PTSD Case Review Update

[Gimpy]

PTSD Case Review Hit:

By Tom Philpott

Military.com

September 29, 2005


Both his grandfather and great uncle served in World War II, said Sen. Barack Obama (D-Ill.), but only his great uncle entered a Nazi death camp as the war came to a close. "According to the story my grandmother told," said the senator in a phone interview, "when he got home he went up to his parents' house, into the attic, and didn't talk for about six months."

It was an era, said Obama, in which many veterans struggled through the trauma of war, without counseling or disability pay.
Obama had several generations of veterans in mind, he suggested, when he joined with fellow Democrats Richard Durbin ( Ill. ), Patty Murray ( Wash. ) and Daniel K. Akaka ( Hawaii ) Sept. 22 on an amendment to block the Department of Veterans Affairs from reviewing case files of 72,000 veterans rated 100-percent disabled by post-traumatic stress disorder (PTSD).

The Senate, on a voice vote, adopted the amendment to the Military Construction and Veterans Affairs Appropriation Act (HR 2528). The House version of the bill has no such language, so a House-Senate conference committee will decide its fate during final negotiations on the bill.

Rep. Steve Buyer (R-Ind.), chairman of the House Veterans Affairs Committee, declined an interview but in a written statement said, "If a veteran's claim is unfairly denied, that is a problem. If a claim is granted in error, that is money taken from another veteran."

VA officials believe some PTSD claims have been decided for veterans without proper documentation. They announced their massive review only after the VA inspector general studied 2,100 randomly-selected cases of PTSD disability awards and found 25 percent lacked documents to verify that a traumatic, service-connected incident occurred.

Given the poor staff work, VA said that in January it would begin to review paperwork for all 100-percent disabled PTSD cases decided over five years, from October 1999 through September 2004. In that period, the IG said, the number of veterans receiving compensation for PTSD rose by 80 percent and annual PTSD payments rose from $1.7 billion to $4.3 billion.

But the Senate's amendment would bar the VA from conducting its case review until it justifies the program to Congress. It also would prohibit the VA from lowering PTSD awards except in cases of fraud. "None of us wants to see any fraud or waste in government spending," said Obama, who serves on the Senate Veterans Affairs Committee. "But nowhere should we be more willing to give people the benefit of the doubt than with the brave men and women who served our country."

The VA, he said, "is presuming significant fraud for people who have received 100-percent disability payments on PTSD claims. They are not conducting a comparable survey of people whose claims were denied. What that indicates, to me at least, is there is some bias against those who have received payments."

He noted that the original IG investigation was launched because of veterans' complaints of wide disparities in claim award between VA regions. "There were a couple of ways the VA could have handled it. They could have said, 'You know, this is troubling. It seems that some veterans are being shortchanged. Let's make sure all veterans are being treated fairly and generously.' "

Instead, the VA decided to "level down rather than up" on benefits. He predicted House conferees will concede to the Senate on this issue. "If you just think about the nature of PTSD, imagine the number of servicemen who come back and never even bother about making a PTSD claim, despite the fact that they've having significant trauma," Obama said. "Think about those who maybe put in a claim but weren't organized enough to have the paperwork, and now, potentially, are going to see benefits reduced." Obama said the rise in PTSD payments likely reflects greater knowledge today of the disorder rather than sloppy staff work or fraud.

http://www.military.com/NewContent/..._092905,00.html

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[Gimpy]

Sure there MUST be some 'interest' and 'concern' about this issue from the many folks around here (and everywhere there is a veteran receiving VA disability compensation for PTSD)for whom this 'review' would possibly affect???

Where are the 'voices' of condemnation and outrage????

[Packo]

RIGHT HERE!

I know what's going on here and it sickens me. When I write my reps about this I'm going to ask a simple question.

Why is it that the VA grants automatic disability to anyone who becomes either Schizophrenic, Manic Depressive, (Bi-Polar Disorder), or suffers from Major Depression? The first two CANNOT EVEN BE CAUSED BY MILITARY SERVICE! Yet when we're talking about Combat related disorders we have to review 72,000 cases to see if someone had a stressor???? I can't believe anybody can go through a war or be in a war zone without incuring at least ONE LIFE THREATENING STRESSOR. What's going to happen here is that they will try and take away a PTSD rating for anyone who wasn't Infantry, Armour, Helo's, Jets, Artillery, or Medics, saying that they couldn't have a stressor if they weren't in a combat MOS. Watch....

Everybody here should be supporting the initative to block this. I have a patient who drove his vehicle over 3 mine booby trap in Iraq. He was not wounded but the 7 ton was destroyed. The Marine Corps says that does not rate a Combat Action Ribbon. Now, tell me that driving over a 3Mine trap ain't stressful and beyond the realm of NORMAL TRAUMA???? When he files a claim someday I can just hear the VA. "No CAR, no disablility. This is friggin crime and we must do what we can to stop this OR force them to also review again every case turned down. Funny they only want to look at ones granted. What a bunch of BASTARDS. Let's go guys....time to spend a little time notifying your Congressmen and Senators.

