Other PTSD Compensation Issues
As part of their charge, the Department of Veterans Affairs (VA) requested that the committee offer their observations on some broad topics concerning compensation for posttraumatic stress disorder (PTSD). It posed four questions:
What are the barriers or disincentives to recovery?
What are or might be incentives to recovery?
What is the evidentiary basis for the physical, psychological, and social influences of compensation on treatment and recovery?
Is periodic reexamination appropriate for asymptomatic patients, as it relates to compensation?
This chapter addresses these questions. As some of the relevant research on the topics comes from nonmilitary populations and civilian compensation programs, the chapter reviews literature in these areas. Sexual assault and gender—two intersecting issues related to exposure to trauma and the frequency and severity of PTSD in veterans—are also discussed. The committee undertook to examine these issues because research indicates that there is gender disparity in service connection for PTSD and that the relative difficulty of documenting in-service sexual assault (as compared to documenting combat exposure) may be a factor in this difference.
BARRIERS OR DISINCENTIVES TO RECOVERY
The committee’s charge directed it to examine the barriers or disincentives to recovery and to “directly assess how PTSD compensation might influence beneficiaries’ attitudes and behaviors in ways that might serve as barriers to recovery.” This section addresses the general topic of barriers or disincentives to recovery, while the section that follows presents the literature on the effect of compensation on recovery and the committee’s conclusions and recommendations regarding this issue. Many of the studies on the barriers to recovery for persons with mental disorders have been conducted on civilian populations receiving support from programs administered by the Social Security Administration (SSA). As such, this chapter examines a broader range of research than other parts of the report.
Recovery can be defined in various ways. In the context of this report, the committee considered recovery to be a reduction in the frequency and intensity of symptoms accompanied by an increase in social and occupational function. The research reviewed and cited in this section often used return to work as the specific measure of recovery.
Research from the fields of disability, economics, health care, and labor studies has documented the wide variety of barriers to recovery and more broadly, to career advancement and economic security that can affect people with disabling mental disorders. In the civilian population, these barriers include low educational attainment, unfavorable labor market dynamics, low productivity, lack of appropriate vocational and clinical services, stigma in seeking services, labor force discrimination due to disabling conditions or race and ethnicity, failure of protective legislation, work disincentives caused by private and public disability policies, linkage of health care access to disability beneficiary status, and ineffective work incentive programs. Several notable barriers are discussed in more detail below.
Barriers Encountered by Veterans and Members of the General Population
One major barrier to recovery for many veterans who leave activeduty service is that they lack the necessary postsecondary education and training required to build careers. The original GI Bill was created, in part, to compensate veterans whose educational and career opportunities were interrupted by military service (Angrist, 1993). Research has shown that users of veterans’ benefits do increase their levels of education, resulting in corresponding increases in earning power (O’Neill, 1977), and that the largest benefits accrue to those who attend college or graduate school (Angrist, 1993). It has been suggested that PTSD is more likely to oc-
cur among veterans at lower educational levels rather than higher ones1 (Breslau et al., 1991), and, indeed, Beckham and colleagues found that the average number of years of education was significantly lower among veterans with PTSD than among veterans without PTSD (Beckham et al., 1998). One implication of this is that analyses of the association between PTSD and occupational success will be confounded by the level of educational achievement.
Deficits in education are critically important because advanced education is increasingly essential to securing a high-paying job. In 2004, all but one of the 50 highest-paying occupations in the U.S. required a college degree or graduate education (BLS, 2006). A multivariate analysis of employment among a nationally representative group of adults with mental illness in the National Health Interview Survey: Disability Supplement found that education was a significant predictor of employment in general as well as, specifically, of employment in executive, administrative, or professional specialty occupations (Mechanic et al., 2002).
Another barrier to recovery stems from the fact that many individuals whose condition improves after the onset of disability reenter the workforce at a significant disadvantage. Research shows that disabled individuals on Supplemental Security Income (SSI) who reenter the labor force tend to work at jobs that are lower paying and held for fewer hours per week than the jobs they held prior to becoming disabled (Schechter, 1999). Further, while workplace accommodations may extend the average duration of employment for disabled individuals (Burkhauser et al., 1995), there is evidence that some injured workers who receive job accommodations also receive lower wages so that they, in essence, “pay the price” of their own accommodations (Gunderson and Hyatt, 1996). In one study of individuals with psychiatric disabilities who returned to work, among those working full-time only 24 percent had jobs that provided medical coverage, 16 percent had dental coverage, 8 percent mental-health coverage, and 20 percent sick leave (Cook et al., 2006).
Disability-income support policies often create unintended employment disincentives that help contribute to under- and unemployment (Burkhauser and Wittenburg, 1996; CBO, 1982). In both private and public disability-
compensation systems, for instance, regulations typically mandate an administrative review of the individual’s disability status upon return to work. This discourages many disabled beneficiaries from seeking employment (Newcomb et al., 2003). And once they become employed, beneficiaries often find that, as their earnings increase, their monthly cash payments are sharply reduced. For example, the SSA) sets an earnings cutoff called the substantial gainful activity (SGA) level. Social Security Disability Income (SSDI) beneficiaries can earn up to the SGA level each month ($830 in 2006) with no loss of benefits; however, once earnings exceed that amount for nine nonconsecutive months plus a three-month grace period, all SSDI cash benefits cease. The sudden cutoff is referred to as the “earnings cliff” (White et al., 2005). SSI beneficiaries face a different penalty: Once their earnings reach $65 per month, their cash payment is reduced by one dollar for every two dollars of additional earnings, a tax rate of 50 percent—far exceeding that paid by the wealthiest individuals (Stapleton et al., 2005). Yet another disincentive is an “implicit tax” on disabled workers whose labor force participation causes them to lose additional benefits such as housing subsidies, utility supplements, transportation stipends, and food stamps (Polak and Warner, 1996). Research has indicated that people with psychiatric disabilities are aware of these disincentives and report that they plan their labor force participation accordingly (Polak and Warner, 1996; MacDonald-Wilson et al., 2003).
The effects of work disincentives are also evident in studies comparing the employment outcomes of disabled individuals who do and who do not receive disability-related income support. One study of individuals with psychiatric disabilities receiving employment services found that those receiving SSI or SSDI cash benefits were significantly less likely to work competitively, to work forty or more hours per month, or to have high earnings than those who didn’t receive such benefits, regardless of clinical condition, level of disability, symptoms, education, or prior work history (Cook et al., 2005). According to research on both national and statewide cohorts of state vocational rehabilitation service recipients with psychiatric disabilities, employment rates are significantly lower among SSI and SSDI beneficiaries than among nonbeneficiaries, after controlling for functional impairment, level of family support, and demographics (Hayward and Schmidt-Davis, 2005; Cook, 2003). Two studies that controlled for a series of confounding demographic and clinical factors found that veterans with psychiatric and other disabilities are less likely to work, earn less money, and work fewer hours if they receive full—versus partial—benefits or if they receive more generous benefit amounts (Rosenheck et al., 1995; Drew et al., 2001). It should be noted that the reasons for the behavior underlying these results are complex and deserve careful thought; one should not simply conclude from them that giving only partial benefits would solve the problem.
Given the evidence suggesting that people respond to work disincentives by altering their labor force participation, it follows that policies designed to discourage reliance on disability income may paradoxically discourage substantial work attempts that could lead to exit from the rolls. Instead, many individuals receiving SSI and SSDI find themselves out of the labor force or trapped in low-paying, entry-level jobs where they are prevented from realizing their full career potential (Stapleton et al., 2005; Cook and Burke, 2002). Those who do successfully overcome their disability and maintain employment—and thus lose their cash benefits and related health insurance—often experience relapses of their illnesses due to their inability to get access to health and mental-health services.
