6
Other PTSD Compensation Issues

As part of their charge, the Department of Veterans Affairs (VA) requested that the committee offer their observations on some broad topics concerning compensation for posttraumatic stress disorder (PTSD). It posed four questions:

  • What are the barriers or disincentives to recovery?

  • What are or might be incentives to recovery?

  • What is the evidentiary basis for the physical, psychological, and social influences of compensation on treatment and recovery?

  • Is periodic reexamination appropriate for asymptomatic patients, as it relates to compensation?

This chapter addresses these questions. As some of the relevant research on the topics comes from nonmilitary populations and civilian compensation programs, the chapter reviews literature in these areas. Sexual assault and gender—two intersecting issues related to exposure to trauma and the frequency and severity of PTSD in veterans—are also discussed. The committee undertook to examine these issues because research indicates that there is gender disparity in service connection for PTSD and that the relative difficulty of documenting in-service sexual assault (as compared to documenting combat exposure) may be a factor in this difference.



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PTSD Compensation and Military Service 6 Other PTSD Compensation Issues As part of their charge, the Department of Veterans Affairs (VA) requested that the committee offer their observations on some broad topics concerning compensation for posttraumatic stress disorder (PTSD). It posed four questions: What are the barriers or disincentives to recovery? What are or might be incentives to recovery? What is the evidentiary basis for the physical, psychological, and social influences of compensation on treatment and recovery? Is periodic reexamination appropriate for asymptomatic patients, as it relates to compensation? This chapter addresses these questions. As some of the relevant research on the topics comes from nonmilitary populations and civilian compensation programs, the chapter reviews literature in these areas. Sexual assault and gender—two intersecting issues related to exposure to trauma and the frequency and severity of PTSD in veterans—are also discussed. The committee undertook to examine these issues because research indicates that there is gender disparity in service connection for PTSD and that the relative difficulty of documenting in-service sexual assault (as compared to documenting combat exposure) may be a factor in this difference.

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PTSD Compensation and Military Service BARRIERS OR DISINCENTIVES TO RECOVERY The committee’s charge directed it to examine the barriers or disincentives to recovery and to “directly assess how PTSD compensation might influence beneficiaries’ attitudes and behaviors in ways that might serve as barriers to recovery.” This section addresses the general topic of barriers or disincentives to recovery, while the section that follows presents the literature on the effect of compensation on recovery and the committee’s conclusions and recommendations regarding this issue. Many of the studies on the barriers to recovery for persons with mental disorders have been conducted on civilian populations receiving support from programs administered by the Social Security Administration (SSA). As such, this chapter examines a broader range of research than other parts of the report. Recovery can be defined in various ways. In the context of this report, the committee considered recovery to be a reduction in the frequency and intensity of symptoms accompanied by an increase in social and occupational function. The research reviewed and cited in this section often used return to work as the specific measure of recovery. Research from the fields of disability, economics, health care, and labor studies has documented the wide variety of barriers to recovery and more broadly, to career advancement and economic security that can affect people with disabling mental disorders. In the civilian population, these barriers include low educational attainment, unfavorable labor market dynamics, low productivity, lack of appropriate vocational and clinical services, stigma in seeking services, labor force discrimination due to disabling conditions or race and ethnicity, failure of protective legislation, work disincentives caused by private and public disability policies, linkage of health care access to disability beneficiary status, and ineffective work incentive programs. Several notable barriers are discussed in more detail below. Barriers Encountered by Veterans and Members of the General Population One major barrier to recovery for many veterans who leave activeduty service is that they lack the necessary postsecondary education and training required to build careers. The original GI Bill was created, in part, to compensate veterans whose educational and career opportunities were interrupted by military service (Angrist, 1993). Research has shown that users of veterans’ benefits do increase their levels of education, resulting in corresponding increases in earning power (O’Neill, 1977), and that the largest benefits accrue to those who attend college or graduate school (Angrist, 1993). It has been suggested that PTSD is more likely to oc-

