Military providers underdiagnosing PTSD?

[O Gurl]

I am just writing to solicit opinions from others who have worked with combat-related trauma. Intern cohortmates and I were discussing a disturbing observation of returning veterans suffering from nearly textbook PTSD with onset of symptoms prior to discharge who were "treated" (using the term loosely here), yet never accurately diagnosed for PTSD while in the service. A recent example was a veteran whose psych assessment from his military provider described symptoms of depressed mood, avoidance of others, insomnia, anger, and anxiety; included a PCL of 70 that was inexplicably never mentioned in the report, and with a final set of diagnoses that did not include PTSD. In fact, one of his diagnoses for sleep disorder actually included a specifier to suggest a rule out of PTSD. This is despite the veteran's spending over 30 months in a combat zone with an MOS in recovery (collecting the bodies of fallen soldiers day in and day out). 😕/😡

Has anyone else observed this? Any thoughts on why mental health providers would seemingly ignore the obvious and most parsimonious explanation for a soldier's problems?

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[erg923]

First, by military providers, I assume you mean psychologists and psychiatrists who are seeing active duty soldiers, right?

I dont doubt this is common, if for any other reason than it means losing boots on the ground. Another is the financial reward soldiers/veterans can reap from being diagnsosed with PTSD as result of military service (ie., service-connected disability). There was as famous set of embarrasing emails leaked in 2007 from top VA brass who encouraged providers to not Dx PTSD for a while..or at least something to that effect.

Personally, my experience is that PTSD is being too easily diagnosed in some settings. I think we should always be especially cautious here, as the VA system is set-up so that it rewards disabilty handsomely. This essentially means that a secondary-gain (of some sort) is going to be pressnt in almost all cases.

 

[O Gurl]

Oh, yeah. The attending psychologist was the provider. I have also seen similar (albeit less atrocious) assessments from military psychiatry.

Erg, you are absolutely right that in the VA one must always be aware of incentives for malingering. On the flip side to this post, I have seen veterans present for trauma recovery intake assessments who are service connected for PTSD with no identified index trauma... which is plain ridiculous. While these cases are typically not accepted to the program, we have no influence on how compensation and pension resolved the claim. While it is frustrating, I guess I am less bothered by that b/c the finances don't carry the same personal weight to me as seeing a person who has been bounced around by providers, is legitimately suffering, and is being deceived by the same professionals who are supposed to help them recover.

 

[ClinicalTrainee]

Isn't it possible that the provider absolutely knew the person had PTSD but didn't want to diagnose it because of the repercussions active service people get for mental health diagnoses? I've been hearing rumors (granted, these are from veterans who like to complain about the system) of people who were granted other-than-honorable discharges due to mental health problems. Which is ridiculous if those mental health problems were created BY military events, but the impression I've received is that PTSD is a manageable diagnosis for a veteran (though not as desirable as TBI) but quite problematic for someone on duty. If this is the case, the provider is actually doing a service to the person by giving treatment and not taking away career options or VA services down the road.

 

[erg923]

The Frontline documentary "The Lost Platoon" dealt with this issue. Ogurl, if you havent seen it, you should. This is kind of what I was talking about when I eluded to "losing boots on the ground." While PTSD certainly isnt grounds for DC in and of itself, I'm sure it happens. Even without that threat, the stigma of the dx is still great, and can conceivably cause or contribute to demotions, lose of comradery with fellow soldiers, etc. I have a buddy doing internship in the AF currently, and he says they are indeed very careful about what goes into a patient's chart...

 

[O Gurl]

Isn't it possible that the provider absolutely knew the person had PTSD but didn't want to diagnose it because of the repercussions active service people get for mental health diagnoses? I've been hearing rumors (granted, these are from veterans who like to complain about the system) of people who were granted other-than-honorable discharges due to mental health problems. Which is ridiculous if those mental health problems were created BY military events, but the impression I've received is that PTSD is a manageable diagnosis for a veteran (though not as desirable as TBI) but quite problematic for someone on duty. If this is the case, the provider is actually doing a service to the person by giving treatment and not taking away career options or VA services down the road.

