Good morning Chairman Filner, Ranking Member Buyer, and Members of the Committee.  Thank you for inviting me to discuss the mental health services the Department of Veterans Affairs (VA) provides our Veterans, and how a Veteran’s discharge for a personality disorder affects his or her access to key VA benefits.  I am accompanied today by Mr. Tom Murphy, Director of the Compensation &Pension Service (VBA).

A personality disorder is defined by the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (Text Revision, or DSM-IV-TR) as an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, manifested in cognition (ways of perceiving or interpreting events and others’ behavior), affect (including the range, intensity, ability to manifest, or appropriateness of emotional responses), interpersonal functioning, and impulse control.  Essentially, this means that a person with a personality disorder displays behavior and attitude that is a consistent, long-term characteristic of the individual and that differs from cultural norms in problematic ways.

In DSM-IV-TR, personality disorders differ fundamentally from other types of mental health disorders.  DSM-IV-TR requires that a new diagnosis of a personality disorder should only be made after considering the possibility that there may be other causes of the behavioral change, such as another mental disorder, the physiological effect of a substance (such as medication), or a general medical condition like head trauma.  Primarily, these requirements exist because many of the problems exhibited by individuals with personality disorders can also be symptoms of other mental health disorders or other health problems, and without a prior personality disorder diagnosis, the clinician cannot assume that these symptoms represent long-standing, enduring characteristics of the individual.  For example, traumatic brain injuries (TBI) and Post-Traumatic Stress Disorder (PTSD) can have effects similar to the symptoms of some personality disorders. 

Given the complexity associated with personality disorders and other cognitive and behavioral issues, VA has developed a comprehensive system involving outreach, screening and treatment for Veterans to determine if they have mental health disorders or TBI.  Our intensive programs ensure that any problems are recognized, diagnosed, and treated, and our benefits programs provide compensation and support for Veterans whose conditions were the result of service in the military.  My testimony today will begin by discussing Veterans’ eligibility for benefits from VBA and health care.  I will then describe the process by which Veterans are screened for cognitive and behavioral problems and discuss three conditions:  personality disorders, TBI and PTSD.  Finally, I will cover the health care benefits and services available to Veterans in VA health care facilities and Vet Centers.

Veteran Benefits Administration

Veterans’ eligibility for benefits under title 38 is generally conditioned on two factors: 1) the character of discharge, and 2) the completion of an enlistment or period to which called.  Title 38 U.S.C. §101(2) and 38 C.F.R. § 3.1(d) define a Veteran “as a person who served in the active military, naval, or air service, and who was discharged or released  under conditions other than dishonorable.”  The uniformed services, when separating a Servicemember, characterize his or her service as one of the following: honorable; general, under honorable conditions; under other than honorable conditions; bad conduct; dishonorable; or, uncharacterized.

VA accepts discharges that are characterized as honorable or general, under honorable conditions, as “other than dishonorable” for VA purposes.  Such discharges generally do not disqualify a Veteran for health care, disability compensation and pension, educational assistance, vocational rehabilitation and employment services, home loan guaranty, and burial and memorial benefits offered by VA as long as the Veteran meets the minimum active duty requirement of two years of service or “the period called” to service if activated for less than two years.  Service “for the period called” would be applicable in the situation of a Reservist or National Guard member called to active duty by a Federal Order (for other than training purposes) and completing the full call-up period.  If VA determines that a Veteran has a service-connected disability the minimum active duty requirement does not apply.  In addition, for purposes of the Montgomery GI Bill and the Post-9/11 GI Bill, a Veteran must have received an honorable discharge. 

VA uses the process outlined in 38 C.F.R. § 3.12 to determine whether other than honorable and bad conduct discharges may be considered “other than dishonorable” for VA purposes.  Dishonorable discharges are all disqualifying.  A separation resulting from a reported personality disorder is of potential significance to VA only if it results in a separation that is less than honorable or if it results in a separation before completion of the minimum active duty requirement. 