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PTSD Compensation and Military Service cur among veterans at lower educational levels rather than higher ones1 (Breslau et al., 1991), and, indeed, Beckham and colleagues found that the average number of years of education was significantly lower among veterans with PTSD than among veterans without PTSD (Beckham et al., 1998). One implication of this is that analyses of the association between PTSD and occupational success will be confounded by the level of educational achievement. Deficits in education are critically important because advanced education is increasingly essential to securing a high-paying job. In 2004, all but one of the 50 highest-paying occupations in the U.S. required a college degree or graduate education (BLS, 2006). A multivariate analysis of employment among a nationally representative group of adults with mental illness in the National Health Interview Survey: Disability Supplement found that education was a significant predictor of employment in general as well as, specifically, of employment in executive, administrative, or professional specialty occupations (Mechanic et al., 2002). Another barrier to recovery stems from the fact that many individuals whose condition improves after the onset of disability reenter the workforce at a significant disadvantage. Research shows that disabled individuals on Supplemental Security Income (SSI) who reenter the labor force tend to work at jobs that are lower paying and held for fewer hours per week than the jobs they held prior to becoming disabled (Schechter, 1999). Further, while workplace accommodations may extend the average duration of employment for disabled individuals (Burkhauser et al., 1995), there is evidence that some injured workers who receive job accommodations also receive lower wages so that they, in essence, “pay the price” of their own accommodations (Gunderson and Hyatt, 1996). In one study of individuals with psychiatric disabilities who returned to work, among those working full-time only 24 percent had jobs that provided medical coverage, 16 percent had dental coverage, 8 percent mental-health coverage, and 20 percent sick leave (Cook et al., 2006). Disability-income support policies often create unintended employment disincentives that help contribute to under- and unemployment (Burkhauser and Wittenburg, 1996; CBO, 1982). In both private and public disability- 1 There is little information on the association between educational level and combat exposure, but available studies do not indicate that lower educational attainment is serving as a proxy for combat exposure and thus accounts for the observed higher rates of PTSD in the less educated. Orcutt and colleagues (2002), who examined a cohort of nearly 3,000 male and female Gulf War veterans, found those with more years of education were both more likely to have been exposed to combat (0.15; p<.001) and less likely to report PTSD symptoms (−0.05; p<.001). Frueh and colleagues (2005) did not identify a statistical association between combat exposure and educational level in a sample of ~100 Vietnam veterans presenting for PTSD treatment at a VA Medical Center.

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PTSD Compensation and Military Service compensation systems, for instance, regulations typically mandate an administrative review of the individual’s disability status upon return to work. This discourages many disabled beneficiaries from seeking employment (Newcomb et al., 2003). And once they become employed, beneficiaries often find that, as their earnings increase, their monthly cash payments are sharply reduced. For example, the SSA) sets an earnings cutoff called the substantial gainful activity (SGA) level. Social Security Disability Income (SSDI) beneficiaries can earn up to the SGA level each month ($830 in 2006) with no loss of benefits; however, once earnings exceed that amount for nine nonconsecutive months plus a three-month grace period, all SSDI cash benefits cease. The sudden cutoff is referred to as the “earnings cliff” (White et al., 2005). SSI beneficiaries face a different penalty: Once their earnings reach $65 per month, their cash payment is reduced by one dollar for every two dollars of additional earnings, a tax rate of 50 percent—far exceeding that paid by the wealthiest individuals (Stapleton et al., 2005). Yet another disincentive is an “implicit tax” on disabled workers whose labor force participation causes them to lose additional benefits such as housing subsidies, utility supplements, transportation stipends, and food stamps (Polak and Warner, 1996). Research has indicated that people with psychiatric disabilities are aware of these disincentives and report that they plan their labor force participation accordingly (Polak and Warner, 1996; MacDonald-Wilson et al., 2003). The effects of work disincentives are also evident in studies comparing the employment outcomes of disabled individuals who do and who do not receive disability-related income support. One study of individuals with psychiatric disabilities receiving employment services found that those receiving SSI or SSDI cash benefits were significantly less likely to work competitively, to work forty or more hours per month, or to have high earnings than those who didn’t receive such benefits, regardless of clinical condition, level of disability, symptoms, education, or prior work history (Cook et al., 2005). According to research on both national and statewide cohorts of state vocational rehabilitation service recipients with psychiatric disabilities, employment rates are significantly lower among SSI and SSDI beneficiaries than among nonbeneficiaries, after controlling for functional impairment, level of family support, and demographics (Hayward and Schmidt-Davis, 2005; Cook, 2003). Two studies that controlled for a series of confounding demographic and clinical factors found that veterans with psychiatric and other disabilities are less likely to work, earn less money, and work fewer hours if they receive full—versus partial—benefits or if they receive more generous benefit amounts (Rosenheck et al., 1995; Drew et al., 2001). It should be noted that the reasons for the behavior underlying these results are complex and deserve careful thought; one should not simply conclude from them that giving only partial benefits would solve the problem.