Recognizing this problem, various work-incentive provisions for individuals receiving public disability income support have been legislated by Congress. The Employment Opportunities of Disabled Americans Act of 1986 (Public Law 99-643), Section 1619(b), provided for continued SSI eligibility and access to Medicaid as long as earnings remain below a threshold established by each state. Another mechanism permitting individuals to work above SGA level while retaining Medicaid benefits was the Medicaid buy-in state plan option under the Balanced Budget Act of 1997 (Public Law105-33). The newest piece of disability legislation designed to address work disincentives is the Ticket to Work and Work Incentives Improvement Act of 1999 (Public Law 106-170). This legislation was intended to give people with disabilities increased vocational service options and reduce employment disincentives, while at the same time reducing government spending on people with disabilities (Stapleton and Livermore, 2003). To accomplish the first objective, vouchers or “tickets” were mailed to all work-disabled SSI and SSDI beneficiaries. The tickets are redeemable for 5 years of vocational services from providers of the beneficiaries’ own choosing (Cook et al., 2006). In addition, Ticket participants were offered free benefits and entitlements counseling to help them gauge the effects of employment on their cash benefits and other unearned income. SSA also placed a moratorium on continuing-disability reviews for Ticket participants and encouraged state Medicaid buy-ins enabling people to keep their health insurance after cash benefits ceased. The idea was that SSA would realize savings from the “outcome payment”-based structure, where providers would be paid only for the months that individuals earned above SGA or only at the time beneficiaries left the rolls because of employment.
Unfortunately, the national evaluation of the Ticket program (Thornton et al., 2006) has identified several problems with its implementation. First, the rate of participation in the program is very low. Even in states where it has operated the longest, just 1.1 percent of beneficiaries have assigned their tickets to providers. Second, the rate of provider participation is similarly low. Only 40 percent of all providers were accepting tickets as of June 2004.
Moreover, consistent with the simulation study cited earlier (Cook et al., 2006), the evaluators’ analysis of provider costs and revenues suggests that those relying solely on Ticket payments would have lost money after two years of operation. Despite this pessimistic picture, Ticket participation is relatively vigorous among individuals with disabling mental disorders, who have the fifth-highest rate of participation among the 21 primary disabling conditions examined (Thornton et al., 2006). At the same time, there is also evidence of reluctance to serve this population since one-third of the providers interviewed for the evaluation mentioned psychiatric or other disabilities as a challenge to finding jobs for Ticket beneficiaries.
Some of the barriers discussed above apply to veterans but are ameliorated by the presence of VA programs, while others are exacerbated by the special circumstances of military service. One ameliorative factor is that veterans’ benefits subsidize education and vocational training. Among the exacerbating circumstances is the high level of stigma that the military culture places on seeking help for mental-health problems. For example, one study found that VA providers reported more negative attitudes toward clinical work involving veterans seeking PTSD compensation than toward clinical work involving other veterans (Sayer and Thuras, 2002). Another exacerbating factor is the lack of VA-sponsored employment programs in some areas of the country.
On the other hand, there is also some evidence that receiving service-connected disability for PTSD actually encourages individuals to seek mental-health treatment. Unpublished research by Sayer and colleagues indicates that the claim process may make it easier to gain access to medical services and that being awarded disability status for PTSD may facilitate access to mental-health services (Sayer et al., 2005b).2
Although there are studies on racial and ethnic influences on PTSD incidence and severity (Beals et al., 2002; Friedman et al., 2004; Kulka et al., 1990a; Loo et al., 2005; Ruef et al., 2000) and on culturally-sensitive diagnosis and treatment for the disorder (Blow et al., 2004; Penk and Allen, 1991; Rosenheck and Fontana, 1996), the information on service connection is far more limited. Murdoch and colleagues (2003a), however, did find that African American service members were less likely to be service connected for PTSD than other veterans (43 percent versus 56 percent; p=.003) after controlling for sociodemographic characteristics, symptom severity, functional status, and trauma histories. A fact sheet produced by the VA’s National Center for PTSD (Loo, 2007) counsels examining clinicians that
[p]rofessional responsibility in providing appropriate services to ethnic minority veterans also applies to Compensation and Pensions examina-
tions. If clinicians do not evaluate for negative race-related events that may have led to psychiatric problems, the ethnic minority veteran may not be receiving the appropriate disability rating or compensation. Thus, it behooves VA clinicians to be particularly attentive to examining possible race, ethnic, or cultural issues among ethnic minority veterans.
The committee’s literature review indicates that there are many barriers to recovery for Vietnam veterans diagnosed with PTSD. Some of these are common to all people with disabilities, some are experienced by all those with mental disabilities, and a few are unique to veterans, to those with PTSD, and to persons using the VA disability system.
The literature suggests that many barriers are endemic to the programs used to provide services to those with disabilities, while some are unfortunate consequences of the symptomatology of certain disabilities, and others result from entrenched attitudes about the disabled and, in particular, about those with psychiatric illnesses. There are no easy solutions: experience with civilian benefits systems has shown that the problems will be difficult to remedy.
THE EFFECT OF COMPENSATION ON RECOVERY
One of the key issues that the committee was asked to assess is how PTSD compensation might influence veteran beneficiaries’ attitudes and behavior in ways that could serve as barriers to recovery. The committee was specifically asked to evaluate the evidentiary basis for various influences of compensation on treatment and recovery (Szybala, 2006).
The effect of disability compensation on beneficiaries’ behavior has long been an issue in research and in practice, both in the general population (IOM, 1991; Bellamy, 1997) and for the military and veterans (IOM, 1999; Drew et al., 2001; Mossman, 1996). Attention has increasingly shifted to the more subjective ailments and injuries, such as chronic pain (Sullivan and Loeser, 1992; Rohling et al., 1995) and mental disorders (Estroff et al., 1997), particularly PTSD (Rosen, 2004, 2006; Mossman, 1994; Guriel and Fremouw, 2003). Because a positive finding often results in monetary or other types of compensation, assessing psychopathology within the context of disability is almost always complicated by the possible influences of secondary gain. Indeed, secondary gain has long been hypothesized to increase the possibility that symptoms and their effects will be exaggerated, both during the course of treatment and during recovery, and both for general disabilities and for combat-related PTSD in particular (Atkinson et al., 1982; APA, 1994; Resnick, 1997). In recent years, however, because of the
dramatic increase in the numbers of veterans seeking and receiving awards for PTSD, the possibility of service-connected disability being awarded because of exaggerated or fraudulent claims has become an increasing concern (DVA, 2005b; Murdoch et al., 2003a,b,c).
These concerns have resulted in a substantial research literature on compensation-seeking attitudes and behaviors among veterans. In the case of PTSD, most studies fall into one of four categories. The first is research on the fabrication, misrepresention, or misrecall of veterans’ combat or trauma exposure; such exposure is, of course, a key criterion if they are to receive service connection for their disabilities. The second—and by far the most common—type of research consists of studies that focus on the detection of misreporting or exaggeration of PTSD and other symptoms by veterans seeking or receiving compensation. Third, there is some research that examines how seeking or receiving compensation affects treatment-seeking or the use of mental-health services. Finally, there are a few studies on how receiving compensation might affect subsequent responsiveness to treatment or treatment outcomes.
Misreporting of Combat or Trauma Exposure
A number of observers have suggested that the opportunity to receive disability compensation might motivate veterans to falsify or exaggerate their combat involvement or exposure. Some case reports describe Vietnamera veterans who have fabricated histories of traumatic events, tours of duty, and even military service itself in order to obtain benefits (Sparr and Pankratz, 1983; Lynn and Belza, 1984; Burkett and Whitley, 1998), but these cases provide no direct evidence of the prevalence of such behaviors or the probable magnitude of their effect on seeking or receiving disability. A 2005 analysis by the VA Office of the Inspector General (OIG) focused on the claim files of 2,100 veterans receiving disability for PTSD and found that 25 percent had no compelling evidence that they had been exposed to any traumatic event whatsoever, thereby raising the specter of questionable compensation payments (DVA, 2005b). Subsequent review of the cases by the VA, however, determined that “[t]he problems with these files appear to be administrative in nature, such as missing documents, and not fraud” (DVA, 2005a).