Personality disorders are considered constitutional or developmental abnormalities and thus are not service-connected.  Therefore the law does not permit payment of compensation for a personality disorder.  However, Veterans who are eligible to enroll for VA health care can be examined by VA clinicians, who may diagnose other mental health disorders.  Veterans are not bound by any diagnosis from the Department of Defense (DoD) when seeking treatment from VA or when submitting a claim for service connection.

Veterans Health Administration

• Eligible Veterans may enroll in the VA health care system.  Once enrolled, they are provided all needed care set forth in the medical benefits package.  VA’s enrollment system manages the enrollment of Veterans in accordance with priority categories.  Currently, the following Veterans are eligible to enroll:
• The Veteran was a former Prisoner of War;
• The Veteran received a Purple Heart Medal;
• The Veteran is determined to have a compensable service-connected disability;
• The Veteran receives a VA pension;
• The Veteran received a Medal of Honor;
• The Veteran is determined to be catastrophically disabled;
• The Veteran has an annual household income below applicable income thresholds.

In addition, Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) combat Veterans may enroll and receive free VA medical care for any condition related to their service.  Under the “Combat Veteran” authority, VA provides cost-free health care services and nursing home care for conditions possibly related to military service to:

• Combat Veterans who were discharged or released from active service on or after January 28, 2003, for 5 years from the date of discharge or release if they enroll for VA health care during this period.
• Combat Veterans who were discharged from active duty before January 28, 2003, but who did not enroll in VA health care system now have until January 27, 2011 to enroll and receive care as combat veterans.   Veterans who enroll with VA under this authority will continue to be enrolled even after their combat-Veteran eligibility period ends but may be required to make applicable copayments.

Screening for Cognitive and Behavioral Conditions

VA clinicians routinely and systematically screen enrolled Veterans for a range of health concerns.  Every Veteran who visits a VA health care facility is screened initially and periodically for PTSD, problem drinking, and depression, and all Veterans receive a one-time screening for Military Sexual Trauma (MST).  Veterans from OEF/OIF are screened for possible TBI as well.  Any Veteran who screens positive for any of these conditions is referred for further assessment and care.  With the widespread integration of mental health into primary care settings, this process has become easier for Veterans, and the potential stigma of being referred to an exclusively mental health environment has been reduced. 

VA’s universal screens are primarily health assessments meant to ensure that appropriate care is delivered, but such assessments may be relevant to service connection claims as well.  VA clinicians, including psychologists or psychiatrists, conduct detailed assessments when Veterans apply for disability benefits for a mental health condition connected to their military service.  These experts review medical records, including screening and further test results, as part of this assessment.

Compensation and pension (C&P) examinations for mental health disorders follow established guidelines and cover psychosocial functioning, as well as self-reports of symptoms of mental disorders that manifested before, during, or after military service.  VA clinicians also assess the Veteran’s individual military experience, including exposure to traumatic events or other stressful experiences that could trigger a mental health problem, and compare this information with the timing of symptoms to determine if the condition is likely to be connected to military service.  If the Veteran exhibited a pattern of maladaptive behavior prior to military service, VA must determine whether there has been a change in behavior connected to and a result of military service.  All VA clinicians, including those responsible for completing C&P evaluations, adhere to the DSM-IV-TR, which is widely recognized as the most current and authoritative source for mental health conditions. 

Personality Disorders, TBI, and PTSD

As I stated earlier, some personality disorders, TBI, and PTSD can share common symptoms.  Behavioral changes may be the result of physical or psychological injuries, or both, and it is our responsibility to properly identify which condition a Veteran has to ensure an accurate record for benefits administration and effective treatment planning.  For this reason, I will spend some time describing the similarities and differences of these conditions.

Personality Disorders

At the beginning of my testimony, I provided an overview of the DSM-IV-TR definition of a personality disorder.  For a VA clinician to make a diagnosis that a Veteran meets criteria for a personality disorder, the clinician must use the full definition and establish each component.  Generally speaking, this means that a personality disorder is not situational, temporary, or recently acquired, and that the person’s behavior has been adversely affected and cannot be explained by other disorders. 

