Current VA policies encourage misrepresentation and invalidism, rather than recovery and reentry into the workforce.
By B. Christopher Frueh.
In this commentary I outline my view of the case for symptom misrepresentation among veterans seeking post-traumatic stress disorder (PTSD) services with the Veteran Administration Hospital system. My perspective is based on 15 years of clinical experience as a psychologist in a VA PTSD clinic (1991-2006) and 23 years of research with veterans and other populations seeking PTSD care (1991-present) in VA, prisons, community mental health centers, primary care settings, and inpatient psychiatric hospitals. I believe PTSD is a real psychiatric disorder and that veterans who suffer from it deserve all the appropriate treatment and safety net help that they need. That said, current VA policies encourage misrepresentation and invalidism, rather than recovery and reentry into the workforce.
The issue is extremely nuanced, with different forms and levels of misrepresentation and many veterans start at one place and then move to another. Among those seeking PTSD services (treatment/benefits) from the VA, there are some who misrepresent or exaggerate their combat experience, some who malinger symptoms they do not have, some who exaggerate symptoms they have, some of misrepresent symptoms of other psychiatric disorders as PTSD, some who do not admit to treatment benefits they experience – and some who are reporting it like it is. There are many veterans who misrepresent perhaps without even realizing it, and many veterans whose behaviors and recovery efforts are influenced by the contingencies the VA has set up (see McNally & Frueh, 2012).
My overarching concerns about the VA’s disability policies are that they are countertherapeutic and harmful to veterans’ recovery efforts and lead to misallocation of resources. Others have noted this concern going back many years (e.g., Mossman, 1996). Recently I co-authored a commentary with Dr. Sally Satel in The National Review, which explains this concern.
Below are the reasons I think we have a serious systemic problem with symptom misrepresentation among veterans seeking PTSD services with the VA. Please note, this is not intended to be an exhaustive literature review.
1. My own clinical experience: My own clinical experience over 15 years in the VA was that a large percentage (> 50%) of veterans appeared to be misrepresenting their symptoms and did not appear to be very invested in their treatment. This was the consensus opinion of most mental health clinicians I worked with, and of most of the VA mental health clinicians I talk with to this day – across disciplines. Also, the treatment response I have observed from PTSD patients treated outside the VA or inside the VA who have disavowed disability, has been markedly different from PTSD patients seeking disability. When I started seeing patients in a community mental health clinic I was shocked at how quickly and significantly they responded to PTSD treatment.
2. Validity profiles of MMPI: In the 1980s and 1990s there was a wide body of evidence from many different VAs consistently showing the mean validity profile on the Minnesota Multiphasic Personality Inventory (MMPI) was one of a malingering (“faking bad”), especially among disability seekers. We summarized this research in a review paper (Frueh et al., 2000). Eventually most clinicians stopped using the MMPI with this population because the profiles were so rarely valid.
3. Clinician and expert perspectives: At least one national survey of VA mental health clinicians found that a majority viewed malingering of PTSD in the VA as a significant concern (Sayer & Thuras, 2002). Also, a consensus opinion of top PTSD experts in the 1990s wrote an opinion piece suggesting that disability seeking veterans should not be included in research studies because of the potential distortions of cash disability incentives (Charney et al., 1998), though this suggestion has been virtually ignored by the entire field – in part because the percentage of treatment-seeking veterans also seeking disability or on disability rose to virtually 100%.
4. Malingering studies: Several small sample studies have produced results directly suggestive of malingering. Our Freedom of Information Act study of military personnel records found many discrepancies with veterans reported military experiences (Frueh et al., 2005). A study by another group used a labor intensive forensic interview developed to identify malingerers and found 25% were clearly responding honestly, 50% were in the range of possible malingering, and 25% were clearly malingering (Freeman et al., 2008). These are relatively small studies, but they may represent the tip of the iceberg. It is notable that the VA has never organized large-scale study to investigate.
5. Economic research: Large economic studies shows that employment consequences of PTSD have as much to do with VA disability cash incentives as with a medical inability to work – and that exposure to combat (and by implication, PTSD) cannot plausibly be the driver of the massive increase in recent Vietnam-era claims (Angrist, Chen, Frandsen, 2010).
6. The VA’s POW issue: In the early 2000s, I conducted DOD-funded research with POWs and found overall they had relatively low rates of PTSD and high rates of functioning. In meeting and talking with Vietnam POWs (e.g., Mike McGrath, then President of NAM-POWs) I learned they were very concerned about fake Vietnam POWs using the VA system. Although there were fewer than 800 Vietnam POWs, extrapolating data from two VA systems indicated the VA had over 10,000 on their roles. McGrath wrote to then VA Secretary Principi, and did not get much if any response (McGrath & Frueh, 2002).