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PTSD Compensation and Military Service Given the evidence suggesting that people respond to work disincentives by altering their labor force participation, it follows that policies designed to discourage reliance on disability income may paradoxically discourage substantial work attempts that could lead to exit from the rolls. Instead, many individuals receiving SSI and SSDI find themselves out of the labor force or trapped in low-paying, entry-level jobs where they are prevented from realizing their full career potential (Stapleton et al., 2005; Cook and Burke, 2002). Those who do successfully overcome their disability and maintain employment—and thus lose their cash benefits and related health insurance—often experience relapses of their illnesses due to their inability to get access to health and mental-health services. Recognizing this problem, various work-incentive provisions for individuals receiving public disability income support have been legislated by Congress. The Employment Opportunities of Disabled Americans Act of 1986 (Public Law 99-643), Section 1619(b), provided for continued SSI eligibility and access to Medicaid as long as earnings remain below a threshold established by each state. Another mechanism permitting individuals to work above SGA level while retaining Medicaid benefits was the Medicaid buy-in state plan option under the Balanced Budget Act of 1997 (Public Law105-33). The newest piece of disability legislation designed to address work disincentives is the Ticket to Work and Work Incentives Improvement Act of 1999 (Public Law 106-170). This legislation was intended to give people with disabilities increased vocational service options and reduce employment disincentives, while at the same time reducing government spending on people with disabilities (Stapleton and Livermore, 2003). To accomplish the first objective, vouchers or “tickets” were mailed to all work-disabled SSI and SSDI beneficiaries. The tickets are redeemable for 5 years of vocational services from providers of the beneficiaries’ own choosing (Cook et al., 2006). In addition, Ticket participants were offered free benefits and entitlements counseling to help them gauge the effects of employment on their cash benefits and other unearned income. SSA also placed a moratorium on continuing-disability reviews for Ticket participants and encouraged state Medicaid buy-ins enabling people to keep their health insurance after cash benefits ceased. The idea was that SSA would realize savings from the “outcome payment”-based structure, where providers would be paid only for the months that individuals earned above SGA or only at the time beneficiaries left the rolls because of employment. Unfortunately, the national evaluation of the Ticket program (Thornton et al., 2006) has identified several problems with its implementation. First, the rate of participation in the program is very low. Even in states where it has operated the longest, just 1.1 percent of beneficiaries have assigned their tickets to providers. Second, the rate of provider participation is similarly low. Only 40 percent of all providers were accepting tickets as of June 2004.