I'll get off my soap box.

Pissed off Pack!

PS THANKS GIMPY FOR GETTING THIS UP!

[catman]

Gimp...I too am here. This issue is so absurb that I find it very hard to talk about without my blood pressure boiling.

Will get emails off to my reps soon.

I stand behind you 100% on this one!

Trav

[Gimpy]

to both of you, Packman and Trav.

I know for sure Packo that you are seeing the affect and results of this screwed up system of 'evaluation' first hand and on a regular basis. It's a cryin phuckin shame this 'new breed' of warriors are having to fight the same damn battles we fought so long ago!

This is something that we ALL should be writing our Senators and Representatives about.

We need to 'nip' this crap in it's early stages before it's too late!

Thanks again.

[billyguns]

I have come to beleive the VA is attempting to discontinue disability ratings for PTSD period. In as much as this disorder effects deferent people in soo many deferent avenues of their lives, it is very difficult for anyone short of mental health specialist to differenciate cronic PTSD from a plain old case of the blues. The fact that everyone, at some point in their lives is ' depresed' leads the average lay person to dismiss how serious and disrupting this condition realy is. I have seen people scoff at the idea of PTSD as if in some way a weakness or lack of grit on the part of an individual. this sickens me beyond expression. Over the years, I have been involved with many veterans diagnosed with this illness. While it is true some could and should do a better job of puting and keeping themselves in a position to help themselves, many of the truly cronic and severe cases are simply so far gone they are unable to make choices in their lives to help put their lives in some form of reasonable order. Futhermore, there is no magic pill or cure for PTSD. To add insult to injury, the adjudicators at the VA know the most severely ill are the least likely to have the witt and resorces to perservere an intentionally long and drawnout claims and appeals process. That is the very reason the gansters at the VA are able to keep grinding most PTSD veterans claims in to the dirt. Pisses me off every time I think about it.

[MORTARDUDE]

It is a fact that many Vietnam war veterans, who were engaging in informal groups to talk about their experiences in Vietnam, got PTSD in the psychiatric DMS-III manual. The record of the psychiatric profession and the VA thru the early '80s regarding PTSD is nothing short of disgusting.

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http://cybersarges.tripod.com/ptsdhistory.html


A HISTORY OF POST TRAUMATIC STRESS DISORDER



In 1980, the American Psychiatric Association added PTSD to the third edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM-III) nosologic classification scheme. Although a controversial diagnosis when first introduced, PTSD has filled an important gap in psychiatric theory and practice. From an historical perspective, the significant change ushered in by the PTSD concept was the stipulation that the etiological agent was outside the individual him or herself (i.e., the traumatic event) rather than an inherent individual weakness (i.e., a traumatic neurosis). The key to understanding the scientific basis and clinical expression of PTSD is the concept of "trauma."

In its initial DSM-III formulation, a traumatic event was conceptualized as a catastrophic stressor that was outside the range of usual human experience. The framers of the original PTSD diagnosis had in mind events such as war, torture, rape, the Nazi Holocaust, the atomic bombings of Hiroshima and Nagasaki, natural disasters (such as earthquakes, hurricanes, and volcano eruptions) and human-made disasters (such as factory explosions, airplane crashes, and automobile accidents). They considered traumatic events as clearly different from the very painful stressors that constitute the normal vicissitudes of life such as divorce, failure, rejection, serious illness, financial reverses and the like. (By this logic adverse psychological responses to such "ordinary stressors" would, in DSM-III terms, be characterized as Adjustment Disorders rather than PTSD.) This dichotomization between traumatic and other stressors was based on the assumption that although most individuals have the ability to cope with ordinary stress, their adaptive capacities are likely to be overwhelmed when confronted by a traumatic stressor.

PTSD is unique among other psychiatric diagnoses because of the great importance placed upon the etiological agent, the traumatic stressor. In fact, one cannot make a PTSD diagnosis unless the patient has actually met the "stressor criterion" which means that he or she has been exposed to an historical event that is considered traumatic. Clinical experience with the PTSD diagnosis has shown, however, that there are individual differences regarding the capacity to cope with catastrophic stress so that while some people exposed to traumatic events do not develop PTSD, others go on to develop the full-blown syndrome. Such observations have prompted a recognition that trauma, like pain, is not an external phenomenon that can be completely objectified. Like pain, the traumatic experience is filtered through cognitive and emotional processes before it can be appraised as an extreme threat. Because of individual differences in this appraisal process, different people appear to have different trauma thresholds, some more protected and some more vulnerable to developing clinical symptoms after exposure to extremely stressful situations. Although there is a renewed interest in subjective aspects of traumatic exposure, it must be emphasized that exposure to events such as rape, torture, genocide, and severe war zone stress, are experienced as traumatic events by nearly everyone.

