PTSD COMPENSATION AND MILITARY SERVICE

Committee on Veterans’ Compensation for Posttraumatic Stress Disorder

Board on Military and Veterans Health

Board on Behavioral, Cognitive, and Sensory Sciences

INSTITUTE OF MEDICINE AND NATIONAL RESEARCH COUNCIL OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS

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PTSD Compensation and Military Service PTSD COMPENSATION AND MILITARY SERVICE Committee on Veterans’ Compensation for Posttraumatic Stress Disorder Board on Military and Veterans Health Board on Behavioral, Cognitive, and Sensory Sciences INSTITUTE OF MEDICINE AND NATIONAL RESEARCH COUNCIL OF THE NATIONAL ACADEMIES THE NATIONAL ACADEMIES PRESS Washington, D.C. www.nap.edu

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PTSD Compensation and Military Service THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This study was supported by Contract No. V101 (93) P-2155 (VA 6096) between the National Academy of Sciences and United States Department of Veterans Affairs. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project. Library of Congress Cataloging-in-Publication Data PTSD compensation and military service / Committee on Veterans’ Compensation for Posttraumatic Stress Disorder, Board on Military and Veterans Health, Board on Behavioral, Cognitive, and Sensory Sciences. p. ; cm. Includes bibliographical references. ISBN-13: 978-0-309-10552-1 (pbk. : alk. paper) ISBN-10: 0-309-10552-8 (pbk. : alk. paper) 1. Post-traumatic stress disorder—United States. 2. Disabled veterans—Mental health—United States. 3. Disabled veterans—Pensions—United States—Evaluation. 4. Military pensions—United States—Evaluation. 5. United States. Dept. of Veterans Affairs. I. Committee on Veterans’ Compensation for Posttraumatic Stress Disorder. [DNLM: 1. Combat Disorders—United States. 2. Stress Disorders, Post-Traumatic—United States. 3. Disability Evaluation—United States. 4. Veterans Disability Claims—United States. WM 184 P975 2007] RC552.P67P82 2007 362.2′5—dc22 2007021841 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2007 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. Suggested citation: IOM (Institute of Medicine) and NRC (National Research Council). 2007. PTSD Compensation and Military Service. Washington, DC: The National Academies Press.

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PTSD Compensation and Military Service THE NATIONAL ACADEMIES Advisers to the Nation on Science, Engineering, and Medicine The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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PTSD Compensation and Military Service COMMITTEE ON VETERANS’ COMPENSATION FOR POSTTRAUMATIC STRESS DISORDER NANCY C. ANDREASEN, M.D., Ph.D. (Chair), Andrew H. Woods Chair of Psychiatry and Director, Neuroimaging Research Center, University of Iowa Carver College of Medicine, Iowa City, IA JACQUELYN C. CAMPBELL, Ph.D., R.N., F.A.A.N., Professor and Anna D. Wolf Chair, The Johns Hopkins School of Nursing, Baltimore, MD JUDITH A. COOK, Ph.D., Professor of Psychiatry and Director, Center on Mental Health Services Research and Policy, University of Illinois, Chicago JOHN A. FAIRBANK, Ph.D., Associate Professor of Medical Psychology, Duke University Medical Center; Co-Director, National Center for Child Traumatic Stress, Durham, NC BONNIE L. GREEN, Ph.D., Professor of Psychiatry and Director, Georgetown Center for Trauma and the Community, Georgetown University Medical School, Washington, DC DEAN G. KILPATRICK, Ph.D., Distinguished University Professor and Director, National Crime Victims Research and Treatment Center, Medical University of South Carolina, Charleston KURT KROENKE, M.D., Professor of Medicine, Division of General Internal Medicine and Geriatrics, Indiana University, Indianapolis RICHARD A. KULKA, Ph.D., Senior Vice-President of Strategic Business Development, Abt Associates Inc.; Senior Research Scientist, Center for Demographic Studies at Duke University, Durham, NC PATRICIA M. OWENS, M.P.A., Independent Consultant, Minisink Hills, PA ROBERT T. REVILLE, Ph.D., Director, RAND Institute of Civil Justice, Santa Monica, CA DAVID S. SALKEVER, Ph.D., Professor of Public Policy, University of Maryland-Baltimore County, Baltimore, MD; Research Associate, National Bureau of Economic Research, Cambridge, MA ROBERT J. URSANO, M.D., Professor of Psychiatry and Neuroscience, Chair, Department of Psychiatry, and Director, Center for the Study of Traumatic Stress, Uniformed Services University of the Health Sciences, Bethesda, MD Gulf War and Health Committee Liaison JANICE L. KRUPNICK, Ph.D., Professor of Psychiatry, Georgetown University, Washington, DC

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PTSD Compensation and Military Service Consultants ROBERT J. EPLEY, Independent Consultant, Waxhaw, NC CAROL S. NORTH, M.D., M.P.E., Nancy and Ray L. Hunt Professor of Crisis Psychiatry, UT Southwestern Medical Center; Director, Program in Trauma and Disaster, VA North Texas Health Care System, Dallas ALFRED V. RASCON, Reserve Major, U.S. Army Medical Service Corps, Laurel, MD Program Staff DAVID A. BUTLER, Ph.D., Senior Program Officer and Study Director AMY R. O’CONNOR, M.P.H., Research Associate JON Q. SANDERS, B.A., Program Associate EILEEN SANTA, M.A., Research Associate FREDERICK (RICK) ERDTMANN, M.D., M.P.H., Director, Board on Military and Veterans Health and Medical Follow-up Agency CHRISTINE HARTEL, Ph.D., Director, Board on Behavioral, Cognitive, and Sensory Sciences

