Duration of Symptom

• Most did not list the duration of sy

• Duration was extrapolated from da

return from deployment and date o

dictation• The median duration was 6 month

• The longest duration reported was

months



F OI A

R

el eas eP age3 1 6

Specific symptoms

• 14% (36 out of 113), documented

DSM-IV-required number of symp

re-experiencing, avoidance, and

hyperarousal• Factoring in Criterion A, only 18 M

(16o/o) met PTSD by DSM-IV



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F OI A

R

el eas eP age3 1 8

Symptom Stats

• Least commonly reported:

• Inability to recall - 3.5%

• Foreshortened future- 13.3%

• Restricted affect - 19%

• Psychological distress to cues- 2



F OI A

R

el eas eP age3 1 9

Association with Criteria A,B

• There was no association betwee

level of documentation of DSM-IV

A, B, C, or D with the disability

determination



F OI A

R

el eas eP age3 2 0

Dysfunction

• 28% of the MEBs did not mention

of impairment in social, civilian-

occupational, or military abilities in

section• 1·2% contained some sort of "posi

comment that an impairment shou

improve with time



F OI A

R

el eas eP age3 2 1

Dysfunction

• 62o/o (71 files) mentioned some so

social dysfunction

• 17o/o (21 files) mentioned some so

civilian occupational dysfunction• 42% (4 7 files) mentioned some so

military dysfunction



F OI A

R

el eas eP age3 2 2

Associations with Dysfun

• Specific dysfunction categories sh

association

• Absolute number of negative dysf

did show an associatio·n• The soldier with 50°/o disability had

of negative dysfunction document

• The 2 soldiers with 0% disability h

negative dysfunctions documented



F OI A

R

el eas eP age3 2 3

_________

Treatment Response

• 61% of the MEBs listed a poor tx

response. 27% made no commen

whatsoever.

• 3 files in the 30% disability categono treatment response documente

• 11 files in the 10% disability categ

received 10% despite having a po

treatment response



F OI A

R

el eas eP age3 2 4

- - - - - - - · - - -

MEB for other injury

• 32% (36 files) received a primary

a physical injury due to the trauma

• In these cases, the PTSD was co

an Addendum to the primary MEB• 24 received 10% disability; 2 rece

30°/o



F OI A

R

el eas eP age3 2 5

Psych/trauma Histor

• 24% of the soldiers had some sor

psychiatric history .

• 12% had a history of childhood tra

• No association with percent disab



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F OI A

R

el eas eP age3 2 7

Psychological testin

• 12% of the soldiers received psyc




F OI A

R

el eas eP age3 2 8

Collateral informatio

• 5 files had letters from coworkers

• 59% had a letter from a command

the soldier's dysfunction. Most w

nonspecific, and were written aftesoldier had been placed on a prof

.PTSD




F OI A

R

el eas eP age3 2 9

Collateral informatio

• 26 (23%) of the files contained ve

that the trauma occurred.

• 5 of those 26 contained 2 letters o

verification• No association with percent disab



F OI A

R

el eas eP age3 3 0

Conclusions

• Disability determiners generally a

diagnosis of PTSD even if insuffic

criteria are documented

• Predictions of the degree of dysfuthe civilian sector is the most imp

criterion in determining disability,

accordance with the regulations



F OI A

R

el eas eP age3 3 1

Conclusions

• Determination of 30% or greater d

may depend on other factors not

examined here:

- Nature of treatment failure-Types of treatment required for mai

- Specific nature of dysfunctions

- Documents other than narrative sum

- Discussions between USAPDA dete



F OI A

R

el eas eP age3 3 2

Conclusions

• Psychiatrists performing MEBs sh

concentrate on incorporating the

the illness (the exact impairments

soldier if they wish to maximally btheir MEB patients



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