How does one doctor diagnose an Iraq war veteran with PTSD while another says the same soldier has a less severe condition called adjustment disorder? Medical records shared by one of the characters in our feature story this week offer some insight into the workings the controversial forensic psychiatry team at Madigan Army Medical Center.
photo by Kevin Casey John Byron Etterlee
On July 15, 2011, a Veterans Affairs (VA) psychiatrist interviewed Etterlee and diagnosed him with Post-Traumatic Stress Disorder (PTSD). But five months later the diagnosis was abruptly changed to "adjustment disorder"--a lesser condition--by a forensic psychiatrist at Madigan Army Medical Center in Tacoma. The switch was made even though the clinician merely reviewed paperwork and never spoke with Etterlee or met him face-to-face. Only later did Etterlee learn that he was one of several hundred Fort Lewis soldiers who'd had their PTSD diagnoses downgraded by Madigan doctors.Unlike other illnesses, there's no X-ray, blood test, or MRI that can definitively spot PTSD. It's a subjective decision made by a psychiatrist who relies almost exclusively on the testimony given by the patient. There are specific criteria outlined by the DSM (the official guide used by doctors to diagnose mental illness) but ultimately it's a judgement call.
A controversy erupted after several servicemen stationed at JBLM complained about the PTSD screening team--the only one of its kind in the military--at Madigan that overturned their original diagnoses. Internal memos emerged revealing that the military psychiatrists had been told by higher-ups to consider the long-term cost of a PTSD diagnosis, which qualifies a soldier for a lifetime of increased disability payments. In some cases, the memos noted, the total taxpayer burden could be as much as $1.5 million for a single soldier over the course of his or her lifetime.
"By downgrading me to adjustment disorder," Etterlee came to realize, "they're eliminating the medical retirement [benefits] and compensation. I was pretty angry."
Both the Madigan commander, Col. Dallas Homas, and the leader of the forensic psychiatry team were relieved of their duties earlier this year, and an investigation into the PTSD diagnosis reversals is ongoing. Army leaders ordered a system-wide review of their behavioral health-care practices, and announced last week that they would end the use of forensic psychiatry for disability evaluations. Col. Homas was reinstated as commander of the hospital.
Those who struggle with trauma-related issues but don't quite meet the criteria for PTSD are typically diagnosed with adjustment disorder. To a layperson, adjustment disorder sounds an awful lot like PTSD. It is defined as "the development of emotional or behavioral symptoms in response to an identifiable stressor," followed by "marked distress" and "significant impairment in social, occupational, or other important areas of functioning."
In Etterlee's case, one doctor said he qualified for PTSD. Another said he had adjustment disorder. It's a fine line, but a look at the reasoning for each diagnosis is revealing.
The VA psychologist, Lawrence W. Smith, noted that Etterlee suffered from "anxiety and constant tension" and sleeplessness as a result of his deployment to Iraq in 2008. Etterlee had limited combat experience, but was exposed to a handful of traumatic events, which caused a host of problems later on, including "intense distress at exposure to similar events."
The forensic psychiatrist at Madigan -- part of a unique Army team created to review PTSD disability claims -- noted that Smith relied on "the service member's subjective report of alleged events," which were, "unverified by any collateral source of information." The suggestion is that Etterlee exaggerated his story. Since Etterlee also showed "an understanding of the secondary gain potential" of being diagnosed with PTSD (i.e. increased disability payments), Dr. Thomas Danner concluded with "a reasonable degree of psychological certainty" that Etterlee did not have PTSD. Danner never met Etterlee in person.
Upon further review, after the policies at Madigan were made public, Congress got involved, and Etterlee had his original PTSD diagnosis restored. The Army Surgeon General has identified more than 300 other reversed diagnoses, and while the results of an internal inquiry have not yet been released, Sen. Patty Murray said in May that at least 100 soldiers have already had their original diagnoses reinstated.
Here are the documents, shared with Etterlee's permission, that show the two diagnoses and the reasoning behind each. (For medical privacy reasons, only a few of the documents are being made public, and some personal information has been redacted.)