Medical University of South Carolina and Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina
Disaster Mental Health Institute, University of South Dakota, Vermillion, South Dakota
Medical University of South Carolina
Medical University of South Carolina and Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina
Plano, Texas
Medical University of South Carolina and Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina, USA
Correspondence: 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{at}musc.edu
Declaration of interest None. Funding detailed in Acknowledgements.
See invited commentary, pp.
473-475, this issue
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ABSTRACT |
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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.
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INTRODUCTION |
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In our study we attempted to verify combat exposure history for a sample of individuals seeking treatment for Vietnam combat-related PTSD through objective historical data (i.e. US government military personnel files) available through the Freedom of Information Act. Historical government records have been used by others to address questions regarding the psychological consequences of war-zone experiences (Jones et al, 2002). Our study was conducted to determine whether there are treatment-seekers misrepresenting their Vietnam combat exposure in a Veterans Affairs specialty PTSD clinic. We also address questions about clinical symptom severity, symptom reporting style and use of Veterans Affairs services by veterans with and without documented combat exposure.
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METHOD |
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Sample demographic characteristics were as follows: mean age was 51.48 years (s.d.=4.29); mean completed years of education was 12.34 (s.d.=2.31); mean annual income was US$21 430 (s.d.=$16 770); 61% were White and 39% were African-American; 51% were unemployed and 46% were employed full-time; 70% were married, 23% were previously married but were currently divorced or widowed and 7% were single. Most participants reported serving in the Army (70%); service in the Marines (18%), Air Force (8%) and Navy (3%) was also represented. The majority (62%) reported applying or intending to apply for Veterans Affairs disability compensation.
Procedure and instruments
At the time of their clinical evaluation, the veterans were diagnosed
according to DSM-IV criteria (American
Psychiatric Association, 1994). The PTSD clinical team, consisting
of a psychiatrist, a clinical psychologist and a social worker, formulated
diagnoses by team consensus after a chart review, a military history interview
and a structured PTSD clinical interview - the Clinician-Administered PTSD
Scale (CAPS; Blake et al,
1995). Team members were trained in CAPS administration and
scoring and routinely met to discuss coding issues.
More than nine-tenths (94%) of the sample were diagnosed with PTSD. Additional (non-mutually exclusive) Axis I diagnoses were based on non-standardised clinical interviews, and included major depressive disorder (88%), substance abuse disorder (42%), anxiety disorder other than PTSD (15%) and psychotic disorder (7%). These rates are consistent with previous comorbidity findings of veterans with combat-related PTSD. The instruments are described in detail below.
Clinician-Administered PTSD Scale
The CAPS (Blake et al,
1995) is a structured clinical interview designed to rate the
frequency and intensity of the 17 symptoms of PTSD based on DSM-IV criteria.
Strong interrater reliability (0.92-0.99), high internal consistency
(0.73-0.85) and high convergent validity have been reported for this measure
(Weathers et al,
2001). The original CAPS scoring rule (item frequency 1 and
intensity
2) was used for diagnosing PTSD. The CAPS total severity score
(frequency plus intensity, summed for criteria B, C and D) was used in
analyses to assess for group differences.
Minnesota Multiphasic Personality Inventory
The Minnesota Multiphasic Personality Inventory - 2 (MMPI-2;
Butcher et al, 2001)
is a 567-item true-false questionnaire which assesses psychopathology, and is
one of the most widely used psychological tests. Test-retest reliability
estimates range from 0.58 to 0.92 for its clinical scales. Raw scores,
k-corrected, were used for the clinical and validity scales. Clinical scales
included depression, psychopathic deviate
(measuring anger and hostility), paranoia,
psychoasthenia (measuring anxiety) and
schizophrenia (tapping cognitive and perceptual difficulties).
Validity scales assessing symptom overreporting included
infrequency-psychopathology and
infrequency-post-traumatic stress disorder
(Elhai et al,
2002).
