As disability awards grow, so do concerns with veracity of PTSD claims
The 49-year-old veteran explained that he suffered from paranoia in crowds, nightmares and unrelenting flashbacks from the Iraq war. He said he needed his handgun to feel secure and worried that he would shoot somebody.
The symptoms were textbook post-traumatic stress disorder.
But Robert Moering, the psychologist conducting the disability examination at a Veterans Affairs hospital in Tampa, Florida, suspected the veteran was exaggerating.
Hardly anybody had so many symptoms of PTSD so much of the time.
As disability awards for PTSD have grown almost fivefold during the past 13 years, so have concerns that many veterans might be exaggerating or lying to win benefits.
Moering, a former Marine, estimates that roughly half of the veterans he evaluates for the disorder exaggerate or fabricate symptoms.
Depending on severity, veterans with PTSD can receive up to $3,000 a month tax-free, making the disorder the biggest contributor to the growth of a disability system in which payments have more than doubled to $49 billion since 2002.
"It's an open secret that a large chunk of patients are flat-out malingering," said Christopher Frueh, a University of Hawaii psychologist who spent 15 years treating PTSD in the VA system.
Diagnosing PTSD can be difficult in the best of circumstances. Experts have long debated how to define the condition. One person can suffer crippling anxiety from an experience that wouldn't faze someone else.
Assessing PTSD becomes even more difficult in a VA system that gives veterans a financial incentive to appear as sick as possible, former and current VA mental health clinicians said. The number of veterans on the disability rolls for the disorder has climbed from 133,745 to more than 656,000 during the past 13 years.
Vietnam and the recent wars have fueled the growth in roughly equal measure.
Frueh and other critics of the disability system have sparred in medical journals with senior VA mental health officials, who argue that the extent of malingering is impossible to know without more research.
The veteran Moering evaluated was already receiving $1,600 a month in disability pay for PTSD as well as various joint problems. But he wanted to increase it.
Three tests designed to detect dishonest patients by looking for highly unlikely response patterns strongly suggested that the veteran was exaggerating,
According to disability records that Moering allowed The Times to review. The case is one of eight that Moering opened to the newspaper. In each, he challenged a PTSD diagnosis. The records were redacted to hide names and other identifying information.
Moering said he could not determine whether the veteran was feigning entirely or simply stretching the truth.
"This is the dilemma we face," Moering said. "How can a disability rater honestly rate this veteran?"
Government policy in cases without a clear answer is to give the veteran the benefit of the doubt. The VA left his disability rating intact.
War's psychic toll
In some ways, the explosion in PTSD cases is a sign of progress.
Though descriptions of the disorder show up in literature as far back as Shakespeare, it did not become a formal diagnosis until 1980, and even then remained controversial. After decades of downplaying the psychological toll of war, the government has finally acknowledged the damage and boosted assistance to veterans in need.
The VA has increasingly recognized non-war-related PTSD as well, extending monthly compensation to tens of thousands of veterans traumatized by accidents — both on- and off-duty — that occurred at the time they were enlisted. In one case The Times reviewed, a woman was awarded PTSD compensation based on breaking her leg in a fall walking to the mess hall.
As the number of cases has climbed, so has debate over their legitimacy.
A 2007 study of 74 Arkansas veterans with chronic PTSD, most of them from the Vietnam War, concluded that more than half were exaggerating symptoms. Other research has found little evidence of malingering.
In the aftermath of serious trauma, most people experience symptoms of the disorder. But the nightmares, concentration problems and heightened state of alert usually go away in a few weeks. In a minority of cases, certain combinations of symptoms persist. That's PTSD.
Because the diagnosis relies mainly on what patients report, it is easy to exaggerate.
In online forums, veterans trade tips on how to behave in their disability evaluations. Common advice: Dress poorly and don't shower, refuse to sit with your back to the door, and constantly scan the room.