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PTSD Compensation and Military Service Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: Kathryn Karusaitis Basham, Ph.D., M.S.W., Professor and Chair, Human Behavior in the Social Environment Sequence; Smith College School for Social Work Lisa B. Dixon, M.D., M.P.H., Professor, Department of Psychiatry, and Director, Division of Services Research, University of Maryland School of Medicine; VA Capitol Health Care Network Mental Illness Research, Education, and Clinical Center Edna B. Foa, Ph.D., Professor, Department of Psychiatry and Director, Center for the Treatment and Study of Anxiety, University of Pennsylvania Richard G. Frank, Ph.D., The Margaret T. Morris Professor of Health Economics, Department of Health Care Policy, Harvard Medical School

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PTSD Compensation and Military Service Nathan Hershey, L.L.B., Professor, Health Policy and Management, University of Pittsburgh Graduate School of Public Health David Silbersweig, M.D., Stephen P. Tobin and Dr. Arnold M. Cooper Professor in Consultation Liaison Psychiatry, Department of Psychiatry, Weill Medical College of Cornell University Robert D. Sparks, M.D., Board of Directors, The TASER Foundation Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by Dan G. Blazer, M.D., Ph.D., Duke University Medical Center, and Edward B. Perrin, Ph.D., University of Washington School of Public Health. Appointed by the National Research Council and Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

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PTSD Compensation and Military Service Acknowledgments This report could not have been prepared without the guidance and expertise of numerous persons. Although it is not possible to mention by name all those who contributed to the committee’s work, the committee wants to express its gratitude to a number of them for their special contributions. Sincere thanks go to all the participants at the public meetings convened on May 2 and July 6, 2006. The intent of the workshops was to gather information regarding issues related to posttraumatic stress disorder (PTSD) compensation; in particular, the conduct of compensation and pension examinations, the evaluation of PTSD claims, and the granting of compensation by the Department of Veterans Affairs VA). The speakers, who are listed in Appendix A, gave generously of their time and expertise to help inform and guide the committee’s work. The committee also acknowledges the help of the staff of the Veterans’ Disability Benefits Commission, who shared the information they gathered in the course of their work; and Tom Pamperin, Sandie Harms-Taylor, and Dan Cunningham of the Veterans Benefits Administration, who provided the committee with compensation and pension data. We are deeply indebted to three hard-working people who served as consultants and made major contributions to the content of this report: Robert Epley applied his encyclopedic knowledge of the VA’s compensation and pension system to answer the committee’s myriad questions; Carol North shared her expertise on traumatic stress; and Major Alfred Rascon (USA), who is currently supporting soldiers in the field in Iraq and Af-

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PTSD Compensation and Military Service ghanistan as an individual mobilization augmentee, helped the committee understand the realities of war and service from his perspective as a Vietnam veteran and Medal of Honor recipient. Thanks are also due to Janice Krupnick, who served as liaison from the Institute of Medicine’s Committee on Gulf War and Health–Physiologic, Psychologic, and Psychosocial Effects of Deployment-Related Stress. The committee extends special thanks to the dedicated and hardworking staff from the Institute of Medicine’s Board on Military and Veterans Health who supported and facilitated their work. Board Directors Rick Erdtmann of the Institute of Medicine and Christine Hartel of the National Research Council helped to ensure that this report met the highest standards of quality. Finally, the committee would like to thank the chair, Nancy Andreasen, for her outstanding work, leadership, and dedication to this project.

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PTSD Compensation and Military Service Contents     SUMMARY   1 1   INTRODUCTION   15      VA’s Mission and Structure,   15      The Compensation Legislation Mandate and Rationale in Practice,   16      The Place of Disability Compensation in VA’s Operation,   17      Why PTSD Compensation Is an Issue Today,   20      Intent and Goals of the Study,   21      Related Institute of Medicine Reports,   22      Organization of the Report,   24 2   BACKGROUND—DISABILITY COMPENSATION   27      Early Compensation for Mental Disabilities,   27      Veterans’ Disability Compensation,   29      Other Mental Disability Compensation Programs,   51 3   BACKGROUND—PTSD AND IMPAIRMENT   70      PTSD Characteristics, Etiology, and Course,   70      Comorbidity and Functional Impairment or Disability,   71      Risk Factors, Protective Factors, Mediators, and Moderators,   75

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PTSD Compensation and Military Service 4   THE PTSD COMPENSATION AND PENSION EXAMINATION   85      Compensation and Pension Examination Overview,   85      C&P Examination Issues,   90      Findings, Conclusions, and Recommendations,   105 5   THE EVALUATION OF PTSD DISABILITY CLAIMS   113      Veterans’ Disability Compensation,   113      Issues Regarding PTSD Disability Rating Criteria,   125      Findings, Conclusions, and Recommendations,   162 6   OTHER PTSD COMPENSATION ISSUES   165      Barriers or Disincentives to Recovery,   166      The Effect of Compensation on Recovery,   171      Periodic Reexaminations and Reevaluations,   186      Gender and Military Sexual Assault,   188      Findings, Conclusions, and Recommendations,   194 7   GENERAL OBSERVATIONS   204     APPENDIXES     A   COMMITTEE ON VETERANS’ COMPENSATION FOR POSTTRAUMATIC STRESS DISORDER: PUBLIC MEETING AGENDAS   211 B   FEDERAL REGULATIONS RELATED TO VA COMPENSATION OF PTSD AND OTHER MENTAL DISORDERS   215 C   AUTOMATED MEDICAL INFORMATION EXCHANGE (AMIE) WORKSHEETS FOR INITIAL AND REVIEW EXAMINATIONS FOR PTSD   221 D   ACRONYMS AND ABBREVIATIONS   238 E   BIOGRAPHICAL SKETCHES OF COMMITTEE MEMBERS, CONSULTANTS, AND STAFF   241