MILITARY-RELATED PTSD, CURRENT DISABILITY POLICIES, AND MALINGERING

An Iraqi boy drinks water from a water pipe crossing an uncovered sewage canal in Fdailiyah, southeast of Baghdad, Iraq, on December 6, 2007. Many of the neighborhoods in Baghdad lack essential infrastructure, including electrical power and clean water systems. According to the United Nations, pollution of waterways by raw sewage is perhaps the greatest environmental and public health hazard facing Iraqis, particularly children. Printed with permission of Getty Images.

Frueh et al.1 argued that longstanding Department of Veterans Affairs (VA) disability policies for posttraumatic stress disorder (PTSD) reward illness behavior, diminish engagement in treatment, and perversely promote chronic disability. Critical examination of the VA mental health disability system may be instructive and timely, but Frueh et al. present an incomplete picture of the literature and neglect substantial evidence that contradicts their thesis. In particular, they fail to cite studies showing that: (1) rates of mental health service use increase among veterans who receive VA disability benefits for military-related PTSD,2 (2) medical and mental health service use increases after filing a disability claim compared with the preapplication period,3 (3) engagement with mental health services is sustained after claim determination for veterans whose disability-related claims are approved,3^,4 and (4) treatment outcomes are comparable between outpatient veterans who seek or receive disability compensation relative to those who do not.5^,6

Selective coverage also is reflected in the Frueh et al. presentation of issues concerning malingering. Although they cite extensively from the 2005 report by the VA inspector general, they fail to acknowledge that the same report found that only 13 of 2100 (0.6%) service-connected PTSD cases subjected to detailed review were deemed to be potentially fraudulent. The highly influential study by Dohrenwend et al. cited by Frueh et al. also presented minimal evidence of attempts to inflate disability claims.7

Furthermore, their suggestion that 53% of treatment-seeking (especially compensation-seeking) veterans exaggerate symptoms or malinger on psychological tests is based on a small sample drawn from a clinical setting.8 The evidence is further limited by reliance on a measure of malingering that has not been validated in relation to assessment of PTSD outside a forensic setting. In addition, interpretation is tempered by previous research suggesting that, among veterans with PTSD, putative symptom exaggeration may be as much a sign of severe distress and psychiatric comorbidity as malingering.9 Even if the limitations of the study are ignored, the finding that service connection for PTSD was equally common for veterans who showed purported signs of symptom exaggeration and those who did not is inconsistent with the hypothesized negative impact of VA psychiatric disability policies.

Frueh et al. raise important issues and challenge the existing system for addressing the disability of those who have incurred psychological injury through military service; unfortunately, their presentation is selective and incomplete. Recommendations concerning policy require balanced and objective consideration of all available evidence.