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PTSD Compensation and Military Service Moreover, consistent with the simulation study cited earlier (Cook et al., 2006), the evaluators’ analysis of provider costs and revenues suggests that those relying solely on Ticket payments would have lost money after two years of operation. Despite this pessimistic picture, Ticket participation is relatively vigorous among individuals with disabling mental disorders, who have the fifth-highest rate of participation among the 21 primary disabling conditions examined (Thornton et al., 2006). At the same time, there is also evidence of reluctance to serve this population since one-third of the providers interviewed for the evaluation mentioned psychiatric or other disabilities as a challenge to finding jobs for Ticket beneficiaries. Some of the barriers discussed above apply to veterans but are ameliorated by the presence of VA programs, while others are exacerbated by the special circumstances of military service. One ameliorative factor is that veterans’ benefits subsidize education and vocational training. Among the exacerbating circumstances is the high level of stigma that the military culture places on seeking help for mental-health problems. For example, one study found that VA providers reported more negative attitudes toward clinical work involving veterans seeking PTSD compensation than toward clinical work involving other veterans (Sayer and Thuras, 2002). Another exacerbating factor is the lack of VA-sponsored employment programs in some areas of the country. On the other hand, there is also some evidence that receiving service-connected disability for PTSD actually encourages individuals to seek mental-health treatment. Unpublished research by Sayer and colleagues indicates that the claim process may make it easier to gain access to medical services and that being awarded disability status for PTSD may facilitate access to mental-health services (Sayer et al., 2005b).2 Although there are studies on racial and ethnic influences on PTSD incidence and severity (Beals et al., 2002; Friedman et al., 2004; Kulka et al., 1990a; Loo et al., 2005; Ruef et al., 2000) and on culturally-sensitive diagnosis and treatment for the disorder (Blow et al., 2004; Penk and Allen, 1991; Rosenheck and Fontana, 1996), the information on service connection is far more limited. Murdoch and colleagues (2003a), however, did find that African American service members were less likely to be service connected for PTSD than other veterans (43 percent versus 56 percent; p=.003) after controlling for sociodemographic characteristics, symptom severity, functional status, and trauma histories. A fact sheet produced by the VA’s National Center for PTSD (Loo, 2007) counsels examining clinicians that [p]rofessional responsibility in providing appropriate services to ethnic minority veterans also applies to Compensation and Pensions examina- 2 This topic is addressed in greater detail later in this chapter in the section entitled “Disability Compensation and the Use of VA Mental-Health Care Services.”

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PTSD Compensation and Military Service tions. If clinicians do not evaluate for negative race-related events that may have led to psychiatric problems, the ethnic minority veteran may not be receiving the appropriate disability rating or compensation. Thus, it behooves VA clinicians to be particularly attentive to examining possible race, ethnic, or cultural issues among ethnic minority veterans. Summary The committee’s literature review indicates that there are many barriers to recovery for Vietnam veterans diagnosed with PTSD. Some of these are common to all people with disabilities, some are experienced by all those with mental disabilities, and a few are unique to veterans, to those with PTSD, and to persons using the VA disability system. The literature suggests that many barriers are endemic to the programs used to provide services to those with disabilities, while some are unfortunate consequences of the symptomatology of certain disabilities, and others result from entrenched attitudes about the disabled and, in particular, about those with psychiatric illnesses. There are no easy solutions: experience with civilian benefits systems has shown that the problems will be difficult to remedy. THE EFFECT OF COMPENSATION ON RECOVERY One of the key issues that the committee was asked to assess is how PTSD compensation might influence veteran beneficiaries’ attitudes and behavior in ways that could serve as barriers to recovery. The committee was specifically asked to evaluate the evidentiary basis for various influences of compensation on treatment and recovery (Szybala, 2006). The effect of disability compensation on beneficiaries’ behavior has long been an issue in research and in practice, both in the general population (IOM, 1991; Bellamy, 1997) and for the military and veterans (IOM, 1999; Drew et al., 2001; Mossman, 1996). Attention has increasingly shifted to the more subjective ailments and injuries, such as chronic pain (Sullivan and Loeser, 1992; Rohling et al., 1995) and mental disorders (Estroff et al., 1997), particularly PTSD (Rosen, 2004, 2006; Mossman, 1994; Guriel and Fremouw, 2003). Because a positive finding often results in monetary or other types of compensation, assessing psychopathology within the context of disability is almost always complicated by the possible influences of secondary gain. Indeed, secondary gain has long been hypothesized to increase the possibility that symptoms and their effects will be exaggerated, both during the course of treatment and during recovery, and both for general disabilities and for combat-related PTSD in particular (Atkinson et al., 1982; APA, 1994; Resnick, 1997). In recent years, however, because of the

