ptsd The Va Is Trying To Sway My Doctor..

[robert51]

So i have been seeing a doctor now 2 times a month for 2 years and she wrote me a great report that helped a lot to get me SSD a year ago and this last time i am in her office and i know she see's other PTSD VA patients as a sub contractor ... well i get part of what i spend back (VA pays cheap ) i get about 1/3 back of what i spend to see her as a private doctor IMO ... by submitting her bill to me and a report to cover my seeing a doctor for a service connected disability twice a month... This session she says to me the VA doctor called her and told her (((( Many vets get on disability and get used to the income as many of them did not hold good jobs before so they the vets tend to want to stay ((( collecting ))) like a retirment for ever and vets can be very good at making something little seems like a big deal... I say... remember FTA well for me its FTG ... i told my doctor if you are going to start acting like a va bean counter i guess we should part ways... This is why a vet has to have the right to have a lawyer ...

[Hoppy]

Many vets did not have good jobs before "what". Their entry into the military or their diagnosis of PTSD. PTSD is usually diagnosed years after the veteran has struggled with employment soley due to the symptoms of the PTSD. Whose to say the veterans would not have found statble employment post service if he did not have PTSD. The VA shrink would have had a hard time graduating from the school where I studied psychology. They would have wrote on his papers "vague" "non specific generalizations" "Unsupported".

There is a popular concept in the system that disbility compensation is a disincentive to vocational rehabilitation. The problem these folks do not understand is that if the veteran did not have PTSD he would see a vocation rather than treatment and compensation. They confuse PTSD with laziness and other less severe psych disorders. You do not get the diagnosis of PTSD just by being lazy. The diagnosis is far more complex.

If your IMO did not jump up and get in his face I would change doctors. By the way. There are other doctors at the VA who will stand up and support and defend PTSD veterans from this type of baseless criticism.

[Chuck75]

I really wish there was a practical way to stop this sort of thing. It just goes to show that the VA's attitude towards Veterans and PTSD is not what it should be. Talk about prejudicial behavior by an inhouse VA doctor!

Since, as you said, the Dr. is a subcontractor, it's doubtful that she would continue to be one if you and she blew the whistle. (Not that this should even be a consideration.)

So i have been seeing a doctor now 2 times a month for 2 years and she wrote me a great report that helped a lot to get me SSD a year ago and this last time i am in her office and i know she see's other PTSD VA patients as a sub contractor ... well i get part of what i spend back (VA pays cheap ) i get about 1/3 back of what i spend to see her as a private doctor IMO ... by submitting her bill to me and a report to cover my seeing a doctor for a service connected disability twice a month... This session she says to me the VA doctor called her and told her (((( Many vets get on disability and get used to the income as many of them did not hold good jobs before so they the vets tend to want to stay ((( collecting ))) like a retirment for ever and vets can be very good at making something little seems like a big deal... I say... remember FTA well for me its FTG ... i told my doctor if you are going to start acting like a va bean counter i guess we should part ways... This is why a vet has to have the right to have a lawyer ...

[carlie]

Robert,

You posted, "This session she says to me the VA doctor called her and told her (((( Many vets get on disability and get used to the income as many of them did not hold good jobs before so they the vets tend to want to stay ((( collecting ))) like a retirment for ever and vets can be very good at making something little seems like a big deal..."

My questions:

Did she tell you what VA doctor made this statement? Was it a VA doctor that is in anyway involved with your healthcare? Would she be willing to state this quote in writing and provide the name and employment location, of this VA doctor ?

Here's a link that may be of interest.

http://www.commondreams.org/archive/2007/09/17/3897/

Hope this helps a vet.

carlie

[Speaking Out]

Carlie is right, get this doc to put it in writing and then go to the news, your elected officials, VAIG, and anyone else who will listen. The VA attorney's tried to get my VA doctor to talk with them without my consent during the medical malpractice suit and he said no. The VA pressured him and he stuck to his guns and refused. He was willing to meet with my attorney and was going to testify for our side if needed. I respect him for that. He was the doctor that actually did the unneeded surgery and I have to admit I was suprised he didn't jump on their wagon. He treated me with the information he got from the VA lab and the VA nurse. I could have sued him individually, but he didn't do anything wrong and the point of my suit was not money, but to get the VA to change their system. So it is true that there are some VA doctor's who work at the VA who are moral and good. Please don't let this go and make sure your doctor is looking out for you and only you, otherwise run. Your treatment comes first.

[carlie]

Perhaps the VA doc that made these statements to your private doc has read or participated in this study. I am not in agreement with the outcome of this study.

http://www.ncptsd.va.gov/ncmain/nc_archive...amp;echorr=true

carlie

[carlie]

Here's another report that doctor may have read or participated in. It's a long read but I think - worth our time.

http://www.ncptsd.va.gov/ncmain/nc_archive...amp;echorr=true

Hope this helps a vet.

carlie

Nc-PTSD Clinical Quarterly Volume 8(3) Simmer 1999

Guidelines for Differentiating Malingering from PTSD

JUDITH G. ARMSTRONG, PH.D. & JAMES R. HIGH, M.D.

