[House Hearing, 110 Congress]
[From the U.S. Government Printing Office]



 
                   POST TRAUMATIC STRESS DISORDER AND
                 PERSONALITY DISORDERS: CHALLENGES FOR
                THE U.S. DEPARTMENT OF VETERANS AFFAIRS

=======================================================================

                                HEARING

                               before the

                     COMMITTEE ON VETERANS' AFFAIRS
                     U.S. HOUSE OF REPRESENTATIVES

                       ONE HUNDRED TENTH CONGRESS

                             FIRST SESSION

                               __________

                             JULY 25, 2007

                               __________

                           Serial No. 110-37

                               __________

       Printed for the use of the Committee on Veterans' Affairs
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                     COMMITTEE ON VETERANS' AFFAIRS

                    BOB FILNER, California, Chairman

CORRINE BROWN, Florida               STEVE BUYER, Indiana, Ranking
VIC SNYDER, Arkansas                 CLIFF STEARNS, Florida
MICHAEL H. MICHAUD, Maine            JERRY MORAN, Kansas
STEPHANIE HERSETH SANDLIN, South     RICHARD H. BAKER, Louisiana
Dakota                               HENRY E. BROWN, Jr., South 
HARRY E. MITCHELL, Arizona           Carolina
JOHN J. HALL, New York               JEFF MILLER, Florida
PHIL HARE, Illinois                  JOHN BOOZMAN, Arkansas
MICHAEL F. DOYLE, Pennsylvania       GINNY BROWN-WAITE, Florida
SHELLEY BERKLEY, Nevada              MICHAEL R. TURNER, Ohio
JOHN T. SALAZAR, Colorado            BRIAN P. BILBRAY, California
CIRO D. RODRIGUEZ, Texas             DOUG LAMBORN, Colorado
JOE DONNELLY, Indiana                GUS M. BILIRAKIS, Florida
JERRY McNERNEY, California           VERN BUCHANAN, Florida
ZACHARY T. SPACE, Ohio
TIMOTHY J. WALZ, Minnesota

                   Malcom A. Shorter, Staff Director

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
published in electronic form. The printed hearing record remains the 
official version. Because electronic submissions are used to prepare 
both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.


                            C O N T E N T S

                               __________

                             July 25, 2007

                                                                   Page

Post Traumatic Stress Disorder and Personality Disorders: 
  Challenges for the U.S. Department of Veterans Affairs.........     1

                           OPENING STATEMENTS

Chairman Bob Filner..............................................     1
    Prepared statement of Chairman Filner........................    74
Hon. Steve Buyer, Ranking Republican Member......................     2
Hon. Ciro D. Rodriguez...........................................     3
Hon. Phil Hare...................................................     4
Hon. Corrine Brown, prepared statement of........................    74
Hon. Stephanie Herseth Sandlin, prepared statement of............    75
Hon. Cliff Stearns, prepared statement of........................    75
Hon. Ginny Brown-Waite, prepared statement of....................    76
Hon. Harry E. Mitchell, prepared statement of....................    76

                               WITNESSES

U.S. Department of Veterans Affairs, Ira R. Katz, M.D., Ph.D., 
  Deputy Chief Patient Care Services Officer for Mental Health, 
  Veterans Health Administration.................................    54
    Prepared statement of Dr. Katz...............................    95
U.S. Department of Defense, Department of the Army, Colonel Bruce 
  Crow, Chief, Department of Behavioral Medicine, Brooke Army 
  Medical Center, Fort Sam Houston, TX, and Clinical Psychology 
  Consultant to the Army Surgeon General.........................    57
    Prepared statement of Colonel Crow...........................    96

                                 ______

Committee on Veterans' Compensation for Post Traumatic Stress 
  Disorder, Institute of Medicine and National Research Council, 
  The National Academies, Dean G. Kilpatrick, Ph.D., Member, and 
  Distinguished University Professor, Director, National Crime 
  Victims Research and Treatment Center, Medical University of 
  South Carolina.................................................    44
    Prepared statement of Dr. Kilpatrick.........................    89
Kors, Joshua, New York, NY, Reporter, The Nation, and 
  Contributor, ABC News..........................................     9
    Prepared statement of Mr. Kors...............................    80
Satel, Sally, M.D., Resident Scholar, American Enterprise 
  Institute......................................................    46
    Prepared statement of Dr. Satel..............................    91
Shea, Tracie, Ph.D., Psychologist, Post Traumatic Stress Disorder 
  Clinic, Veterans Affairs Medical Center Providence, RI, 
  Veterans Health Administration, U.S. Department of Veterans 
  Affairs (on behalf of herself).................................    42
    Prepared statement of Dr. Shea...............................    87
Town, Jonathan, Findlay, OH......................................     6
    Prepared statement of Mr. Town...............................    78
Veterans for America, Jason W. Forrester, Director of Policy.....     5
    Prepared statement of Mr. Forrester..........................    77
Veterans for Common Sense, Paul Sullivan, Executive Director.....    11
    Prepared statement of Mr. Sullivan...........................    83

                       SUBMISSION FOR THE RECORD

Miller, Hon. Jeff, a Representative in Congress from the State of 
  Florida, statement.............................................    98


                   POST TRAUMATIC STRESS DISORDER AND
                 PERSONALITY DISORDERS: CHALLENGES FOR
                THE U.S. DEPARTMENT OF VETERANS AFFAIRS

                              ----------                              


                        WEDNESDAY, JULY 25, 2007

                     U.S. House of Representatives,
                            Committee on Veterans' Affairs,
                                                    Washington, DC.

    The Committee met, pursuant to notice, at 10:00 a.m., in 
Room 334, Cannon House Office Building, Hon. Bob Filner 
[Chairman of the Committee] presiding.

    Present: Representatives Filner, Brown of Florida, Michaud, 
Herseth Sandlin, Mitchell, Hall, Hare, Berkley, Salazar, 
Rodriguez, Donnelly, McNerney, Walz, Buyer, Stearns, Moran, 
Baker, Brown of South Carolina, Brown-Waite, Turner, and 
Lamborn.

    Also Present: Representative Kennedy.

              OPENING STATEMENT OF CHAIRMAN FILNER

    The Chairman. This hearing of the House Committee on 
Veterans' Affairs is called to order. Today, we will be 
focusing on the relationship between treatment for post 
traumatic stress disorder (PTSD) for our returning veterans 
from Iraq and Afghanistan and the diagnosis of personality 
disorder and how that affects later support for our veterans.
    Once again it seems that America has to be educated by the 
media. Just as we found out about Walter Reed from good 
reporting in the Washington Post we have had incredibly 
persuasive documentation on this issue from members of the 
press, especially one of our panelist here today, Mr. Kors, 
working for both The Nation and ABC News. And we thank you for 
educating America and we will hear more from you.
    What the press has learned is that thousands of cases, over 
20,000 of the cases in recent years, of soldiers who were 
claiming PTSD or other mental issues with regard to their 
service and their claim for disability were in fact diagnosed 
with a personality disorder. Then the military says that this 
was a pre-existing condition, which begs the question, of why 
these young men and women were taken into the Armed Services to 
begin with and what our obligation is after that occurs, but 
allows discharge with a very difficult time to get later care 
from the U.S. Department of Veterans Affairs (VA).
    If the facts that we have read in the press are true or if 
the statements that we read in the press are true, this is 
doing an incredible disservice to our young men and women who 
are serving this Nation. We have heard that they are not 
getting the full story of what the implications are for that 
PTSD discharge. We have representatives of servicemembers and 
servicemembers who have talked to the press that we will hear 
today that they were not given the full truth in their 
evaluations. They were lied to in terms of the implications of 
this diagnosis.
    In addition, there is some indication that higher policy is 
leading to this or--policy made at higher levels. I have 
personally talked to a doctor psychiatrist who told me that his 
commander told him to make the diagnosis of personality 
disorder rather than PTSD which would lead to further cost and 
obligations by this Nation to our veterans.
    So we have a real problem here. Not only are soldiers being 
denied treatment for a very real problem, but they are put in 
the position where it is very, very difficult to get that 
treatment even later on. So once the servicemember is diagnosed 
with personality disorder we want to know what happens at the 
VA and how to deal with--how the VA deals with those veterans. 
Is the burden on the veteran to prove that he or she doesn't 
have a personality disorder? Will that diagnosis prevent the 
veteran from receiving healthcare once the initial period for 
coverage ends? What barriers does the veteran face?
    So we want to look at this, at first from the soldier's 
perspective and that is what our first panel is about, to let 
them tell the story of what happens with this diagnosis, how 
that affects their lives and the lives of their comrades..
    So we thank you all for being here. It takes a lot of 
courage for you to testify and talk about your own lives. And I 
know that is hard. And we will hear from Mr. Kors who talked to 
many, many of these veterans. We will have a panel that deals 
with the response from the VA and, in this case, the Army 
Surgeon General. We want to know if this is being taken 
seriously; what is being done if these statements are true; 
what is being done to rectify it.
    There is legislation that has been introduced. I believe in 
the Senate that makes personality disorder on the diagnosis not 
a valid one. That would get rid of that as a potential 
diagnosis in dealing with, or at least in terms of the 
obligations that we have for treatment, and we may have to do 
that on the House side also.
    So we have, I think, a very important issue to look into 
today. We thank both the soldiers who are here, their 
representatives and the reporter who first brought this to 
America's attention.
    I would yield to the Ranking Member of this Committee, Mr. 
Buyer.
    [The prepared statement of Chairman Filner appears on p. 
74.]

