The Department of Veterans Affairs (VA) needs to make changes to ensure that PTSD disability claims decisions are reliable and valid. When claims decisions are inconsistent, inequitable, and inaccurate, which they often are currently, the public will regard the VA disability compensation program as lacking integrity.
By integrity, I mean “Strict adherence to a moral code, reflected in transparent honesty and complete harmony in what one thinks, says, and does.”1
This definition is very consistent with Strategy Nine in VA’s Blueprint for Excellence: “Operate and communicate with integrity, transparency and accountability that earns and maintains the trust of Veterans, stewards of the system (Congress, Veterans Service Organizations) and the public” (p. 37).
To be transparent and honest about the Mental Health (MH) C&P exam program, VA must acknowledge to Veterans, VSOs, Congress, and the public that:
- VHA does not currently evaluate C&P exam consistency, fairness, and accuracy, i.e., few, if any, VAMCs have established a rigorous Quality Assurance program for MH C&P exams.2
- Therefore, we do not know what percentage of C&P exams would pass a rigorous QA program and be considered reliable and valid. However, reports from the field, some scientific research, and, especially, reports from individual Veterans suggest a high percentage of inconsistent and inaccurate MH C&P exam results.3
- The inaccurate results for MH C&P exams include both false negatives and false positives. Before 2010, I suspect the false negative rate was higher. But since 2010, I have no doubt that the false positive rate is higher, for reasons best explained by Russo (2014).4
Such transparency and honesty will open the way to a frank dialogue with VSOs about what I call “the NSR mental disorder claims problem.” NSR stands for Non-Service-Related claims, which seem to fall into four categories:
Inaccurate Referrals – A Veteran’s family member, friend, or service officer urges him or her to file a disability claim for PTSD or other mental disorders, despite scant evidence that a service-related mental order exists, or if one does exist, there is little or no evidence that it is service related. The Veteran often complies with the request to file a claim in order to placate someone else, or out of respect for the person making the request. They often tell the C&P examiner something like, “I really don’t think I have this PTSD thing, but my wife really wanted me to do this, and I love her and wanted to at least do what she asked me.”
Mistaken Attribution – The Veteran has a genuine mental disorder, usually a depressive and/or anxiety disorder, and over time they come to believe that the disorder is related to their military service when it actually is not. I have defined this as an innocent process, i.e., the Veteran is not malingering (if they know that their current problems are not service-related but they pretend that they are, it is called false imputation, which is a form of malingering),5 they truly believe their current difficulties were incurred during or aggravated by their military service. Mistaken attribution often occurs with secondary disability claims, e.g., depression secondary to a knee problem. The degree to which the Veteran truly believes that his or her mental disorder is caused by his service connected medical problem(s) probably exists on a spectrum from genuine belief to conscious fabrication, so when I refer to “mistaken attribution” in secondary claims, I mean that the Veteran truly believes that his or her medical condition(s) are causing his psychological problems when this is not actually the case. If they know that their medical condition(s) did not cause their psychiatric disorder, then it is a case of feigning/malingering.
Exaggeration – The Veteran exaggerates symptom severity (duration, frequency, and intensity of symptoms) in order to become service-connected or to increase their disability rating. This exaggeration occurs on a continuum from full awareness to no conscious awareness. The concept of compensation neurosis (Hall & Hall, 2012) would be an example of exaggeration that occurs on the reduced conscious awareness part of the spectrum.6
Feigning/Malingering – C&P psychologists and psychiatrists should only rarely diagnose malingering, because the diagnosis requires persuasive evidence that the Veteran consciously intended to feign a mental disorder in order to receive VA disability benefits. Identifying feigning is much more common, at least for examiners given enough time to conduct a thorough, evidence-based psychological/psychiatric disability evaluation. (Feigning indicates that the Veteran fabricated information, but there is not enough evidence of conscious fraudulent intention to assign a malingering diagnosis.) Examples of evidence for feigning include:
- Multiple inconsistencies in the evidence of record for which there is no reasonable explanation.
- Standardized psychometric tests (symptom validity tests [SVTs] and performance validity tests [PVTs]).
- Reliable records (usually from the Veteran’s military personnel or medical records) that prove a Veteran has lied about some aspect of the places, types, and circumstances of his or her service,7 e.g., claiming they were traumatized by the bombing of the Marine Corps barracks in Beirut, Lebanon in 1983, when their personnel records show they were not stationed in Lebanon during the incident or its aftermath.
