PTSD Compensation and Military Service (2007) / Chapter Skim
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6 Other PTSD Compensation Issues
6 Other PTSD Compensation Issues
Pages 165-203
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From page 165... ...
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.
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From page 166... ...
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.
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From page 167... ...
did not identify a statistical association between combat exposure and educational level in a sample of ~100 Vietnam veterans presenting for PTSD treatment at a VA Medical Center.
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From page 168... ...
. 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)
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From page 169... ...
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)
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From page 170... ...
rofessional responsibility in providing appropriate services to ethnic minority veterans also applies to Compensation and Pensions examina 2 This topic is addressed in greater detail later in this chapter in the section entitled "Disability Compensation and the Use of VA Mental-Health Care Services."
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From page 171... ...
. 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)
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From page 172... ...
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.
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From page 173... ...
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)
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From page 174... ...
. 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.
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From page 175... ...
6 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)
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From page 176... ...
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.
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From page 177... ...
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)
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From page 178... ...
Burkett and Whitley (1998) summarize this second view as follows: One common-sense question might weed out imposters: Do PTSD claim ants continue with therapy and Vet Center counseling after they suc cessfully obtain PTSD disability compensation?
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From page 179... ...
. 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.
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From page 180... ...
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.
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From page 181... ...
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.
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From page 182... ...
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. 9 A separate IOM committee addressing PTSD treatment issues will also examine compensa tion as a factor in treatment outcomes.
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From page 183... ...
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, PTSDrelated disability status showed no association with the PTSD diagnostic status at posttreatment or follow-up (Monson et al., 2006)
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From page 184... ...
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)
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From page 185... ...
will be assigned without regard to other provisions of the rating schedule when it is established that a service-connected disability has required hospital treatment in a Department of Veterans Affairs or an approved hospital for a period in excess of 21 days or hospital observation at Department of Veterans Affairs expense for a service-connected disability for a period in excess of 21 days." [emphasis in original] The 100 percent rating is maintained until discharge and may be extended for a convalescence period.
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From page 186... ...
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.
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From page 187... ...
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.
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From page 188... ...
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.
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From page 189... ...
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)
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From page 190... ...
. 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]
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From page 191... ...
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)
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From page 192... ...
. 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.
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From page 193... ...
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.
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From page 194... ...
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.
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From page 195... ...
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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From page 196... ...
1982. Assessment of Vietnam veterans for posttraumatic stress disorder in Veterans Administration disability claims.
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From page 197... ...
2003. Symptom exaggeration and compensation seeking among combat veterans with posttraumatic stress disorder.
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From page 198... ...
2006. Treatment of female veterans with posttraumatic stress dis order: the role of comfort in a predominantly male environment.
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From page 199... ...
2005. Adverse race-related events as a risk factor for posttraumatic stress disorder in Asian American Vietnam veterans.
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2003a. Racial disparities in VA service connection for posttraumatic stress disorder disability.
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From page 201... ...
1991. Comparison of successful, unsuccessful, and relapsed Vietnam veterans treated for posttraumatic stress disorder.
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2000. The prevalence of military sexual assault among female Veterans' Administration outpatients.
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From page 203... ...
2006. DSM-IV diagnosed posttraumatic stress disorder in women veterans with and without military sexual trauma.
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