Mr. Chairman, Mr. Ranking Member, and Members of the Committee, thank you for the opportunity to testify on Personality Disorder discharges and the Department’s progress in implementing recommendations made by the Government Accountability Office (GAO) to improve oversight of the Personality Disorder discharge process.  In response to the October 2008, GAO audit, the Department implemented policy changes and established a reporting process to maintain oversight of the Military Departments’ progress in carrying out these requirements.   Today, I will report on those policy changes and how the Military Departments’ compliance with those policy changes has progressed.

Separation Policy

Through the Department’s separation policies, individuals are provided an orderly transition after service to the Nation and the Department can properly husband the forces under arms to meet national security needs.  As the requirements for service are often physically demanding, fitness for duty is a key element of these policies.  

Medical fitness determination is an area where great care must be taken to ensure accuracy and fairness.  In that regard, the nature of the signature injuries sustained in Operations Iraqi Freedom and Enduring Freedom (OIF/OEF) of Traumatic Brain Injuries (TBI) and Post Traumatic Stress Disorder (PTSD) has challenged the Department’s understanding and treatment of those injuries.  As the body of knowledge of PTSD and TBI has matured, personnel policies have also evolved to provide Service members a thorough evaluation prior to consideration of a discharge from military service.  The Department’s separation and transition policies offer multiple levels of oversight to tender the appropriate characterization of each service member’s separation.  This critical review by medical professionals is especially important in ensuring the proper diagnosis and treatment of wounded warriors with PTSD, TBI, or other physical and psychological conditions and initiate an appropriate, compensable, physical disability discharge when warranted.

Leadership awareness and understanding of PTSD and TBI, and accurate diagnosis of mental health conditions, as they relate to Personality Disorder separations, are Department priorities.  On August 28, 2008, the Department issued new policy on personality disorders separations, which added greater rigor and oversight.  The revised policy only permits a personality disorder separation if diagnosed by a psychiatrist or PhD-level psychologist.  Implementation of this change has increased the Department’s confidence in our ability to accurately diagnose personality disorders, which by themselves are not compensable.  This change serves to help ensure accurate diagnoses of mental health conditions and improve the identification of any co-morbidity of PTSD or TBI, which are compensable disabilities.  

In addition, members who have served in an imminent danger pay area must have their diagnosis corroborated by a peer psychiatrist, PhD-level psychologist, or higher level mental health professional and endorsed by The Surgeon General of the Military Service concerned.   This change specifically addresses concerns early in the War that members suffering PTSD or TBI might be separated without proper treatment under the non-compensable, exclusive diagnosis of a personality disorder.  To ensure continued monitoring of this critical process, the Department implemented oversight mechanisms to include an annual personality disorder report and periodic reviews of personality disorder separation data by the Department’s Medical and Personnel (MedPers) Council.

By adding new requirements for personality disorder separations to the requirements that were already contained in Department of Defense Instruction 1332.14, Enlisted Administrative Separations, there are now eight requirements that must be met prior to separating a Service member for personality disorder.

Personality Disorder Separations Oversight and Compliance

On January 14, 2009, the Under Secretary of Defense for Personnel and Readiness directed the Secretaries of the Military Departments to report their compliance with the personality disorder separation requirements in DoDI 1332.14, for two fiscal years beginning with fiscal year 2008.  The Services were directed to review, at a minimum, a random sampling of at least ten percent of all personality disorder separations for compliance with the eight DoD personality disorder separation requirements and report the total number of personality disorder separations for Service members who had served in an imminent danger pay area since September 11, 2001.

Of note is that fact that the early reports were impacted by the delay between when the Department issued new personality disorder separation policy and the incorporation of that new guidance into Military Service regulations.  The Military Departments made considerable progress between FY2008 and FY2009 to fully comply with the personality disorder separation requirements in DoDI 1332.14.  To ensure this progress is not lost, the Under Secretary of Defense for Personnel and Readiness has extended the requirement for the Military Departments to report their compliance until FY2012. 

The number of personality disorder separations across the Department by more than a third since 2008 when the more rigorous processes were implemented.  Each of the Military Services has similarly experienced decreases in personality disorder separations.  While other factors may have contributed to this decrease, the increased oversight and awareness clearly supported this trend.