'Iron Mike" came as a forensic referral two years after an accident in which he was slightly injured. Shortly after, a treating physician declared him perma- nently disabled by "soft" neuro- logic symptoms. A month later he was hospitalized for anxiety, de- pression, and psychotic-like behav- ior. In the hospital he reported that before his accident he had begun

JudithAnnstrong,PhD. seeing rifle-caixying Viet Cong. He said that since the accident he suf- fered "flashbacks" of a painful Vietnam combat experience that earned him his nickname. He expressed horror and guilt at reliving histerror and hisbuddy's gruesome death. Thismemory was related with great catharsis, after which his diagnosis was changed fromAdjustment Disorder to Post-Traumatic Stress Dis- order. However, he began exhibiting more neurologic symp- toms, necessitating re-evaluation. The neurologist's findings were inconsistentwith true brain damage. Some symptoms, including transient paralysis, appeared conversion-like, while others, in- cluding "volitional" nystagmus, were intentional. Nevertheless this doctor diagnosed "Post-Concussion Syndron~e." It was tempting to dismiss "Iron Mike's" clinical pic- ture as Malingering, the intentional production of false symp- toms motivated by external incentives. Hissymptom and dis- ability far exceeded objective findings. Some were intentionally produced. Furthermore, he would receive a great deal of money from his lawsuit were his symptoms believed. Yet, he had been declared pemunently disabled before he developed these symptoms, and he reported his "flashbacks" as beginning shortly before the accident, suggesting a prior active PTSD. An alternative to Malingering is Factitious Disorder. This also involves the intentional production of false symptoms, but is motivated by the compulsion to assume a sick role. "Iron Mike's" combat history, flashbacks, and pseudo-neurological symptoms occurred in a medical setting, eliciting both medical attention and sympathy. However, he was already accepted as veiy sick. His symptoms did little to enhance this perception. Finally, Conversion Disorder deriving from a core of mild brain damage and F'TSD was possible. A combat veteran with latent, chronic PTSD could experience conversion symptoms following a concussion from a recent frightening accident that

re-awakened trauma. However, conversion would not explain Mike's intentionally produced symptoms.

PTSD implies a definite causal link to what is often a com- pensable event. Therefore, when evaluating possible F'TSD with ex- ternal incentives at stake it becomes necessary to carefully assess causal-ity, intentionality, and motivation as well as traumatic events and symp- _{JamesHigh, M.D.tonis. Furthermore, when incentives}

_{are at issue, clinicians must report their opinions outside the therapeutic dyad. Thisdficult situation demands anobjective, thorough, and sensitive clinical evaluation in which clinicians must struggle with the implications of believing or disbelieving their patients' reports, often while feeling awed by the enor- mity of the reported traumatic events. As the case of Iron Mike illustrates, differentiating malingering from PTSD in the real world is not simple.}