The most widely cited empirical study on this issue is that of Frueh and colleagues (2005), who found that only 41 percent of 100 treatment-seeking veterans reporting Vietnam combat involvement had objective evidence of combat exposure documented in their publicly available military personnel records. They concluded from these results that a “meaningful” number of treatment-seekers “may be exaggerating or misrepresenting their involvement [and combat exposure] in Vietnam,” and, by inference, they attributed
this to “the disability benefit incentive” and compensation-seeking. They concluded, for example, that “concerns that exaggerated or false reports of combat exposure are at least in part associated with financial incentives are supported by our findings that the ‘no combat’ group appeared to be applying or intending to apply for disability benefits at the same rate as the ‘combat’ group.” However, both prior and subsequent research has called into question whether the information available solely in the military personnel files—commonly referred to as 201 files—is adequate to support such a strong conclusion.
In contrast, a later study (Dohrenwend et al., 2006) came to a very different conclusion when it combined data from the National Vietnam Veterans Readjustment Study (NVVRS) (Kulka et al., 1990b) with newly developed data from military records and a comprehensive set of other archival sources in order to address questions raised about the influence of self-report bias on NVVRS estimates of the prevalence of PTSD among Vietnam veterans. Those researchers found “a strong positive relationship between [the veterans’] record-based … exposure measures and the dichotomous measure of … war zone stress constructed by the NVVRS investigators on the basis of veterans’ retrospective reports of their experiences.” While acknowledging McNally’s caution that “one cannot generalize from an epidemiological sample to a clinical one” and advice that “archival sources are important in both contexts” (McNally, 2006), it is also important to know the strengths and limitations of these sources.
In its role as the conservator of the military personnel records, which was the sole records source used by Frueh and colleagues, the National Archives and Research Administration offers the following caveat for users on its website:3 “Detailed information about the veteran’s participation in military battles and engagements is NOT contained in the record” (U.S. National Archives and Records Administration, 2006; emphasis in original). The methods developed by Dohrenwend and colleagues (2006) clearly demonstrate the value of broad-based research into other indicators of the likelihood of having experienced traumatic stressors and the importance of using information from historical accounts (for example, unit assignments and dates of service). A veteran’s 201-file information is a necessary but not always sufficient source with which to confirm self-reported information related to combat involvement or exposure. A careful reading of the meticulous methodology employed by Dohrenwend and colleagues reveals that their analysis depended a great deal on indicators not directly obtainable from 201 files and shows that they did not consult with archival sources only as needed, despite what McNally implied and suggested in both the original and follow-up commentaries (McNally, 2006, 2007). Moreover,
Frueh and colleagues explicitly acknowledge the great potential value of adding “objective military records, including research on unit records and casualty reports” (Frueh et al., 2005).
In summary, while misrepresentation of combat involvement and exposure undoubtedly does happen among veterans seeking treatment and compensation for PTSD, the evidence currently available is insufficient to establish how prevalent such misrepresentations are and how much effect they have on the ultimate outcome of disability claims. And no matter how common such behavior ultimately proves to be, the best strategy for addressing this problem is most likely already at hand, based on the research that has been conducted to date.
The committee concludes that the most effective strategy for dealing with problems with self-reports of traumatic exposure is to ensure that a comprehensive, consistent, and rigorous process is used throughout the VA to verify veteran-reported evidence. One approach to achieving this objective is routine and consistent use of the full range and battery of methods implemented and tested by Dohrenwend and colleagues (2006). The best-practice manual for C&P examinations, written by VA clinicians, already recognizes the value of careful and in-depth review of records (Watson et al., 2002).
Consistent with such a strategy, a GAO report (GAO, 2006) described methods that the VA can use to improve its procedures for obtaining military service records, including several used by Dohrenwend, and reiterated the VA’s “duty to assist” veterans in obtaining any records relevant to their claims. One potential records issue that emerged from the committee’s research is the need for claimants to identify the dates of their stressor events within a fairly narrow time window.4 Given the potential for a substantial gap between the time these events occurred and the time that claims are filed, it is possible that claimants might misremember dates and thus valid events might fail to be verified. In contrast, Dohrenwend used the full range of service dates to identify unit exposures from records and other archival sources. While it is recognized that such a protocol may increase both the time and expense required to complete these examinations, the OIG estimates of both the annual and lifetime costs of possible questionable compensation payments (DVA, 2005b) suggest that the long-term benefits of a more rigorous assessment may greatly outweigh such increases in costs (McGrath and Frueh, 2002).
Misreporting or Exaggeration of Symptoms
As noted above, the majority of empirical studies conducted to date on the possible influence of the VA disability compensation system on PTSD and its treatment have addressed symptom-reporting issues. These issues include “symptom elevation” (Fairbank et al., 1983), “overreporting” (Hyer et al., 1988), “exaggeration” (Smith and Frueh, 1996) and “extreme exaggeration” (Gold and Frueh, 1999) in veterans seeking or receiving compensation for PTSD, and many of the studies have examined the use of standardized test measures to detect malingering or the feigning of PTSD symptoms (Frueh et al., 2000).5 It is well established that combat veterans who are evaluated for PTSD frequently exhibit extreme elevations across various assessment measures (Fairbank et al., 1983). These elevated measures are also typically accompanied by a pattern of elevations on the MMPI/MMPI-2 validity scales consistent with symptom overreporting (Fairbank et al., 1983; Frueh et al., 1996, 1997; Hyer et al., 1986; Elhaiet al., 2001; Franklin et al., 2002), so concerns have been raised regarding the accuracy of veterans’ accounts of their psychological functioning, which in turn poses significant challenges for diagnostic assessment and treatment. On the other hand, several researchers have noted that this response pattern—the reporting of a wide range of symptoms and overreporting of symptoms in general—is part of the overall profile of PTSD, a disorder characterized by the presence of a heterogeneous set of symptoms, high rates of comorbidity, and, quite often, extreme symptom severity (APA, 2000; Elhai et al., 2000, 2001; Fairbank, et al., 1983; Hyer et al., 1988; Keane and Wolfe, 1990).
While research and commentary (Elhai et al., 2000; Frueh et al., 1996, 1997; Smith and Frueh, 1996) suggests that this pattern may reflect, at least in part, symptom overreporting by a subset of veterans who are motivated by possible receipt of financial compensation, access to treatment, and other incentives, the literature examining the relationship between compensation seeking and reported levels of psychopathology has in fact yielded mixed results. Frueh and colleagues found that veterans they defined as compensation-seeking6 scored significantly higher than non-compensation-seeking veterans on several MMPI scales (including the F scale) as well as on several associated pathology scales (Frueh et al., 1996). Similar results
Chapter 5, which addresses issues surrounding the conduct of the PTSD C&P examination, also discusses the topic of testing to detect malingering in the context of a broader examination of the use of psychometric instruments.
Compensation-seeking veterans were defined as “those who were currently seeking or planning to seek VA disability compensation or increases in existing disability payments for PTSD” while non-compensation-seeking veterans were “those who were not intending to seek VA disability compensation for their PTSD symptoms” (Frueh et al., 2003).
were reported where compensation-seeking was not restricted to claims for PTSD (Frueh et al., 2003). When Smith and Frueh classified veterans as “exaggerators” and “nonexaggerators” of psychopathology based on the MMPI-2 F-K index, they found that exaggerators had higher rates of affective disorders and scored higher on self-report measures of various psychological symptoms but were no more likely to be seeking compensation (Smith and Frueh, 1996). In a follow-up study using stricter criteria for exaggeration, Gold and Frueh reported that “extreme exaggerators” were much more likely to be compensation-seeking and scored much higher on self-report measures of various symptoms, despite having lower rates of PTSD diagnoses and similar rates of comorbid disorders (Gold and Frueh, 1999).