Events characterized by repeated exposure to traumatic stress can result in symptoms and behaviors that appear, on the surface, to resemble some of these personality disorders.  In addition to a comprehensive psychological assessment of the individual, VA advises clinicians to consult with family members or others with knowledge of the individual prior to his or her military service when considering whether a Veteran should be diagnosed with a personality disorder. 

Traumatic Brain Injury

Traumatic brain injury is the result of a severe or moderate force to the head, where physical portions of the brain are damaged and functioning is impaired.  Depending upon where the injury is sustained and its severity, the effects of a TBI on a person’s behavior will vary.  A mild TBI, which is also commonly called a concussion, may simply require some time to recover.  Short term effects might include dizziness, nausea, memory lapses, or other conditions, and in many cases, there are no long term effects.  Moderate and severe TBI can have more lasting effects and may impact a person’s behavior.  For example, a person may be more irritable or aggressive as a result of a brain injury. 

Due to the severity and complexity of their injuries, Servicemembers and Veterans with moderate to severe TBI require an extraordinary level of coordination and integration of clinical and other support services.  Veterans who screen positive for TBI are referred for a comprehensive evaluation at one of 22 Polytrauma Network Sites or one of 83 Polytrauma Support Clinic Teams.  This comprehensive evaluation assesses the Veteran’s current physical, behavioral, emotional, and cognitive status.  The evaluation includes a 22-item Neurobehavioral Symptom Inventory, which allows for systematic assessment of a wide array of potential current problems.  This diagnostic tool allows VA to develop an appropriate diagnosis of current TBI-related symptoms and problems and to contribute to developing an interdisciplinary plan for care.

PTSD

According to the DSM-IV-TR clinical criteria, PTSD can follow exposure to a severely traumatic stressor that involves personal experience of an event involving actual or threatened death or serious injury.  It can also be triggered by witnessing an event that involves death, injury, or a threat to the physical integrity of another.  The person’s response to the event must involve intense fear, helplessness or horror.  The symptoms characteristic of PTSD include persistent re-experiencing of the traumatic event, persistent avoidance of stimuli associated with the trauma, numbing of general responsiveness, and persistent symptoms of increased arousal.  It is extremely rare that an individual would display all of these symptoms, and a diagnosis requires a combination of a sufficient number of symptoms, while recognizing that individual patterns will vary. 

PTSD can be experienced in many ways.  Symptoms must last for more than 1 month, and the disturbance must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.  Military combat certainly can create situations that fit the DSM-IV-TR description of a severe stressor event that can result in PTSD, and VA recognizes that being stationed in a combat area where there is constant danger and inability to predict or control the threat of danger also can meet the description of a severe stressor event.  The likelihood of developing PTSD is known to increase as the proximity to, intensity of, and number of exposures to such stressors increase.  In addition, PTSD can be a result of many other experiences besides combat exposure, such as sexual assault, life-threatening accidents, or natural disasters.

PTSD is associated with increased rates of other mental health conditions, including Major Depressive Disorder, Substance-Related Disorders, Generalized Anxiety Disorder, and others.  PTSD can directly or indirectly contribute to other medical conditions.  Duration and intensity of symptoms can vary across individuals and within individuals over time.  Symptoms may be brief or persistent; the course of PTSD may ebb and return over time, and PTSD can have a delayed onset.  Clinicians use these criteria and discussions with patients to identify cases of PTSD, sometimes in combination with additional psychological testing. 

Comparing and Contrasting Personality Disorders, TBI, and PTSD

The significance of an accurate diagnosis cannot be underestimated, as the diagnosis will inform our approach to treatment and care, and a person can meet criteria for more than one problem at a time.  For example, a Veteran could have experienced events that led to both PTSD and TBI.  A person previously able to function in spite of a long-standing mild-to moderate personality disorder can develop PTSD after trauma.  Such a person could also have sustained a TBI, which could contribute to aggression, poor impulse control, or suspiciousness.

