Sally Satel, MD
Thank you for the invitation to appear before the Committee. I am a psychiatrist who formerly worked with disabled Vietnam veterans at the West Haven VA Medical Center in Connecticut from 1988-1993. Currently, I am a resident scholar at the American Enterprise Institute. I have been interested in applying the lessons we learned in treating Vietnam veterans to the new generation of service personnel returning from Iraq and Afghanistan.
A particularly unsettling story appeared on ABC News on July 12 called “Used Up and Spit Out – The Personality Disorder Discharge.” The segment portrayed two young men who had served in Iraq with military distinction but then suffered what appeared to be, in one case, posttraumatic stress disorder, and in the other, a traumatic brain injury inflicted by a close-range rocket blast as well as post traumatic stress disorder. Ultimately, both soldiers were given a “separation because of personality disorder” discharge (Chapter 5-13) from the Army.
In the wake of these and other reports of Chapter 5-13 discharges, lawmakers, veterans’ advocates, and military families have wondered if the military is using personality disorder discharges to avoid covering the healthcare needs of service members. Without question, to use the diagnosis of personality disorder to deny proper care and benefits to men and women who have served honorably and were injured in their service is a grave clinical error, not to mention a deep injustice.
Relevance to the Department of Veterans Affairs
Understandably all eyes are on the Department of Defense because that is the jurisdiction in which Chapter 5-13 discharges originate. Yet the matter of personality disorder separation has implications for the Department of Veterans Affairs as well. Just as it is a serious mistake to diagnose a soldier who became mentally impaired as a result of military service as suffering, instead, from a personality disorder (and discharge him on that basis), overlooking opportunities to identify significant behavioral problems among soldiers – at enlistment or early in training or after deployment -- imposes an equally significant challenge for the VA. Why? Because it is these individuals who are particularly vulnerable to developing psychiatric impairment under the strain of combat stress. Upon discharge, they may turn to VA mental health facilities for long-term treatment that may have been prevented with proper screening or more effectively resolved with immediate care within the service.
A Brief Word on Personality Disorders and the Military
What is a personality disorder (PD)? -Personality disorders are defined by the Diagnostic and Statistical Manual as enduring maladaptive patterns of behavior and cognition that leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning. The early signs are usually evident in adolescence or early adulthood.
Does military service cause PD? No, but it might intensify underlying maladaptive traits and PDs and these can make the soldier unfit for duty. This scenario, it seems to me, would form an appropriate foundation for the use of a Chapter 5-13
Can stress injury look like PD? Yes. In addition to the anxiety features that characterize a stress reaction, behavioral problems such as misconduct and disobedience can accompany it. At any given point in time such a serviceman or woman might appear to have a PD but if review of his or her enlistment record (e.g., evidence of criminal activity) and, especially, review of training file reveal solid performance, most likely the soldier is wrestling with a stress reaction, perhaps full-blown PTSD.
Can a soldier have both PTSD and PD? Yes. However, presumably an individual with both conditions was once judged mentally fit to assume active duty. Such judgments were made first at the time of enlistment, then throughout training, and eventually before deployment. If a soldier progressed that far and had been considered mentally fit along the way, it is only logical to conclude that whatever deterioration he suffered was due to his military service. This calls into question the judgment that he is now mentally unfit because of a pre-existing personality disorder “that is so severe that the soldier’s ability to function effectively in the military environment is significantly impaired.”
Thus, if many soldiers are being discharged late in their tours of duty, diagnosed with PD through Chapter 5-13, two questions must be considered: First, are the PD diagnoses accurate in the first place? The media and lawmakers have focused on this important question. Secondly, if they are indeed accurate, are enlistment and ongoing screening procedures adequate to identify these problems earlier?
Adequacy of screening? - A soldier unfit for duty because of a PD can often be identified in the training or early deployment phases of duty. Boot camp and related activities are emotionally intense and demanding crucible. As such they act as a natural “stress test,” unmasking a person’s innate problems with coping and impulse control – difficulties that the he or she could otherwise compensate for in civilian life. Individuals’ tendencies to become hostile, aggressive, resistant to authority under pressure, suspicious of others’ motives, and disruptive to unit cohesion will likely assert themselves in the context of these environments, to the notice of those around including command and especially peers.
