As disability awards for PTSD have grown nearly five-fold over the last 13 years, so have concerns that many veterans might be exaggerating or lying to win benefits.
Robert Moering, a former Marine and psychologist conducting disability examinations at the Veterans Affairs hospital in Tampa, Fla., estimates that roughly half of the veterans he evaluates for the disorder exaggerate or fabricate symptoms.
Depending on severity, veterans with PTSD can receive up to $3,000 a month tax-free, making the disorder the biggest contributor to the growth of a disability system in which payments have more than doubled to $49 billion since 2002.
“It’s an open secret that a large chunk of patients are flat-out malingering,” said Christopher Frueh, a University of Hawaii psychologist who spent 15 years treating PTSD in the VA system.
Diagnosing PTSD can be difficult in the best of circumstances. Experts have long debated how to define the condition. One person can suffer crippling anxiety from an experience that wouldn’t faze someone else.
Assessing PTSD becomes even more difficult in a VA system that gives veterans a financial incentive to appear as sick as possible, former and current VA mental health clinicians said. The number of veterans on the disability rolls for the disorder has climbed from 133,745 to more than 656,000 over the last 13 years. Vietnam and the recent wars have fueled the growth in roughly equal measure.
Frueh and other critics of the disability system have sparred in medical journals with senior VA mental health officials, who argue that the extent of malingering is impossible to know without more research.
The veteran Moering evaluated was already receiving $1,600 a month in disability pay for PTSD as well as various joint problems. But he wanted to increase it. Three tests designed to detect dishonest patients by looking for highly unlikely response patterns strongly suggested that the veteran was exaggerating, according to disability records that Moering allowed The Times to review. The case is one of eight that Moering opened to the newspaper.
In each, he challenged a PTSD diagnosis. The records were redacted to hide names and other identifying information. Moering said he could not determine whether the veteran was feigning entirely or simply stretching the truth.
“This is the dilemma we face,” Moering said. “How can a disability rater honestly rate this veteran?” Government policy in cases without a clear answer is to give the veteran the benefit of the doubt. The VA left his disability rating intact.
In some ways, the explosion in PTSD cases is a sign of progress. Though descriptions of the disorder show up in literature as far back as Shakespeare, it did not become a formal diagnosis until 1980, and even then remained controversial. After decades of downplaying the psychological toll of war, the government has finally acknowledged the damage and boosted assistance to veterans in need.
The VA has increasingly recognized non-war-related PTSD as well, extending monthly compensation to tens of thousands of veterans traumatized by accidents — both on- and off-duty — that occurred at the time they were enlisted.
In one case The Times reviewed, a woman was awarded PTSD compensation based on breaking her leg in a fall walking to the mess hall. As the number of cases has climbed, so has debate over their legitimacy.
A 2007 study of 74 Arkansas veterans with chronic PTSD, most of them from the Vietnam War, concluded that more than half were exaggerating symptoms. Other research has found little evidence of malingering.
In the aftermath of serious trauma, most people experience symptoms of the disorder. But the nightmares, concentration problems and heightened state of alert usually go away in a few weeks. In a minority of cases, certain combinations of symptoms persist. That’s PTSD.
Because the diagnosis relies mainly on what patients report, it is easy to exaggerate. In online forums, veterans trade tips on how to behave in their disability evaluations. Common advice: Dress poorly and don’t shower, refuse to sit with your back to the door, and constantly scan the room.
If an examiner asks about homicidal thoughts, a Vietnam veteran posted, say: “Doc, doesn’t everyone, I mean didn’t you ever think about killing someone? Hell, I think about it every time someone gets too close to me.”
He also urged veterans to purposely fail memory and other cognitive tests. The motivation behind such advice is not always clear.
It may be aimed at helping veterans get what they deserve from a system that many see as rigged against them. Exaggeration can also be a sign of distress itself. Though VA investigations have exposed scams — including disability recipients who never served in the military — the department has focused on making the system friendlier to veterans.
To get paid for PTSD, veterans must link their symptoms to trauma that occurred during their service. In 2010, the VA expanded what situations could qualify. Credible fear of being attacked — without actually suffering or witnessing violence — became sufficient.