Since the onset of personality disorders by definition occurs by late adolescence or early adulthood, there typically should be evidence of the behavior pattern prior to adulthood.  A history of solid adjustment and good psychosocial functioning prior to adulthood would not be expected in an individual with a personality disorder.  Following an extended event characterized by traumatic stressors, it is particularly important to determine if problematic behaviors are due to PTSD.  The DSM-IV-TR explicitly states, “When personality changes emerge and persist after an individual has been exposed to extreme stress, a diagnosis of Post-Traumatic Stress Disorder should be considered” (p. 632).  PTSD can induce irritability or outbursts of anger, feelings of detachment or estrangement from others, and restricted range of affect (unable to experience feelings such as love).  In addition, PTSD may increase the risk of self-destructive and impulsive behavior, social withdrawal, hyper-vigilance, and impaired relationships with others.

Many Veterans who screen positive for possible TBI and who are seen for a comprehensive evaluation have co-occurring conditions, including PTSD.  A Veteran may exhibit significant interpersonal difficulties that were not present prior to the TBI.  Inability to control anger, trouble with social tact, and other interpersonal difficulties are examples, and these occur more frequently in those with moderate to severe TBI.  Clinicians are able to distinguish a TBI-related interpersonal change by taking a thorough history and obtaining collateral interview data.  Pinpointing the onset of interpersonal and personality change to the time of sustaining a TBI provides evidence of acquired interpersonal dysfunction and rules out a longstanding personality disorder. 

The symptoms and problems related to TBI and PTSD can be particularly challenging to differentiate for several reasons, most notably because the same event may have resulted in TBI and led to the development of PTSD.  However, specific criteria in the DSM-IV-TR guide clinicians in distinguishing between the two conditions by looking for symptoms that are specific to one or the other disorder, such as persistent re-experiencing of a traumatic event and avoidance of stimuli associated with the trauma, which would only be related to PTSD. 

To address this, VA uses interdisciplinary polytrauma rehabilitation teams and neuropsychologists and rehabilitation psychologists to determine if a Veteran with TBI also has PTSD.  Standardized questionnaires such as the PTSD Checklist—Military Version (PCL-M) and structured interviews such as the Clinically Administered PTSD Scale (CAPS) also aid VA clinicians in determining whether a Veteran meets criteria for PTSD, with or without TBI.  VA clinicians consider factors such as symptom presentation and a psychosocial history from the Veteran that creates a timeline of symptom development.  Clinicians also conduct a medical record review, a psychological and neuropsychological assessment, and interviews.  Following a thorough evaluation, the polytrauma rehabilitation team, often in concert with mental health providers, collaborates to develop and execute a comprehensive treatment plan. 

According to the DSM-IV-TR classification system, these clinical scenarios involving personality change after a TBI are diagnostically distinct from Personality Disorders and are coded as such.  Most frequently, they fall under the category of Mental Disorders Due to a General Medical Condition (i.e., diagnostic code 310.1 - Personality Disorder Due to General Medical Condition) or Relational Problem Related to a General Medical Condition (code V61.9).  When these diagnostic codes are used, TBI also must be coded as the relevant medical condition. 

Treatment

VA offers mental health services to Veterans through medical facilities, community-based outpatient clinics (CBOC), and in VA’s Vet Centers, discussed later in my testimony.  VA has been making significant enhancements to its mental health services since 2005, through the VA Comprehensive Mental Health Strategic Plan and special purpose funds available through the Mental Health Enhancement Initiative from fiscal years 2005 to 2009.  In 2007, VA approved the Handbook on Uniform Mental Health Services in VA Medical Centers and Clinics to define what mental health services should be available to all enrolled Veterans who need them, no matter where they receive care, and to sustain the enhancements made in recent years. 

