Why the VA doesn’t want to diagnose Iraq War Veterans’ PTSD

Earlier this month, Dr. Norma Perez an employee of a VA hospital somewhere in America wrote the following email and sent it out to a number of VA clinical employees:

"Given that we are having more and more compensation seeking veterans, I'd like to suggest that you refrain from giving a diagnosis of PTSD straight out. Consider a diagnosis of Adjustment Disorder, R/O PTSD."

"Additionally, we really don't or have time to do the extensive testing that should be done to determine PTSD"

"Also, there have been some incidence where the veteran has a C & P, is not given a diagnosis of PTSD, then the veteran comes here and we give the diagnosis and the veteran appeals his case based on our assessment."

"This is just a suggestion for the reasons listed above"

Sounds awful, doesn't it? At first glance it seems to be confirmation that the VA is motivated to withhold care and benefits from needy veterans. It may well mean exactly that too; we don't know yet. Apparently, Democratic presidential candidate Senator Barack Obama, who serves on the Senate Veteran's Affairs Committee has asked for an investigation, and maybe we'll learn more as a result of that. Time will tell. Whatever else the above email indicates, it is certainly an internal communication that was never intended to be broadcast publicly, and it certainly looks bad.

Because people may be wondering what exactly goes into a diagnosis of PTSD, and what exactly Adjustment Disorder R/O PTSD might be, I thought I'd write on these subjects so as to provide some clarification.

The Nature of PTSD

PTSD stands for Post Traumatic Stress Disorder. It is a disorder that can occur after (post) someone has been exposed to trauma which has caused intense stress. Trauma, used in this context, has a specific meaning. It refers to situations that involve death, or the likely threat of death, or at the very least, intense violence. People sometimes define trauma more loosely saying things like, "it was traumatic for him when his parents divorced". While that sort of situation is undoubtedly traumatic in a lessor sense, that is not really the sort of situation that can cause PTSD. Trauma of the sort that triggers PTSD may occur in the wake of a serious car accident, torture (including water boarding), a rape, a violent beating, a threat of lethal force, a bomb explosion, a natural disaster involving death or threat of death, a combat operation. We need a new term for lesser but still significant emotional traumas.

The simplest way to think about PTSD is to think of it as an interrupted grief process. What is grief but a stressful adaptation to significant (and often rapidly occurring) life change? Think of times in your life when you've experienced a sudden, overwhelming loss, such as at the death of a close friend or family member; one you've depended on deeply. People's reactions to such an event tend to be polarized and intense. Reactions vary between excruciating, unrelenting emotional pain, and numbness and unreality, often swinging between these extremes. Seldom is there a feeling of normality. Mood swings typically continue for weeks and months, perhaps varying in intensity at different moments, but ultimately the trend is for the intensity to die down. Grief never entirely ends, but at the conclusion of the practical grief process, people feel back to normal again and their moods do not swing noticeably more than they did prior to the loss.

Substitute a trauma experience (or more than one) for a grief-triggering loss and you have PTSD. Except a few things happen differently than in a typical grief progression. For one thing, the emotional intensity of the trauma experience is significantly greater than that which accompanies a typical loss. In grief, we mourn for people we have loved and lost. This is personal and painful, but not as personal or painful as trauma. In grief there is generally no actual threat to our own lives or to our most fundamental beliefs. In trauma, however, we are directly threatened ourselves, as are in many cases, our fundamental understanding of the world as a safe, predictable place.

The trauma experience violates and shatters expectations in a way that normal losses do not. This combination of intensity and expectation violation causes the trauma experience to become indelibly written into the trauma victim's memory, such that it becomes impossible for the person to stop thinking about that experience without resorting to heroic and often self-destructive methods.

The major symptoms of PTSD mostly are a reaction to the "burned in" and intense quality of trauma memory.