A later study (DeViva and Bloem, 2003) replicated the results reported by Smith and Frueh, finding no relationship between exaggeration and compensation-seeking status using the lower cutoff for exaggerators, but the study did not replicate an earlier finding (Frueh et al., 1997) that compensation seekers scored higher on MMPI-2 subscales. Grubaugh and colleagues (2004) found that self-reports of distress and validity scale indices on the MMPI-2 were higher among compensation-seeking veterans than among non-compensation-seeking veterans, despite a lack of difference in actual PTSD diagnoses. Similarly, Tolin and colleagues (2004) found compensation-seeking status associated with extreme elevations across clinical and validity scales, but, in contrast to previous findings, compensation-seeking veterans were also found to be more likely to receive a PTSD diagnosis.
As a body of literature, these studies have weaknesses that limit their informativeness. Most of them, for instance, examined veterans seeking treatment through specialized PTSD programs, and these samples have generally been small. They generally study veterans who apply for compensation as opposed to those who actually receive a service-connected disability for PTSD. The definitions used to define compensation seekers, while similar, are not identical, and heterogeneities in the group not seeking compensation are generally left unaddressed. There are also alternative explanations for some reported malingering: Certain claimants whose test scores are inconsistent with a diagnosis of PTSD, for example, may be experiencing another compensable psychiatric condition whose symptoms are being misattributed to PTSD. And the studies are all cross-sectional rather than longitudinal, thereby further limiting their ability to yield consistent and firm conclusions (Friedman, 2006). Thus, while considerable research has been conducted to date, it is not as consistent or comprehensive as it needs to be if it is to provide reliable answers to questions regarding how large a role compensation plays in malingering or symptom overreporting or, if it is, to help identify a clear direction or policy.
Many of the studies examining misreporting or exaggeration of symp-
toms use the MMPI-2 and its validity scales or else some other more recently derived measures, such as the FP7 (Arbisi et al., 2004; Tolin et al., 2004). Generally, the focus of these studies is the potential use of one or more of these instruments as a tool to detect exaggeration or illness simulation in veterans seeking or receiving compensation for PTSD. A key question then is whether these standardized measures are able to play a larger role in detecting and screening out those who are feigning PTSD in order to receive service-connected status and compensation.
While these studies indicate that the validity and related indices derived from the MMPI-2 can play a role in identifying veterans who may be exaggerating their psychopathology to gain disability compensation (Gold and Frueh, 1999; Arbisi et al., 2004; Keane, 2006), it is also true that “currently, there is no method or single instrument that is universally recognized as being the best tool to detect malingering in PTSD claimants” (Guriel and Fremouw, 2003).
Arbisi and colleagues observe:
It is important to bear in mind that the MMPI-2 is a single source of information in a comprehensive diagnostic evaluation for PTSD and should never be the sole piece of data used to make a disability determination. [Rather, it should] be used within the context of a careful review of the military history and medical treatment records contained in the claims file as well as a thorough clinical interview including a structured interview for PTSD before reaching a conclusion regarding claimed disability resulting from PTSD (Arbisi et al., 2006, p. 258).
The Diagnosis and Assessment report (IOM, 2006) and this committee (in Chapter 5) found that available data support the role of the MMPI-2 and other psychometric instruments as a valuable source of information in the C&P process. It should be noted, though, that if these or other such measures were ever to be used as the sole source of information for detecting and screening out potential malingerers, motivated claimants would quickly learn how to respond to these items to avoid detection (Bury and Bagby, 2002). It is thus unlikely that the either the MMPI-2 or any other measure will ever provide a “silver bullet” that will allow for a quick and easy identification of fabrication or malingering among PTSD claimants.
The committee thus concluded in Chapter 5 that psychological testing may be a useful adjunct to the PTSD C&P examination but also recommended that the choice of whether to test and which tests to use should be left to the discretion of the clinician, the person who is best able to evaluate the individual circumstances of the case. In the absence of a definitive measure, the most effective way to detect inappropriate claims is to require a consistent and comprehensive state-of-the-art examination and assess-
ment that allows the time to conduct appropriate testing in those specific circumstances where the examining clinician believes it would inform the assessment.
Testimony presented to the committee indicated that clinicians often feel pressured to severely constrain the time that they devote to conducting a PTSD C&P examination—to as little as 20 minutes (Arbisi, 2006)—even though the examination protocol suggested in the Best Practice Manual (Watson et al., 2002) requires up to three hours to complete, with additional time needed for complex cases. While a more thorough examination would increase upfront costs, it may produce significant long-term cost savings by reducing inappropriate awards, and it may provide substantial benefits as well by increasing the fairness and validity of the system—not only reducing the number of false-positive determinations but also avoiding many of the false negatives that would deny benefits to veterans who truly deserve them.
Disability Compensation and the Use of VA Mental-Health Care Services
Given the consistent cross-sectional findings that indicate that veterans with VA disability benefits are more likely to use VA services (Wolinsky et al., 1985), it would be reasonable to assume that claimants who are awarded service-connection disability for PTSD would increase their use of mental-health care services. However, if claimants exaggerate symptoms or malinger for the purpose of obtaining compensation they are not entitled to, one would instead suspect that these persons would tend to drop out of treatment for PTSD (Burkett and Whitley, 1998) or use VA services less often (Campbell and Tueth, 1997) once they achieve the benefits level they seek and no longer need such services to help validate their claim. Burkett and Whitley (1998) summarize this second view as follows:
One common-sense question might weed out imposters: Do PTSD claimants continue with therapy and Vet Center counseling after they successfully obtain PTSD disability compensation? Valid sufferers would persevere, seeking alleviation of their suffering; malingerers would not (p. 280).
The evidence base available to evaluate this issue is sparse. In its report on variances in disability compensation, the OIG provides some data that do appear to be consistent with a “malingerer/drop-out” hypothesis:
When PTSD ratings were increased to 100 percent, veterans sought less treatment for the conditions. In a judgment sample of 92 PTSD cases, we found that 39 percent of the veterans had a 50 percent or greater decline in mental-health visits over the 2 years after the rating decision. The average decline was 82 percent, and some veterans received no mental-health treat-
ment at all. While their mental-health visits declined, non-mental-health visits did not (DVA, 2005b, p. 52).
And, in keeping with that hypothesis, it was asserted that “the compensation program has a built-in disincentive to get well when veterans are reapplying to get their disability ratings increased” (DVA, 2005b). Although the OIG analysis has received some attention (McNally, 2005, 2006), it is clearly limited by the selective nature of the sample and the lack of supporting data. To the committee’s knowledge, no further work has been done with the data to explore this critical issue. This is unfortunate because other scientific evidence does not support the OIG findings. During a presentation to the committee, Friedman (2006) summarized the evidence as follows:
Longitudinal studies suggest that disability claim approval results in increased use of mental-health services.
Cross-sectional research shows that veterans with service-connected disability for PTSD do not differ from non-service-connected veterans in their levels of participation in treatment, and there is some evidence that service-connected veterans are more likely to participate in treatment.
A cross-sectional study of the potential effect of compensation-seeking on service utilization found no significant differences between compensation-seeking and non-compensation-seeking veterans in their use of health care, but compensation-seeking veterans were more likely to use PTSD services (Grubaugh et al., 2004). The best way to address this question, however, would be to compare veterans granted service connection for PTSD versus those denied service connection, instead of examining compensation-seeking versus non-compensation-seeking veterans, and to use longitudinal rather than cross-sectional designs.
Sayer and colleagues did conduct such longitudinal research, the results of which were shared with the committee (Sayer et al., 2005a). In one study effort (Sayer et al., 2004a, 2005b) data were abstracted from VA administrative databases for 452 veterans who had disability evaluations for a new PTSD claim between 1997 and 1999. The rates of mental-health service use before the initiation of a disability claim and mental-health service use soon after the claim were determined and compared. Mental-health service utilization increased after disability benefits were awarded, from an average of 2.5 mental-health appointments during the preclaim period to 5.6 after the award, and the proportion of veterans using mental-health services more than doubled, increasing from 25 to 52 percent. Furthermore, as the disability level increased, the rate of mental-health service use increased significantly, with the rate of mental-health service utilization higher among veterans with 70 to 100 percent disability for service-connected PTSD than
for those veterans with ratings of 50 percent or less. A separate analysis for these claimants that looked at three different time periods (Spoont et al., 2002) found that for veterans whose claims were ultimately awarded the numbers of mental-health visits during the examination and postnotification periods were higher than they had been during the preclaim period.