VA’s enhanced mental health activities include outreach to help those in need to access services, a comprehensive program of treatment and rehabilitation for those with mental health conditions, and programs established specifically to care for those at high risk of suicide.  To reduce the stigma of seeking care and to improve access, VA has integrated mental health into primary care settings to provide much of the care that is needed for those with the most common mental health conditions.  In parallel with the implementation of these programs, VA has been modifying its specialty mental health care services to emphasize psychosocial as well as pharmacological treatments and to focus on principles of rehabilitation and recovery.  VA is ensuring that treatment of mental health conditions includes attention to the benefits as well as the risks of the full range of effective interventions.  Making these treatments available responds to the principle that when there is evidence for the effectiveness of a number of different treatment strategies, the choice of treatment should be based on the Veteran’s values and preferences, as well as the clinical judgment of the provider.

Veterans with TBI seen in VA receive some of the best care available.  The VA Polytrauma System of Care, which is composed of 4 regional Polytrauma/TBI Rehabilitation Centers, 22 Polytrauma Network Sites, and 83 Polytrauma Support Clinic Teams, currently provides specialty rehabilitation care.  Veterans with TBI can also be seen at other VA facilities for treatment, including via telehealth.

Vet Center Services

In addition to the clinical care and diagnostic services discussed previously, VA’s Vet Centers offer an important complement that assists Veterans with readjustment issues.  Vet Centers provide quality outreach and readjustment counseling services to returning war Veterans of all eras and their family members in confidential, easy to access community-based sites.  The Vet Centers’ mission goes beyond medical care in providing a holistic mix of services designed to treat the Veteran as a whole person in his or her community setting.  Vet Centers provide an alternative to receiving treatment in traditional mental health care settings that helps many combat Veterans overcome the stigma and fear related to accessing professional assistance for military-related problems.  Vet Centers are staffed by interdisciplinary teams that include psychologists, nurses and social workers, many of whom are Veterans themselves. 

Vet Center care consists of a continuum of social and psychological services including community outreach to special populations, professional readjustment counseling to Veterans and families, and brokering of services with community agencies that provides a key access link between the Veteran and other needed services both in and outside of the VA.  Readjustment counseling offered at Vet Centers may address problems such as war-related psychological readjustment, PTSD counseling, family or relationship problems, lack of adequate employment or career goals, lack of educational achievement, social isolation, homelessness and lack of adequate resources, and other psychological problems such as depression or substance use disorders.  Vet Centers also provide military-related sexual trauma counseling, bereavement counseling, employment counseling and job referrals, preventive health care information, and referrals to other VA and non-VA medical and benefits facilities.

The Vet Center program promotes early intervention and ease of access to services by helping combat Veterans and families overcome all barriers of care.  To facilitate access to services for Veterans in hard to reach outlying areas, 50 mobile Vet Centers have been deployed across the country to provide assistance to Veterans, military service personnel, and family members.  There are currently 267 operational Vet Centers nationwide, with another 33 expected to open in 2011, for a total of 300.

In addition to the wide range of services and increased accessibility for Veterans to access these services, Vet Centers provide assistance and support for combat Veterans through referrals to other agencies.  Section 402 of the Caregivers and Veterans Omnibus Health Services Act of 2010 (Public Law 111-163) provides VA the authority to assist Veterans with problematic discharges through referral to services outside VA or referral for assistance with discharge upgrades when appropriate.  Until 1996, VA had specific statutory authority to refer ineligible Veterans to non-VA resources and to advise such individuals of the right to apply for review of the individual’s discharge or release.  With this renewal, the Vet Centers have the authority to help combat Veterans with problem discharges that may be related to traumatic war-time stress.  We appreciate the renewal of this provision, and VA has advised its readjustment counselors that they should provide such help to Veterans when needed.

Conclusion

Thank you again for this opportunity to speak about VA’s role in providing care for all our Veterans, including those with personality disorders, PTSD, or TBI.  VA recognizes the sacrifice all of our Veterans have made, and we seek to ensure we offer the right diagnosis in all clinical settings, whether for a compensation and pension examination or as part of a standard mental health assessment and treatment plan.  Once a Veteran is enrolled in the VA health care system, it does not matter when or where the condition developed; we will deliver appropriate, Veteran-centered care as set forth in the medical benefits package.  We are prepared to answer your questions at this time.