7. Clinical trial data: The published clinical trial literature on the treatment of PTSD among civilians (e.g., rape victims) shows substantial treatment gains, with about 50% of patients showing full remission from the disorder; the published literature on treatment of PTSD in combat veterans shows almost no treatment benefits, with almost 0% in full remission (see review by Bradley et al., 2005). There are a few current small open trial studies published showing treatment benefits with OIF/OEF veterans (e.g., Tuerk et al. 2011) – however, these are non-controlled studies that seem to have carefully selected the patients they accepted. Most studies, including recent studies, show no or very little treatment benefit. Several other concerns with the clinical trial studies: (1) Since negative trials are often not published, it’s hard to know about the failure studies, especially in pharmacotherapy trials. I’ve talked with several psychiatrist who do industry sponsored research and they have offered the opinion that we would have more FDA approved meds for PTSD if veterans had been left out of the trials. (2) Across the country right now, many million dollar clinical trials for PTSD in combat veterans (funded by VA and DOD) are struggling to meet their recruitment goals. They simply cannot recruit sufficient numbers of OIF/OEF veterans with PTSD. (3) Another open secret among clinical trial investigators is that veterans often acknowledge to researchers that the treatment has helped them, but ask them not to document in the record for fear of losing disability. We’re currently experiencing this in a large DOD-funded trial we are conducting outside of the VA.
8. Lack of VA administrative data to support treatment effectiveness: To date, the VA system nationally has provided no data to support the efficacy of their vast treatment programs nationally. None. How can this be? The Institute of Medicine report released June 20, 2014 scolded the VA for not having such systematic data. However, what the IOM missed somehow is that for about five years the VA has mandated collection of PTSD symptom severity via a checklist (the “PCL”) at 90-day intervals for every veteran diagnosed with PTSD in the VA system nationally (see Frueh, 2013). It is a performance measure. What do these data show? As far as I can tell the VA has never disseminated these data. Why not? What might they tell us?
9. Administrative data that raise concerns: VA administrative data raises concerns, much of it noted in the OIG report (2005), which we have described and synthesized elsewhere (Frueh et al., 2007). For example, OIG found that most veterans’ self-reported symptoms of PTSD become worse over time until they reach 100% disability, at which point an 82% decline in use of VA mental health services occurs; with no change in use of other VA medical services. While virtually 100% of treatment seeking veterans apply for disability; of those applying for PTSD disability only about 50% are seeking treatment. According to Alan Zarembo (LA Times, August 3, 2014, http://www.latimes.com/local/la-me-ptsd-disability-20140804-story.html#page=1 ) of the 572,612 veterans on the disability rolls for PTSD at the end of 2012, 1,868 — a third of 1% — saw a reduction in their ratings the next year, according to statistics provided by the VA. This is despite strong evidence that PTSD can be effectively treated in other populations. Why are there almost no veterans benefiting from the VA’s vast PTSD treatment services and coming off disability?
10. Data from epidemiological studies: Rates of applications and service connections far exceed what epidemiological studies indicate is the actual prevalence of the disorder. Point prevalence of PTSD for Vietnam veterans was 9% in the 1980s and for OIF/OEF veterans was 8% (Richardson, Acierno, Frueh, 2010). Moreover, 30-50% of those meeting criteria for PTSD had mild symptom severity. Set these against the number of veterans now receiving and/or applying for PTSD disability. One report suggests that 35% of OIF/OEF veterans have already applied for PTSD disability – a war with lower KIA/WIA rates than other US wars of the 20th Century (as reported in McNally & Frueh, 2013). Also, the rates of PTSD in US veterans of OIF/OEF are higher than UK veterans, and UK veterans have different disability contingencies. It is also worrisome that OIF/OEF veterans are seeking disability from VA (for PTSD and many other conditions) at historically unprecedented rates – much higher than Vietnam, Korea, and WWII cohorts (McNally & Frueh, 2012), though other factors could also account for this.
11. VA’s resistance to studying the issue: A national study conducted by the congressionally funded VA National Centers for PTSD found that although the system’s mental health clinicians are not using standardized diagnostic procedures (e.g., clinical interviews, self-report measures) or standardized forensic measures to detect malingering or symptom exaggeration (Jackson et al., 2011), there is somehow no reason to worry because the malingering rate is estimated to be so low as to be irrelevant. The VA National Centers for PTSD leaders vigorously defend their view that there is virtually no malingering of PTSD in the system. Yet, they have essentially ignored all the evidence to the contrary and failed to conduct the type of rigorous research it would take the address the concern. Some of these senior leaders in the field were co-authors on the Charney et al consensus statement (1998) urging exclusion of veterans seeking disability connection from clinical trials, yet now they seem to have changed their minds. Why did they once worry about apparent malingering and now dismiss it as a non-problem? Finally and anecdotally, there is evidence that PTSD evaluators are heavily discouraged from using forensic measures that might identify symptom misrepresentation (e.g., Poyner, 2010).
The VA has the data available and/or could easily gather the data to address this concern and many of the other angles of it definitively. Why has it not done so?
A final thought: The real problem is not so much veterans misrepresenting to the VA – though this is a large cost driver for the system – but misrepresenting to themselves, and in the process irreparably harming their mental well-being by accepting a life as a psychiatric invalid – rather than engaged, productive members of society who have conquered their emotional troubles. The VA’s disability policies are well-intentioned, but they are hugely wasteful and destructive to the lives of veterans and their families. It should reconsider its outdated and iatrogenic disability policies.
B. Christopher Frueh, PhD, is a professor of psychology at the University of Hawai‘i at Hilo and directs research at The Menninger Clinic in Houston, Texas. He is author of over 250 scientific publications, and of They Die Alone and five other crime novels writing under the pseudonym Christopher Bartley. Contact.
This commentary was originally published in Psychology Today, Sept. 9, 2014: “11 Reasons that Combat Veterans with PTSD are Being Harmed” (in “Curious,” a column by Todd Kashdan, PhD).