A separate study by Sayer (2006a,b; also in Spoont et al., 2005) conducted standardized assessments of symptoms and functioning for a group of 102 veterans who had filed original PTSD claims. Two assessments were performed: one near the time of claim initiation, and the other several weeks after notification of claim determination. The researchers also abstracted data on service utilization from VA administrative databases for 260 days before claim initiation and for the same period after claim determination. Those awarded benefits had more severe PTSD symptoms and poorer functioning than those denied benefits, both at the time of claim initiation and after notification. While the proportion of those using VA medical services increased about equally among those awarded and denied claims, the proportion of those using mental-health services increased significantly—in this case, from 48 to 70 percent—only among those who had been awarded claims.
Thus, while the OIG’s findings are quite provocative and sobering, the preponderance of evidence currently available is not consistent with its results or conclusion. As Sayer (2006a) noted, in summarizing this research, “This is not the pattern of effects that one would expect if financial incentives were driving symptom levels and service utilization among veterans who seek PTSD disability status.”
There are some important limitations to the studies performed by Sayer and colleagues. The samples are fairly small, are limited to one VA region, and include only those already using VA medical services (including, in many cases, mental-health services) prior to initiating a disability claim for PTSD. While it was logical to design these studies to include in their samples only those veterans for whom VA medical care was an option both before and after obtaining service-connection for PTSD, it has been noted elsewhere that nearly half of the veterans seeking service-connected disability for PTSD have never used mental-health services (Sayer et al., 2004b). It has also been reported that from 69 to 94 percent of veterans who seek treatment for PTSD in the VA system apply for psychiatric disability (Frueh et al., 2003), although it is unclear how many veterans applying for PTSD disability have not used VA services or mental-health care.
Access to VA health care services requires the claimant to demonstrate eligibility; once eligibility is demonstrated, priority and the cost of services (if any) are based on a ranking system by which veterans with service-connected injuries or conditions, regardless of their financial circumstances, take precedent over low-income veterans without such condi-
tions (Murdock et al., 2005). The 452 beneficiaries examined by Sayer and colleagues (2004a, 2005b) were all already entitled to VA medical care without charge, either because of service connection for other conditions or because they met low-income criteria. Such veterans are likely to be quite different from those not already in the system—that is, not already eligible for free or priority VA mental-health treatment before obtaining a service-connected disability for PTSD. If the dynamics behind the use of post-service-connection mental-health services are to be better understood, both larger and more diverse samples will need to be examined.
It is possible that Sayer and colleagues observed an increase in the use of VA mental-health treatment in the months following receipt of service connection for PTSD because the C&P process, which would necessarily include revisiting the traumatic stressor in rather great detail, placed a strain on the mental and physical health of the claimant. An alternate, or additional, explanation is that the C&P evaluation process generated referrals to services. However, such referrals are not a formal part of the C&P process, and it is highly unlikely that they occur in any systematic way.8
In addition to the literature on veterans, there are a small number of studies that address the determinants of PTSD treatment participation in nonmilitary populations. These studies suggest, in general, that symptom severity is an important factor in attrition from programs. A 2006 meta-analysis of 11 studies found that persons who dropped-out of treatment programs were more likely to have had elevated PTSD symptoms scores prior to participation than those who did not drop out (Matthieu and Ivanoff, 2006). Holtzheimer and colleagues (2005) evaluated the records of 587 persons hospitalized for PTSD and comorbid depression and a matched cohort with depression alone. They found that, all else equal, those with PTSD and depression were far more likely to have been discharged against medical advice than those with depression alone (OR=6.10; 95% CI 2.96–12.57).
In summary, while some veterans do drop out of mental-health treatment once they obtain service-connected disability compensation for PTSD, the currently available data suggest that this concern may well not apply to the majority of veterans who seek and obtain such awards. Sayer and colleagues (2004b) found that veterans report many reasons other than monetary gain for seeking disability compensation, including acknowledgement from the government of their contribution and sacrifice and validation of the health problems they are experiencing. Over half of the veterans in their sample endorsed the statement, “If I get service connected for PTSD,
I can focus on getting better,” an attitude that is inconsistent with the malingering/drop-out hypothesis. Research examining the full range of reasons why beneficiaries discontinue seeking mental-health care in the VA system—including access to services, degree of satisfaction with VA services or treatment outcome, and pursuit of treatment in non-VA venues—would make it possible to carry out a more informed and less politically charged consideration of this topic.
Disability Compensation and Treatment Outcome9
In addition to concerns that veterans may participate in treatment merely to get compensation, there are related concerns that disability compensation for PTSD may create a situation in which secondary-gain issues produce obstacles and disincentives for therapy or treatment (Mossman, 1996). Specifically, some researchers have speculated that veterans may be reluctant to acknowledge therapeutic gains because they believe that this may lead VA to lower their disability rating and thus lower their benefits (Frueh et al., 2003). Some of the evidence for these concerns is indirect. For example, in contrast to studies reporting relative success in the treatment of non-combat-related PTSD, there is a general lack of treatment efficacy for PTSD related to combat (Carlsen et al., 1998; Johnson et al., 1996). In a meta-analysis of psychotherapy for PSTD conducted by Bradley and colleagues (2005), the overall effect size from studies of combat veterans was significantly lower than the effect sizes for other trauma groups. Other research has found that the VA clinicians treating veterans seeking compensation for PTSD often have negative impressions of these veterans (Bell and Williamson, 2002), with “most clinicians express[ing] a belief that pursuit of service connection for PTSD has a negative impact on the therapeutic relationship” (Sayer and Thuras, 2002).
One empirical study more directly related to the hypothesized association between compensation seeking and treatment outcomes found that veterans classified on the MMPI as “symptom overreporters” were less likely to show improvement after six weeks of partial hospitalization, even though clinicians rated them as no more dysfunctional than other veterans before treatment (Perconte and Griger, 1991). In contrast, DeViva and Bloem (2003) found no relationship between either symptom exaggeration or compensation seeking and treatment outcome in an eight-week residential treatment program at a specialized VA Medical Center inpatient PTSD unit.
As Friedman (2006) noted in his presentation to the committee, data from evaluations of VA programs on the relationship between compensation seeking or disability status and treatment outcomes are inconclusive. The most widely cited of these is by Fontana and Rosenheck (1998a), who found that veterans in outpatient programs who were compensation-seeking improved more than veterans who were not compensation-seeking, while veterans in inpatient programs who were seeking compensation either improved less or deteriorated in comparison with those who were not seeking compensation. When inpatient programs were classified according to length of stay, however, outcomes were worse for those seeking compensation only in the group of inpatients in programs with very long lengths of stay (100 days on average). There were no differences in treatment outcomes by compensation status for inpatients in moderate-stay programs (30 days).
Friedman (2006) noted that no relationship between treatment outcome and PTSD disability status has been found in any of the VA clinical trials that have tested the potential effects of seeking or receipt of a service-connected disability. This was also the case in a 2006 study of cognitive processing therapy by Monson and colleagues. They found that treatment participants receiving PTSD-related disability compensation had reductions in their PTSD symptoms over time that were similar to the reduction in symptoms among those participants without PTSD disability status, PTSD-related disability status showed no association with the PTSD diagnostic status at posttreatment or follow-up (Monson et al., 2006).