Most Veterans will tell you that they know at least one Veteran who receives unwarranted VA disability benefits. It’s a frequent complaint about group therapy, e.g., “I couldn’t stand listening to these two guys whining and complaining about everything, especially when I know they were never actually in combat!”
And goodness knows almost every MH C&P examiner will testify to the fact that a fairly high percentage of the Veterans they evaluate present with NSR claims.
And there is even some scientific evidence suggesting a significant false positive rate for MH C&P exams (see citations in footnote #3). And then there is the fact highlighted above, that VHA does not conduct a rigorous quality review of MH C&P exams, which does not, in itself, prove a high inaccuracy rate, but one must wonder why VHA has never implemented a top-notch QA program for MH C&P exams.
So it is not exactly a secret that a problem exists, even if some VA administrators and VSOs seem to go to great lengths to ‘ignore the elephant in the middle of the room’.
Therefore it is time to have open and direct discussions with the VSOs, which have tremendous clout at 810 Vermont Avenue (VA Central Office) and in the halls of Congress. Not much will change without VSO support. And if the VA is not transparent and honest about the current state of affairs, the department will not possess the credibility necessary for VSOs to listen and engage in a meaningful dialogue about the high rate of NSR mental disorder claims that pass through the claims process unchallenged.
2. This conclusion might be true for nonpsychiatric medical and audiology exams, but I defer to those professionals for more informed conclusions.
Evans, F. B. (2011). Introduction to practice matters special section on VA compensation and pension exams for PTSD and other mental disorders. Psychological Injury and Law, 4(3-4), 169-170.
Institute of Medicine and National Research Council (2007). PTSD compensation and military service. Washington, DC: National Academies Press. | bit.ly/IOM-PTSD-Compensation
Jackson, J. C., Sinnott, P. L., Marx, B. P., Murdoch, M., Sayer, N., Alvarez, J. M., Greevy, R. A., Schnurr, P. P., Friedman, M. J., Shane, A. C., Owen, R. R., Keane & Speroff, T. M. (2011). Variation in practices and attitudes of clinicians assessing PTSD-related disability among Veterans. Journal of Traumatic Stress, 24(5), 609–613. | http://onlinelibrary.wiley.
Poyner, G. (2010). Psychological evaluations of veterans claiming PTSD disability with the Department of Veterans Affairs: A clinician’s viewpoint. Psychological Injury and Law, 3, 130– 132. doi:10.1007/s12207-010-9076-x
Ridgway, J. D.(2009). Lessons the veterans benefits system must learn on gathering expert witness evidence. Federal Circuit Bar Journal, 18(3), 405-428. | http://ssrn.com/abstract=
Speroff, T., et-al. (2012). Impact of evidence-based standardized assessment on the disability clinical interview for diagnosis of service-connected PTSD: A cluster-randomized trial. Journal of Traumatic Stress, 25(6), 607-615. doi:10.1002/jts.21759 | http://onlinelibrary.wiley.
Wisdom, N. M., Pastorek, N. J., Miller, B. I., Booth, J. E., Romesser, J. M., Linck, J. F., & Sim, A. H. (2013). PTSD and cognitive functioning: Importance of including performance validity testing. The Clinical Neuropsychologist, 1–18. | doi:10.1080/13854046.2013.
Worthen, M. D. & Moering, R. G. (2011). A practical guide to conducting VA compensation and pension exams for PTSD and other mental disorders. Psychological Injury and Law, 4(3-4), 187-216. doi:10.1007/s12207-011-9115-2 | bit.ly/ptsd-exams
4. Russo, A. C. (2014). Assessing veteran symptom validity. Psychological Injury and Law, published online 5 March 2014. doi:10.1007/s12207-014-9190-2 | bit.ly/vet-symptom-validity
5. Resnick, P. J. (1997). Malingering of posttraumatic disorders. In R.Rogers (Ed.), Clinical assessment of malingering and deception (2nd Ed.), pp. 130–152. New York: Guilford Press.
6. Hall, R. C. W. & Hall, R. C. W. (2012). Compensation neurosis: A too quickly forgotten concept? The Journal of the American Academy of Psychiatry and the Law, 40(3), 390-398. | bit.ly/
7. See 38 C.F.R. § 3.303(a)