             OPENING STATEMENT OF HON. STEVE BUYER

    Mr. Buyer. What was originally focused and appropriate for 
this review was a Subcommittee hearing on post traumatic stress 
disorder compensation and veterans claims at the Department of 
Veterans Affairs. That is how this began. We have now morphed 
it out of the Subcommittee to the Full Committee. And the focus 
is now on lanes outside the jurisdiction of this Committee. If 
the Chairman wanted to explore these matters, what would have 
been substantive and helpful to all of us is for this to have 
been a joint hearing with the House Armed Services Committee. 
While we can have witnesses before us, we can take no 
substantive action. There are many times when we are the 
receiver of individuals based on policies and actions from the 
U.S. Department of Defense (DoD).
    So a lot of this is important, but we should be working in 
concert with the House Armed Services Committee. The 
legislation I think that the Chairman was referring to, was 
legislation introduced by Senator Obama, and Senator Obama's 
legislation would stay the discharges for a personality 
disorder. I think that is a bad idea. We have individuals who 
are taken into the military. We do the best we can as a nation 
to screen individuals. At some point through the military 
matriculation process, individuals begin to exhibit certain 
types of actions that would not be appropriate. When you put a 
weapon into someone's hands and you ask them to work in concert 
and as a team with other individuals, it requires mental 
steadfastness. And it requires a lot of other institutional 
values and virtues in order for that team to work with great 
cohesion and for them to be the very best.
    And we have no idea as a country when an individual is 
going to break down. And in fact, if there are personality 
disorders, we have no idea when they are going to exhibit 
themselves. And to disarm the military from this ability to 
essentially discharge this individual so there is no harm not 
only to the individual, but also to the team, is extremely 
important.
    So while what perhaps well intentioned, I think Senator 
Obama's legislation would be very harmful to the military and 
thereby the national security of the country. It is also 
equally important for us not to confuse PTSD and personality 
disorder. These are clinical diagnoses. For individuals to be 
discharged from the military for personality disorders, you 
just can't have a company commander or a first sergeant or a 
master chief come forward and say, ``Well, I think this person 
has got a personality disorder. I want to get rid of them.'' I 
mean these are clinical judgments made by psychiatrists and 
doctorate level psychologists through a peer review process. 
And this allegation that they can just be thrown out is false.
    So while much of the testimony we are going to hear today 
is interesting and might be helpful, much of this is outside 
the jurisdiction of this Committee. I also do recognize that 
when we take an issue to the Full Committee, generally the 
Veterans' Affairs Committee seeks the counsel and input from 
many of the chartered veterans service organizations (VSOs), 
and they are absent here today. And I find that to be a curious 
matter.
    I yield back.
    The Chairman. Thank you, Mr. Buyer. I guess once again we 
understand only for the last 4 years, these issues were not 
taken up and not explored. This is a scandal. And I don't care 
who's jurisdiction it is, although we have tremendous 
jurisdiction in this. It is up to this Congress to deal with 
it.
    Are there any other opening statements by my colleagues? 
Mr. Rodriguez.

          OPENING STATEMENT OF HON. CIRO D. RODRIGUEZ

    Mr. Rodriguez. I just would make a comment that eventually 
it will become our problem, because when someone is diagnosed 
incorrectly, eventually that individual is going to come to the 
VA and that diagnosis remains with that individual. So it will 
become our problem as dealing with veterans.
    The other reality is this: I worked over 8 years in the 
area of mental health and I understood very quickly when I was 
told that in order for us to provide any service to any 
individuals, they have to receive a specific type of diagnosis 
otherwise we couldn't deal with them. And so that also drove 
unfortunately a lot of times what we could do or not do based 
on the specific diagnosis that they were given.
    So I am, and it is an area that we ought to be, concerned 
about and I know personally this, in terms with when you are 
diagnosed in that area, presupposes that the individual came in 
with those problems prior to. And so, that is important for us 
to come to grips with that as quickly as possible and making 
sure that that is not occurring and is not happening. And if 
anyone is going to get diagnosed, that we do everything we can 
to diagnose them appropriately as much as we can. And in some 
cases, if that is the case then we got to go back and reassess 
in terms of what has been happening and what is occurring with 
those soldiers that are out there.
    And so with that, I will stop and look forward to the 
testimony.
    The Chairman. Thank you, Mr. Rodriguez. Mr. Hare.

              OPENING STATEMENT OF HON. PHIL HARE

    Mr. Hare. Mr. Chairman, I would respectfully disagree with 
the Ranking Member. I think this is well within this 
Committee's jurisdiction. I cannot, for the life of me, believe 
that we would see 22,000 plus of our best and our brightest 
treated like this. I think it is grossly unfair. I think it is 
beneath what they certainly have deserved. There is substantive 
action that I would suggest to my friends on the other side 
that we can take and that would be including perhaps sponsoring 
my bill H.R. 3167, the ``Fair Mental Health Evaluation for 
Returning Veterans Act.''
    I would again disagree with the Ranking Member. I don't 
think Senator Obama idea is a bad idea at all. I think from my 
perspective, when we see something wrong I don't think we need 
to wait around for another Committee to tell us what is wrong. 
I think we need to, as a Committee, get together and to try to 
help our servicemen and women. So from my perspective, I think 
this is well within the purview of this Committee. I commend 
the Chair for holding this. I have said many times at this 
Committee, if not us, who? And if not now, when?
    And I want to thank you, Mr. Chairman, for doing this and 
to the witnesses I look forward to hearing this. But we cannot 
take the treatment of people in our military like this anymore. 
And I am not here to worry about whether or not the Armed 
Services is here. I am here. We are here. And I want to hear 
from these witnesses. And I want to see this problem solved.
    So I thank you, Mr. Chairman, for giving us the opportunity 
to listen today. Thank you.
    The Chairman. Thank you, Mr. Hare. We will hear from the 
first panel. If you have a written statement, that will be made 
a part of the record.
    Jason Forrester is a representative from Veterans for 
America (VFA). We thank you for what your group is doing and we 
thank you for being here today.

STATEMENTS OF JASON W. FORRESTER, DIRECTOR OF POLICY, VETERANS 
FOR AMERICA; JONATHAN TOWN, FINDLAY, OH (VETERAN); JOSHUA KORS, 
NEW YORK, NY, REPORTER, THE NATION, AND CONTRIBUTOR, ABC NEWS; 
  AND PAUL SULLIVAN, EXECUTIVE DIRECTOR, VETERANS FOR COMMON 
                             SENSE

                STATEMENT OF JASON W. FORRESTER

    Mr. Forrester. Thank you, Mr. Chairman. Chairman Filner, 
Ranking Member Buyer, Members of the Committee, Veterans for 
American works closely with Congress, DoD, the media, active-
duty troops and veterans to identify the unique challenges 
facing today's military. Much of our work is investigative. 
Specifically, our work at Ft. Carson, Colorado, where we first 
met Specialist Town, and our current work at Camp Pendleton, 
California, has prompted considerable media attention and 
Congressional action and has helped identify where our country 
is failing our servicemembers.
    Given the distressing disconnect between VA and the DoD, 
the greatest service that VFA can provide today is to highlight 
the trends we have identified and are working to correct within 
DoD and to offer some ideas regarding how the VA can help 
ensure that those who have served in Iraq and Afghanistan get 
the assistance they deserve.
    It is important for VA to understand that the experiences 
of nearly one million servicemembers from Iraq and Afghanistan 
who are still on active duty and who will eventually enter the 
VA system. The DoD's Mental Health Task Force found that 49 
percent of Guard members, 38 percent of soldiers, and 31 
percent of Marines are experiencing some mental health issues 
after serving in Iraq and or Afghanistan. DoD characterized 
post traumatic stress disorder as a signature wound of today's 
wars. At Ft. Carson, we found soldiers who had been diagnosed 
with chronic PTSD who are only receiving 1 hour of individual 
therapy per month. Often, these soldiers saw a new therapist 
each visit.
    At Ft. Carson, we worked with soldiers who were not 
receiving the treatment they needed even though they clearly 
indicated on their post-deployment health reassessment that 
they were having difficulty readjusting to post-deployment 
life.
    In some cases, these soldiers had been re-deployed only to 
have their wounds compounded by further exposure to combat. In 
other cases, undiagnosed and untreated PTSD led soldiers to 
turn to drugs and alcohol. The civilian medical community has 
long recognized that substance abuse is a symptom of PTSD. 
Unfortunately, it is DoD policy not to treat soldiers for PTSD 
until their substance abuse problems are addressed. There are 
no DoD dual track PTSD and substance abuse programs. We have 
worked with several soldiers who have suffered greatly from 
this deficiency and in a few cases, have gotten them into VA 
facilities that offered dual track care.
    Since PTSD is so prevalent, VA must increase the number of 
dual track programs that treat substance abuse and PTSD. VA can 
help greatly reduce anti-mental healthcare stigma by increasing 
its outreach to servicemembers and their families on bases and 
within military medical facilities. Today's servicemembers need 
to know that PTSD is an injury and that they deserve every 
opportunity to recover. PTSD is not a sign of weakness. It is a 
proven medical reality of sustained exposure to combat.
    Finally, another distressing trend that we identified at 
Ft. Carson was the prevalence of pre-existing personality 
disorder discharges for soldiers with clear service-connected 
mental health problems. The consequences of such a dismissal 
are severe, including denial of VA benefits due to the disorder 
being, ``pre-existing.'' At Ft. Carson we met numerous soldiers 
who had been diagnosed with a pre-existing personality disorder 
regardless of the fact that they were deemed fit when they 
entered the service and regardless of the fact that they have 
been diagnosed with PTSD post-deployment to Iraq and 
Afghanistan.
    Pre-existing personality disorder discharges remove the 
government's burden to help the servicemember deal with their 
service connected injuries. It is unacceptable to ask an 
American to sacrifice for this country and not to treat the 
consequences of their service.
    In May of this year, as a result of our work at Ft. Carson, 
a congressional staff delegation returned there where they met 
with the soldiers and family members who we had been helping. 
This visit prompted a U.S. Government Accountability Office 
(GAO) investigation into mental health treatment in the 
military and it led to a bipartisan group of 31 Senators 
sending a letter to Secretary Gates calling for a moratorium on 
pre-existing personality disorder discharges. This problem 
provides a great opportunity for VA leadership.
    While VA has no obligation to treat a veteran with a pre-
existing personality disorder discharge, these men and women 
need help. To address this problem, VA should create a 
streamlined process for face to face medical evaluations for 
such discharges. We owe these veterans a second chance to get 
much needed help for their service connected injuries.
    This concludes my statement. Thank you.
    [The prepared statement of Mr. Forrester appears on p. 77.]
    The Chairman. Thank you very much.
    Jonathan Town is an Army veteran who was diagnosed with a 
personality disorder. And I understand after all the publicity 
about your case, the VA, or you can tell us, the VA has decided 
they we owe you treatment. We thank you for your courage in 
coming forward. Many soldiers who are in the same position as 
you are do not feel comfortable about testifying, and we thank 
you for speaking on behalf of thousands of soldiers.