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PTSD Compensation and Military Service dramatic increase in the numbers of veterans seeking and receiving awards for PTSD, the possibility of service-connected disability being awarded because of exaggerated or fraudulent claims has become an increasing concern (DVA, 2005b; Murdoch et al., 2003a,b,c). These concerns have resulted in a substantial research literature on compensation-seeking attitudes and behaviors among veterans. In the case of PTSD, most studies fall into one of four categories. The first is research on the fabrication, misrepresention, or misrecall of veterans’ combat or trauma exposure; such exposure is, of course, a key criterion if they are to receive service connection for their disabilities. The second—and by far the most common—type of research consists of studies that focus on the detection of misreporting or exaggeration of PTSD and other symptoms by veterans seeking or receiving compensation. Third, there is some research that examines how seeking or receiving compensation affects treatment-seeking or the use of mental-health services. Finally, there are a few studies on how receiving compensation might affect subsequent responsiveness to treatment or treatment outcomes. Misreporting of Combat or Trauma Exposure A number of observers have suggested that the opportunity to receive disability compensation might motivate veterans to falsify or exaggerate their combat involvement or exposure. Some case reports describe Vietnamera veterans who have fabricated histories of traumatic events, tours of duty, and even military service itself in order to obtain benefits (Sparr and Pankratz, 1983; Lynn and Belza, 1984; Burkett and Whitley, 1998), but these cases provide no direct evidence of the prevalence of such behaviors or the probable magnitude of their effect on seeking or receiving disability. A 2005 analysis by the VA Office of the Inspector General (OIG) focused on the claim files of 2,100 veterans receiving disability for PTSD and found that 25 percent had no compelling evidence that they had been exposed to any traumatic event whatsoever, thereby raising the specter of questionable compensation payments (DVA, 2005b). Subsequent review of the cases by the VA, however, determined that “[t]he problems with these files appear to be administrative in nature, such as missing documents, and not fraud” (DVA, 2005a). The most widely cited empirical study on this issue is that of Frueh and colleagues (2005), who found that only 41 percent of 100 treatment-seeking veterans reporting Vietnam combat involvement had objective evidence of combat exposure documented in their publicly available military personnel records. They concluded from these results that a “meaningful” number of treatment-seekers “may be exaggerating or misrepresenting their involvement [and combat exposure] in Vietnam,” and, by inference, they attributed

