Skip to main content
×
×
Home

Documented combat exposure of US veterans seeking treatment for combat-related post-traumatic stress disorder

  • B. Christopher Frueh (a1), Jon D. Elhai (a2), Anouk L. Grubaugh (a3), Jeannine Monnier (a3), Todd B. Kashdan (a3), Julie A. Sauvageot (a3), Mark B. Hamner (a1), B. G. Burkett (a4) and George W. Arana (a5)...
Abstract
Background

There are concerns regarding the validity of combat exposure reports of veterans seeking treatment for combat-related post-traumatic stress disorder (PTSD) within US Veterans Affairs Medical Centers.

Aims

To verify combat exposure history for a relevant sample through objective historical data.

Method

Archival records were reviewed from the US National Military Personnel Records Center for 100 consecutive veterans reporting Vietnam combat in a Veterans Affairs PTSD clinic. Cross-sectional clinical assessment and 12-month service use data were also examined.

Results

Although 93% had documentation of Vietnam war-zone service, only 41% of the total sample had objective evidence of combat exposure documented in their military record. There was virtually no difference between the Vietnam ‘combat’ and ‘no combat’ groups on relevant clinical variables.

Conclusions

A significant number of treatment-seeking Veterans Affairs patients may misrepresent their combat involvement in Vietnam. There are implications for the integrity of the PTSD database and the Veterans Affairs healthcare system.

  • View HTML
    • Send article to Kindle

      To send this article to your Kindle, first ensure no-reply@cambridge.org is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle. Find out more about sending to your Kindle.

      Note you can select to send to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

      Find out more about the Kindle Personal Document Service.

      Documented combat exposure of US veterans seeking treatment for combat-related post-traumatic stress disorder
      Available formats
      ×
      Send article to Dropbox

      To send this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Dropbox.

      Documented combat exposure of US veterans seeking treatment for combat-related post-traumatic stress disorder
      Available formats
      ×
      Send article to Google Drive

      To send this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Google Drive.

      Documented combat exposure of US veterans seeking treatment for combat-related post-traumatic stress disorder
      Available formats
      ×
Copyright
Corresponding author
Dr B. Christopher Frueh, VA Medical Center (116), 109 Bee Street, Charleston, South Carolina 29401, USA. Tel: +1 843 789 7967; fax: +1 843 805 5782; e-mail: fruehbc@musc.edu
Footnotes
Hide All

See invited commentary, pp. 473–475, this issue

Declaration of interest

None. Funding detailed in Acknowledgements.

Footnotes
References
Hide All
American Psychiatric Association (1994) Diagnostic and Statistical Manual of Mental Disorders (4th edn) (DSM-IV). Washington, DC: APA.
Beck, A. T., Steer, R. A. & Garbin, M. G. (1988) Psychometric properties of the Beck Depression Inventory: twenty-five years of evaluation. Clinical Psychology Review, 8, 77100.
Blake, D. D., Weathers, F. W., Nagy, L. M., et al (1995) The development of a clinician-administered PTSD scale. Journal of Traumatic Stress, 8, 7590.
Burkett, B. G. & Whitley, G. (1998) Stolen Valor: How the Vietnam Generation Was Robbed of its Heroes and its History. Dallas, TX: Verity Press.
Butcher, J. N., Graham, J. R., Ben-Porath, Y. S., et al (2001) MMPI–2 (Minnesota Multiphasic Personality Inventory – 2): Manual for Administration, Scoring, and Interpretation. Minneapolis, MN: University of Minnesota Press.
Charney, D. S., Davidson, J. R. T., Friedman, M., et al (1998) A consensus meeting on effective research practice in PTSD. CNS Spectrums, 3, 710.
Elhai, J. D., Ruggiero, K. J., Frueh, B. C., et al (2002) The Infrequency-Posttraumatic Stress Disorder scale (Fptsd) for the MMPI–2: development and initial validation with veterans presenting with combat-related PTSD. Journal of Personality Assessment, 79, 531549.
Frueh, B. C., Hamner, M. B., Cahill, S. P., et al (2000) Apparent symptom overreporting among combat veterans evaluated for PTSD. Clinical Psychology Review, 20, 853885.
Frueh, B. C., Elhai, J. D., Gold, P. B., et al (2003) Disability compensation seeking among veterans evaluated for posttraumatic stress disorder. Psychiatric Services, 54, 8491.
Jones, E., Palmer, I. & Wessely, S. (2002) War pensions (1900–1945): changing models of psychological understanding. British Journal of Psychiatry, 180, 374379.
Keane, T. M., Caddell, J. M. & Taylor, K. L. (1988) Mississippi Scale for Combat-Related Posttraumatic Stress Disorder: three studies in reliability and validity. Journal of Consulting and Clinical Psychology, 56, 8590.
Keane, T. M., Fairbank, J. A., Caddell, J. M., et al (1989) Clinical evaluation of a measure to assess combat exposure. Psychological Assessment, 1, 5355.
Kulka, R. A., Schlenger, W. E., Fairbank, J. A., et al (1990) Trauma and the Vietnam War Generation: Report of Findings from the National Vietnam Veterans Readjustment Study. New York: Brunner/Mazel.
Landis, J. R. & Koch, G. G. (1977) The measurement of observer agreement for categorical data. Biometrics, 33, 159174.
McNally, R. J. (2003) Progress and controversy in the study of posttraumatic stress disorder. Annual Review of Psychology, 54, 229252.
Murdoch, M., Nelson, D. B. & Fortier, L. (2003) Time, gender, and regional trends in the application for service-related post-traumatic stress disorder disability benefits, 1980–1998. Military Medicine, 168, 662670.
Oboler, S. (2000) Disability evaluations under the Department of Veterans Affairs. In Impairment Rating and Disability Evaluation (eds Rondinelli, R. D. & Katz, R. T.), pp. 187217. Philadelphia, PA: Saunders.
Shephard, B. (2001) A War of Nerves: Soldiers and Psychiatrists in the Twentieth Century. Cambridge, MA: Harvard University Press.
Southwick, S. M., Morgan, C. A., Nicolaou, A. L., et al (1997) Consistency of memory for combat-related traumatic events in veterans of Operation Desert Storm. American Journal of Psychiatry, 154, 173177.
Weathers, F. W., Keane, T. M. & Davidson, J. R. (2001) Clinician-administered PTSD scale: are view of the first ten years of research. Depression and Anxiety, 13, 132156.
Wessely, S., Unwin, C., Hotopf, M., et al (2003) Stability of recall of military hazards over time: evidence from the Persian Gulf War of 1991. British Journal of Psychiatry, 183, 314322.
Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