The DSM-III diagnostic criteria for PTSD were revised in DSM-III-R (1987) and DSM-IV (1994). A very similar syndrome is classified in ICD-10. Diagnostic criteria for PTSD include a history of exposure to a "traumatic event" and symptoms from each of three symptom clusters: intrusive recollections, avoidant/numbing symptoms and hyper arousal symptoms. A fifth criterion concerns duration of symptoms. One important finding, which was not apparent when PTSD was first proposed as a diagnosis in 1980, is that it is relatively common. Recent data from the national co morbidity survey indicates PTSD prevalence rates are 5% and 10% respectively among American men and women.

As noted above the "A" stressor criterion specifies that a person has been exposed to a catastrophic event involving actual or threatened death or injury, or a threat to the physical integrity of him/herself or others. During this traumatic exposure, the survivor's subjective response was marked by intense fear, helplessness or horror.

The "B" or intrusive recollection criterion includes symptoms that are perhaps the most distinctive and readily identifiable symptoms of PTSD. For individuals with PTSD, the traumatic event remains, sometimes for decades or a lifetime, a dominating psychological experience that retains its power to evoke panic, terror, dread, grief, or despair as manifested in daytime fantasies, traumatic nightmares, and psychotic reenactments known as PTSD flashbacks. Furthermore, trauma mimetic stimuli that trigger recollections of the original event have the power to evoke mental images, emotional responses, and psychological reactions associated with the trauma. Researchers, taking advantage of this phenomenon, can reproduce PTSD symptoms in the laboratory by exposing affected individuals to auditory or visual trauma mimetic stimuli.

The "C" or avoidant/numbing criterion consists of symptoms reflecting behavioral, cognitive, or emotional strategies by which PTSD patients attempt to reduce the likelihood that they will either expose themselves to trauma mimetic stimuli, or if exposed, will minimize the intensity of their psychological response. Behavioral strategies include avoiding any situation in which they perceive a risk of confronting such stimuli. In its most extreme manifestation, avoidant behavior may superficially resemble agoraphobia because the PTSD individual is afraid to leave the house for fear of confronting reminders of the traumatic event(s). Dissociation and psychogenic amnesia are included among avoidant/numbing symptoms by which individuals cut off the conscious experience of trauma-based memories and feelings. Finally, since individuals with PTSD cannot tolerate strong emotions, especially those associated with the traumatic experience, they separate the cognitive from the emotional aspects of psychological experience and perceive only the former. Such "psychic numbing" is an emotional anesthesia that makes it extremely difficult for people with PTSD to participate in meaningful interpersonal relationships.

Symptoms included in the "D" or hyper arousal criterion most closely resemble these seen in panic and generalized anxiety disorder. Whereas symptoms such as insomnia and irritability are generic anxiety symptoms, hyper vigilance and startle are more unique. The hyper vigilance in PTSD may sometimes become so intense as to appear like frank paranoia. The startle response has a unique neurobiological substrate and may actually be the most path gnomonic PTSD symptom.

The "E" or duration criterion specifies how long symptoms must persist in order to qualify for the (chronic or delayed) PTSD diagnosis. In DSM-III the mandatory duration was six months. In DSM-III-R the duration was shortened to one month, where it has remained in DSM-IV.

The new "F" or significance criterion specifies that the survivor must experience significant social, occupational, or other distress as a result of these symptoms.

Since 1980 there has been a great deal of attention devoted to the development of instruments for assessing PTSD. working with Vietnam war zone veterans have developed both psychometric and psycho physiologic assessment techniques that have proven to be both reliable and valid. Other investigators have modified such assessment instruments and used them with natural disaster victims, rape/incest survivors, and other traumatized cohorts. Research using such techniques has been used in the epidemiological studies mentioned above and in other research protocols.

Neurobiological research indicates that PTSD may be associated with stable neurobiological alterations in both the central and autonomic nervous systems. Psycho physiological alterations associated with PTSD include hyper arousal of the sympathetic nervous system, increased sensitivity and augmentation of the acoustic-startle eye blink reflex, a reducer pattern of auditory evoked cortical potentials, and sleep abnormalities. Neuropharmacologic and neuroendocrine abnormalities have been detected in the noradrenergic, hypothalamic-pituitary-adrenocortical, and endogenous opioid systems. These data are reviewed extensively elsewhere.

Longitudinal research has shown that PTSD can become a chronic psychiatric disorder that can persist for decades and sometimes for a lifetime. Patients with chronic PTSD often exhibit a longitudinal course marked by remissions and relapses. There is a delayed variant of PTSD in which individuals exposed to a traumatic event do not exhibit the PTSD syndrome until months or years afterwards. Usually, the immediate precipitant is a situation that resembles the original trauma in a significant way; (for example, a war veteran whose child is deployed to a war zone or a rape survivor who is sexually harassed or assaulted years later).