Thus, the time to intercept these individuals in order to treat or discharge them as unfit for duty, as the military deems appropriate, is at intake, during training, before they are deployed, or early in the in the deployment period. Yet it is my understanding that the Pentagon has lowered standards to meet quotas and that an increased number of so-called moral waivers have been granted so that recruits with felony records and other significant evidence of behavioral problems can enlist. Those waivers may be officially overlooking exactly the behaviors that are symptoms of personality disorders.
There is a modest literature on screening. I will mention just two interesting reports. A 2003 report called Reducing the Threat of Destructive Behavior by Military Personnel, which was commissioned by the Deputy Assistant Secretary of Defense, documents a meaningful correlation between pre-service history (e.g., arrests, convictions, disciplinary problems, and especially, failure to finish high school) and in-service criminal behavior, destructive acts, and attrition.
The report identified two main areas of concern regarding initial selection and continuing evaluation procedures of military personnel
“(1) lack of effective prescreening procedures to identify military entrants with criminal records and other behavioral adjustment problems, and
(2) inadequate management practices that have allowed the retention on active duty of military personnel who have shown a pattern of substandard behavior.”
A four-year follow-up study by Eli Flyer, for the Naval Post Graduate School, and John Noble of the Navy Recruiting Command found that Navy recruits who did not complete high school had a significantly higher attrition rate during their initial tour compared to graduates. 
The controversy surrounding Chapter 5-13 discharges would suggest need for a re-evaluation of screening protocols currently used by DoD.
Misapplication of the Chapter 5-13 discharge sets up a kind of Catch-22 for the DoD. First the military deems a recruit sufficiently mentally fit to be sent into training and then into a war zone, but then when psychiatric problems arise it turns around and claims that those problems were there all along – problems that should have shown up earlier in their tour of duty.
Patients with PTSD and Personality Disorder Who Seek Care at VA Facilities
Co-occurrence – PD and PTSD, especially chronic PTSD, are common in treatment seeking populations.  It is generally difficult to parse the relationship because there are few longitudinal, prospective studies. The vast majority of studies are cross-sectional, or snap-shot, analyses making it difficult to infer temporal order.
Possible explanations of co-occurrence:
- PD can predispose to PTSD This is a plausible inference to draw from the considerable volume of data showing that traits and predispositions associated with PDs (borderline and antisocial types, in particular) are the same ones that enhance risk for developing PTSD after traumatic experience. These dispositions and traits include childhood conduct disorder, neuroticism (a tendency to react to adversity with depression or anxiety), impulse control problems, early family instability, and exposure to traumatic events (which are more common in children and teens with behavioral difficulties and adults with antisocial personality). 
- PTSD can “look like” PD: The symptoms of PTSD such as anxiety, nightmares and sleep deprivation can lead to irritability, intense anger, aggression, substance abuse, and emotional instability—symptoms commonly associated with borderline personality disorder and/or asp. One could call this pseudo-personality disorder. It should remit if the underlying stress reaction is treated and resolves. If PTSD becomes chronic, however, these dysfunctional attributes may persist.
- Living with chronic PTSD can induce personality changes - An analogy can be made to chronic pain patients insofar as it is unknown whether many of the psychopathological features observed in chronic pain patients (e.g., anger, manipulativeness, suspiciousness, interpersonal hostility to comply, emotional instability) are the consequence of chronic pain and its related difficulties, or whether pre-existing psychopathology predisposed some individuals to develop chronic pain. 
Thus, there are three potential pathways by which veterans can manifest symptoms of PTSD and features of personality disorders at the same time: maladaptive personality features (1) were present before military service, (2) are a byproduct of the trauma and should resolve when the stress reaction remits, (3) are a response to living with PTSD.  In the absence of prospective studies or baseline information on individuals it is difficult to distinguish between these scenarios.
- PTSD aggravates features of PD - In civilian settings, we frequently observe that when patients with longstanding personality disorders encounter stressful experiences such as physical illness, pain, bereavement, divorce, or on the job tension, they often fail to adapt and behave more erratically, impulsively, etc.