Beck Depression Inventory
The Beck Depression Inventory (BDI; Beck
et al, 1988) is a widely used 21-item self-report measure
of depressive symptoms. It has demonstrated good reliability, yielding mean
internal consistency estimates of 0.86 across studies, and has been well
validated, with concurrent validity ranging from 0.55 to 0.96
(Beck et al,
1988).
Mississippi Combat PTSD Scale
The Mississippi Combat PTSD Scale (M-PTSD) is a 35-item, Likert format
self-report measure of combat-related PTSD symptoms. In the National Vietnam
Veterans Readjustment Study (Kulka et
al, 1990) the M-PTSD served as a primary indicator and the
best self-report measure of PTSD. Psychometric properties have been reported
for this measure, with excellent sensitivity (0.93) and specificity (0.89),
and an overall hit rate of 0.90 in predicting PTSD diagnoses
(Keane et al,
1988).
Chart review: health service use, medications and combat exposure
Each participant's computerised medical chart was examined for the types of
Veterans Affairs health services used within the 365 days following the
initial PTSD evaluation. Information on the number of clinic visits
(out-patient PTSD, primary care and specialty care clinics) and number of
psychiatric medications prescribed was examined. We also examined self-reports
of combat exposure as noted in the clinicians' progress notes, focusing on
reports of specific combat experiences and details that were described.
Military personnel records review
We officially requested patients' publicly accessible military personnel
records through the Freedom of Information Act. Requests were sent to the US
National Personnel Records Center, Military Personnel Records, 9700 Page
Avenue, St Louis, Missouri 63132-5100, USA. Details on Freedom of Information
Act procedures are explained in detail on the US National Archives and Records
Administration's internet website:
http://www.archives.gov/research_room/foia_reading_room/foia_reading_room.html.
We received a 100% response. Most records arrived within 1-2 months,
although some took as long as 8 months. In eight cases we did not initially
receive a response and filed a second request. Once all responses were in, the
military records were carefully reviewed to ensure that identifying data
(names, social security numbers and birth dates) matched those of our sample,
and all identifying data were then removed before any historical review or
analyses were conducted. We have since destroyed the identifying link to
further protect the veterans' anonymity. Each record was reviewed by two
independent raters, B.C.F. and B.G.B. (an Army veteran with Vietnam war-zone
service and extensive professional experience of analysing military personnel
records). Based on these record reviews, the sample was classified into six
military/combat status categories representing a continuum of combat
involvement (see Table 1).
These classifications were made on the basis of available documentation
indicating military service, advanced individual training, transit records,
Vietnam war-zone service, military occupational specialty, duty assignments,
medals and badges, and any other relevant information included in the record
such as conduct or legal problems. Interrater agreement on these
classifications was 90%, and the coefficient was 0.85, which indicates
a high degree of correspondence (Landis
& Koch, 1977). All but one interrater discrepancy occurred
between the categories of unclear combat and no
combat status. In each instance, the most conservative classification
(i.e unclear combat) was used in subsequent reporting and
analyses, to give the individual the benefit of the doubt.
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RESULTS |
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Combat classification and group differences
Based on our classification of the sample into six military/combat status
categories (Table 1), we found
that 41% of the sample had served in Vietnam, with objective evidence of
combat exposure (Vietnam combat group). An additional 20% had
served in Vietnam during the war era, but it was unclear whether they had
combat exposure (Vietnam unclear combat group). Veterans
classified in this group generally had combat training and a military
occupational specialty, but did not have documentation of the expected combat
medals or badges or other indicators of combat exposure. Another 32% had
served in Vietnam but did not appear to have been involved in combat (Vietnam
no combat group). Many of the veterans in this category were
clerks or mechanics serving at large airbases. Two per cent had documentation
of military service, but it could not be determined from the records whether
they had served in Vietnam (unknown group). Another 3% had
served in the military, but had never served in Vietnam (no
Vietnam group). Last, 2% had no documentation of any military service
(no military group).
