APDA Guidance for MEB Psychiatrists

Jason Perry

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This is the text of the body of an e-mail I sent to Army Times today. Hopefully, they will be covering this issue. In the meantime, this outlines some of the concerns I have with the new guidance.

"The Army has been criticized for separating injured Soldiers administratively for personality or adjustment disorders. This link to an article explains how this shameful practice plays out: http://www.thenation.com/doc/20070409/kors . Despite criticism for this practice, on October 23, 2007, the US Army Physical Disability Agency (APDA) published new guidance (found here, https://www.hrc.army.mil/site/Active/TAGD/Pda/pdapage.htm) which may only worsen this practice of wrongfully denying disabled Soldiers the benefits they are entitled to receive.

To its credit, the APDA publishes more guidance and is more transparent in its practices than any of the other Service agencies with oversight of the PDES. However, while it is correct to not compensate for personality disorders, the following excerpts from the Guidance for MEB Psychiatrists raise some troublesome questions.

"At first blush, it may appear that a Soldier is accurately diagnosed as having a major depressive disorder. However, a further review of the Soldier’s data may reveal that the Soldier has an alternative diagnosis. When appropriate, consider personality traits/disorders in your differential diagnosis. If you conclude that the Soldier does, in fact, have a personality disorder (with or without an Axis I diagnosis) discuss the effect of the personality disorder on the Soldier’s current functioning.

Posttraumatic Stress Disorder (PTSD) is a diagnosis that sometimes presents issues for the PDES because the documentation requirements are more involved than for other psychiatric conditions. Absent any element, the diagnosis of PTSD is uncertain."
If used correctly by MEB psychiatrists, there is nothing wrong with this guidance. The worrisome development, though, is that the Army has made errors in over-diagnosing personality disorders. This type of guidance may have the undesired effect of compounding this problem, not alleviating it.

"Some data is of low probative (i.e., little) value. For example, a statement from a health care provider that the fact a Soldier was present in Iraq validates the stressor does not supplant the need for a “verified stressor”. It is unacceptable to presume the Soldier was necessarily exposed to a stressor based solely on the fact that the Soldier was in Iraq . Where a data source includes information based only on what the Soldier has related, you should not use this data source as supportive collateral information."
This guidance is troubling for placing an additional hurdle in front of Soldiers who may have encountered their stressor in a combat environment where recordkeeping is difficult at best. This also is a huge departure from the evaluation of the Soldier's testimony that he or she will receive at the VA. In fact, the law requires the VA to credit combat veterans statements about the incurrence of their injury unless there is clear and convincing evidence to the contrary. 38 United States Code, Sec. 1153(b) requires this type of evidence to be credited; however, a Soldier going through the PDES has a higher burden placed upon him or her.

"Caveats

Do not assume that when a Soldier has symptoms such as a depressed mood, anxiousness or issues with inappropriate expressions of anger, that these symptoms are manifestations of PTSD. It is easy (but could be wrong) to attribute symptoms to PTSD when the symptoms began after witnessing horrifying events. Go through the stepwise process/analysis of confirming the diagnosis of PTSD by verifying the presence of each DSM-IV element. Then, determine whether the symptoms are due to PTSD, due to some other DSM-IV diagnoses (including personality traits/disorders) or are normal transient adjustment reactions."
There is nothing wrong with this guidance on its face. The problem is that taken together with the pervasive guidance to consider personality disorders, a psychiatrist could unconsciously come to the conclusion that PTSD diagnoses should be downplayed in favor of personality disorders.

"If you are the Soldier’s treating psychiatrist, consider whether an alternate examiner should complete the Soldier’s evaluation because your participation in the MEB may adversely impact the therapeutic relationship. For example, if the Soldier is dissatisfied with the PEB’s determination, the Soldier may become angry with you because he or she may feel you are responsible for the PEB’s findings. Further, if the Soldier asks you to submit additional information to support a fit or unfit determination or a different rating, you will be in an uncomfortable position if you believe your first submission was complete and accurate. As a matter of general practice, some psychiatrists may decide not to complete MEBs on their own patients."
The APDA is correct to identify this issue. Treating psychiatrists are placed in the untenable position of stepping out of their therapeutic role and assuming the role of a cross-examiner, to the detriment of the Soldier's mental health. The problem that arises is that someone else completing the MEB evaluation will not have the depth of experience or knowledge of the Soldier's history. It is a classic Catch-22...do we treat the Soldier or get an accurate evaluation?

"A Soldier may relate a history of trying to use alcohol or other substance “to numb” himself, i.e., for purposes of “self-medication”. Nonetheless, medical literature indicates that alcohol use will worsen many mental disorders including depression and PTSD. Among other things, alcohol use can lead to difficulties in sleeping and in coping with stress. Where a Soldier continues to drink moderate amounts of alcohol despite being advised of its ill effects, you should include what discussions have taken place with the Soldier regarding alcohol use. You should also indicate, when you can, how much worse the Soldier’s symptoms are on account of the alcohol abuse."
This guidance again places the psychiatrist in a difficult position in regard to the therapeutic relationship. It is a sad fact that many Soldiers with PTSD do "self-medicate." But with this guidance a Soldier is again faced with the choice of being forthcoming about their condition and getting the help needed or keeping quiet to ensure his alcohol use, even if moderate, will not be used against him to deny benefits. Furthermore, moderate alcohol use is not necessarily something that is harmful to Soldiers with PTSD. It is only excessive use that causes problems. This guidance sets the stage for a lower rating due to something that may not have any impact on the Soldier's condition whatsoever.