Perhaps... but evidence-supported treatment for PTSD requires an understanding of the syndrome. I'm not sure that shoveling meds at a severely ill soldier while leaving him/her in line for more trauma exposure is really doing him/her any favors at all. While I can appreciate the soldier's desire to remain in the service and to not be stigmatized, I would much prefer we educate the military rather than deceive and potentially harm the patient. Also, I think that hiding their true diagnosis from them further feeds into the misconception that PTSD is controllable and does reflect some personal weakness.

Erg, I will def check out that documentary. I actually interviewed for AF internship, but backed away due to lifestyle constraints and a fear that I would ever find myself in a position where I was torn between doing what is best for my patient and fulfilling my duty to the service.

 

[stigmata]

"who are service connected for PTSD with no identified index trauma... which is plain ridiculous."

Wow, really. Tell this to the vietnam vets who saw horrors where the convenience of having an officer handy to document it was not readily available, and on and on. The VA now only requires a report of trauma and clinically valid symptoms for comp and pen. Sure people get by with screwing the system, but unlike years past many more are getting benefits who really deserve them.

 

[O Gurl]

"who are service connected for PTSD with no identified index trauma... which is plain ridiculous."

Wow, really. Tell this to the vietnam vets who saw horrors where the convenience of having an officer handy to document it was not readily available, and on and on. The VA now only requires a report of trauma and clinically valid symptoms for comp and pen. Sure people get by with screwing the system, but unlike years past many more are getting benefits who really deserve them.

I think you misread "identified" as "documented." Of course the vast majority of military trauma is not documented. I mean that there are a few who get SC for PTSD with no reported trauma(s) that meet criterion A for the diagnosis (imminent risk to self or other, intense fear/helplessness/horror reaction, etc).

 

[erg923]

Erg, I will def check out that documentary. I actually interviewed for AF internship, but backed away due to lifestyle constraints and a fear that I would ever find myself in a position where I was torn between doing what is best for my patient and fulfilling my duty to the service.

We condsidered it briefly, but the idea was vetoed by "the lady of the house..." as she likes to be called. 😉

 

[KillerDiller]

I would much prefer we educate the military rather than deceive and potentially harm the patient. Also, I think that hiding their true diagnosis from them further feeds into the misconception that PTSD is controllable and does reflect some personal weakness.

Erg, I will def check out that documentary. I actually interviewed for AF internship, but backed away due to lifestyle constraints and a fear that I would ever find myself in a position where I was torn between doing what is best for my patient and fulfilling my duty to the service.

I'm still considering applying for the AF internship this coming fall. Several current officers I've spoken with have given me the impression that military psychologists are in the process of mounting large educational campaigns to get information to active duty personnel before they deploy. It's definitely an important area of work, so I hope those programs are well implemented.

 

[stigmata]

The VA's change to allow the Dx if one was in a situation where trauma could have been experienced (active duty) is actually in line with proposed DSM-5 changes.

 

[lseefeld]

This is a subject that I see come up every day actually as I am a behavioral health technician in the US Army. PTSD actually can be grounds for discharge as a medical board (which can be categorized as either honorable or other-than-honorable which is not the same as dishonorable) in and of itself if the disorder does not respond to treatment and interferes with the soldier's ability to function in a military environment. Its a sustainment issue. That being said, your veteran's rule out diagnosis may have just ment that the provider didn't have sufficient time with the patient to make an accurate assessment. You can't really fully diagnosis PTSD after one or two visits, or you would be diagnosing nearly every soldier that walked through your door. The diagnosis was in the provider's mind, otherwise they never would have put the r/o there. Afterall in my experience the r/o actually means the said diagnosis needs further explanation before you can rule it out, not that you should rule it out. The military is complicated, and hard to understand in how it operates sometimes but it is a wonderfully rewarding area when you look to the successes and not the downfalls. That position with the AF may not be such a bad idea if you are so passionate about the soldiers getting the proper diagnosis.

 

[stigmata]

R/O always means that more assessment is still needed to confirm or deny. However, I am pretty sure that is old DSM language and now we are supposed to say "provisional".