                   STATEMENT OF JONATHAN TOWN

    Mr. Town. Thank you for the opportunity. Mr. Chairman, 
distinguished Members of the Committee, ladies and gentleman, 
thank you for inviting me to address the Committee to tell my 
story.
    On January 20, 1961----
    The Chairman. Mr. Town. Could you just--get the microphone 
right up to you and make sure it is turned on. It is hard 
sometimes to hear, if not.
    Mr. Town. On January 20, 1961, a United States military 
veteran and Purple Heart awardee who was being sworn in as 
President at that time said during his inaugural speech, ``Ask 
not what you can do for your country, ask what--ask not what 
your country can do for you, ask what you can do for your 
country.''
    Since January 2000, countless citizens have answered this 
call to duty and served in the United States Armed Forces. 
Thousands, in fact, 22,500 of these servicemembers who served 
honorably have been discharged from the military with a Chapter 
5-13, Personality Disorder Discharge. The result of which they 
have all been denied medical care and disability benefits by 
our government.
    There has now arisen a debate about whether these 
discharges were done to save the government money or to help 
with the military wartime and deployment strength. Regardless 
of the reason, it is an outrage that these servicemembers and 
their families have been put through this.
    Now I would like to tell you my story. I served 4\1/2\ 
years honorable years at Fort Knox, Kentucky, as an 
administrative specialist. I was then given orders to permanent 
change of station (PCS) to Korea. After arriving in Korea, I 
was told that the unit I was assigned to had just received it's 
deployment orders to Iraq. In August 2004, the STEEL battalion 
which I was now a part of, deployed to Ramadi, Iraq. On October 
19, 2004, I was running mail for our battalion and incoming 
rounds started exploding across the street from where my 
vehicle was parked. While running for shelter in my S-1 shop's 
office, a 107 millimeter rocket exploded three feet above my 
head, leaving me unconscious on the ground with a severe 
concussion, shrapnel in my neck and blood pouring from my ears.
    I was taken to the battalions aid station where I was 
treated for these various wounds. I was given quarters for the 
rest of the day and went back to work the next day. Two months 
later, I was awarded a Purple Heart for my injuries I suffered 
on that traumatic day in October. This is when everything 
started to go downhill health-wise for me. Throughout the next 
9 months while continuing to serve my country, I battled severe 
and non-stop headaches, bleeding from my ears, and insomnia.
    We finally got the word that we were headed home and then I 
would finally be able to get some assistance for the medical 
issues I was going through. After a few days back in the United 
States, I realized a new battle was taking place. My ability to 
adjust to loud noises, large groups of people and forgetting 
what happened to my unit and myself while we were in Iraq was 
going to be another battle.
    About 45 days after coming back stateside to Ft. Carson, 
Colorado, I was finally able to see a psychiatrist. The first 
few meetings with the doctor were good and it seemed like he 
actually cared about helping me get through my issues, if it 
were possible. Then word came down that our unit was going to 
be re-deployed. The next time I went to see the doctor, he 
informed me that he was going to push a Personality Disorder 
Chapter and explained why.
    The doctor said, ``You have the medical issues that call 
for a medical board, but the reason I am going to push this 
Chapter is because it will take care of both the needs of the 
Army and the needs of you. You will be able to receive all the 
benefits you would if you were going to go through a medical 
board, get out of the military, and focus on your treatment to 
get better. For the military, they can get a deploy-able body 
to fill your spot.''
    I told him that this is--if this is what the thought was 
best for the military and my family that he could do what he 
needed to do. I never realized that everything that was said to 
me during that day was all lies. I went through the final out 
process to leave the military. The day I was signing out, I was 
told by the final out personnel that I would not receive any 
severance pay or benefits and I actually owed the military 
$3,000.
    I do not know everyone in this room, but I think that if 
you were to work hard for a company or an agency, only to be 
told that you owe them money, that you owed them money when you 
went to leave, you would obviously be--you would obviously 
think something is wrong. If it weren't for my family taking us 
in and supporting us both financially and emotionally and new 
friends helping us, I don't know where my family and I would be 
right now.
    The last 9 months have been spent trying to get assistance 
both medically and financially through the Veterans Department, 
getting the word out to the public about what is happening to 
my fellow servicemen and myself, and trying to get my family 
and myself back on our feet.
    Eight months after being denied medical benefits as a 
Chapter 5-13 discharge, the Veterans Administration awarded me 
the disability status that my Purple Heart and wounds I 
suffered entitled me to. I am fortunate because my story 
received national exposure, unfortunately there are many, many 
injured military personnel Purple Heart winners also who have 
never received their benefits that they are entitled to.
    In the absence of a concerted effort by the Committee to 
right this horrible wrong, I am afraid that the other 22,499 
veterans will not be as lucky as me.
    I think the government should fix the personality disorder 
issue in the time it takes a servicemember to receive the start 
of their disability from the time they leave the Armed Forces. 
The Chapter 5-13 personality disorder should be completely 
taken out of the DoD regulation, or if the military really 
wants a way to get servicemembers out of the service that do 
not have over 6 months of active service or have not been 
deployed overseas, then it needs to be written that way in the 
regulations.
    It is 100 percent wrong to be able to use this discharge 
for any servicemember that has been on active service for a 
substantial amount of time or who has fought in a war for their 
country. Some have suggested a way to reduce the amount of time 
a servicemember has to wait till they finally start receiving 
disability after leaving the Armed Forces. The servicemember 
starts his or her disability paperwork and process at the 
station where he or she is currently stationed 2 months prior 
to getting out of the service. The servicemember should not be 
able to final out from their branch of military until he or she 
is either guaranteed or denied their disability claim. By going 
through this route it will allow the servicemember to receive 
their first disability check immediately after their last 
paycheck from the Armed Services and they will be able to 
receive medical assistance as soon as they leave the service.
    Such a system would also facilitate the electronic transfer 
of the servicemembers medical records from the service branch 
of the veteran--to the Veterans Administration, thus allowing 
the Department of Defense to better work hand in hand with the 
Veterans Administration to assist these soldiers in need.
    In closing, I want to state that I did not have a 
personality disorder before I went into the Army, as they have 
stated in my paperwork. I did not suffer severe non-stop 
headaches. I did not have memory loss. I did not have endless, 
sleepless nights. I have post traumatic stress disorder and 
traumatic brain injury (TBI) now due to injuries I received in 
the war for which I received a Purple Heart. I shouldn't be 
labeled for the rest of my life with a personality disorder and 
neither should my fellow soldiers who also incorrectly received 
this stigma. I would like to ask the Committee and panel 
members to thoroughly think about the ideas I have mentioned to 
fix some of the issues we as veterans are facing. Please help 
those who have helped their country and remember that every 
time the military discharges a servicemember out of the Armed 
Service the way I was discharged, not only do you destroy hope 
for healing, but they destroy the soldier's families hope for 
healing as well.
    [Applause.]
    [The prepared statement of Mr. Town appears on p. 78.]
    The Chairman. Thank you, Mr. Town, you did not sign up to 
have to do this, but you are helping a lot of people and we 
thank you for----
    Mr. Town. It is an honor.
    The Chairman [continuing]. Your courage.
    Joshua Kors is a journalist. He has written on this topic 
extensively and has been the source of much of the facts and 
stories around us, both for The Nation and for ABC News. So we 
thank you, Mr. Kors, for what you have done and we look forward 
to your testimony.

