In response to the diary by DEFuning, he/she does make a few good points, e.g that the military health care system is overburdened with inadequate resources, and that having a personality disorder does not rule out a possible co-occuring diagnosis of PTSD.
However, the interpretation of Dr. Perez's memo is off the mark. Perez begins the memo: "Given that we are having more and more compensation seeking veterans..." The term "compensation seeking" is not a neutral or medical term. It is meant, usually deliberately, to imply that the veteran is trying to obtain money (benefits) to which he/she is not entitled, by pretending to have, or exaggerating, his/her symptoms and/or disability.
Although PTSD can be rather complex, the DSM-IV-TR (American Psychiatric Association) criteria for its diagnosis are not so complex. Importantly, one criterion is that "Duration of the disturbance is more than 1 month." While Acute Stress Disorder has similar symptoms to PTSD, its duration is "for a minimum of 2 days and a maximum or 4 weeks..."Thus, if a veteran has symptoms of PTSD which have lasted more than a month, by definition s/he has PTSD, not Acute Stress Disorder.
Adjustment Disorder is different not only in terms of duration (generally if symptoms persist longer than 6 months, it is not adjustment disorder). It is also different in terms of severity: "marked distress that is in excess of what would be expected from exposure to the stressor." The Adjustment Disorders which might be most liable to be considered instead of PTSD are Adjustment Disorder with Depressed Mood: "when the predominant manifestations are symptoms such as depressed mood, tearfulness, or feelings of hopelessness," and Adjustment Disorder with Anxiety: "when the predominant manifestation are symptoms such as nervousness, worry, or jitteriness..."
Clearly, the above symptoms are less severe than those of PTSD. And, the diagnostic manual spells out a number of quite specific symptoms for the diagnosis of PTSD, different and far beyond what is required for the diagnosis of Adjustment Disorder.
While I agree with DEFuning that the military may have insufficient resources, this is a political issue that needs to be remedied by more funding. The memo by Dr. Perez is misleading in stating "we really don’t have time to do the extensive testing that should be done to determine PTSD." This is, again, meant to discourage the diagnosis from being made. Of course you need more than the fact that a veteran was in Iraq and has some symptoms, to warrant a PTSD diagnosis. But the diagnosis can be made by careful interviewing, supplemented by self-reports, and also in some cases by obtaining information from others, such as those who served with the veteran, as to what behavior or symptoms they observed in the veteran.
In summary, from the actual wording of the VA memo, it is clear that the purpose of the memo was not to encourage careful "differential diagnosis," which of course is a requirement in all of medicine, including psychiatry, all the time. Rather, the purpose, as seen in the misleading sections I have quoted above, was to discourage the diagnosis of PTSD as a way of avoiding, or delaying, having to provide benefits to veterans who might well have PTSD.
A final point is that in addition to denying or delaying monetary and other benefits to the veteran, if s/he is incorrectly diagnosed with Adjustment Disorder instead of PTSD, the veteran will not receive proper treatment for his/her PTSD. The treatment of Adjustment Disorder generally is not intensive and often can be carried out by mental health workers without extensive training. In contrast, there are some specific, effective types of psychotherapy for PTSD (e.g., Cognitive Reprocessing Therapy) which require intensive treatment by specifically trained therapists. The more general, less intensive treatment which can be effective for Adjustment Disorder is NOT effective for PTSD. And, the longer PTSD remains untreated or inadequately treated, the more likely it is to become chronic—often dooming the veteran (and his/her loved ones) to years of suffering.
Permalink | 30 comments