 

[O Gurl]

R/O always means that more assessment is still needed to confirm or deny. However, I am pretty sure that is old DSM language and now we are supposed to say "provisional".

To be fair, it signifies that the assessor did not completely ignore the glaring possibility. However, all to often, "R/O" is used as a cop-out or CYA clause. All diagnoses are working/provisional in nature. The job of the professional is to reassess and modify accordingly as treatment ensues. It is also our job to make the most accurate diagnosis from the beginning. It just shocks me that the person was given a multitude of other diagnoses (sleep disorder, depressive disorder, anxiety disorder) all cobbled together and apparently got some meds and was on his way. This is despite meeting all criteria for PTSD, a disorder in which education and processing is crucial. Bleh...

 

[paramour]

I know military vets who were discharged due to mental health diagnoses (to be fair, these cases were many years ago; Vietnam era).

I also know of a fair number of individuals currently/recently serving who are so greatly paranoid of what will be reflected in their service records that they refuse to seek the services/benefits of military mental health care, as well as others because they think it's inferior care. The folks I know tend to go to the civilian sector and pay out-of-pocket for mental health services. Again, these are just the people I personally know, but I find it disheartening that so many believe that they are unable to take advantage of the services offered to help them in their time of need. 🙁

I'm another who was considering one of the military internships when the time rolls around (although I'm uncertain whether I can pass through MEPS again with recent changes to my health 👎), but I start to question the decision when I am presented with some of the intricacies of what happens to those serving when they really need the help and do not receive it, or choose to go elsewhere because they do not trust in their own system.

 

[DD214_DOC]

A couple of things from someone in a military psych program.

We are never told not to diagnose PTSD if we think it is the most accurate diagnosis. However, many are, "encouraged" to be careful in making this diagnosis, sometimes using it as a provisional diagnosis or even hedging for Anxiety Disorder NOS for cases that are not blatantly obvious. Even if the case is obvious in a first-time presentation, I never ever diagnose PTSD in the ER or on the consult service. The degree of malingering is absolutely staggering and we typically do a little investigating into claims from active duty patients. This typically includes going over military records and contacting members of the soldier's command to verify any accounts of combat or traumatic experiences. Even a "textbook case" can be a fabrication, as military personnel suffer countless courses on combat stress and can easily look up the appropriate diagnostic criteria. I had a patient this past year who was saying all of the right things, had a good story that could not be either verified or refuted, and was meeting the criteria. Something felt "squirrely" about this guy so in a later session I literally made up things that were additional diagnostic criteria to talk to the patient about. He "met" this "criteria" as well, which was all ridiculous things that I'm surprised he bought into.

Obviously, verification requires a lot of time and resources so it's better left to an established outpatient provider.

Unfortunately, these new providers will look at the ER or consult records and simply copy over any previous diagnoses without formulating their own.

 

[stigmata]

A couple of things from someone in a military psych program.

We are never told not to diagnose PTSD if we think it is the most accurate diagnosis. However, many are, "encouraged" to be careful in making this diagnosis, sometimes using it as a provisional diagnosis or even hedging for Anxiety Disorder NOS for cases that are not blatantly obvious. Even if the case is obvious in a first-time presentation, I never ever diagnose PTSD in the ER or on the consult service. The degree of malingering is absolutely staggering and we typically do a little investigating into claims from active duty patients. This typically includes going over military records and contacting members of the soldier's command to verify any accounts of combat or traumatic experiences. Even a "textbook case" can be a fabrication, as military personnel suffer countless courses on combat stress and can easily look up the appropriate diagnostic criteria. I had a patient this past year who was saying all of the right things, had a good story that could not be either verified or refuted, and was meeting the criteria. Something felt "squirrely" about this guy so in a later session I literally made up things that were additional diagnostic criteria to talk to the patient about. He "met" this "criteria" as well, which was all ridiculous things that I'm surprised he bought into.

Obviously, verification requires a lot of time and resources so it's better left to an established outpatient provider.

Unfortunately, these new providers will look at the ER or consult records and simply copy over any previous diagnoses without formulating their own.

I too have seen A LOT of malingering when I perform comp & Pen exams.