                    STATEMENT OF JOSHUA KORS

    Mr. Kors. Good morning. I have been reporting on the 
personality disorder discharge for the last 10 months.
    The Chairman. Please speak close to the microphone so we 
can hear.
    Mr. Kors. I have been reporting on the personality disorder 
discharge for the last 10 months and I am here today to talk 
about the 22,500 soldiers discharged in the last 6 years with 
that condition.
    A personality disorder discharge is a contradiction in 
terms. Recruits who have a severe pre-existing condition like a 
personality disorder do not pass the rigorous screening process 
and are not accepted into the Army. The soldiers I interviewed 
this past year passed that first screening and were accepted 
into the Army. They were deemed physically and psychologically 
fit in a second screening as well before being deployed to Iraq 
and served honorably there in combat. In each case, it was only 
when they came back physically and psychologically wounded and 
sought benefits that this pre-existing personality disorder 
discharge was discovered.
    Discharging soldiers with a personality disorder prevents 
them from being evaluated by a medical board and getting 
immediate medical care. This can be life threatening for our 
soldiers. A good example is Chris Mosier who served honorably 
in Iraq where he watched several of his friends burn to death 
in front of him. After that, he developed schizophrenic-like 
delusions. He was treated at Ft. Carson for a few days then 
discharged with a pre-existing personality disorder. He 
returned home to Des Moines, where he left a note for his 
family saying that Iraqis were after him, they are in Iowa, 
then shot himself.
    Surgeon General Gale Pollock agreed to review a stack of 
personality disorder cases. After 5 months, she produced a memo 
saying her office had, ``thoughtfully and thoroughly'' reviewed 
the cases, including Jon Town's, and determined all of them to 
be properly diagnosed. With further reporting I discovered that 
as part of that thoughtful and thorough 5-month review, 
Pollock's office did not interview anybody, not even the 
soldiers whose cases she was reviewing. Some of those soldiers 
said they called the Surgeon General's office offering 
information about their ailments. Their efforts were rebuffed.
    The one thing the Surgeon General's office did do was 
contact a doctor at Ft. Carson where many of the personality 
diagnoses were made, and ask him whether his doctors got it 
right the first time. The doctor said yes, his staff's original 
diagnoses was correct and Pollock shut down the review at that 
point.
    The Surgeon General's office denied that for many months, 
insisting that the review was conducted by a panel of health 
experts who were not involved in the original diagnoses. This 
wasn't a case of one many reviewing his own work, they said. 
But eventually it did come out that the only reviewer was 
Colonel Steven Knorr, who as Chief of Behavioral Health at Ft. 
Carson, oversaw many of the personality disorder diagnoses and 
in his capacity as a psychiatrist was reportedly involved in 
creating many of them as well.
    When the problems with Walter Reed became public, the 
Pentagon took two actions: It accepted the resignation of 
Surgeon General Kevin Kiley and it hired the public relations 
firm LMW Strategies with a $100,000 no-bid contract to put a 
positive spin on those events. This past week as these 
personality disorder discharges became public, VA Secretary 
Nicholson stepped down. And today, Surgeon General Pollock is 
not here to discuss the issue.
    As a journalist it is not my role to make any 
recommendations, but I do want to share with you the hopes of 
the wounded veterans I spoke to this year, which is a hope that 
someone be held responsible and that officials go back through 
the 22,500 cases and seek out the thousands of Jon Towns who 
are waiting there, struggling right now without benefits or the 
media spotlight.
    [The prepared statement of Mr. Kors appears on p. 80.]
    The Chairman. Thank you, Mr. Kors.
    And concluding this panel will be Paul Sullivan 
representing Veterans for Common Sense. And we thank you again 
for your efforts at making these kinds of situations public for 
the American people to understand.