We compared the military records with the medical record charts of self-reports of combat exposure in clinicians' progress notes. Results from the chart review showed that clinician descriptions of patients' combat reports varied widely. Specific examples of traumatic combat stressors were located for two-thirds of the total sample, whereas virtually no details were reported for the remaining third other than to indicate general Vietnam combat experiences. For the Vietnam no combat group, 22 out of 32 (69%) reported specific combat stressors such as seeing other soldiers wounded or killed in action, enemy firefight, witnessing or committing atrocities, receiving fire from rockets, mortars or snipers, and long-range reconnaissance patrols behind enemy lines. In the majority of cases in which such details were noted, a number of events were recorded, indicating that the patient had reported extensive combat experiences. Seven individuals from the Vietnam unclear combat and no combat groups reported being wounded in combat, although none had a Purple Heart in their military records. Two individuals reported prisoner-of-war captivity in Vietnam, and five reported classified combat activities in Vietnam, Cambodia or Laos, although none of these experiences was documented in military records and all were reported by individuals classified in the Vietnam no combat group. Further, these individuals were not on an accepted registry of repatriated prisoners of war (Burkett & Whitley, 1998). Those in the Vietnam no combat group were also more likely to report witnessing or committing battlefield atrocities (28%; 9/32) compared with those in the Vietnam combat group (12%; 5/41).
We compared the three groups with documented Vietnam war era service (combat, n=41; unclear combat, n=20; no combat, n=32) on demographic variables (other groups were not included, owing to limited cell sizes). Groups did not statistically differ (P<0.05; effect size f ranged from 0.09 to 0.26) on continuous variables of age, educational level or annual income, or on categorical variables (effect size w ranged from 0.07 to 0.16) of ethnic group membership, employment status, marital status or intent to seek disability compensation. Military branch reported was significantly different between groups, with an unexpectedly high number of veterans in the no combat group self-reporting service in the Army. Groups did not differ (effect size w ranged from 0.07 to 0.27) on any of the diagnostic variables (PTSD, major depressive disorder, substance abuse disorder, anxiety disorder other than PTSD and psychotic disorder).
Next, we compared the three Vietnam groups on clinical and Veterans Affairs health service use variables (Table 2). Groups were compared on relevant MMPI-2 scales and on scores on the CAPS, BDI and M-PTSD. The only significant difference was found on the CAPS, with higher scores in the Vietnam unclear combat group. In the comparison of indices of health service use, the three groups were not statistically different in terms of number of PTSD, primary care or specialty clinic visits or number of psychiatric medications prescribed in the year after their initial evaluation.
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Post hoc power analysis with these variables (assuming
=0.05, minimum power of 80%, using effect size f for analyses
of variance and effect size w for
2-tests) indicated
the following. First, for demographic and diagnostic variables - aside from
military branch (which had adequate power) - only one variable (education
level) reached the minimum threshold for producing a medium effect size.
However, even that variable would have required a total sample size of at
least 153 (nearly three times the analysed sample size) to obtain sufficient
power to detect true differences (with remaining variables averaging a
required sample size of 731 to detect differences). Second, for the primary
clinical and service use variables (Table
2) - aside from the CAPS (which approximated adequate power) -
only four variables (MMPI-2 psychasthenia and
schizophrenia, M-PTSD score and primary care clinic service use)
obtained at least medium effect sizes. However, these variables would have
required an average of 116 total participants (nearly twice the analysed
sample sizes) to obtain sufficient power to detect true differences (with
remaining variables averaging a required sample of 1636). The power analyses
provided further evidence that the non-significant results demonstrated a lack
of true group differences.
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DISCUSSION |
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Results further indicate that veterans presented in a similar manner for treatment services regardless of combat exposure classification. Virtually no between-group difference was found on demographic, clinical or Veterans Affairs service use variables, suggesting that those in the Vietnam unclear combat or no combat groups were no different with regard to reported symptom severity or use of Veterans Affairs healthcare services from the combat group. 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. That is, all groups were seeking benefits, including veterans whose military records did not support their reports of combat exposure.