The British Journal of Psychiatry
  • ISSN: 0007-1250
  • EISSN: 1472-1465
  • URL: /core/journals/the-british-journal-of-psychiatry
Please enter your name
Please enter a valid email address
Who would you like to send this to? *
×

Metrics

Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed

Documented combat exposure of US veterans seeking treatment for combat-related post-traumatic stress disorder

  • B. Christopher Frueh (a1), Jon D. Elhai (a2), Anouk L. Grubaugh (a3), Jeannine Monnier (a3), Todd B. Kashdan (a3), Julie A. Sauvageot (a3), Mark B. Hamner (a1), B. G. Burkett (a4) and George W. Arana (a5)...
Submit a response

eLetters

Individual Military Personnel Records Are a Valid and Important Data Source

B. Christopher Frueh, Professor of Psychiatry
12 September 2005

Dear Editor,

Mr. Moore makes a strong accusation that our study is “dangerously misleading.” However, there are several important factual errors in his letter and we respectfully disagree with his conclusion. First, we did not, as he asserted, imply that all veterans being treated for PTSD are seeking disability benefits. In fact, we clearly described our sample as treatment-seeking and reported that 62% reported applying or intending to apply for Veterans Affairs (VA) disability compensation. Second, we did not, as he asserted, use any individual DD-214 forms as the basis for our research. We obtained publicly available individual military personnel records from the U. S. National Personnel Records Center in St. Louis. These records include far more information than a DD-214, including military training experiences, military occupational specialties, overseasduty assignments, dates, and frequently narrative descriptions of combat activities.

As acknowledged in our Discussion, individual military personnel records are imperfect, but then so is every other possible source, including unit records and individual memory for past experiences. While we appreciate that military record keeping during war time was occasionally incomplete at the individual level, one cannot “invalidate” asource of data in either social science or historical scholarship by an act of Congress. A legislative action is a political or legal event; it has no bearing on the evidential merit of the archival data. We agree that Company and Battalion level records might provide useful additional information in some cases. However, the historical documentation of a large military unit deployed over a large geographical area and responsible for a wide range of different military duties cannot necessarily tell us much about the experiences of individuals within that unit. Further, someone claiming to have had Special Forces experience, POW status, or Vietnam service should easily have such documentation in their individual military personnel records.

The results of our study are consistent with a report (2) recently released by the Department of Veterans Affairs Office of Inspector General(OIG). The OIG investigators found that 25% of veterans recently awarded high levels of service connected disability for PTSD had insufficient documented evidence of verifiable military stressors, with an estimated monetary risk to the VA of $19.8 billion. They also found that most veterans’ symptoms of PTSD got worse over time until they reached the 100%disability level at which point there was an 82% drop in use of VA mental health services, but no change in other VA medical service use. This is ample cause for concern.