                   STATEMENT OF PAUL SULLIVAN

    Mr. Sullivan. Thank you, Mr. Chairman. Chairman Filner and 
Members of the Committee, thank you very much for inviting 
Veterans for Common Sense to testify about post traumatic 
stress disorder and about personality disorder discharges among 
our Iraq and Afghanistan war veterans. My oral testimony 
focuses on offering solutions so our veterans receive prompt 
medical care and prompt disability benefits for PTSD.
    So far, the Department of Defense has discharged more than 
22,000 veterans in the past 5 years with a personality disorder 
or PD. The current DoD system assumes soldiers are malingering. 
And the current VA system is designed to fight fraudulent 
claims. These DoD and VA barriers to prevent abuse of the 
system are blocking too many deserving veterans from getting 
the high quality medical care from VA, and the prompt 
disability benefit payments from VA that they need and they 
earned.
    When the military uses PD to discharge a veteran who fought 
honorably, then the military is breaking it's own rules. 
Chapter 5-13 states that if a veteran was in combat then the 
military is generally prohibited from using PD. VA's recent 
review of PTSD claims found no evidence of fraud. A veteran 
discharged with PD is usually denied VA healthcare and benefits 
based on VA rules prohibiting services for a pre-existing 
condition.
    Here are VA's latest statistics on post traumatic stress 
disorder. As of March 31, VA diagnosed 52,000 Iraq and 
Afghanistan war veterans with PTSD. However, VA approved only 
19,000 PTSD claims. This disparity should be investigated.
    Veterans for Common Sense urges Congress to adopt a robust 
package of policies listed in our written statement so Iraq and 
Afghanistan veterans with PTSD receive prompt medical care and 
benefits. Here are our top three proposals.
    First, Congress should legislate a presumption of service 
connection for veterans diagnosed with PTSD who deployed to a 
war zone after 9/11. A presumption makes it easier for our 
dedicated and hard working VA employees to process the veterans 
claims. This results in faster medical treatment and faster 
benefits for our veterans.
    Second, the military should stop discharging Iraq and 
Afghanistan war veterans uses PD. The military should review 
all personality disorder discharges for veterans deployed since 
9/11. Congress should order VA to review applications for 
healthcare and benefits where PD was an issue at VA.
    Third, DoD and VA should establish a policy to reduce the 
stigma against people with mental health conditions that 
military studies confirm hinders many of our war veterans from 
seeking care. The scope of PTSD in the long term is enormous 
and it must be taken seriously. PTSD is real. When all of our 
1.6 million servicemembers eventually return home form the wars 
in Iraq and Afghanistan, based on the current rate of 20 
percent, then VA may face up to 320,000 total new veterans 
diagnosed with PTSD.
    In conclusion, Mr. Chairman, if America fails now to act 
and overhaul the broken DoD and VA disability systems, there 
may be a social catastrophe among many of our returning Iraq 
and Afghanistan war veterans. That is why Veterans for Common 
Sense reluctantly filed suit against VA in Federal Court this 
week. Time is running out. The consequences of failure among 
our veterans are severe, including broken families, lost jobs, 
stigma, drug abuse, alcoholism, crime, homelessness, and 
suicide. The disastrous consequences are preventable, yet our 
window of opportunity to prevent these problems from happening 
is closing.
    Thank you, Mr. Chairman. I would be more than happy to 
answer any of your questions.
    [The prepared statement of Mr. Sullivan appears on p. 83.]
    The Chairman. Thank you all very much. You have made some 
very powerful statements. I am going to call on Members of our 
panel in the order in which they got here. The Chairman of our 
Health Subcommittee is Mr. Michaud and the floor is yours for 5 
minutes.
    Mr. Michaud. Thank you very much, Mr. Chairman. I want to 
thank the panel for the enlightening testimony. And I have a 
few questions. First of all, for Mr. Town. You had mentioned in 
your testimony that when you went through the final out process 
to leave the military, when you signed out that they said that 
you actually owed them money. What was the reasoning they gave 
why you owed them $3,000? Was it for medical bills or?
    Mr. Town. While I was in Iraq I re-enlisted for 6 years and 
a $15,000 tax-free bonus while in Iraq. And when I came back 
stateside, or when I was being chaptered out, they said I had--
I had served 1 year of that 6 years. So I stilled owed $12,000 
roughly. And there was, I had leave that I was selling back to 
Defense Finance and Accounting Service, and I sold my leave 
back. And how it came out is, I still owed $3,000 of that 
$12,000. And that is how that debt was made.
    Mr. Michaud. Okay. Thank you. For Mr. Sullivan, you had 
mentioned the lawsuit and being a former VA employee we have 
been dealing with a lot issues dealing with traumatic brain 
injury, and PTSD. If the lawsuit is successful and VA has to 
respond, the lawsuit might also say in order to respond to the 
huge influx of men and women from this conflict and previous 
conflicts, Vietnam era conflict, what are your thoughts about 
the VA not utilizing to the degree that they probably should be 
to take care of the influx as far as contracting out services, 
particularly in rural areas for mental health services? Would 
you comment on that? Do you think that that is what they should 
do in the short term to help with the influx is to fee for 
services?
    Mr. Sullivan. Thank you for your question, Congressman. I 
am not an expert on rural care for veterans, but there are two 
pretty simple standards that VA should be held to. The first 
standard is when a veteran comes home from war and he needs an 
appointment for a mental health condition. It shouldn't matter 
if he lives in Nome, Alaska, or New York City. The 
servicemember turn veteran should be able to see a mental 
healthcare provider as soon as possible so the condition 
doesn't worsen.
    It is better for the veteran to get treatment sooner, it is 
also cheaper for the taxpayer so that you don't have more 
complicated problems later on. So it would be a very good idea 
for VA to make sure, especially for Guard and Reserve units, 
that they beef up their rural programs.
    One note related to that. I mentioned that there are fewer 
claims for PTSD that are approved then there are veterans who 
are diagnosed. One related concern is this: National Guard and 
Reserve, mainly from rural areas, are about half as likely to 
file a claim. However, Congressman, they are about twice as 
likely to have their claim denied. So not only do they need 
access to healthcare, they also need access to a good 
representation to assist them with their claim.
    Mr. Michaud. Well why is it that they are half as likely to 
file, because they don't know about the services or they just 
afraid of the stigma that is attached to it?
    Mr. Sullivan. I don't know the answer to that, Congressman. 
However, I did raise it while I worked at VA and it was in some 
of the briefing materials that I provided to VA executives. 
However, I am not aware that they took any action. You may want 
to ask them if they have investigated the discrepancy and if 
they have any answers.
    Mr. Michaud. Okay. Thank you. And my last question to Mr. 
Kors is being a journalist you definitely have the power to 
inform the public of what is going on. Have you ever been 
persuaded by one side or another to be more aggressive or less 
aggressive as you move forward in dealing with this issue of 
claims?
    Mr. Kors. Sure. Well any journalist works hard to keep 
their neutrality, but certain issues seem logical when looking 
at them. For example, in Jon Town's case, they gave him a 
Purple Heart for his wounds of war, but yet Surgeon General 
Pollock says he was not wounded in war. Contradictions like 
that call out the strangeness, the sense of absurdity here. And 
I think actually that question deserves a little more detail.
    Following the review that said that Jon's case and the 
stack of others was properly diagnosed, the Pentagon released a 
second statement that went a lot farther. A statement by 
Lieutenant Colonel Bob Tallman, what has become known to the 
reporters reporting on this issue as the Tallman memo. In the 
Tallman memo, they said not only did they review the stack of 
cases presented to them, but they went back and reviewed all 
the cases from the last 4 years at Ft. Carson where Specialist 
Town was based. After it was revealed that--after it was 
revealed that there were no interviews in this 5-month 
thoughtful and thorough review, I later discovered that the 4-
year review was simply invented.
    I called Lieutenant Colonel Tallman to ask him about this. 
How they could call this a thoughtful and thorough review when 
not a single soldier was interviewed. And he said to me, well 
he really didn't think that they could. And he said, ``Joshua, 
let me be clear with you. I didn't write this memo and I have 
no knowledge of it's contents.'' He told me that the memo was 
ghost written by Surgeon General Gale Pollock's office. 
Something that Pollock's office readily admitted. And after it 
was revealed that the review was simply invented, the 4-year 
review referred to here, they really said that was all the 
information they could provide.
    Mr. Michaud. Thank very much. That is very enlightening. 
Thank you very much for all of the work that you all are doing, 
I really appreciate it.
    The Chairman. Thank you. Mr. Moran?
    Mr. Moran. Mr. Chairman, thank you very much. I appreciate 
the opportunity to learn about this circumstance that our 
servicemen and ultimately veterans are facing.
    Mr. Kors, apparently--if I understand the situation, 
apparently pre-existing, that word is very significant. And I 
guess my initial question is, are there findings with our 
servicemen and women, that they have a personality disorder as 
a result of actions or activities that occur in war that result 
in the designation of a personality disorder for which the 
there is no pre-existing--let me ask this question. I am not 
very clear, but I want to make sure do we have a non pre-
existing condition? And in that case, is there a different 
result? Or is everything found in these circumstances to be 
pre-existing and, therefore, the consequences are bad in each 
and every case? What makes Mr. Town's situation different? Are 
other servicemen and women found to have a personality disorder 
but not a pre-existing one?
    Mr. Kors. Well that is exactly the point, Congressman. And 
that is why it is such an important VA issue. The VA is not 
required to treat pre-existing conditions. They are required to 
treat wounds of combat. And why is Town's case unique? It is 
not and that is precisely the point.
    I looked at cases of one soldier for example who suffered a 
bilateral hernia in Iraq. His condition was decided as the 
result of pre-existing personality disorder. Another case, for 
example, the soldier who damaged the lens of eyeball in Iraq. 
That ocular damage was seen as the result of a pre-existing 
personality disorder.
    Mr. Moran. Are there cases in which there is no finding of 
a pre-existing condition? And those soldiers are treated 
differently than Mr. Town?
    Mr. Kors. Well in Town's case, as in all the others, there 
is no previous history. And in fact, it goes further to the way 
that the Army looks at how one does--how do they discover that 
a person had a condition that was pre-existing? Standard Army 
policy is to interview no one. In fact, I got a call recently 
from a psychiatrist at a major east coast Army facility who 
said that he is the only person in the in his Fort Hospital who 
does interview families. You know, for Town's case for example, 
you know, perhaps his family would of noticed if he had severe 
hearing loss before joining the Army.
    This doctor was the one and only who did seek out families 
to interview to see whether it was pre-existing. He said he was 
ceaselessly mocked by both the Chief of Behavior Health at his 
Fort's hospital, and others, as being completely out of step 
with the Army and VA ways.
    Mr. Moran. So the finding of the condition to be pre-
existing is nearly automatic in each and every case?
    Mr. Kors. It is simply asserted without proof. I think that 
is the best--I mean you know at that point we really have to 
look at why this is happening. And that was a considerable part 
of my 10-month investigation.
    Jon Town and the others here have talked about the 