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PTSD Compensation and Military Service this to “the disability benefit incentive” and compensation-seeking. They concluded, for example, that “concerns that exaggerated or false reports of combat exposure are at least in part associated with financial incentives are supported by our findings that the ‘no combat’ group appeared to be applying or intending to apply for disability benefits at the same rate as the ‘combat’ group.” However, both prior and subsequent research has called into question whether the information available solely in the military personnel files—commonly referred to as 201 files—is adequate to support such a strong conclusion. In contrast, a later study (Dohrenwend et al., 2006) came to a very different conclusion when it combined data from the National Vietnam Veterans Readjustment Study (NVVRS) (Kulka et al., 1990b) with newly developed data from military records and a comprehensive set of other archival sources in order to address questions raised about the influence of self-report bias on NVVRS estimates of the prevalence of PTSD among Vietnam veterans. Those researchers found “a strong positive relationship between [the veterans’] record-based … exposure measures and the dichotomous measure of … war zone stress constructed by the NVVRS investigators on the basis of veterans’ retrospective reports of their experiences.” While acknowledging McNally’s caution that “one cannot generalize from an epidemiological sample to a clinical one” and advice that “archival sources are important in both contexts” (McNally, 2006), it is also important to know the strengths and limitations of these sources. In its role as the conservator of the military personnel records, which was the sole records source used by Frueh and colleagues, the National Archives and Research Administration offers the following caveat for users on its website:3 “Detailed information about the veteran’s participation in military battles and engagements is NOT contained in the record” (U.S. National Archives and Records Administration, 2006; emphasis in original). The methods developed by Dohrenwend and colleagues (2006) clearly demonstrate the value of broad-based research into other indicators of the likelihood of having experienced traumatic stressors and the importance of using information from historical accounts (for example, unit assignments and dates of service). A veteran’s 201-file information is a necessary but not always sufficient source with which to confirm self-reported information related to combat involvement or exposure. A careful reading of the meticulous methodology employed by Dohrenwend and colleagues reveals that their analysis depended a great deal on indicators not directly obtainable from 201 files and shows that they did not consult with archival sources only as needed, despite what McNally implied and suggested in both the original and follow-up commentaries (McNally, 2006, 2007). Moreover, 3 www.archives.gov/veterans/military-service-records/.

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PTSD Compensation and Military Service Frueh and colleagues explicitly acknowledge the great potential value of adding “objective military records, including research on unit records and casualty reports” (Frueh et al., 2005). In summary, while misrepresentation of combat involvement and exposure undoubtedly does happen among veterans seeking treatment and compensation for PTSD, the evidence currently available is insufficient to establish how prevalent such misrepresentations are and how much effect they have on the ultimate outcome of disability claims. And no matter how common such behavior ultimately proves to be, the best strategy for addressing this problem is most likely already at hand, based on the research that has been conducted to date. The committee concludes that the most effective strategy for dealing with problems with self-reports of traumatic exposure is to ensure that a comprehensive, consistent, and rigorous process is used throughout the VA to verify veteran-reported evidence. One approach to achieving this objective is routine and consistent use of the full range and battery of methods implemented and tested by Dohrenwend and colleagues (2006). The best-practice manual for C&P examinations, written by VA clinicians, already recognizes the value of careful and in-depth review of records (Watson et al., 2002). Consistent with such a strategy, a GAO report (GAO, 2006) described methods that the VA can use to improve its procedures for obtaining military service records, including several used by Dohrenwend, and reiterated the VA’s “duty to assist” veterans in obtaining any records relevant to their claims. One potential records issue that emerged from the committee’s research is the need for claimants to identify the dates of their stressor events within a fairly narrow time window.4 Given the potential for a substantial gap between the time these events occurred and the time that claims are filed, it is possible that claimants might misremember dates and thus valid events might fail to be verified. In contrast, Dohrenwend used the full range of service dates to identify unit exposures from records and other archival sources. While it is recognized that such a protocol may increase both the time and expense required to complete these examinations, the OIG estimates of both the annual and lifetime costs of possible questionable compensation payments (DVA, 2005b) suggest that the long-term benefits of a more rigorous assessment may greatly outweigh such increases in costs (McGrath and Frueh, 2002). 4 Claimants requesting documentation from the U.S. Army and Joint Services Records Research Center are requested to provide the month and year of the stressor event[s] (Stichman, 2006). The committee understands that records researchers typically bracket their search by also checking the months before and after the dates provided.