Concerns about the PTSD database
Although disconcerting, results from our study can be used to clarify other
troubling findings in the PTSD research literature regarding the assessment
and treatment of veterans, including the following:
The disability benefit incentive
The financial incentive to present as psychiatrically disabled with PTSD
within the US Veterans Affairs healthcare system is significant. Veterans may
obtain monetary compensation if they are rated as
service-connected for PTSD. A veteran with a 100%
service-related disability rating for PTSD receives approximately US$36 000
per year (tax-free) in total Federal benefits
(Oboler, 2000). Furthermore,
69-94% of veterans seeking treatment within Veterans Affairs specialty PTSD
clinics apply for psychiatric disability
(Frueh et al, 2003).
Evidence from the Veterans Affairs system indicates that PTSD disability
claims among veterans reporting combat exposure have risen dramatically since
1985 (Murdoch et al,
2003), representing the largest number of claims for any
psychiatric condition (Oboler,
2000). Such financial compensation may provide incentive for some
to falsely report combat exposure and/or overreport psychiatric symptoms.
Placing our findings within this context, it seems likely that secondary gain
incentives may be clouding clinical results and research findings obtained
with veterans. This amplifies the recommendation by Charney et al
(1998) that perhaps
disability-seeking veterans should be excluded from clinical trials and other
phenomenological and epidemiological research.
Study limitations
All the individuals investigated in our study were drawn from one Veterans
Affairs Medical Center PTSD clinic. Thus, the generalisability of these
results is unknown and there is a need for multisite replication studies.
Moreover, the data were drawn from a relatively small sample (n=100),
which also affects generalisability and power. However, this concern is muted
because our power analyses provided evidence that the non-significant results
demonstrate a lack of meaningful group differences. Another concern is that
military personnel files are not necessarily error-proof, and some veterans
might have been misclassified.
It is possible that some of the no combat veterans in our study experienced isolated, undocumented combat-related trauma, such as receiving incoming mortar fire while stationed at a large airbase. Furthermore, it is likely that many of the veterans in our no combat group experienced acute stress and fear in an unpredictable war-zone environment. Nevertheless, such experiences are quite different from the descriptions of direct and heavy combat exposure, such as infantry search and destroy missions and multiple firefights, typically reported by veterans seeking Veterans Affairs care for PTSD and specifically documented in the medical records of two-thirds of our sample. In fact, many in the no combat group reported one or more of the following dramatic experiences: witnessing or committing battlefield atrocities, being wounded in combat, classified combat activities or being a prisoner of war. Thus, it is evident that a considerable percentage of those seeking treatment and disability for combat-related PTSD do not have documented exposure to the specific combat experiences that they report to clinicians. It is improbable that US military records would be so inaccurate as to offer no reflection of these experiences for such a considerable percentage of our sample. Future research might benefit from a comparison of individuals' specific self-reports of combat experiences, using a standardised measure such as the Combat Exposure Scale (Keane et al, 1989), and objective military records, including research on unit records and casualty reports.
However, these findings must be kept in perspective. Certainly, these results should not be interpreted to deny that many combat veterans do suffer from severe and debilitating symptoms of PTSD. A balanced perspective must acknowledge that, although this study focuses on the possibility of false positives, there are strong data to suggest that false negatives are also a significant problem within and outside the Veterans Affairs system.
Implications of the study
It appears that a number of veterans in our sample were misrepresenting the
extent of their combat involvement in Vietnam. This complicates accurate
clinical assessment and appropriate treatment. Clinicians, disability raters
and investigators should consider these findings when evaluating how best to
meet the needs of veterans within the US Veterans Affairs system at both the
individual and the systemic level. Careful evaluation procedures should
routinely be used to verify combat exposure reports among veterans seeking
treatment and disability benefits. Ultimately it is hoped that the Department
of Veterans Affairs will take steps to ensure that its scarce resources are
directed towards people who are both deserving and in need. Such efforts are
essential to guard the legacy of actual combat veterans from being
trivialised.
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Clinical Implications and Limitations |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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Received for publication May 18, 2004. Revision received September 14, 2004. Accepted for publication September 30, 2004.