Intrusion:

First, the trauma victim experiences intrusive trauma memories at inconvenient times. Often there is an intense clarify of recall such that the memory is more vivid than a regular memory and more like a recreation of the trauma event. Nightmare recreations are common, and even hallucinations of trauma related events can occur. The threshold for recall of trauma memories is very, very low, making it quite inevitable that they will be triggered to reoccur at the smallest provocation.

The constant re-experience of the trauma memories is horrifying, overwhelming and generally agitating, just as is the case with grief. Unlike grief, however, in PTSD, trauma memories do not become less horrifying and agitating with time. This is a critical aspect of the disorder and probably the defining thing that makes it a diagnosable illness rather than just a variety of grief or stressful adaptation. There is no simple way to face and adapt to the trauma memory as there is in normal grief. As a consequence, a lot of trauma memory avoiding occurs, and irritability results, along with fear reactions (which could be termed panic attacks), and anger problems. Trauma victims can become so irritable that they end up attacking the people around them, or running away from those people so that they don't attack them.

Avoidance:

In an effort to escape the vivid trauma memories, trauma victims do what they can to numb themselves or escape from trauma-memory-triggering stimulation. Frequently, this takes the form of substance abuse (on the theory that if you drink or drug yourself into oblivion, you can't re-experience the trauma memories). Another common strategy is to hide from other people, sometimes quite literally by moving to very rural locations, or by becoming a recluse. The idea here is to minimize irritation and stimulation by minimizing exposure to stressful interactions (which can becomes most all interactions in some cases).

Arousal:

The third major symptom is jumpiness and startle. This is not so much a reaction to the trauma memory as it is a byproduct of the process by which that memory became so vividly burned into the victim's brain. All people have a fear threshold pass which they will experience startle and panic. Exposure to trauma has the effect of lowering people's fear threshold so that it takes very little to get them into a state of fear, startle and hyper-awareness.

The VA's Conflicting Dual Roles

With this background information in place, we can return to the issue of diagnosing PTSD as spelled out in the email we started with.

The VA system is more than a healthcare system; it also pays out cash disability payments (called service connections) in monthly installments to veterans who have been disabled during their service. Becoming service connected means that you will receive, often for the rest of your life, a monthly payment in partial compensation for your disability. Unfortunately, as dispenser of service connection payments, the VA system has to worry about the possibility of fraud; a scenario where a veteran would claim a disability payment that is unjustified. In this time of uncritical support for the troops, this is perhaps not something nice to discuss, but there is is. I don't think this sort of thing is particularly common, but it does occur nevertheless.

To combat the possibility of inappropriate payment, the VA likes to be careful about signing off on diagnoses that might lead to a service connection. In cases like PTSD, they like to do things like document that a trauma actually occurred. When I worked at a VA hospital in the mid 90s, it wasn't enough to take a veteran's word for where they had served. Instead, we would have to verify with documentation that tours of service actually matched veteran's claims.

In her email, Dr. Perez suggests that clinicians not diagnose PTSD right away, but instead diagnose Adjustment Disorder R/O PTSD. In order to unpack the meaning of this statement, we need to define Adjustment Disorder.

To quote DSM (page 681), "Adjustment Disorder is a residual category used to describe presentations that are a response to identifiable stressors and that do not meet the criteria for another specific Axis I disorder." In other words, if someone comes to you for diagnosis after encountering a stressor, if you can't legitimately fit their issue into a defined disorder category within DSM, what you should do is to give them the Adjustment Disorder diagnosis, which tells everyone who needs to know that something significant is going on in the wake of a stressful event, but it doesn't fit criteria for some other illness. Adjustment disorder might be diagnosed in the wake of a person's breakup from a treasured relationship, or in the wake of the loss of a job, if the person displays significant anxiety or depressive symptoms that seem to stem from that stressful event.

The use of the abbreviation "R/O" above stands for "Rule Out". This is a clinical term telegraphing to clinicians that another condition may be present, but cannot yet be diagnosed cleanly, so that other diagnosis is not being made. The idea is to rule the other disorder in or out conclusively by collecting more definitive diagnostic data.