With regard to the possible effect of PTSD disability status on short-and long-term recovery, Murdoch told the committee of some work in progress that indicates that veterans who were service-connected for PTSD for longer periods of time have less severe symptoms and better functioning than those who were service-connected for shorter periods of time or who never achieved PTSD-related disability status (Murdoch, 2006). Such effects might, though, reflect maturation or cohort effects rather than recovery related to treatment. But they are not consistent with concerns that, in spite of the intent of the regulations stating that veterans receiving VA disability benefits for nonpermanent conditions should be reevaluated every two to five years, the provision of disability payments might provide a disincentive for improvement and an incentive to exaggerate symptomatology (Sayer et al., 2004a).
In summary, although it may seem logical that secondary-gain considerations would create obstacles and disincentives for therapy or treatment among combat veterans, and although there is a body of indirect evidence consistent with this logic, there is little direct evidence that either compensation-seeking or receipt of compensation has secondary gain effects on PTSD treatment outcomes. Most empirical studies or trials conducted to date show no relationship between compensation seeking, PTSD disability
status, and treatment outcomes. And the authors of the one study that does show significant differences conclude that
[s]eeking to obtain or maintain compensation status does not have an inhibiting effect on improvement in treatment among outpatients or among most inpatients. Among inpatients in programs which are designed to provide an extremely long length of stay (100 days on average), however, the motivation to apply for and maintain compensation does appear to inhibit improvement (Fontana and Rosenheck, 1998a, p. 229).
Hospitalizations of more than 21 days entitle veterans to receive disability payment at a rate of 100 percent for the duration of the stay. This may account at least in part for the worse outcomes in long-term programs, and it has lead some to suggest that this regulation be eliminated (Mossman, 1994). The data needed to evaluate the determinants of outcomes in long-term programs are lacking, though, and it is not possible to draw a firm conclusion on this issue.
Thus, in spite of concerns that disability compensation for PTSD may create a context in which veterans are reluctant to acknowledge or otherwise manifest therapeutic gains because they have a financial incentive to stay sick, the preponderance of evidence does not support this possibility. While some beneficiaries will undoubtedly understate their improvement in the course of pursuing compensation, the scientific literature suggests that such patients are in the minority, and there is some evidence that disability payments may actually contribute to better treatment outcomes in some programs (Fontana and Rosenheck, 1998a). The authors note, though, that the data needed to confidently separate unconscious influences on symptom reporting from deliberate attempts to game the system for economic advantage are lacking.
VA asked the committee to “recommend strategies for reducing disincentives and maximizing incentives for achieving optimal mental functioning” (Szybala, 2006). Chapter 5 presents the committee’s framework for formulating a revised set of criteria for evaluating disability due to PTSD. One part of that framework proposes the elimination of occupational impairment as the defining factor in rating the severity of disability and suggests that a broader approach that evaluates the psychosocial and occupational dimensions of functional impairment be used in its place. Allowing a claimant to have his or her rating based on the more severe of those two dimensions would allow a veteran who is symptomatic or impaired in other ways but capable of working to do so, thus eliminating one possible disincentive to both work and recovery.
Based on the literature reviewed in previous chapters and here, the committee additionally recommends that the VA consider instituting a set, long-term minimum level of benefits that would be available to any veteran with service-connected PTSD at or above some specified rating level without regard to that person’s state of health at a particular point in time after the C&P examination.10
Regulation already specifies an analogous approach for other disorders, including conditions whose symptoms may remit and relapse over time. Multiple sclerosis, for example, has a minimum rating of 30 percent without regard to whether the condition is disabling at the moment that the subject is evaluated.11 However, rather than being limited to a particular minimum rating, the committee suggests that the VA consider what minimum benefits level—where “benefits” comprise compensation and other forms of assistance, such as priority access to VA medical treatment—would be most likely to promote wellness. It is beyond the scope of the charge to the committee to specify the particular set of benefits that would be most appropriate or the level[s] of impairment that would trigger provision of these benefits. This would require a careful consideration of the needs of the population, of the new incentives that the policy change would create, of the possible effects on compensation outlays and demand for other VA resources, and of how to maintain fairness with respect to other conditions that have a remitting/relapsing nature.
Providing a guaranteed minimum level of benefits would take explicit account of the nature of chronic PTSD by providing a safety net for those who might be asymptomatic for periods of time. A properly designed set of benefits could eliminate uncertainty over future timely access to treatment
and financial support in times of need and would in part remove the incentive to “stay sick” that some suggest is a flaw of the current system.
PERIODIC REEXAMINATIONS AND REEVALUATIONS
In its charge to the committee, the VA noted that:
VBA currently has no set schedule for re-examining veterans receiving compensation for PTSD. It would be very helpful to us if the committee would address whether such a re-examination schedule is advisable and, if so, what it might be (Szybala, 2006).
With a few exceptions,12 regulation does not offer specific advice on when such reexaminations are required. The Automated Medical Information Exchange worksheet for review evaluations for PTSD (reproduced in Appendix C) does provide a template for the information to be gathered when such examinations are conducted. This includes details of the beneficiary’s psychosocial adjustment since the last examination and the clinician’s evaluation of the effect and effectiveness of any treatments received. Since disability determinations are dependent on the degree of impairment, it is thus possible that compensation could be adjusted downward for a veteran who showed improvement as a result of treatment. However, VA does not code the information needed to evaluate how often this happens.
Based on the information provided to the committee, it does not appear to be standard practice to require periodic reexaminations after a disability rating has been established, although a notation for a follow-up examination after a specified time has elapsed may be placed in a beneficiary’s record. Data are not available on the number or percentage of PTSD disability cases that are scheduled for reexamination by raters or the extent to which disability ratings change as a result of such evaluations.13
The VA’s primary motivation for conducting reexamination is presumably to determine if an improvement in disability status has occurred since the last disability rating. A veteran, or a representative acting on her or his behalf, can file an appeal to a disability determination or rating by requesting a reexamination. It is reasonable to assume that veterans will initiate such requests if they believe that the initial rating was in error or if their
condition deteriorates to the point that they think their disability rating should be increased.
The committee does not believe it is appropriate to require across-the-board periodic reexaminations for veterans with PTSD service-connected disability. It recommends that reexamination be done only on a case-by-case basis when there are sound reasons to expect that major changes in disability status might occur.
The committee reached this conclusion on the basis of the following two considerations. First, there are finite resources—both funds and personnel—to conduct C&P examinations and determine disability ratings. According to data provided by the VA, over 300,000 veterans were receiving disability compensation for PTSD in 2006, with over 233,000 of these having PTSD as their primary disability. While certain of these veterans would be exempt by regulation from reexamination, any periodic review policy would still entail significant numbers of beneficiaries and put additional strain on the system. The committee believes that resources should be focused on the performance of uniformly high-quality C&P clinical examinations. It believes that allocating resources to such examinations—in particular, to initial C&P evaluations—is a better use of resources than periodic, across-the-board reexaminations. Second, as the committee understands it, across-the-board periodic reexaminations are not required for other mental disorders or medical conditions.14 The committee’s review of the literature on misreporting or exaggeration of symptoms by PTSD claimants yielded no justification for singling out PTSD disability for special action and thereby potentially stigmatizing veterans with the disability by implying that their condition requires extra scrutiny.
The committee recommends that the VA develop criteria for reexamination to be used on a case-by-case basis. These criteria should be based on factors that might be expected to influence the course of PTSD symptomatology and disability. An example of a circumstance that might be expected to improve PTSD symptomatology and reduce a disability rating is the successful completion of evidenced-based treatment. While it is reasonable to consider reexamination after such situations, it would be important to structure reexamination policy in a way that limits disincentives for receiving treatment or rehabilitation services. Setting a long-term minimum level of benefits, as suggested above, would be one way to address this issue. Case-by-case criteria for reexamination should also include any future event in the veteran’s life that would be expected to produce a dramatic change in his or her clinical and disability status. Ideally, a recommendation for reexamination in a given case could be made by the clinical examiner in
the initial C&P exam if there was some reason to expect a change in the veteran’s status or by a treatment, vocational, or rehabilitation professional upon completion of these services.