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PTSD Compensation and Military Service Misreporting or Exaggeration of Symptoms As noted above, the majority of empirical studies conducted to date on the possible influence of the VA disability compensation system on PTSD and its treatment have addressed symptom-reporting issues. These issues include “symptom elevation” (Fairbank et al., 1983), “overreporting” (Hyer et al., 1988), “exaggeration” (Smith and Frueh, 1996) and “extreme exaggeration” (Gold and Frueh, 1999) in veterans seeking or receiving compensation for PTSD, and many of the studies have examined the use of standardized test measures to detect malingering or the feigning of PTSD symptoms (Frueh et al., 2000).5 It is well established that combat veterans who are evaluated for PTSD frequently exhibit extreme elevations across various assessment measures (Fairbank et al., 1983). These elevated measures are also typically accompanied by a pattern of elevations on the MMPI/MMPI-2 validity scales consistent with symptom overreporting (Fairbank et al., 1983; Frueh et al., 1996, 1997; Hyer et al., 1986; Elhaiet al., 2001; Franklin et al., 2002), so concerns have been raised regarding the accuracy of veterans’ accounts of their psychological functioning, which in turn poses significant challenges for diagnostic assessment and treatment. On the other hand, several researchers have noted that this response pattern—the reporting of a wide range of symptoms and overreporting of symptoms in general—is part of the overall profile of PTSD, a disorder characterized by the presence of a heterogeneous set of symptoms, high rates of comorbidity, and, quite often, extreme symptom severity (APA, 2000; Elhai et al., 2000, 2001; Fairbank, et al., 1983; Hyer et al., 1988; Keane and Wolfe, 1990). While research and commentary (Elhai et al., 2000; Frueh et al., 1996, 1997; Smith and Frueh, 1996) suggests that this pattern may reflect, at least in part, symptom overreporting by a subset of veterans who are motivated by possible receipt of financial compensation, access to treatment, and other incentives, the literature examining the relationship between compensation seeking and reported levels of psychopathology has in fact yielded mixed results. Frueh and colleagues found that veterans they defined as compensation-seeking6 scored significantly higher than non-compensation-seeking veterans on several MMPI scales (including the F scale) as well as on several associated pathology scales (Frueh et al., 1996). Similar results 5 Chapter 5, which addresses issues surrounding the conduct of the PTSD C&P examination, also discusses the topic of testing to detect malingering in the context of a broader examination of the use of psychometric instruments. 6 Compensation-seeking veterans were defined as “those who were currently seeking or planning to seek VA disability compensation or increases in existing disability payments for PTSD” while non-compensation-seeking veterans were “those who were not intending to seek VA disability compensation for their PTSD symptoms” (Frueh et al., 2003).

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PTSD Compensation and Military Service tary social support from family and friends was found to be an important factor in recovery (King et al., 1998) as well as a protective agent against the development of PTSD (Fontana and Rosenheck, 1998b). The study by King and colleagues (1998) also found that hardiness and additional negative life events postwar were additional factors affecting recovery. In a somewhat similar vein, Fontana and Rosenheck (2006) in a later study found that female veterans were more comfortable in a specialized treatment program for women; it increased their participation (attendance and commitment), but had no effect on outcomes. Studies of PTSD treatment for female veterans are badly needed—and, fortunately, under way—but it is unclear if the current studies will have samples that are sufficiently large to disentangle the differential treatment effects for women whose trauma is primarily MSA versus those whose trauma is primarily combat or to determine if multiple traumas are part of the etiology of the PTSD experience. Conclusions and Continuing Issues Although there has been increasing attention paid to women in the military, to their experiences with both combat trauma and sexual trauma, to their increased vulnerability to PTSD and its comorbidities, and to their need for gender-specific PTSD treatment, research is only beginning to illuminate some of the issues involved. Very little research exists on the subject of PTSD compensation and female veterans. What information is available suggests that female veterans are less likely to receive service connection for PTSD and that this is a consequence of the relative difficulty of substantiating exposure to noncombat traumatic stressors—notably, MSA. The committee notes that PTSD training and reference materials for raters (VBA, 2005) address MSA but that scant attention is paid to the challenges of documenting it as an in-service stressor or to approaches to addressing this problem.16 In contrast, a great deal of guidance is given on various service medals and devices that can be used to support PTSD claims and on how to use DOD resources to corroborate possible combat-related traumatic exposures. The committee believes that it is important to gain a better understanding of the sources of gender disparity in awards for PTSD service connection and to better substantiate MSA-related traumas in both women and men when they do occur. The committee therefore makes the following recommendations: 16 The slides accompanying the instructor’s materials for the rater’s PTSD training do address PTSD secondary to sexual or personal trauma (VBA 2005), but this is a one-time, six-hour class.