_{We ague here that assessing PTSD claims for possible malingering requires sharpening, not discarding, one's clinical sensitivity. As with any other diagnosis, detection of malinger- ing begins with a thorough evaluation of history and symp- toms. Recounting an event said to be traumatic is insufficient. A simple listing of symptoms, even if obtained in a well vali- dated structured interview, is not enough. Obtaining an alli- ance with the patient is essential in determining when breaks in communication occur, when one needs to question further, and in distinguisliing between confusion and genuine memory prob- lems versus lack of cooperation. Verbal descriptions also are not enough. Observation of emotional and physical behav- iors surrounding communication is essential to determining the meaning and reliability of information. Moreover, unques- tioning acceptance of die patient's formulation of the problem is insufficient Alternative explanations and collateral sourcessuch as records, family, and testingmust alsobe considered. Our expe-rience is that when cliniciansareduped by malingem,their blind- ness canusuallybe traced to an important issuethey failed to ad- dressin theinitial evaluationprocess. Thefollowingguidelinesare offered with basic principles of good clinical practice in mind. Resnick(11,Pitman et al. (21, and Rogers (3) offer further discus- sion on a number of these points. NGPTSD Clinical Quarterly Volume 8 (3) Summer 1999 ARMSTRONG & HIGH Malingering Guidelines An essential safeguard against being duped by a PTSD malingerer is having an index of suspicion for malinger-ing. The clinician's index of suspicion should rise when the patient: - does not cooperate with the evaluation. This includes statements of being unable, unwilling, or "forgetting" to perform diagnostic tests; - calls attention to his or her distress but is evasive about details of symptoms. The malingerer often appears to relish talking about the trauma but becomes eva-sive when asked for details of symptoms, while the opposite tends to be true of the PTSD sufferer; - shows behavior discrepant with reported symptoms, e.g. claiming to be unable to work because of anxiety and flashbacks but engaging in recreational activities; - presents pre-trauma functioning in an over-idealized light; - tends to blame all life problems on the trauma and resultant PTSD. Patients with true PTSD tend to avoid treatment, focus on their responsibity-induced sense of guilt, and attempt to appear normal. By contrast, malingerers place their trauma at the forefront and use it to justify their ends. Some common misconceptions about malingerers that may obscure the clinician's percepttveness include: - malingerers tend to be men. There is no evidence of gender differences in frequency of malingering. - malingerers tend to be sociopaths. Despite the DSM-N assertion of a connection between sociopathy and malingering, no studies link these two behaviors (3). - trauma clinicians can spot a fake story of trauma, and therefore, a convincing story is likely to be true. There is no connection between the vividness and emotional impact of a trauma story and its truthfulness. PTSD is unique among psychiatric disorders in that the patient's state of mind at the time of the event is crucial to diagnosis and therefore must be carefully explored in the inte~ew. True PTSD sufferers are able to describe Criterion A peritraumatic horror, helplessness, and/or dis-sociation. Absence of, or vagueness about, these "state of mind aspects of PTSD when recounting relatively recent traumatic experiences is therefore suspicious. When inquiring about trauma, it is important to begin with non-suggestive questions that encourage patients to tell their stories. Question carefully for details of "B criteria re-experiencing and don't accept labels. For ex-ample, ask what it's like for the patient to "relive" an expe-rience or have a "flashback." There are differences be-tween flashbacks and mere unpleasant memories. These differences must be carefully explored by the clinician. Stan-dardized structured interviews are highly suggestive to malingerers and are piÂ¥irnaiil useful in situations where ma-lingering is not an issue. Malingerers tend to forget "negative" symptoms of PTSD. Carefully check with the patient regarding DSM-N PTSD ' C criteria such as avoidance of trauma-related activities and detachment from close relationships. Wishing to be likeable and believable, malingerers often assert their deep love and closeness toward family, not realizing this is incon-sistent with emotional numbing. Tme PTSD avoidance serves the purpose of controlling painful symptoms. Ma-lingered avoidance tends to have an external incentive such as enhancing monetary compensation. 'With unsophisticated malingerers, we have had success us-ing die common clinical technique of inserting a rare and unlikely symptom (such as hair pulling or decreased need for sleep) into a series of questions about PTSD syinp-toms. Even sophisticated malingerers may find it diEcult to con-sistently mimic behavioral cues for PTSD such as physical signs of "D" criteria hyperarousal and dissociative "spac-ing out" when trauma is discussed. Therefore, careful ob-servation of behavioral responses such as staring, startling and somatic reactions when traumatic material is discussed during interview can help to distinguish between a true PTSD sufferer and a malingerer. Carbon (4), Briere (51, and Wilson and Keane (6) have pub-lished excellent guides for choosing and interpreting tests for PTSD. The MMPI-2 validity scales can detect symp-tom exaggeration which may support a finding of malin-gering. However, the F scale is often elevated in acute PTSD sufferers since this scale contains many trauma symptoms. We have found Arbisi and Ben-Porath's (7) recently devel-oped F(p) scale to be extremely helpful in differentiating individuals who are highly disturbed by trauma from ma-lingerers. Self-report measures without validity scales such as the Dissociative Experiences Scale, can also help identify malingering "yea-sayers'' if you ask for detailed examples of any symptoms reported. It is essential to