"Consider the following examples of symptoms often associated with PTSD: nightmares and social withdrawal. For purposes of this discussion, assume that you have determined that these two symptoms are due to PTSD. A Soldier reports he has two nightmares every night relating to a gruesome combat experience. The Soldier does not report that he is afraid to fall asleep for fear of having the nightmares. The nightmares do not cause him to remain up the rest of the night. This same Soldier prefers to remain solitary and isolated. The Soldier tolerates other people at work and has adequate job performance. Therefore, you determine that his PTSD symptoms of nightmares and withdrawal do not interfere with his industrial adaptability. It is up to you, the examiner, to determine whether and to what degree the Soldier’s symptoms appear to adversely affect the Soldier’s industrial adaptability. However, you must cite the supporting evidence and rationale for your conclusions. Regarding the nightmares and social isolation, your report should include an assessment of the effect this has on duty performance. For example: the Soldier appears to get restorative sleep and while the nightmares are deeply disturbing, he is able to refocus on other events and does not dwell on the nightmares. With regard to his social withdrawal, while he prefers to work alone, he can work with others when necessary. Therefore, neither symptom contributes to industrial inadaptability."
Again, this guidance is not flawed on its face. The problem is that MEB psychiatrists may end up using this as a template to apply to individual Soldiers who are then denied benefits they are entitled to receive for their injuries.

"A Soldier who is severely compromised in performing in the military environment may or may not be impaired in the context of the civilian world. For example, a Soldier may have severe PTSD symptoms due to the hyperarousal component of PTSD. These symptoms may appear in response to military stimuli/military work environment. However, you may determine that that same Soldier may not be severely impaired in industrial adaptability if the Soldier is relatively symptom-free when away from this military stimuli/military work environment."
I am concerned about this guidance because it puts the psychiatrist in the position of speculating about how a Soldier may react in a hypothetical future environment. While it is possible to speculate, it seems unfair to do so when the better evidence is the Soldiers current limitations.

"Based on its review of commander statements, the Agency notes that many Soldiers demonstrate remarkable adaptability and are capable of working despite having a psychiatric diagnosis with significant symptomatology. If, up until this point in writing MEB reports, you have neither reviewed nor considered the Commander’s statements when providing your assessment of the Soldier, you will likely begin to appreciate that many Soldiers demonstrate considerable industrial adaptability. "
I am concerned with this guidance because it sends a message to MEB psychiatrists that across the board many Soldiers have little functional impairment. The problem is when this message prods the evaluator to downplay the true nature of the Soldier's limitations. This has the potential to lead to lower ratings at the Physical Evaluation Board than are warranted by the Soldier's injuries.

"Be aware that sometimes profiles are “overly restrictive.” Some physicians who prepare profiles believe that any Soldier with a psychiatric diagnosis cannot fire a weapon. This is not true. Look at the Soldier’s profile and verify that the profile does not appear to be overly restrictive. It is helpful if you comment on whether the Soldier’s current profile, as it relates to the Soldier’s psychiatric condition, appears reasonable given your evaluation of the Soldier."
This sets the stage for the psychiatrist to "overule" the profiling officer, who is also a physician. While the PEB comes to their own conclusions regarding a profiles reasonableness in making their decision on fitness, it seems like this guidance only serves to buttress an argument for a lower rating. The profiling officer is the person charged with coming to an accurate statement of the Soldier's limitations. If used improperly, this guidance only serves to cloud the issues and not come to a true picture of a Soldier's disabilities.

"7. Are there other explanations for symptoms that may be attributed to PTSD?

Yes. Symptoms attributed to PTSD may be similar to symptoms due to other mental disorders including: adjustment disorder; depression; another anxiety disorder; panic attacks; maladaptive reactions reflecting an underlying personality disorder; maladaptive traits; and malingering. Symptoms and behaviors such as social withdrawal, “flashbacks” (often poorly described and even misunderstood by clinicians), nightmares, irritability, substance/alcohol abuse, and insomnia are not unique to PTSD and may be indicative of one of the other above conditions."
This is another example of the pervasive theme of the guidance to find other diagnoses other than PTSD. It is certain that some Soldiers are inaccuratley diagnosed with PTSD. The worrisome part of this guidance is that given the Army's track record of denying benefits due to personality disorder to those who are in fact suffering from PTSD, this may serve to worsen the problem. The PDES is not meant to be an adversarial process. I fear that this guidance may move the system in that direction."
 
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brianwl

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Great letter Jason.

One other issue is the volumonous documentation the Psychiatrist is required to provide to support a PTSD diagnosis, versus the need for little or no documentation to support a Personality Disorder.

Consider the Psychiatrist that is evaluating Soldiers on a daily basis, they have no time to do all the required research and documentation. Consequently the Soldier gets shorted.
 

Jason Perry

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More thoughts...

Remember that alcohol use or abuse is part of the rating criteria under DODI 1332.39. The relevant section states,"E2.A1.5.1.2. Social impairment. Information that relates to social impairment includes, but is not limited to, the following:...
E2.A1.5.1.2.5. Substance use or abuse (alcohol and/or illicit drugs)."

It strikes me that the APDA "Guidance" (I think it will be interpreted as binding) on the alcohol use/abuse by Soldiers that I commented on earlier may be patently illegal. If the rating criteria recognize this symptom as an incident of mental disorders, it seems to me that the APDA cannot choose to ignore this criteria. The effect of this "Guidance" is to eliminate one of the criteria for ratings recognized by the Department of Defense. If you are lowballed by the PEB for this reason, I would challenge this vigorously.
 
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