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PTSD Compensation and Military Service The VBA should conduct more detailed data gathering on the determinants of service connection and ratings level for MSA-related PTSD claims, including the gender-specific coding of MSA-related traumas for analysis purposes. The VBA should develop and disseminate reference materials for raters that more thoroughly address the management of MSA-related claims. Training and testing on MSA-related claims should be a part of the certification program addressed in Chapter 4 for raters who deal with PTSD claims. The committee observes that appropriate management of MSA-related claims begins with the proper documentation of incidents that occur during active service. Therefore, improved training of military medical and nursing personnel on how to document and collect evidence regarding sexual assault is needed. Civilian sector SANE17 and Forensic Nursing programs are models for such training. The committee also observes that more research is needed on the as yet unexplained gender differences in vulnerability to PTSD, which could help identify useful sex-specific approaches to prevention and treatment, and on more effective means for preventing military sexual assault and sexual harassment. FINDINGS, CONCLUSIONS, AND RECOMMENDATIONS On the basis of the review of the papers, reports, and other information presented in this chapter, the committee has reached the following findings, conclusions, and recommendations, and identified the following research needs. Findings and Conclusions The most effective strategy for dealing with problems with self-reports of traumatic exposure is to ensure that a comprehensive, consistent, and rigorous process is used throughout the VA to verify veteran-reported evidence. In the absence of a definitive measure, the most effective way to detect inappropriate claims is to require a consistent and comprehensive state-of-the-art examination and assessment that allows the time to conduct 17 The Sexual Assault Nurse Examiner (SANE) program was developed with funding from the U.S. Department of Justice to provide advanced education in the forensic examination of sexual assault victims (Ledray, 1999).

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PTSD Compensation and Military Service appropriate testing in those specific circumstances where the examining clinician believes it would inform the assessment. Research reviewed by the committee indicates that PTSD compensation does not, in general, serve as a disincentive to seeking treatment. It is not appropriate to require across-the-board periodic reexaminations for veterans with PTSD service-connected disability. Recommendations VA should consider instituting a set, long-term minimum level of benefits that would be available to any veteran with service-connected PTSD at or above some specified rating level without regard to that person’s state of health at a particular point in time after the C&P examination. The determination of whether and when reevaluations of PTSD beneficiaries are carried out should be made on a case-by-case basis using information developed in a clinical setting. Specific guidance on the criteria for such decisions should be established so that these can be administered in a fair and consistent manner. The VBA should conduct more detailed data gathering on the determinants of service connection and ratings level for MSA-related PTSD claims, including the gender-specific coding of MSA-related traumas for analysis purposes. The VBA should develop and disseminate reference materials for raters that more thoroughly address the management of MSA-related claims. Training and testing on MSA-related claims should be a part of the certification program addressed in Chapter 4 for raters who deal with PTSD claims. More research is needed on the as yet unexplained gender differences in vulnerability to PTSD, which could help identify useful sex-specific approaches to prevention and treatment, and on more effective means for preventing military sexual assault and sexual harassment. REFERENCES Angrist J. 1993. The effect of veterans benefits on education and earnings. Industrial and Labor Relations Review 46(4):637–652. APA (American Psychiatric Association). 1994. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC: APA. APA. 2000. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Washington, DC: APA. Arbisi PA. 2006 (July 6). Issues and Barriers to Implementation of Best Practice Guidelines in Compensation and Pension Examinations. Presentation to the Committee on Veterans’ Compensation for Post Traumatic Stress Disorder. Washington, DC.

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