financial components. By preventing these wounded veterans from 
receiving their benefits, the military is saving $12.5 billion 
in disability and medical care. With that financial pressure 
comes political pressure. I spoke to multiple trial defense 
services lawyers who said the commanders at their base were 
pressuring doctors to falsely diagnose. What one told me he 
knew this was happening because the commander had come to him 
and confessed to doing it.
    On a basic level, on simply a practical level, the 
hospitals there are overrun, both at the Army and the VA. And 
you have situations where they need to get someone out of their 
hair fast to free that space up for the four or five soldiers 
who are waiting to take it. As Frank Ochberg, the doctor who 
codified post traumatic stress disorder for the government 
said, there's a further public relations issue that even goes 
deeper than simply getting soldiers out of their hair. And that 
is making soldiers like Jon Town invisible. If Town comes back 
with a Purple Heart and severe problems with memory, with 
sleep, with headaches, we can delete him from the cost of the 
war if we simply say it was a pre-existing condition unrelated 
to his military service.
    Mr. Moran. Mr. Town, thank you very much for your service 
to our country. You indicate now that the VA is providing 
benefits to you? Is that true?
    Mr. Town. Yes, sir.
    Mr. Moran. But are those benefits unrelated to a 
personality disorder?
    Mr. Town. Correct. They actually diagnosed me with post 
traumatic stress disorder. The VA has.
    Mr. Moran. And are you being treated by the VA for those 
for that condition?
    Mr. Town. Yes, sir.
    Mr. Moran. And the reason that you were successful or your 
case is no longer considered ineligible for benefits because it 
was pre-existing is what? Why the change? Is there some 
medical----
    Mr. Town. Well----
    Mr. Moran [continuing]. Finding that allowed the VA to 
reach a different conclusion or----
    Mr. Town. No.
    Mr. Moran [continuing]. They just reached a different 
conclusion?
    Mr. Town. No. They just--I saw this psychiatrist for about 
25 minutes when I got to the Dayton VA. And she was pretty much 
in tears after I had talked to her for about 25 minutes. And 
that was all she needed for her evaluation of what I had been 
going through for the last 2 years.
    Mr. Moran. Thank you very much, Mr. Chairman.
    The Chairman. Mr. Moran, just as I understand it, 
personality disorder is by definition pre-existing. If the 
other possibility is PTSD which means we gave it to you, which 
means you are eligible.
    Mr. Sullivan. That is correct.
    The Chairman. And, you know, Mr. Town was called, I think 
from a very pretty high level of in the VA, after all the 
publicity came out about it. He----
    Mr. Moran. The--excuse me, Mr. Chairman. But the 
distinction is that the VA still has not--they will still 
consider Mr. Town, at least initially, of having a pre-existing 
personality disorder. Now they have reached the conclusion he 
has post traumatic stress syndrome, which then qualifies him 
for assistance from the VA.
    Mr. Kors. Congressman? That is another key issue here. The 
VA flatly rejected the Army's diagnosis. In cases where a 
soldier gets a tremendous amount of press, this often happens. 
He was decided after the Army decided he wasn't disabled at all 
the VA decided he was 100 percent disabled. And top officials 
at the VA explained to me why this is such a severe problem for 
the VA. False diagnoses of personality disorder short flagged--
short circuited the VA's red flag system. That is internal VA 
speak for the way in which the VA keeps it's eye out for those 
who are severely wounded to get them immediate medical and 
disability benefits.
    They keep their eye out by looking at the Army's medical 
board and who comes out of the medical board with a very high 
disability rating. Soldiers like Jon who got a pre-existing 
personality disorder are denied the opportunity to see a 
medical board, thus they don't get a disability rating at all, 
thus they fly under the VA's radar and in Jon's case, didn't 
receive a single doctor's visit for 8 months.
    Mr. Moran. So, Mr. Chairman, we have one diagnoses by the 
military and one diagnosis by the VA resulting in a different 
outcome?
    Mr. Kors. That is right.
    Mr. Moran. Thank you.
    The Chairman. Right. But that person has to come to the VA, 
there has to be an aggressive effort. And in conditions which 
make them very vulnerable and they have to fight for that new 
diagnosis. So fighting the bureaucracy when you are suffering 
from these kinds of things is not the easiest thing to do.
    Mr. Kors. In Jon's case he submitted his paperwork five 
times before the VA decided to take up his case and look at his 
medical condition.
    The Chairman. Thank you. Mr. Hare, you have the floor.
    Mr. Hare. Thank you, Mr. Chairman. I have to tell you I am 
beyond even angry. I don't even know what word I can use.
    Let me--I want to see if I can sum up this because this is 
almost surreal. As I understand it, we have over 22,000 people 
who have who got in the military, somehow slipped under the 
radar screen. Now they are being diagnosed incorrectly. Mr. 
Town, I am amazed that not only did they, since you obviously 
weren't wounded according to them, that not only they asked for 
$3,000 I am surprised they didn't ask for your Purple Heart 
back.
    I think this is amazing. And so if I get this straight 
then, nobody has reviewed any of these cases for any of these 
people at all, but they made up the fact that they did. They, 
someone in the military or some has said, that they interviewed 
these people. Nobody, not one person has been talked to about 
this. And their lives and their families and everybody is 
affected. And not one person. So I guess what I would like to 
understand is, and maybe somebody on the panel could help me 
out here, in your opinion, did this really say to treat people 
like Mr. Town and thousands of other people to save $12.5 
billion in savings that they don't have to pay out? And then 
you had to try to get this five times on your own? And what 
about the people that give up or they feel frustrated that some 
how--and now we are suing the veterans once again, have to go 
back and sue people because of the way they are being treated. 
Unbelievable.
    And I want to commend you, Mr. Kors, for your reporting on 
this issue. I know this is just maybe an opinion I would like 
to get from you. Are you after doing this investigation 
convinced that the reason that these people that this happened 
to them was they were just trying to get out of saving $12.5 
billion?
    Mr. Kors. I think there are a multitude of reasons. And, 
you know, it goes from the ground level to the top level. I 
think where the pressure on the commanders to pressure the 
doctors to purposely misdiagnose comes from. That is something 
that, you know, perhaps we are here today to look at.
    You are absolutely right that the 22,500 soldiers in the 
last 6 years, none of them had been looked at. Not the 5,600 
from the Army itself, or the of the stack of cases directly 
presented to the Surgeon General. I think another key feature 
we need to look at when we are figuring out how this happened 
is to talk at a ground level how this goes from doctor to 
soldier. As Specialist Town said, he like every soldier I 
looked at was directly lied to by their military doctor. The 
doctor would say, ``If you accept the personality disorder 
discharge you will get disability pay, you will get VA medical 
care, you will get to keep your signing bonus for the years 
that you are too wounded to serve.'' Their final day as they 
are walking out the door, their last day in uniform, they find 
out none of those promises are true.
    For the soldiers that further resist, those block of 
soldiers all told me of an arm twisting tactic that the doctors 
would use. They would say, ``Look, you know you don't have a 
personality disorder, we know you don't have a personality 
disorder. But if you accept this discharge we can get you out 
in a few days whereas if go for medical board, it will take 
about 6 months. Your unit is redeploying to Iraq and you are 
wounded. Your job in Iraq is going to be to cover your friends 
back. Do you really want your friends to die because you fought 
for further benefits? Wouldn't it be better to forget about the 
benefits and let your friends live.''
    And at that point a lot of these guys say, ``Well you know, 
I know I don't have a personality disorder, certainly wasn't 
pre-existing as is mandated by the personality disorder 
discharge. But, you know, I care about my fellow unit members. 
I want them to live. Sure, I'll take it.''
    Mr. Hare. I will tell you this, someone mentioned that 
somebody needs to be held responsible for this. And whoever 
that somebody or someone are, I hope this Committee will 
thoroughly hold those people responsible. In my opinion, they 
have no business, absolutely no business dealing with any of 
these men and women in the military. I think this is shameful. 
Absolutely shameful. And to have to sue, you know, and thank 
goodness that you are doing that.
    And I guess one last question, Mr. Town, and I thank you 
for your service and for your bravery and for your 
steadfastness. What do you think from your perspective, you 
sir, what do you think this says to the people who are 
currently serving? Not just to those 22,000, who is next? I 
mean and to the people who are going to enlist that if 
something happens they are going to try to duck it by 
mislabeling you and putting the blame on you. What do you think 
it says?
    Mr. Town. Hopefully right now it says a lot and the 
situation gets fixed. And they take it out of the regulation. 
They fix the way that the veterans are receiving their 
disability when they get out of service and how long it takes. 
And people see then that the VA, the DoD, the government does 
care about their soldiers. And I hope there is citizens out 
there that are thinking about serving don't veer away from the 
Army. Army was, I mean you know, I would have done 40 years in 
the Army if I could. I loved it. Loved it to death. And 
hopefully that doesn't discourage anybody from joining the 
military or the people that are in the military right now. And 
the situation can get fixed in the near future so they are 
taken care of. Yes, sir?
    Mr. Hare. Thank you.
    Mr. Forrester. If I may, Congressman, just quickly 
regarding what is at the root of the problem and so to the 
question of who is to blame. I would like to take a step back 
and say that I think that this is an issue that crosses 
partisan lines. There is no partisan divide on this issue. 
Fortunately, the DoD Mental Health Task Force which reported 
out about a month ago has done a great service for this 
country. And I would, I am sure that many of you have read it, 
but for those who haven't I would recommend that you read it, 
because in this official document of the DoD Mental Health Task 
Force, they talk about the great magnitude of the mental health 
problems coming out of the war. They talk about the inadequate 
resources that have been devoted to treating mental health 
problems within the military, the poor training that exists in 
some cases. And then the pervasive stigma against treatment.
    As people within the military mental health community will 
tell you, the military, as we know, is part of society. And so 
these are in some ways societal problems where people haven't 
been well educated on the mental health needs and mental 
health, proper mental health treatment as for instance, your 
bill works to address some of these issues. Once again, I am 
heartened by the fact that in the Senate--while Senator Obama 
was quite prominent in the proposing of this amendment to have 
a moratorium on PD dismissals--as we know, the letter calling 
for this was signed by 31 Senators. This is a bipartisan group. 
Fortunately the four offices that lead on this issue in the 
Senate are Senator Christopher Bond from Missouri, Senator Joe 
Lieberman from Connecticut, Senator Barbara Boxer from 
California, and then Senator Obama among others. So just to 
tell you, those four offices, putting those four offices 
together shows that this is not a partisan issue, this is an 
issue that we as a country are beginning to recognize the 
magnitude and as I said, fortunately, documents such as the DoD 
Mental Health Task Force, we will just call it an achievable 
vision have helped to lay out the path forward.
    Mr. Hare. Thank you, Mr. Chairman.
    The Chairman. Thank you. Mr. Lamborn?
    Mr. Lamborn. Thank you, Mr. Chairman. Mr. Kors, this is a 