If an individual meets diagnostic criteria for PTSD, it is likely that he or she will meet DSM-IV criteria for one or more additional diagnoses. Most often these co-morbid diagnoses include major affective disorders, dysthymia, alcohol or substance abuse disorders, anxiety disorders, or personality disorders. There is a legitimate question whether the high rate of diagnostic co-morbidity seen with PTSD is an artifact of our current decision rules for making the PTSD diagnosis since there are not exclusionary criteria in DSM-III-R. In any case, high rates of co-morbidity complicate treatment decisions concerning patients with PTSD since the clinician must decide whether to treat the co-morbid disorders concurrently or sequentially.

Although PTSD continues to be classified as an Anxiety Disorder, areas of disagreement about its nosology and phenomenology remain. Questions about the syndrome itself include: what is the clinical course of untreated PTSD; are there different subtypes of PTSD; what is the distinction between traumatic simple phobia and PTSD; and what is the clinical phenomenology of prolonged and repeated trauma. With regard to the latter, has argued that the current PTSD formulation fails to characterize the major symptoms of PTSD commonly seen in victims of prolonged, repeated interpersonal violence such as domestic or sexual abuse and political torture. She has proposed an alternative diagnostic formulation that emphasizes: multiple symptoms, excessive somatization, dissociation, changes in affect, pathological changes in relationships and pathological changes in identity.

PTSD has also been criticized from the perspective of cross-cultural psychology and medical anthropology, because it has usually been diagnosed by clinicians from Western industrialized nations working with patients from a similar background. Major gaps remain in our understanding of the effects of ethnicity and culture on the clinical phenomenology of post-traumatic syndromes. We have only just begun to apply vigorous ethno cultural research strategies to delineate possible differences between Western and non-Western societies regarding the psychological impact of traumatic exposure and the clinical manifestations of such exposure.

Before closing, it is necessary to discuss treatment. The many therapeutic approaches offered to PTSD patients are presented in comprehensive book on treatment. The most successful interventions are those implemented immediately after a civilian disaster or war zone trauma. This is often referred to as critical incident stress debriefing (CISD) or some variant of that term. It is clear that the best outcomes are obtained when the trauma survivor receives CISD within hours or days of exposure. Such interventions not only attenuate the acute response to trauma but often forestall the later development of PTSD.

Results with chronic PTSD patients are often less successful. Perhaps the best therapeutic option for mild-to-moderately affected PTSD patients is group therapy. In such a setting the PTSD patient can discuss traumatic memories, PTSD symptoms and functional deficits with others who have had similar experiences. This approach has been most successful with war veterans, rape/incest victims and natural disaster survivors. For many severely affected patients with chronic PTSD a number of treatment options are available (often offered in combination) such as psychodynamic psychotherapy, behavioral therapy (direct therapeutic exposure) and pharmacotherapy. Results have been mixed and few well-controlled therapeutic trials have been published to date. It is important that therapeutic goals be realistic because in some cases, PTSD is a chronic and severely debilitating psychiatric disorder that is refractory to current available treatments. The hope remains, however, that our growing knowledge about PTSD will enable us to design more effective interventions for all patients afflicted with this disorder.



Helpful Web Links Web Addresses Description
http://www.nara.gov/regional/mpr.html National Personnel Records Center, Military Personnel Records Web Site
http://www.nara.gov/regional/mprsf180.html Download form SF 180 to request a copy of DD Form 214
http://www.va.gov/index.htm Veterans Administration & Benefits
http://www.vba.va.gov/bln/21/Benefits/index.htm Compensation & Pension Benefits
http://vabenefits.vba.va.gov/vonapp/ Veterans online application web site (VONAPP)
http://www.va.gov/FORMS/default.asp VA Forms
http://www.vva.org/benefits/vvaguide.htm Agent Orange, VA Claims and Appeals, Post-traumatic Stress Disorder, VVA's Guide To Veterans Preference
http://www.vva.org/benefits/vvgvaclaims.htm VVA's Guide on VA CLAIMS and APPEALS
http://www.ssa.gov Social Security Online
http://www.ssa.gov/disability/ Social Security Disability Information
http://www.senate.gov/ U.S. Senate
http://www.house.gov/Welcome.html U.S. House of Representatives
http://www.pld.ttu.ee/~gert/jwz/covernment.html U.S. Government Links

[billyguns]

Excelent information Mortardude, thanks !

[Gimpy]

billguns said!

Thanks Larry.

[Gimpy]

Believe this may get lost in the 'shuffle'!

We need MORE folks to 'write'.....'E-mail'...or.....'call' their Senators and Representatives!