The results of our study will not “make the VA deny a greater percentage of worthy PTSD claims,” as asserted by Mr. Moore. In fact, we believe and hope they will have quite the opposite effect. As we stated in our article: “Ultimately it is hoped that the VA will take steps to ensure that its scarce resources are directed towards those veterans who are both deserving and in need. Such efforts are critical to guard the legacy of actual combat veterans from being trivialized (pp. 472).”

Sincerely,B. Christopher Frueh, Ph.D.1Anouk L. Grubaugh, Ph.D.1Jon D. Elhai, Ph.D.2

1Veterans Affairs Medical Center, Charleston, SC and Medical University of South Carolina, Charleston, SC

2Disaster Mental Health Mental Health InstituteThe University of South Dakota, Vermillion, SD

References

1. Frueh BC, Elhai JD, Grubaugh AL, Monnier J, Kashdan TB, SauvageotJA, Hamner MB, Burkett BG, Arana GW. Documented combat exposure of U. S. veterans seeking treatment for combat-related post-traumatic stress disorder. British Journal of Psychiatry 2005; 186:473-475.

2. Department of Veterans Affairs Office of Inspector General (2005). Review of State Variances in VA Disability Compensation Payments (#05-00765-137). Washington D.C.

Declaration of Interest: This work was partially supported by grantsMH01660 and MH61983 from the National Institute of Mental Health to Dr. Frueh. This work was also supported by the Office of Research and Development, Medical Research Service, Ralph H. Johnson VA Medical Center,Charleston, SC.
... More

Conflict of interest: None Declared

Write a reply

A Misleading Premise and Flawed Methodology

Joseph R Moore, Attorney
24 July 2005

The study "Documented combat exposure of US veterans seeking treatment for combat-related post-traumatic stress disorder" is dangerously misleading. It is based on a misleading presumption and its basic methodology is fatally flawed.

The star statistic from this study being cited is that combat exposure could not be verified for 59% of the veterans being treated for PTSD. The implication is of course that 59% of veterans receiving PTSD benefits are lying or cheating the system. What the study does NOT mention, however, is the following:

1. The survey sample was veterans being treated for PTSD, not those who are service connected for PTSD, or even those who had filed claims forPTSD. There is an enormous difference. Veterans are treated for non service-connected disabilities all the time by VA. This study clearly implies that all veterans being treated for PTSD are seeking benefits or being paid disability benefits for PTSD. This is simply untrue.

2. The designation of combat in this study was based on each veterans’ service medical and service personnel records (primarily on a form called a DD-214). But this is not where one goes to verify combat.

All a veteran's service records will show is whether that veteran hasa Combat Infantryman Badge or a Purple Heart (if they do, combat is presumed by VA). But that does not mean only those veterans have verifiedcombat. This is not just speculation. This fact has been legally recognized by VA. There are guidelines as to where a VA adjudicator should go to verify claimed stressor events.

In order to verify a stressor event, Company and Battalion level records need to be obtained. Soldiers in Vietnam did not each have an individual clerk who transcribed into that soldier’s personnel records every stressful event that occurred. But Companies and Battalions did, which is why those are the records used to verify claimed inservice stressor events.

The authors of this study did not find verification of combat for themajority of veterans in this study because they did not look in the records commonly used by VA to verify combat.

I challenge the authors to obtain the unit records for each veteran in the study and have them reviewed by a legal professional. This would undoubtedly change the results substantially. Combat designation is a legal question, not a medical or military one. A lawyer should have been used to review the records.

This study was clearly conducted with an eye towards adjudication outcomes, as evidenced by the “Clinical Implications.” Yet the standards used by the authors for verifying combat fall well short of the standards used in adjudicating a benefits case.

It is therefore hoped the authors of this study have the courage to admit their mistakes and retract it before it can be used to hurt the interests of disabled veterans on a wide scale.

Joseph R. MooreManaging PartnerBergmann & Moore, LLC332 Main Street, Suite 200Gaithersburg, MD 20878P: 301/519-1683F: 301/519-1684

DECLARATION OF INTEREST

I am Managing Partner of a law firm, Bergmann & Moore, LLC, whichrepresents veterans against the Department of Veterans Affairs in the U.S.Court of Appeals for Veterans Claims. Previously, I was an attorney with the Department of Veterans Affairs’ Board of Veterans' Appeals for three years.

My financial interests and that of my law practice will only be benefited by publication of this flawed study, since we make money off claims which are denied erroneously by VA. This study will embolden VA todeny more PTSD claims.

The fact is, there is a legal standard as to what defines “combat,” and there is years of caselaw regarding that subject. This study will make the VA deny a greater percentage of worthy PTSD claims, but will not affect the jurisprudence of the Court of Appeals for Veterans Claims.
... More

Conflict of interest: None Declared

Write a reply

×

Reply to: Submit a response


Your details


Conflicting interests

Do you have any conflicting interests? *