very important issue and I want to look at the numbers that you 
are using to make sure that we are using the best numbers 
possible.
    You talk about 22,500 soldiers. Now I see that from your 
table on page three that you are including in that number of 
Army, Air Force, Navy, and Marines.
    Mr. Kors. That is right. The 22,500 from the last 6 years 
that spans the entire Armed Forces. You can see how this is a 
problem that is crossed services lines. In the last 6 years in 
just the Army, it is 5,631.
    Mr. Lamborn. Okay. Now out of that those troops, how many 
of them that were discharged under the Chapter for personality 
disorder do you believe had PTSD?
    Mr. Kors. We don't know. We don't know. Having reported on 
this issue and looking at dozens of cases, all of the soldiers 
either had PTSD or like in Jon's case, traumatic brain injury. 
But who exactly these people are I think is precisely why we 
are here today.
    Mr. Lamborn. Okay. I have only got 5 minutes so I will have 
to interrupt here. Now of that 22,500 I noticed that 8,000 are 
Army and Marines. And 14,000 are Air Force and Navy. Now I 
think you would agree with me that the brunt of the ground 
combat has been the Army and Marines. Our Air Force and Navy 
have done really wonderful on other things, but the brunt of 
the ground combat are of those two branches of the services. 
And of those 8,000, how many of them do you think had PTSD 
versus pre-existing personality disorder?
    Mr. Kors. I just don't know. Those figures simply don't 
exist yet because no one is looking.
    Mr. Lamborn. Now the 14,000 who were Air Force and Navy, do 
you think that they had post traumatic stress disorder?
    Mr. Kors. You know, part of the difficulty of finding out 
the answers to those questions is that getting access to the 
medical records for those soldiers has been locked off to the 
media. It has only been soldiers like Jon Town who have bravely 
stepped forward or internal people like Jeff Peskoff who 
processed these personality cases----
    Mr. Lamborn. Okay. Thanks.
    Mr. Kors [continuing]. Come forward----
    Mr. Lamborn. Okay. Thank you.
    Mr. Kors [continuing]. That shares these numbers.
    Mr. Lamborn. Now without seeing all of these individually, 
I don't know the answer either, but is it more likely that PTSD 
is associated with ground combat, even though it can probably 
come from a lot of different other reasons, but is it a safe 
assumption that it is more associated with ground combat and 
the experiences, the traumatic experiences, suffered in ground 
combat as opposed to some of the other military service 
experiences?
    Mr. Kors. I think that is a safe assumption. The soldiers I 
looked at all had served in Iraq came back changed by that 
experience.
    Mr. Lamborn. And you used the years 2001 and 2002 in this 
same table, but the current conflict in Iraq started in 2003. 
So wouldn't it be more accurate to start it from 2003 forward? 
And if you did that you would have 5,500 instead of 8,000. I 
mean would that be a fair gloss to put on this number?
    Mr. Kors. If you wanted to look at that segment, I mean, 
that would certainly be, you know, a good approach as well.
    Mr. Lamborn. Okay. Well anyway I just wanted to ask those 
questions, Mr. Kors, because 22,500 tells me something 
different than, you know, 5,500.
    Mr. Kors. Uh huh.
    Mr. Lamborn. Either way, this is a vital thing and I do 
wish we were working with the Armed Services Committee on this 
as well, but we are not, so we will do what we can. But thank 
you all for being here today.
    Mr. Kors. Thank you.
    Mr. Forrester. May I quickly add, Mr. Chairman? The GAO--
there is--I am sorry Congressman Lamborn. But there is a GAO 
investigation afoot that is asking the kind of questions that 
you are asking right now. And we have and among others we have 
been in touch with them and they have asked for input. So we 
are hopeful that within the next few months they will release 
their report and that they will be able to provide a lot more 
information on this.
    I know that one of the criteria that they are looking at is 
have the regulations been followed when PD discharges have been 
affected. And so once we start to get that sort of level of 
detail, I am hopeful that we will have a much better 
understanding of the numbers.
    Mr. Lamborn. Okay. Thank you all for being here today.
    Mr. Town. Thank you.
    Mr. Lamborn. I yield back, Mr. Chairman.
    The Chairman. Thank you, Mr. Lamborn. Let me make clear, by 
the way, that we are working with the Armed Services Committee. 
They just could not schedule either a Subcommittee and our Full 
Committee before the August recess, and I thought it was 
important for us to hear about this problem. So we are working 
with them and we will continue to do that.
    Mr. McNerney is next, please.
    Mr. McNerney. Thank you, Mr. Chairman. First of all, I want 
to thank Mr. Town and all the active duty members in the 
audience and all the veterans in the audience for their 
service. It is difficult to listen to what we have heard today 
without feeling something is amiss here. And it is going to be 
our duty to get to the bottom of that and to find out what the 
proper course of treatment is.
    There is something in particular that is bothering me a 
little bit about the data that you have presented here Mr. 
Kors, in your presentation. It looks to me like the rate of 
examining or coming up with this discharge, this personality 
disorder discharge, hasn't increased that much since the start 
of the war.
    Mr. Kors. Uh huh.
    Mr. McNerney. Now that tells me that this problem or this 
treatment of servicemembers has been going on for a long time 
before the war started. Could you address that please?
    Mr. Kors. Absolutely. I spoke with a psychiatrist who had 
been looking at this personality disorder issue, you know, back 
as far as the Vietnam era and said this has been a common 
thing. We see this outside the military as well with insurance 
problems people discovering pre-existing conditions as a way of 
not paying. It is a longstanding problem.
    Mr. McNerney. So the war itself hasn't been something that 
has caused a large increase in this sort of treatment, is that 
true?
    Mr. Kors. Well, the numbers on a broad scale would say not. 
I think at individual installations it is, it has. We look at 
Ft. Carson where Jon Town is from. Jeff Peskoff who stepped 
forward for our Night Line broadcast and talked about the 
discharges there. He said that it started off normal and then 
at one point he was getting two or three personality discharges 
a day. Then he say the numbers sharply rise in recent years.
    So how that averages out over, you know, Ft. Campbell, Ft. 
Polk, all the other installations, we just don't know at this 
point.
    Mr. McNerney. Well it is certainly incumbent upon us to 
make sure that no servicemembers are treated in an 
inappropriate way. I am just trying to understand if we look at 
the numbers for the Air Force, they are higher before the war 
and the Navy, then they decrease, whereas, the Army--excuse 
me--seems to increase. So we, as a Committee, need to look at 
this pattern. If it has been continuing on since the Vietnam 
war, how many of people have been mistreated like this? And if 
not, what is the appropriate way to describe the situation?
    Mr. Kors. Frank Ofberg, the doctor I referred to earlier 
who codified post traumatic stress disorder, he said in the 
olden days it was actually much worse when there was no such 
thing as post traumatic stress disorder. He said at that point 
you either got a false personality disorder diagnosis or 
nothing. There was no alternative. At least now, some lucky few 
who fight aggressively are able to reach a medical board and 
get disability pay.
    Mr. McNerney. Thank you, Mr. Kors.
    The Chairman. Thank you, Mr. McNerney. Mr. Brown?
    Mr. Brown of South Carolina. Thank you, Mr. Chairman. 
Thanks for holding this hearing today. And it has just been 
very informative for me and I know, and as personal note my 
brother-in-law had PTSD and his last few years on Earth was not 
very pleasant. And so, we understand the need for it and this 
is something that we have been addressing for some time. Thank 
you for coming and help sharing some of the information that 
has, you know, surrounded that issue.
    Mr. Sullivan, are you a veteran?
    Mr. Sullivan. Yes. I am an Army veteran. I served in the 
First Armor Division as a cavalry scout in the invasion of Iraq 
in 1991.
    Mr. Brown of South Carolina. Okay. My question is, and I 
guess like Mr. McNerney, is looking at those numbers that, you 
know, before the Iraqi conflict and after Iraqi conflict, is 
there a good pre-screening for the enlistees that come into the 
military to be sure there are no pre-existing conditions?
    Mr. Sullivan. Is that addressed to me or to----
    Mr. Brown of South Carolina. Yes. Yes. To you. Anybody who 
wants to answer. I guess I am trying to get a handle of how the 
numbers really hadn't changed very much on a yearly basis, but 
before and after the conflict. And so, I am just trying to look 
for some other reasoning in this questioning. So I am just 
going to start with that. I have got some other follow ups on 
that too.
    Mr. Sullivan. Thank you, Congressman. What Veterans for 
Common Sense is doing is asking for the investigation. We know 
that there is a GAO investigation that started on this. Our 
concern is this: Is deployment one of the factors in the 
personality disorder diagnosis discharge? We are concerned that 
it may be impacted at specific military installations like Ft. 
Carson where it may be going up. And it may be masked by 
decreases at other locations.
    So, Congressman, we won't know until there has been a 
thorough analysis. What that Joshua Kors has done is provide 
the initial statistics to indicate that there is a problem. 
What we need is some further analysis to make sure we get at 
the why. And then as soon as we know that, then we can begin to 
correct it.
    That is why we also called for a moratorium on the 
Personality disorder discharges until they can figure out what 
is going on.
    Mr. Brown of South Carolina. And I guess that is what 
raised the question to me is that is there something in the 
military lifestyle that maybe I know that the battle weariness 
is certainly one of those components. But or is there something 
that is in training or something that is involved in the 
military that would, you know, would influence the PTSD? And I 
guess that is since those numbers certainly don't seem to move 
very much whether we are at war or not at war, there must be 
some underlying other reasons that influence PTSD. I know you 
know certainly with the Mr. Town, I can understand his. But 
there are other events that must influence you know PTSD too. 
And I guess that is a broader range and I don't whether Mr. 
Kors whether he actually looked at that or not or whether he 
was just focused, just on the those influenced by some level of 
battle.
    Mr. Kors. Pardon me. Whether I looked at what now?
    Mr. Brown of South Carolina. The overall picture. You saw 
those numbers, right? That they the numbers really have not 
moved much prior to the conflict in Iraq and the years, the 
last 3 years coming up to that. And I have, you know, so I 
was--I am just kind of concerned that if there are some other 
major issues out there in the military that would influence 
causing PTSD other than just being a part of the battle 
conflict.
    Mr. Kors. I just can't say. And I should back up Paul's 
comment by saying it is not just important to talk about the 
why, but the who. Who are these, you know, 22,000 people? Who 
are these 5,600 from the Army? I know the veterans groups like 
Paul has expressed to me. There is a hope that not only will we 
look to Obama's amendment to stop this from happening, but to 
go back and look at the thousands of other Jon Towns who need 
help right now.
    Mr. Brown of South Carolina. And let me say, I am very 
sympathetic for that. And I think we have got to address that. 
But what I am more concerned with, not more concerned with, but 
absolutely concerned with is, is there, if we can some how 
eliminate the cause.
    Mr. Forrester. Congressman, if I may? To this question of 
what causes PTSD, the Mental Health Advisory Team, MHAT IV. 
Well there have been four of them now. This is done by the Army 
Surgeon General's office. They have done detailed studies on 
what is happening in theater at present and how combat 
experiences among other stresses, family stresses, combat, and 
so forth, are affecting the mental health.
    And this is once again a good resource that we have and 