GENDER AND MILITARY SEXUAL ASSAULT
Gender and sexual assault are two important intersecting issues to consider when discussing the subject of PTSD compensation among veterans. A substantial body of literature has emerged that documents measurable gender differences in PTSD frequency and severity. A recent, well-conducted meta-analysis of more than 200 studies meeting reasonable inclusion criteria and including military as well as civilian samples found that PTSD was twice as prevalent in females as in males, even controlling for potential confounders, including study methods (Tolin and Foa, 2006). This gender difference holds up even though males report significantly more traumatic events than do females overall. Males do report significantly less sexual assault than females do, however (Tolin and Foa, 2006). Tolin and Foa (2006) concluded that sex differences in the prevalence of adult and child sexual abuse may account for some of the disparity in PTSD rates between men and women but that the variance they found in the meta-analysis was not completely due to this difference. After controlling for type of trauma, the largest gender difference they found was in adult nonsexual assault. However, the exact type of traumatic experience was not well differentiated in most studies. For instance, adult nonsexual assault was usually not differentiated between chronic (e.g., intimate partner violence, with female victimization more likely) and acute (such as robbery, with male victimization more likely). One potential methodological contributor to the observed variance relates to PTSD measurement, with “[t]he sex difference in PTSD [seeming] most clear when the PTSD assessment is explicitly linked to one specific traumatic event” (p. 978).
Tolin and Foa were able to rule out some of the possible reasons for the gender differences, but the studies they reviewed were not able to rule out gender differences in cognitive response to the event, immediate coping strategies, or amount of fear associated with experience. There also may be sex differences in willingness to admit symptoms because of differences in gender role expectations or in pretrauma psychiatric history and trauma exposure during military service. Sex differences are particularly likely in chronic trauma, such as repeated childhood sexual assaults by a family member or recurring intimate-partner violence, or in a history of multiple traumas, which may be more frequent among females than males. Researchers seldom examine sex-specific effects of various types of trauma, or chronic versus episodic or one-time events, even though these different
types of trauma can have different repercussions in terms of physiological responses (Gill and Page, 2006).
There are also sex differences in the manifestation of conditions commonly comorbid with PTSD—females being more likely than males to have major depressive disorder (MDD) along with PTSD. Females with PTSD tend to experience symptoms for a longer duration and have more associated physical health problems than do males (Gill and Page, 2006; Kimerling, 2004; Ouimette et al., 2004). Few of the studies examining this issue have been conducted among female military populations, however, and among female victims of intimate-partner violence some of the PTSD and MDD comorbidity patterns differed between female civilians and women on active military duty (O’Campo et al., 2006).
Tolin and Foa (2006) did not observe a significant sex difference in postcombat PTSD in the 11 studies of veterans they analyzed. However, these studies did not evaluate any interaction between combat and sex, and those looking at Somalia and Desert Storm I participants did not examine sexual assault while in the military (abbreviated here as MSA for military sexual assault15) as a source of trauma separate from combat.
In contrast, a narrative synthesis of 21 large cohort samples from the Gulf War era by Goldzweig and colleagues (2006) found that in most, although not all, of the studies females were more likely to develop PTSD than males. Among Vietnam War-era veterans, the same review found that males were more likely to be diagnosed with PTSD than females, but female military personnel in that war were not involved in direct combat. Those developing PTSD were most often nurses who had witnessed horrific physical trauma and death, were victims of sexual assault but were not exposed to combat, with the exception of the exposure to shelling (Zatzick et al., 1997).
Prevalence of Military Sexual Assault
The prevalence of sexual assault in the military is alarming and has been the object of several recent congressional hearings and military reports (e.g., U.S. Air Force, 2004). A narrative synthesis of 21 studies found that 4.2 to 7.3 percent of active duty military (ADM) females had experienced a military sexual assault, while 11 to 48 percent of female veterans reported having experienced a sexual assault during their time in the military (Goldzweig et al., 2006). One of the studies included was a nationally representative sample of veterans (Skinner et al., 2000), which found a 23 percent prevalence of MSA among females. A sample of female reservists (Street et al., 2003) also found a 23 percent prevalence of MSA.
The greater prevalence among veterans and reservists than among current ADM females may be related to a reluctance to report sexual assault while pursuing a military career; there may also be differences in cohort experiences, with current ADM females experiencing less sexual assault than their counterparts who were on active duty at an earlier point in time. The latter interpretation is somewhat supported by the fact that a higher percentage of ADM females reported sexual assault and sexual harassment in a 1995 survey than did in 2002 (Lipari and Lancaster, 2003). In addition, some of the veteran cohorts (e.g., Yaeger et al., 2006) consisted of females who were seeking medical or psychiatric services (prevalence by type of service not reported), and these are females who would be expected to have increased PTSD prevalence. Indeed, 41 percent of the 896 female veterans studied by Yaeger and colleagues reported having experienced sexual assault while in the military.
By contrast, Campbell and Raja (2005), using a convenience sample of primarily African-American veterans or reservists from a VA women’s clinic, found a 15 percent prevalence of MSA. This study is noteworthy for being one of the few to actually describe the type of MSA. Among the 104 females who reported that they were sexually assaulted while in military service, 13 percent reported sexual assault from a marital partner and 8 percent from a date, which highlights a type of MSA that is not usually considered. Eighty-two percent of the perpetrators in the MSAs were military peers or supervisors. The females in this sample also reported a great deal of secondary victimization by the military and by the VA system, an experience that is known to make the PTSD symptoms worse. Two other studies found subsequent secondary victimization and sexual harassment, exposing the women to additional trauma over and above rape and combat (Fontana and Rosenheck, 1998b; Murdoch et al., 2006 a,b,c). Social support from family and friends was an important factor influencing whether and how PTSD developed in the women examined in these studies.
The synthesis by Goldzweig and colleagues (2006) found a 55 to 79 percent prevalence of sexual harassment for females while in military service across the 21 studies it reviewed, but two other efforts found a somewhat lower prevalence of sexual harassment: 46 percent in a small convenience sample of Gulf War I veterans (Wolfe et al., 1998), and 24 percent in a more representative DOD survey of active-duty personnel in 2002 (Lipari and Lancaster, 2003). Kang and associates found that among soldiers in the Gulf War I theatre, sexual harassment contributed to PTSD over and above sexual assault both for males (with an adjusted odds ratio [aOR] equal to 4.26) and for females (aOR = 2.52), although the harassment occurred much more often for females (Kang et al., 2005).
It is recognized that the circumstances of military service may create barriers to reporting sexual assault above and beyond those extant in other
sectors of the population. A 2004 U.S. Air Force report, addressing information for that service only, noted:
Available evidence suggests that the majority of sexual assaults occurring in the Air Force might not be reported…. Air Force victims face numerous real or perceived reporting barriers. The lack of privacy/confidentiality is the most frequently cited barrier to reporting. Other barriers include stigma, fear, or shame; fear of disciplinary action because of a victim’s misconduct; fear of being reduced in the eyes of one’s commander/colleagues; fear of re-victimization; and fear of perceived operational impacts, including loss of security clearances, effect on training, and impact on overseas deployments (U.S. Air Force, 2004, p. 10).
The same report noted that “these barriers can have a significant impact on sexual assault reporting rates” (p. 42).