If an examiner asks about homicidal thoughts, a Vietnam veteran posted, say: "Doc, doesn't everyone, I mean didn't you ever think about killing someone? Hell, I think about it every time someone gets too close to me."
He also urged veterans to purposely fail memory and other cognitive tests.
The motivation behind such advice is not always clear. It may be aimed at helping veterans get what they deserve from a system that many see as rigged against them. Exaggeration can also be a sign of distress itself.
Though VA investigations have exposed scams — including disability recipients who never served in the military — the department has focused on making the system friendlier to veterans.
To get paid for PTSD, veterans must link their symptoms to trauma that occurred during their service. In 2010, the VA expanded what situations could qualify.
Credible fear of being attacked — without actually suffering or witnessing violence — became sufficient.
The VA also dropped its requirement to support each case of war-related PTSD with records of the underlying trauma. Those veterans are now taken at their word.
After the changes, the number of new PTSD claims rose 60% to more than 150,000 a year, and approval rates jumped from 55% to 74%.
The shift raised new concerns.
In a 2014 paper, Arthur Russo, a VA psychologist in Brooklyn, argued that the disability system is prone to "collusive lying," in which veterans fake mental illness and clinicians go along with it.
He cited an email from an unnamed VA chief psychologist to staff members instructing them not to diagnose malingering or "make any comments that appear to question patients' reports of trauma."
Gail Poyner, an Oklahoma City psychologist, said she was dismissed in 2010 from a company the VA hired to conduct disability exams because she insisted on giving veterans tests to determine whether they were exaggerating.
"It's political," Poyner said. "It's not prudent to suggest that people who have served our country are not being honest."
The VA issued a statement to The Times saying it encourages examiners "to conduct comprehensive, accurate and thorough evaluations" and to use their clinical judgment in deciding whether to test for malingering.
An issue of honesty
The quest for VA disability benefits begins before service members leave the military.
Jill Wilschke, a therapist who worked at Camp Lejeune, N.C., until late last year, said many of her patients had witnessed the horrors of war and were being forced out of the military because of PTSD.
"People I worked with were really hurting and scared about how they would survive when they left," Wilschke recalled.
But in several cases, she said, Marines whose symptoms were fading expressed concern that medical records documenting their progress would be used against them in disability exams. One with mild PTSD was contemplating putting off college because he worried attending would make him appear too healthy.
Wilschke worried that some patients weren't being honest with her.
Several VA mental health providers said the incentives of the disability system have undermined their relationship with patients and inhibited them from fully engaging in treatment.
In 2005, the VA office of the inspector general looked at 92 cases of PTSD and found that while most veterans received treatment when their disability ratings had room to rise, visits dropped off after their ratings topped out at 100% disabled.
Frueh and other researchers have argued that the incentives of the disability system may help explain why veterans tend to report less improvement than other patients in response to treatment.
In its statement, the VA pointed to several studies casting doubt on that view and said "it is counterproductive to disparage VA disability policies and treatment efforts without clear supporting evidence."
Many veterans — including those receiving disability pay — make substantial progress with treatment, it said.
Among the most encouraging results came in a study published last year in JAMA Psychiatry. It looked at 1,888 veterans who began a treatment known as prolonged exposure therapy. Almost 800 went on to fall below the threshold for PTSD on a standard assessment scale. Their traumas included combat, sexual violence and painful childhood experiences.
In the VA disability system, however, the disorder is usually permanent.
Of the 572,612 veterans on the disability rolls for PTSD at the end of 2012, 1,868 — a third of 1 percent — saw a reduction in their ratings the next year, according to statistics provided by the VA.
Even some veterans whose diagnosis falls under deep suspicion have managed to keep their disability ratings.
In one case that Moering reviewed in 2009, he searched military records and concluded that a Navy veteran on the disability rolls for PTSD had lied to VA clinicians about having served in the elite SEALs and concocted his combat history.
The VA responded by reducing his PTSD rating from 50 percent to 30 percent, records show.