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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
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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
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["},
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.)
I, .r& ..rkO;I-1 G.o r r . ~ & . . . , 1 - c.lL {;·c.-te ,..c..{ ;"\ .0 u / . ,
6. , f .pc;.l'r...opJ.. )._ r e . ~
•
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fvtt ;(}Co/Vl ~ ! ~ , · ~ , . ~ , . . d . J . . ~ - " ' 1 #-/ .
Cof; 4 I J-:. r, d " A - , ~ , . 4 / k p f t-C l. l t'd4./ h t - ' .t'l"t'l ('\
Tn.; "'r,l /I,'"··· f.9 .rr. ~ f l . • ~ / ¥ - , a r ; wpy ,;{ ~ ~ ~
~ ~ ~ c f ¥ " " <5NJ!,t, ~ v , ~ .f..P
E/.f<:.--11- {.,._ a.cf.. ·II' . .\
Page 4 of4 pages, DA Form 1574, Mar83USAPAV1.20
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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
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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
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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)
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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
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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
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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
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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
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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)
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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
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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
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SAMR-MPSUBJECT: Screening of Personality and Adjustment Disorder Discharges
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
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SAMR-MPSUBJECT: Screening of Personality and Adjustment Disorder Discharges
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
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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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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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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."
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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.
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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
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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.
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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)
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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
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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 (
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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.
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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
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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
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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
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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)
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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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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
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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)
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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.
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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Considerations for Civili
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
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Considerations for Civili
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
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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
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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
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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
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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.
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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
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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
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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.
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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.
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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.
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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.
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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.
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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.
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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.
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
• No association with percent disab
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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
• No association with percent disab
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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
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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
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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
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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