So, the line of thinking Dr. Perez was suggesting in her email suggesting was probably something like the following:

1. PTSD is both a complex diagnosis to make, requiring documentation and testing that generally takes more than a single visit, and also a desirable diagnosis to have because of the possibility of service connection disability payments.
2. When it isn't absolutely crystal clear that a PTSD diagnosis is correct, a rule out diagnosis the best policy should be to be conservative and withhold the PTSD diagnosis. Care must be taken to get the diagnosis right, so that the possibility of fraud is minimized.
3. The Adjustment Disorder diagnosis can be made instead of the PTSD diagnosis, so as to inform other clinicians that PTSD is likely.

Adjustment Disorder is a residual diagnostic category. It is what you use when you can't use something more specific, as is the idea of a rule out diagnosis. It is also a stress disorder in its own right, and not at all inappropriate to use when PTSD is suspected but not confirmed yet. I should clarify that last statement: It is entirely appropriate to diagnose Adjustment Disorder when the the intention is to follow through over time with the research and documentation that is necessary to confirm or reject PTSD and ultimately make the most appropriate diagnosis. The acceptable reason for delaying diagnosis is to insure accuracy. If the goal is not accuracy but rather to substitute a less specific diagnosis for a more specific one for political purposes (e.g., to save the VA from having to pay out money to a disabled veteran), then that more or less would amount to malpractice.

Even the desire to avoid fraud is not reasonable under the present war-time circumstances, however. The serious issue is not how soon veterans get a service connection; it is how quickly can they can get the care they need to address their healthcare concerns. I don't know whether the delay in diagnosing PTSD for purposes of being careful about service connection payments also results in a delay of connecting veterans to appropriate care for their PTSD. The important question for us to ask becomes, "If a veteran has been diagnosed with Adjustment Disorder, R/O PTSD, are they eligible to be included in PTSD treatment programs?" If the answer to this question is No, the VA would be basically saying with their policies that it is more important to conserve money than it is to provide expedient care to those who need it. I hope this is not the case. It should not be the case, ethically and morally. I suspect that it could easily be the case, however. Removed as they are from the consequences of their decision-making, policy-making bureaucrats all too frequently seem to think in just such inhuman, abstracted terms.

If it is the case that the VA is more concerned with money conservation than with fast and accurate matching of patients to care and the provision of that appropriate care, it is particularly ironic and disgusting inasmuch as there is certainly no shortage of money available for continuing the war. We're happy to fund the actions that break our troops, but not to fund the actions that help to put them back together again.

To summarize my points:

1. Dr. Perez's email looks worse than it actually is, I think. It looks like the VA doesn't care about veterans at all. What it probably more likely reveals is that the VA is worried about the possibility of fraudulent disability claims.
2. While taking time to make correct diagnoses and to avoid fraud might be a legitimate concern during peace-time when there are fewer wounds to work on, it seems less appropriate to a period of war-time when there are many urgent wounds that need caring for right now.
3. If a veteran can't get a legitimate diagnosis of PTSD because the VA wants to save money; and if this keeps the veteran from getting timely PTSD care, that would be especially disgusting and wrong.

All of which lead to a final point on which I'll close:

The VA has a dual relationship with the veterans it cares for. It is both their healthcare provider, and also their judge as to whether they are disabled. The intermingling of the service connection and healthcare divisions of the VA puts VA clinicians into a dual role that interferes with their ability to do their jobs. They become, in effect, both clinician and judge, and veteran patients can't help but sometimes feel that their clinician is judging them, or denying them due benefits by failing to make a desirable diagnosis. The care process can start to feel adversarial in such an environment, and that gets in the way of good provision of care. It would be far better if the VA divisions that handle disability and health care were wholly split into different groups with a strong firewall between them. Compensation judgments should never be allowed to impact care decisions.

If someone who has recent VA experience has any information that could help clarify the issues and concerns I've written about here, I'd appreciate it greatly if they could share that information with us in the form of a comment below.