carefully explore the chain of causality, and consider alternative causes. We have noted earlier that NC-PTSD Clinical Quarterly Volume 8 (3) Summer 1999 good clinical practice demands that we not accept un-challenged the patients' hypotheses as to the cause of their problems. Resnick (1) points out that even when the pa-tient has PTSD, providing misleading information about the cause of one's disorder is as much malingering as is reporting false symptoms. Ultimately, n"laliixgering is not simply a diagnosis of clinical judgement or psychological testing. It is a decision that the patient more likely than not is misrepresenting facts con-ceming the nature, severity, and/or cause of his or her dis-tress. Therefore, differentiating due from malingered PTSD requires seeking corroboration through collateral sources. Records from medical, military, and legal sources must be obtained. Likewise, partners should be interviewed to corroborate behaviors such as die frequency of night time awakenings, physical acnvily during sleep, and changesin sexual activity and emotional availability since tie tiam. Discussion Where does Iron Mike stand in view of these guide-lines? The development of his symptoms in a legal context, his intentional neurological symptoms, and his eagerness to re-count his dramatic Vietnam story as part of his compensation seeking raised the index of suspicion for malingering. As we have seen, the fact that his psychiatric nurse and later a court reporter were moved to tears when he told his combat story was no guide to the accuracy of his report. Our review of medical records showed no evidence of peritraumatic alter-ation of consciousness, organic or psychological, following his accident. Also, his post accident MMPI was invalid due to exaggeration. Most importantly, his service records indicated that he had neverbeen in Vietnam. Iron Mike malingered his combat and accident-related PTSD and neurological symp-toms. An interview with his older brother, however, corrobo-rated chronic, severe physical abuse during his childhood. Thus, it is possible that his conversion symptoms, as well as some of his PTSD symptoms, were valid expressions of genuine trauma. In his case, as in others, the diagnosis of malingering did not rule out the presence of another psychiatric disorder. Dealing with the possibility of malingering when asked to examine on behalf of a third party is relatively straightfor-ward since the evaluator's role as decision maker is clear. The task of separating true from malingered PTSD arises with greatly increased immediacy and complexity when the patient in treatment seeks to enlist his or her clinician's intervention "with outside oarties to obtain external incentives such as fman-provider, it is often acceptable to use clinical judgment alone. As an evaluator, however, more than clincial judgment is re-quired. Careful history taking and symptom evaluation then take on a new importance. Validated psychological testing should be obtained. Corroboration whenever possible be-comes a necessity. Otherwise clinicians risk colluding with their patients' malingering. The mere act of requiring that the patient "prove" their PTSD is genuine may irreparably damage the therapeutic alliance. Furthermore, even if you discover malingering there may still be other illness to treat, including PTSD. A judge-ment that malingering exists may not end the need for treat-ment. In fact, die frank discussion of the patient's deception may allow the therapeutic alliance to evolve into a more realis-tic and genuine relationship, a task requiring exceptional skill and sensitivity. Sadly, even when the skill exists and the treat-ment need is acute, confronting the deception more often irre-vocably ruptures the alliance. Iron Mike's psychiatrist attempted to discuss Mike's deceptions in therapy. Mike fired him and continued "therapy" with a less skilled andmore gullible clinician. References 1. Resnick, P.J. (1997). Malingering of Posttraumatic Disorders. In R. Rogers (Ed.), Clinical assessment of malingering and deception. New York: Guilford Press. 2. Pitman, R.K., Span, L.F., Saunders, L.S. & McFarlane, A.C. (1996). Legal Issues in Posttraumatic Stress Disorder. In B.A. van der KO&, A.C. McFarlane & L, Weisaeth (Eds.), & matic stress ( pp. 378-397). New York: Guilford Press. --3. Rogers, R. (1997). Clinical assessment of malingering and deception. New York: Guilford Press. 4 Carlson, E.B. (1997). Trauma assessments: A clinician's guide. New York: Guilford Press. 5. Briere, J. (1997). Psvcholoeical assessment of adult post-traumatic states. Washington, DC: American Psycho-logical Association. 6. Wilson, J.P. & Keane, T.M. (1997). Assessine psvchological trauma and PTSD. New York: Guilford Press. 7. Arbisi, P.A. & Ben-Porath, Y.S. (1995). An MMPI-2 Infre-quent Response Scale for use with Psychopathological Populations: TheInfrequency- Psychopathology Scale, F(p). Psvchological Assessment, 7,424-43 1. 8. Strasburger, L.H., Gutheil, T.G. & Brodsky, B.A. (1997). On Wearing Two Hats: Role Conflict in Serving as Both Psychotherapist and Expert Witness. American Journal of Psvchiatry, m, 448-456. ~~ ~ cia1 benefits, avoidance of onerous duties and punishments, judith G. A~~mstrorzgisCli?zicalAss0~1'atePmfessorofftyhohsyat and obtaining narcotics of questionable necessity. Strasburger the ~n~~ofSoutheriz^lifomiaaruihasa~mteclinicaland et al. (8) point out that clinicians who agree to help in this way forei7siqr~t&i?z~arzta~&zico.,~~ . ~ ~ n & m ? z g k a n a n t /  ¥ ? must recognize that they have taken on an additional role that along with Frank Pu.tizanz andEve Carbon of the Adolescent may conflict with their therapist role. We agree with these au- m~ociat~Fxtxiv'acR'sSmlefA-DB). ~ ~~ thorn that, whenever possible, clinicians should avoid this role dilemma. J a m High isa boardmtliedpsychiatrist inSantaMo1zicawith When this is not possible, die clinician enters into the exteiwiisdinicalai~dfoi~micexpeiieiiceiizassesmei~tandt~ati~~ei~t dual roles of treatment provider and evaluator. In the role of ofFTSD. Dr. High is ClinicalAssodatePmfassorofPsychiatry at the IflzWCiÂ¥sityoJYouther California.}