PTSD Disability Evaluation System (DES) Case Disposition Trends

The Military Departments combined reported 979 more PTSD DES case dispositions (a 47 percent increase) in FY 2009 versus FY2008.   There were 3,063 PTSD DES case dispositions in FY2009 versus 2,084 PTSD DES case dispositions in FY2008.  The Army accounted for 81 percent of all PTSD DES case dispositions.

The Military Departments reported they complied with requirements in the Veterans Affairs Schedule for Rating Disabilities (VASRD) when rating mental illness due to traumatic events.  Conditions classified as mental disorders by the VASRD existed in 5,141 (27 percent) of 19,215 FY 2009 DES case dispositions. 

PTSD DES case dispositions comprised 16 percent of the total 19,215 DES case dispositions in FY2009.  In FY2008, PTSD DES case dispositions comprised 11 percent of the total 19,583 DES case dispositions. 

In FY2009, 119 (3.9 percent) of the PTSD DES case dispositions resulted in the Service member being placed on the Permanent Disability Retirement List (PDRL).  2,936 (95.8 percent) of the FY2009 PTSD DES case dispositions resulted in the Service member being placed on the Temporary Disability Retirement List (TDRL).  This represents 42 percent of the total of 6,965 Service members placed on the TDRL in FY2009.  Six (.2 percent) case dispositions resulted in Separation with Severance Pay and three (.1 percent) case dispositions resulted in Separation without benefits.

In FY2008, 233 (11.2 percent) of the PTSD case dispositions resulted in the Service member being placed on the PDRL.  1,352 (64.9 percent) of the FY2008 PTSD DES case dispositions resulted in the Service member being placed on the TDRL.  489 (23.5 percent) case dispositions resulted in Separation with Severence Pay and two (.1 percent) case dispositions resulted in Separation without Benefits.   

 Mental Health Assessments

A Mental health assessment is a bio-psycho-social evaluation examining every aspect of the patient’s life.  A psychiatric diagnosis is made if the patient demonstrates symptoms that meet clinical criteria as defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR).

Symptoms that may be present in PTSD represent a challenge in the differential diagnosis and treatment of the disorder.  Moreover, chronic PTSD is frequently complicated by co-morbid (dual diagnosis) psychiatric disorders including depression and other mood disorders, substance abuse, dissociative disorders, other anxiety disorders, and psychotic symptoms or disorders.  These co-morbidities offer a further challenge in the diagnosis and management of PTSD.  Concurrent (pre-existing) character pathology (personality disorders) is important to diagnose since it may affect the course, severity, and prognosis of PTSD.  When personality changes (newly) emerge and persist after an individual has been exposed to extreme stress, a diagnosis of Posttraumatic Stress Disorder should be considered. 

Policy issuances currently require an examination and multiple reviews by medical professionals prior to administrative separation for a Personality Disorder.  Service members diagnosed with or reasonably asserting post-traumatic stress disorder (PTSD) or traumatic brain injury (TBI) fall under guidance provisions for psychiatric and/or medical disorders, respectively (DoDI 1332.38).  If a Service member is diagnosed with PTSD or TBI at the time of their separation examination, it is policy that a Medical Evaluation Board should be initiated.  If a Personality Disorder is diagnosed after all other medical and mental health disorders have been ruled out, and the patient is considered to be a hazard to themselves or others and unable to function in the military setting, one of the criteria for an administrative separation would be met.  Ultimately, it is the Service member’s commander, with the advice of medical professionals, who makes the final decision as whether the Service member should be processed for Administrative Separation.

PTSD and TBI Related Discharge Review Board and BCMR Request

The Department realizes that the new policies and body of knowledge of PTSD and TBI evolved too late to benefit many Service members.  In that regard, the Department continues to encourage veterans who are later diagnosed with PTSD or other mitigating disorders to request review of their separations through their respective Military Department Discharge Review Board (DRB) and Board for Correction of Military Records (BCMR).  As expected, the number of DRB and BCMR appeals related PTSD or TBI has increased.  This process has worked well, and we continue to work with the Military Departments and the Department of Veterans Affairs to identify those with PTSD and TBI who may have transitioned prior to our current understanding of these conditions.  

Conclusion

The Department is confident that given the positive trends Service members who experience or assert PTSD or TBI are being diagnosed and that those diagnoses are being considered prior to separation.  Rigorous execution and oversight of the Department’s separation policies is crucial to ensuring the proper transition of our veterans and the readiness of the military forces.  The Department is committed to continue efforts to improve the accuracy and efficacy of these policies.  I will be happy to answer any questions you might have at this time.