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Witness Testimony of Ms. Tracie Shea, Ph.D., Veterans Affairs Medical Center, Providence, RI, Psychologist, Post Traumatic Stress Disorder Clinic, Veterans Health Administration, U.S. Department of Veterans Affairs

Good morning Mr. Chairman, I am honored at the opportunity to provide testimony to the Committee on issues related to Post Traumatic Stress Disorder (PTSD) and Personality Disorders.  

Mr. Chairman, I come before this Committee, not as a representative or spokesperson for the Department of Veterans Affairs (VA) but as a mental health researcher who has conducted extensive research on Personality Disorders.  My thoughts and opinions, which I will share with you today, are my own and should not be taken as VA’s views or policy.   

As a psychologist on the clinical staff of the Post Traumatic Stress Disorder Clinic at the Veterans Affairs Medical Center in Providence, Rhode Island for the past 17 years, I have assessed and treated hundreds of veterans.  I also conduct research on personality disorders and on PTSD as part of my academic role as professor of Psychiatry and Human Behavior at the Warren Alpert Medical School, Brown University.  Of note to the topic of today’s hearing, I was a member of the subcommittee responsible for the revision of the Personality Disorders section for the 4th edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM-IV).

The Committee has requested my testimony regarding PTSD and Personality Disorders in the context of service members and veterans.  My comments will focus on requirements set forth in VA and used at all VAMC facilities for an adequate assessment and diagnosis of personality disorder. With regard to the use of appropriate procedures, I will speak to my personal experience conducting assessments as a psychologist at the VA in Providence.

Definition of Personality Disorder

A Personality Disorder is defined by the DSM-IV 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, others’ behavior), affect (range, intensity, lability, appropriateness of emotional response), interpersonal functioning, or impulse control.  For a diagnosis to be made, several requirements must be met:

  1. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations. This means that problematic behaviors should be evident in multiple situations.
  2. The pattern of behavior is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood.
  3. There is evidence of significant distress or impairment in functioning associated with the enduring pattern of behavior.
  4. The pattern of behavior is not better accounted for as a manifestation or consequence of another mental disorder
  5. The pattern is not due to the direct physiological effects of a substance (e.g. a drug of abuse, a medication) or a general medical condition (e.g. head trauma).  

Distinguishing between personality disorder and PTSD in service members following stressful event

There are several implications of these requirements for determining a diagnosis of personality disorder following deployment. 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.

It is critical to rule out other mental disorders that may be responsible for the maladaptive behaviors in making a clinical diagnosis of 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 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).  Exposures to severe or prolonged trauma can result in behaviors that look like features of personality disorders.  PTSD criteria include irritability or outbursts of anger, feeling of detachment or estrangement from others, and restricted range of affect (unable to experience feelings such as love).  In addition, the DSM-IV describes several associated features of PTSD that may be present, including self-destructive and impulsive behavior, social withdrawal, feeling constantly threatened, and impaired relationships with others.

The recognition of possible personality changes following severe or prolonged stress is apparent in the International Classification of Diseases (ICD-10), which includes a diagnostic category of “Enduring personality change after catastrophic experience.”  This diagnosis is used in cases of persistent change in personality following extreme stress, including prolonged exposure to life-threatening situations, characterized by two or more of the following features newly present after the trauma:

  1. A hostile or distrustful attitude toward the world
  2. Social withdrawal
  3. A constant feeling of emptiness or hopelessness
  4. An enduring feeling of “being on edge” or being threatened without any external cause, as evidenced by an increased vigilance and irritability.
  5. A permanent feeling of being changed or being different from others (estrangement).

These features may be present in individuals exposed to extreme trauma.  Again, such features overlap with many of the criteria for Personality Disorders.  The critical distinction is whether they represent change in personality following exposure to severe traumatic stress.  Although I have focused here on the distinction between Personality Disorders and PTSD, it is important to recognize that these conditions can co-exist.  A person able to function in spite of a mild-to moderate personality disorder can develop PTSD after trauma.  An additional consideration I have not discussed is Traumatic Brain Injury (TBI), which is sometimes associated with behavioral changes that may look like features of personality disorders, for example, aggression, poor impulse control, or suspiciousness.  For individuals with exposure to head injury (including closed head injury), neuropsychological testing may be indicated to rule out brain injury as a cause of such behaviors. 

Assessments at the VA

VA psychologists conduct assessments for service connected disability applications.  These “compensation and pension” exams follow established guidelines, and cover psychosocial functioning and symptoms of mental disorder present prior to, during, and following military service.  Military experience, including exposure to traumatic events, is assessed, and the timing of the onset of symptoms in relation to military service is determined.  Most of the exams that I personally have conducted have been to establish service connection for PTSD. These require detailed questioning of symptoms of PTSD and other mental disorders, including timing of onset.  If there is a pattern of maladaptive behavior existing prior to military service, it is important to determine whether there has been a change in connection with military service.  Diagnoses reflect a personality disorder if present but, in my personal experience, this has been rare.  As noted above, a personality disorder can also co-exist with PTSD.  In my experience, these exams take about 60 minutes on average, but can take longer in more complicated cases.

Also of note is that VA policy now requires screening of all OEF / OIF veterans for TBI.  Positive responses to the screen are followed up with more detailed assessments by neuropsychologists.

Summary

To summarize, events characterized by repeated exposure to traumatic stress can result in symptoms and behaviors that appear, on the surface, to resemble personality disorder.  A clinical diagnosis of personality disorder should be made only when it can clearly be established that the behavioral patterns and associated psychosocial impairment or distress were present by late adolescence or early adulthood, existed prior to stressful events, and cannot be better explained by the experience during an event of traumatic stress or brain injury.  In addition to a comprehensive psychological assessment of the individual, consultation with family members or others with knowledge of the individual prior to service is advisable when considering a personality disorder diagnosis.  The significance of an accurate diagnosis cannot be underestimated.

Thank you for this opportunity to testify.  I will be pleased to answer any questions you may have.