Relationship of Sexual Assault and PTSD
Sexual-assault experiences were strongly associated with PTSD in both civilian and military cohorts. In one of the few large-sample studies (2,131 females; 9,310 males) to examine the strength of the association between combat exposure and sexual assault in male and female veterans, Kang and associates found that MSA increased the risk of PTSD among a representative sample of Gulf War I veterans by an adjusted odds ratio of 5.41, when controlling for other covariates, including combat status (Kang et al., 2005). MSA increased the risk of developing PTSD among males to a greater degree than among females (aOR = 6.21), although MSA occurred in only 0.2 percent of the males compared to 3.3 percent of females while in theater. In a less representative sample of 327 female veterans being treated in a VA clinical program for women with stress disorders, military sexual stress was four times stronger as an etiological factor in the development of PTSD than military stress (Fontana and Rosenheck, 2006). Of those 327 women being treated for stress, 63 percent had been exposed to sexual harassment, 43 percent had been raped, and 12 percent had been exposed to enemy fire. Another study, this one of a convenience sample of female veterans using medical or mental-health services in the Texas area, found that the association of PTSD with MSA for female veterans (aOR = 9) was stronger than the association of PTSD with childhood sexual assault (aOR = 7) or with civilian adult sexual assault (aOR = 5) (Suris et al., 2004). Yeager and associates (2006) also found MSA associated with PTSD over and above other trauma in a similar sample from the Los Angeles area. However, neither of the last two studies offered any comparison with combat trauma, and it is unclear how much combat exposure those cohorts experienced.
In the Kang analysis (2005), the risk for PTSD associated with high
combat level was slightly greater for males (aOR = 4.45) than for females (aOR = 4.03), with males more likely to have combat experience. Murdoch and associates (2006c) found a similar relationship of MSA versus combat exposure for females in a representative sample of 1,655 male and 1,682 female veterans who had filed PTSD claims between 1985 and 1998. The sample represented 54 percent of the females who had filed such claims compared to 1.7 percent of the males. For females, MSA was a stronger predictor of PTSD than was combat history (MSA: F = 51.6, 3.1 percent variance explained; combat history: F = 26.1, 1.6 percent variance explained). However, the opposite situation was true for males, with combat history (F = 45.4; 2.7 percent variance explained) a much stronger factor than sexual assault (F = 4.7; 0.3 percent variance explained). Prevalence of in-service sexual assault for females who had filed PTSD claims was 71 percent, while for males who filed PTSD claims it was only 4 percent; by contrast, combat exposure was reported by 30 percent of the females and 94 percent of the males. The difference in reported MSA in females between the Kang (3.3 percent) and Murdoch (71 percent) studies is striking, and it can be partially explained by the difference in samples (a representative cohort sample versus females filing claims for PTSD) and partly explained by the Kang use of MSA “in theatre” while Murdoch used MSA in the more generic sense (any sexual assault while in ADM service). The degree of specificity in measurements and the comparisons between males and females make these two studies extremely helpful in illuminating the intersections of military sexual trauma and combat in the development of PTSD, but neither study differentiated between the prevalence of MSA while in theatre compared to other MSA.
PTSD Comorbidities and Recovery for Female Veterans
In all of the studies of female veterans, PTSD symptoms and PTSD diagnoses were associated with comorbidities such as depression, substance abuse, smoking, and physical health problems (e.g., Dobie et al., 2004) as well as with increased medical utilization (Dobie et al., 2006). In the only study found to address the issue, Murdoch and associates (2003b) found that a significantly smaller percentage of females (52 percent) as compared to males (71 percent) had their PTSD deemed to be service connected. This was primarily related to the lower rates of combat exposure among females, with their increased rates of sexual trauma apparently not being taken into account. When MSA was substantiated in the claims file, service-connected PTSD determinations increased substantially (Murdoch, 2006). Unfortunately, there are huge barriers to women being able to independently substantiate their experiences of MSA, especially in a combat arena.
In the few studies of recovery from PTSD for female veterans, postmili-
tary social support from family and friends was found to be an important factor in recovery (King et al., 1998) as well as a protective agent against the development of PTSD (Fontana and Rosenheck, 1998b). The study by King and colleagues (1998) also found that hardiness and additional negative life events postwar were additional factors affecting recovery. In a somewhat similar vein, Fontana and Rosenheck (2006) in a later study found that female veterans were more comfortable in a specialized treatment program for women; it increased their participation (attendance and commitment), but had no effect on outcomes. Studies of PTSD treatment for female veterans are badly needed—and, fortunately, under way—but it is unclear if the current studies will have samples that are sufficiently large to disentangle the differential treatment effects for women whose trauma is primarily MSA versus those whose trauma is primarily combat or to determine if multiple traumas are part of the etiology of the PTSD experience.
Conclusions and Continuing Issues
Although there has been increasing attention paid to women in the military, to their experiences with both combat trauma and sexual trauma, to their increased vulnerability to PTSD and its comorbidities, and to their need for gender-specific PTSD treatment, research is only beginning to illuminate some of the issues involved.
Very little research exists on the subject of PTSD compensation and female veterans. What information is available suggests that female veterans are less likely to receive service connection for PTSD and that this is a consequence of the relative difficulty of substantiating exposure to noncombat traumatic stressors—notably, MSA. The committee notes that PTSD training and reference materials for raters (VBA, 2005) address MSA but that scant attention is paid to the challenges of documenting it as an in-service stressor or to approaches to addressing this problem.16 In contrast, a great deal of guidance is given on various service medals and devices that can be used to support PTSD claims and on how to use DOD resources to corroborate possible combat-related traumatic exposures.
The committee believes that it is important to gain a better understanding of the sources of gender disparity in awards for PTSD service connection and to better substantiate MSA-related traumas in both women and men when they do occur. The committee therefore makes the following recommendations:
The VBA should conduct more detailed data gathering on the determinants of service connection and ratings level for MSA-related PTSD claims, including the gender-specific coding of MSA-related traumas for analysis purposes.
The VBA should develop and disseminate reference materials for raters that more thoroughly address the management of MSA-related claims.
Training and testing on MSA-related claims should be a part of the certification program addressed in Chapter 4 for raters who deal with PTSD claims.
The committee observes that appropriate management of MSA-related claims begins with the proper documentation of incidents that occur during active service. Therefore, improved training of military medical and nursing personnel on how to document and collect evidence regarding sexual assault is needed. Civilian sector SANE17 and Forensic Nursing programs are models for such training. The committee also observes that more research is needed on the as yet unexplained gender differences in vulnerability to PTSD, which could help identify useful sex-specific approaches to prevention and treatment, and on more effective means for preventing military sexual assault and sexual harassment.
FINDINGS, CONCLUSIONS, AND RECOMMENDATIONS
On the basis of the review of the papers, reports, and other information presented in this chapter, the committee has reached the following findings, conclusions, and recommendations, and identified the following research needs.
Findings and Conclusions
The most effective strategy for dealing with problems with self-reports of traumatic exposure is to ensure that a comprehensive, consistent, and rigorous process is used throughout the VA to verify veteran-reported evidence.
In the absence of a definitive measure, the most effective way to detect inappropriate claims is to require a consistent and comprehensive state-of-the-art examination and assessment that allows the time to conduct
appropriate testing in those specific circumstances where the examining clinician believes it would inform the assessment.
Research reviewed by the committee indicates that PTSD compensation does not, in general, serve as a disincentive to seeking treatment.
It is not appropriate to require across-the-board periodic reexaminations for veterans with PTSD service-connected disability.
VA should consider instituting a set, long-term minimum level of benefits that would be available to any veteran with service-connected PTSD at or above some specified rating level without regard to that person’s state of health at a particular point in time after the C&P examination.
The determination of whether and when reevaluations of PTSD beneficiaries are carried out should be made on a case-by-case basis using information developed in a clinical setting. Specific guidance on the criteria for such decisions should be established so that these can be administered in a fair and consistent manner.
The VBA should conduct more detailed data gathering on the determinants of service connection and ratings level for MSA-related PTSD claims, including the gender-specific coding of MSA-related traumas for analysis purposes.
The VBA should develop and disseminate reference materials for raters that more thoroughly address the management of MSA-related claims. Training and testing on MSA-related claims should be a part of the certification program addressed in Chapter 4 for raters who deal with PTSD claims.
More research is needed on the as yet unexplained gender differences in vulnerability to PTSD, which could help identify useful sex-specific approaches to prevention and treatment, and on more effective means for preventing military sexual assault and sexual harassment.
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