- PD alone: see below 
VA clinicians are unlikely to misdiagnose PTSD and/or Traumatic Brain Injury (TBI) as personality disorders. The core symptoms of PTSD and neuropsychiatric impairment are distinguishable from PD. Sometimes these diagnoses are made simultaneously in the same individual, and when they are it can be hard to know which is dominant, especially prior to a course of treatment. Even so, PTSD and TBI, by definition, are caused by service and are not pre-existing.
Treatment: Clinicians will be familiar with the scenarios outlined above and treat patients accordingly with combinations of cognitive-behavioral therapy, desensitization/exposure therapy, psychopharmacology, family counseling, and vocational rehabilitation. It is essential to treat veterans with PTSD and severe readjustment problems as early as possible when their conditions will be most responsive to therapeutic intervention. This can often make the difference between a time-limited impairment and chronic mental illness. Patients with both chronic PTSD and features of a personality disorder can be less responsive to treatment. A point worth raising here is the importance of qualified staffing at VA mental health facilities. Anecdotal reports suggest that many facilities do not have adequate numbers of clinicians who can perform cognitive-behavioral therapies. This is a deficit that must be addressed. 
Disability Determination - The eligibility standard for disability payments differs from that of treatment. In order to qualify for disability on the basis of specific injuries or illnesses, an explicit causal connection between those afflictions and military service must be demonstrated.
Last May, the Institute of Medicine released a report entitled PTSD Compensation and Military Service. It emphasized the need for a consistent evaluation process across centers and the dire importance of competent evaluation (quality evaluations often take several hours, involve extensive review of medical and military records, and, critically, interviews of collateral sources of information). I agree with these points.
Improved behavioral and psychological screening for enlistment is needed to help predict behavioral adjustment to the military.
VA clinicians are unlikely to misdiagnose PTSD and/or TBI as personality disorder. The core symptoms of PTSD and neuropsychiatric impairment are distinguishable from PD.
VA must be equipped with mental health staff trained in state of the art PTSD treatment. Treatment should be delivered at early as possible to avert development of chronic syndromes.
In determining disability there should be a consistent, high quality evaluation process across centers.
 AR 635-200 Active Duty Enlisted Administrative Separations http://gidischarges.org/odpmc/army/index.html, accessed July 23, 07
 Fiedler E, Oldmanns T, Turkheimer E. “Traits associated with personality disorders and adjustment to military life: predictive validity and self and peer reports.” Military Medicine. 169 (3) (2004), pp. 207-211.
 Badkhen, Anna. “Army Relaxes Its Standards to Fill Ranks: Critics say push to meet quotas may let unstable recruits join up.” San Francisco Chronicle. June 11, 2006.
 Flyer, Eli and Noble, John. Development and Validation of a Biographical Questionnaire to Screen GED/Non-High School Graduate Applicants for Navy Service: Four –Year Follow-Up Findings. On file with author. Note: 50% of drop outs were within the first year of active duty. The researchers asked 7,000 Navy recruits to complete an eight-item questionnaire about pre-enlistment behaviors (e.g., difficulty taking orders, previous suicide attempts, having run away from home, having visited a mental health professional). Those who did not complete high school (about 1,000 of the recruits). Non-graduates with the most pre-enlistment problems (the bottom quartile) and had an attrition rate of 72 percent compared to graduates who had an attrition rate of 52 percent; while grads in the top three quartiles had a mean attrition rate of 33 percent. Also note, there is a well-documented relationship between cognitive factors such as educational attainment and IQ and development of stress reactions and PTSD which can lead to attrition. Failure to finish high school may partly reflect this phenomenon. For review see Gilbertson MW, Paulus LA, Williston SK, Gurvits TV, Lasko NB, Pitman RK, Orr SP. “Neurocognitive Function in Monozygotic Twins Discordant for Combat Exposure: Relationship to Posttraumatic Stress Disorder”. Journal of Abnormal Psychology. 115 (3) (2006), pp. 484-495; For relationship between educational level and active duty stress casualties, see Helmus TC, Glenn RW. “Steeling The Mind: Combat Stress Reactions and their Importance for Urban Warfare.” RAND. Document MG-191-A, 2005.
