Are dodgy diagnoses being used to
save the military money on mental health care? That’s the charge
from some legislators and activists, who say U.S. service members
with post-traumatic stress disorder (PTSD) are being
diagnosed with and discharged for “adjustment disorders”
instead, and that this is especially true for those who report
being sexually assaulted.
What’s to gain from the latter diagnosis? The question is
probably better phrased, “What’s to lose?” For the U.S. military
and government, adjustment disorder diagnoses provide a way to lose
benefit obligations.
Because adjustment (and personality and mood) disorders are
considered preexisting conditions, the Department of Veteran’s
Affairs (VA) isn’t required to cover veterans’ treatment for these
conditions as it would be for veterans’ discharged with PTSD. Under
a law enacted in 2008, veterans with PTSD get an honorable
discharge and medical care.
Rep. Mike Coffman (R-Colo.) introduced a provision to the
annual defense authorization bill—passed
by the House May 22—that would have given service members
discharged with mental illness an opportunity to appeal the
military’s diagnosis.
“As a Marine Corps combat veteran, I cannot accept the fact that
combat veterans have been discharged who were clearly suffering
from PTSD,” Coffman said in a statement. “They were not only denied
treatment before being discharged, but because of the type of
discharge they received, did not have access to mental health care
after they left the military.”
But Coffman’s provision was one of 136 defense bill amendments
that were rejected by the Rules Committee, including several sexual
assault and mental health-related provisions from Rep.
Jackie Speier (D-Calif.). One would have required the
inspector general of the Department of Defense (DOD) to review all
personality and adjustment disorder designations given to service
members who report sexual assaults.
“The personality disorder designation often is used as a tool to
retaliate against survivors for coming forward,”
Speier’s amendment said. She also says that the adjustment
disorder diagnosis is used in the same way.
It’s impossible for you or me to determine whether the bulk of
adjustment disorder diagnoses are justified. But there’s no doubt
they’re increasing. From
The Washington Times:
According to a Vietnam Veterans of America study, the military
discharged 31,000 service members because of a personality disorder
from 2001 to 2010.But after lawmakers and the press reported on the high rate of
such disorder diagnoses tied to sexual assault cases, the number
dropped—and the number of adjustment diagnoses began to rise.In the Air Force, for example, personality disorder discharges
went from more than 1,200 in fiscal 2007 down to just over 100 two
years later in fiscal 2009, according to a Yale Law report.
Adjustment disorder discharges in the Air Force spiked over that
same period, increasing sevenfold.
General mental health care trends could be at play, but the
extent of this shift doesn’t seem to belie totally good-faith
diagnostic efforts. More believable to me than a coordinated plot
to discredit rape victims, however, is that this could be a
ploy to save the VA and other federal agencies money. (I don’t
doubt that discrediting or shushing up assault complaintants is
sometimes a welcome side effect.)
Regardless of why adjustment disorder diagnoses are rising, the
diagnosis is a strange one for soldiers who report sexual assault.
Being sexually assaulted can obviously produce lingering
psychological trauma, and surely this is severe enough in some
cases to warrant military discharge. But severe, negative,
post-assault responses would seem to be a very classic
form of PTSD.
“It’s likely that if the person doesn’t have symptoms when they
enter the military and then is exposed to traumatic stress—the two
classic ones in the military are combat and sex assault—it’s most
likely PTSD,” psychologist David L. Kupfer told
The Washington Times.
“When you look at the numbers, it does seem like there is some
financial incentive affecting the diagnosis of people who are
showing symptoms after exposure to trauma.”
Adjustment disorder is also
a type of stress-related mental illness, with symptoms
including anxiety, depression, crying spells, anger, feeling
overwhelmed, and trouble sleeping, according to the Mayo Clinic.
But it’s triggered not by discrete, traumatic events but relatively
commonplace life changes, such as moving, starting at a new school
or job, ending a relationship, etc.
It’s a diagnosis for people who have a high degree of trouble
coping with new circumstances—the Diagnostic and Statistical
Manual of Mental Disorders (“psychiatry’s bible”) describes it
as “marked distress that is in excess of what would be expected
from exposure to the stressor.” Are military psychiatrists
suggesting that sexual assault is a standard part of military life,
one which some people just have a pathologically hard time
adjusting to? It sure seems that way.
To be clear, the adjustment disorder diagnoses aren’t only going
to those who report being sexual assault victims. For example:
During a deployment to Iraq in 2008, former Army Pfc. Michael Nahas
survived two roadside bomb explosions and one rocket-propelled
grenade attack. He began feeling “anxious and guilty about people
he believed had died needlessly,”
according to Veterans Today, and eventually attempted
suicide. He was diagnosed with PTSD at the hospital, went back to
his unit, and was given an administrative discharge for adjustment
disorder.
And in November 2013, the Veterans Legal Services Clinic at
Yale Law School filed a federal
lawsuit on behalf of William Cowles. The suit claims
Cowles, a 20-year veteran of the U.S. Army National Guard, was
erroneously diagnosed with an adjustment disorder instead of PTSD,
barring him from collecting military retirement benefits.
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