 Richman H, Frueh BC. “Personality disorder symptomatology among Vietnam veterans with combat-related PTSD.” Anxiety. 2(6) (1996), pp. 286-295; Southwick SM, Yehuda R, Giller EL Jr. “Personality disorders in treatment-seeking combat veterans with posttraumatic stress disorder.” American Journal of Psychiatry. 150 (1993), pp. 1020-1023; Bollinger AR, Riggs DS, Blake DD, Ruzek JI. “Prevalence of personality disorders among combat veterans with posttraumatic stress disorder.” Journal of Traumatic Stress. 13(2) (2000), pp. 255-271; T. Keane, D. Kaloupek. “Comorbid Psychiatric Disorders in Posttraumatic Stress Disorder: Implications for Research.” Annals of the New York Academy of Sciences. 821(1) (1997), pp. 24-34.
 Brewin CR, Andrews B, Valentine JD. “Meta-analysis of risk factors for posttraumatic stress disorder in trauma-exposed adults.” Journal of Consulting and Clinical Psychology. 68(5) (October 2000), pp. 748-66; Ozer E, Best SR, Lipsey TL, Weiss DS. “Predictors of posttraumatic stress disorder and symptoms in adults: a meta-analysis.” Psychological Bulletin. 129(1) (2003), pp. 52-73; Breslau N, Davis GC, Andreski, P. “Risk factors for posttraumatic stress disorder-related traumatic events.” American Journal of Psychiatry. 152(4) (1995), pp. 529-35; King DW, King LA, Foy DW, Gudanowski DM. “Prewar factors in combat-related posttraumatic stress disorder: structural equation modeling with a national sample of female and male Vietnam veterans.” Journal of Consulting and Clinical Psychology. 64(3) (June 1996), pp. 520-31; Jang KL, Stein MB, Taylor S, Asmundson GJG, Livesley WJ. “Exposure to traumatic events and experiences: aetiological relationships with personality function.” Psychiatry Research. 120 (2003), pp. 61-69; Schnurr PP, Vielhauer MJ. “Personality as a risk factor for posttraumatic stress disorder.” In Risk Factors for Posttraumatic Stress Disorder. Ed: R. Yehuda. Washington, DC: American Psychiatric Press, 2000
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 Axelrod S, Morgan CA, Southwick SM. “Symptoms of Posttraumatic Stress Disorder and Borderline Personality Disorder in Veterans of Operation Desert Storm” American Journal of Psychiatry. 162 (2005), pp. 270-275.
 No PTSD or other Axis I Mental Disorder: There may be situations in which a veteran has no diagnosable features of PTSD but seeks treatment because he is struggling with problems at home or on the job because of a severe personality disorder.
- Exacerbation of maladaptive personality traits due to service: It is possible that war stress alone intensified a pre-existing personality disorder. Although veterans with severe PD may not be particularly sympathetic, one could argue that the military should have been better attuned to the fact such men and women can be too psychologically fragile to handle the great pressure of the combat environment and that more intensive screening at enlistment and during the first term was warranted.
- No change in intensity of PD traits: It is always possible that some veterans seeking care at the VA will be as maladapted to civilian life after their service duty as they were when they first entered the service. In other words, they were made no worse as a result of their military service. Granted, such a scenario may not occur too often, yet for the sake of completeness it is worth considering. The first question it raises is why such men and women were permitted to enlist in the military or to deploy in the first place – an issue discussed earlier. Nonetheless, since they did indeed serve in Iraq or Afghanistan, the VA has responsibility for their mental health needs. (But not for granting disability benefits because the problem is not service-connected).
 “Practice Guidelines for the Treatment of Patients with Acute Stress Disorder and Posttraumatic Stress Disorder.” American Psychiatric Association. Accessed on July 20, 2007. www.psych.org/psych_pract/treatg/pg/PTSD-PG-PartsA-B-C-New.pdf
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 A specific form of exposure-desensitization therapy under development is called “Virtual Iraq.” Studies are in progress. The therapy was developed with funding from the Naval Research Office and is considered promising. The veteran wears a virtual-reality helmet and goggles and headphones. A therapist manipulates virtual situations via a keyboard to best suit the individual patient during 45-50 minute sessions. By gradually re-introducing the patients to the experiences that triggered the trauma, the memory becomes tolerable and feelings of panic no longer accompany once-feared situations (such a driving on city streets, being in crowds). http://www.defense-update.com/products/v/VR-PTSD.htm, accessed July 21, 2007