that I think will be fed into these GAO studies and others to 
get a better idea of how this whole system fits together from 
CONAS to theater and back. The DoD Mental Health Task Force, 
when they talked about the resource problem, they talked about 
a lot of the mental health resources having been surged into 
the field as people would expect. So that has a left a 
deficiency in the United States and a lot of the military 
facilities.
    And fortunately, and I know Ft. Carson has been raised a 
number of times, but to take Ft. Carson, the leaders at Ft. 
Carson are talking about increasing the number of mental health 
providers. They know they have a mess on their hands----
    Mr. Brown of South Carolina. Right.
    Mr. Forrester [continuing]. And they are doing what they 
can to address it. So as we all know it is a mini--a multi 
faceted problem and so hopefully after more study we will have 
a better idea of how it all fits together.
    Mr. Brown of South Carolina. Well let me say, thank you 
very much for coming and thank you Mr. Town for your 
perseverance on this. And although I know that you are one of 
22,000, at least you know you have been able to get your 
message. And we certainly have a commitment to those other 
22,000 to be sure their needs are being met too.
    But I just wanted to put in there a caveat too that we 
would like to be able to help solve the recurrent problem, 
whatever it is in the military to be sure that those lifestyles 
are being addressed that would help prevent more. I know you 
had a particular incident that you can relate to, but maybe a 
lot of others can't. But it is certainly a major concern. It 
has been a major concern of mine since I have been on this 
Committee for 7 years. And I appreciate you all's advocacy on 
it.
    And thank you all for being here. Thank you, Mr. Chairman.
    Mr. Sullivan. Congressman Brown, if I could add one other 
point. Not only is combat one of the important variables, we 
also have an increase in sexual assault and rape both of women 
and men, servicemen and women in theater. And that can also 
play a role in the development of PTSD and someone who went to 
a war zone. And sometimes someone who did go to a war zone.
    Mr. Town. And, sir, I actually have a comment as well. As 
far as the screening that you were asking about. I was screened 
prior to coming into the military. I was screened prior to 
PCSing to Korea. I was screened prior to deploying to Iraq. I 
was screened when I came back from Iraq and that is when I was 
diagnosed with a personality disorder.
    Mr. Brown of South Carolina. So the other screening's 
reflected no indication at all?
    Mr. Town. Correct.
    Mr. Brown of South Carolina. Okay. Thank you very much.
    The Chairman. Thank you, Mr. Brown. Mr. Rodriguez?
    Mr. Rodriguez. Thank you, Mr. Chairman. And first I want to 
personally thank you for holding this hearing and I am glad you 
didn't wait. And I am really concerned and I think that it 
might even be worse because if someone is diagnosing and is 
doing it for the purpose and knows full well that the purposes 
are to try to just come up with then there is no doubt that 
they could be doing that on other diagnoses. I know that if my 
son or daughter were diagnosed in this way that I would quickly 
ask for a second opinion if not a third. I am interested in the 
recommendations that you have, Mr. Sullivan, and I know the 
Chairman has already touched upon them, about trying to come up 
with a way for our soldieries who fall under a war zone to 
automatically have to go through some process of assessment so 
that they won't be a--there won't be a stigma to that. And just 
make it a mandatory kind of approach that that would be doing.
    Does your lawsuit include the Department of Defense and the 
VA or is it just the VA?
    Mr. Sullivan. At this time the lawsuit, I have a copy of it 
with me if you want to see it, is against the Department of 
Veterans Affairs, but it also includes the Department of 
Justice and some of their responsibilities.
    Mr. Rodriguez. The DoD. Now you also asked, you know, and I 
agree that we need to go back and reassess, not just those 22 
because once again if there is a psychiatrist there that has 
diagnosed them wrong, whatever other diagnosis ought to be in 
question. You know and so I think that we have a more serious 
situation.
    I had done some studies when I taught 11 years at the 
School of Social Work, and I knew that there were some 
disparities and discriminatory practices as it dealt with 
certain diagnosis when it came to women or African Americans 
and those kind--have you picked up on any types of disparities 
besides you know individuals and PTSD?
    Mr. Kors. On racial or gender lines I haven't. But you make 
a very strong point about the doctors themselves. I am so glad 
you asked that.
    As I mentioned before, Surgeon General Gale Pollock tapped 
Colonel Steven Knorr, the Chief of Behavior Health at Ft. 
Carson, as the one and only reviewer. And when we look at who 
he is, I think that is critical. National Public Radio's Daniel 
Zwerdling, an award winning reporter, wrote a fantastic recent 
piece about Knorr as this key figure in this national review. 
And I just want to read a small snippet of that.
    ``Knorr has written a memo warning commanders that trying 
to save every soldier is 'A mistake.' We can't fix every 
soldier, Knorr's memo states, we have to hold soldiers 
accountable for their behavior. Everyone in life besides 
babies, the insane, the demented and the mentally retarded has 
to be held accountable for what they do in life.''
    Knorr's memo, which he posted on his office's bulletin 
board, also warns commanders not to make another mistake. 
``Procrastination on discipline and separation, translation, 
officers should get rid of troubled soldiers quickly.''
    He seems a strange choice to be the one and only person to 
look at these issues.
    Mr. Rodriguez. And it is unfortunate. I want to personally 
thank you, Mr. Town, for being here with us. I want to 
personally thank you for your service to our country and for 
what you are doing now, and because I know that it will have an 
impact in terms of what are we going to be doing to making sure 
that we do the right thing and start in that direction.
    And so--yes, sir?
    Mr. Forrester. If I may, very quickly add, Congressman 
regarding your question about the racial and or sexual issues 
within the military. At present the Wounded Warrior Bill in the 
Senate has a provision calling for a comprehensive study of the 
readjustment needs of this generation of servicemembers and 
veterans. This amendment was unanimously approved by the Senate 
Armed Services Committee about a month ago. And was also later 
approved on the Floor and we are hopeful that it will make its 
way to Conference eventually.
    This study would get at the kind of questions that you are 
asking. Let us look at our military from top to bottom. Those 
people who are coming out of these wars, as we know each war 
creates a unique set of needs. And so our argument is that we 
should not wait a decade as we did after the Vietnam war to do 
a national study of the readjustment needs of this generation 
and all--and there are many diverse parts as we know.
    And so I would also urge Members of this Committee to 
consider this provision which there may be a House version 
introduced soon as well.
    Mr. Rodriguez. And I agree. And that there is also a large 
number of individuals afterward that have committed suicide. 
And that is something that we all need to look at. I know I 
heard a personal story about a soldier that supposedly 
committed suicide in Iraq, and was treated very differently 
from the other soldiers that have lost their lives. And of 
course the family is devastated.
    And so I am still trying to get a personal assessment of 
that since the parents had a discussion with the soldier the 
day before, and all indications were that things were okay. So 
once again, let me thank the entire panel for what you are 
doing here and hopefully we will get to the bottom of it. Thank 
you.
    The Chairman. Thank you. Mr. Stearns. Okay. I have the list 
if you want to change, that's fine. Ms. Brown-Waite?
    Ms. Brown-Waite. Thank you, Mr. Chairman. There certainly, 
when reading through the testimony, I didn't, Mr. Kors I have 
to say I did not see the television show. But reading through 
the testimony, certainly I am glad that the Chairman said that 
he is working with the Armed Services Committee, because this 
clearly is a Department of Defense situation.
    The Chairman. Ms. Brown-Waite, if you could use the 
microphone. Thank you.
    Ms. Brown-Waite. Certainly. It is a Department of Defense 
situation where they made that decision. But, Mr. Kors, I want 
to ask you a question. I am completely diametrically opposite 
to this. I had a constituent who had been diagnosed with 
personality disorder. Turned 18. Went to the local recruiter 
and the local recruiter said stop taking your medicine, do not 
tell anyone. This very impressionable 18 year old got into the 
military. Had a nervous break down. Parents and grandparents 
both contacted me.
    Had you the opportunity to look into this at all about 
recruiters misleading those people before they join, as an 
incitement to join getting them to not take their medication 
because some of the recruiters are desperate. If you could 
answer that.
    Mr. Kors. Congresswoman, I am glad you mentioned that. Just 
recently my conversation with that psychiatrist from the 
prominent east coast Army facility, he talked about that 
approach to recruiting soldiers, warm bodies as they call it 
with the recruiting shortage that we are facing now because of 
the Iraq war. He quoted his Chief of Behavior Health at the 
Hospital as phrasing it this way: Regardless of what their 
problems are, if they are not homicidal or suicidal, let's get 
them to Iraq. If they can't function anymore, as was the case 
with Jon's memory loss, let's find a way to slip them out the 
side door with a pre-existing condition.
    Ms. Brown-Waite. You know it is very interesting because 
specifically what happened was this young man only spent out of 
2\1/2\ months, he only spent 2 weeks in boot camp. The rest of 
the time they were paying for him to be in a private facility. 
I was talking with the brass and saying to them, I can get you 
his previous mental health records. This recruiter, by the way 
who only got a slap on the wrist, who really encouraged him 
first of all to stop taking his medication and to virtually lie 
to get into the military. I can't help but believe that this 
doesn't happen more often.
    And then, when he was in, it was a ``he is here and we are 
going to make a man out of him. You are not getting him out.'' 
Well the parents went and contacted the Army. My office 
contacted the Army. I spoke to his commanding officer who 
basically said ``he is here, he is ours, you are not getting 
him back. If he lied, he committed fraud. We will bring him up 
on charges, but we are not letting him go.''
    It was last summer I spent a great deal of my summer 
fighting for this young man who never ever should of been 
enlisted in the military. And when, you know, when this issue 
goes before the Armed Services Committee, Mr. Chairman, I hope 
that you will also make sure that that issue is brought up. 
That is a serious problem. The one thing that I said was, ``So 
you are willing to spend almost $1,000 a day to keep this young 
man in a private facility, when you would not want him next to 
you on the battlefield,'' because certainly the multiple mental 
health issues that he had do not make him any where near fit 
for the military, let alone to go into a war zone.
    It was it really was--he at that point was a captured 
prisoner by the U.S. Army. So I do hope that we will also look 
into that situation where truly he had a personality disorder. 
They had him and they were not going to let him go. So it is 
180 degrees from the situation with Mr. Town.
    But let me ask one other question.
    Mr. Kors. Congresswoman? I just----
    Ms. Brown-Waite. Yes.
    Mr. Kors [continuing]. Can I address that issue? The 
accusation you highlighted that the soldiers lied during their 
incoming screening is, has really been, the salt in the wounds 
for these disabled soldiers.
    Ms. Brown-Waite. I didn't say that.
    Mr. Kors. No, no. No. This is what the----
    Ms. Brown-Waite. Right.
    Mr. Kors. No, no, no. You meant you quoted----
    Ms. Brown-Waite. Right.
    Mr. Kors [continuing]. The Army officer as saying that. And 
that has been a common refrain from the upper brass of the 
military in ourNightline piece. Surgeon General Gal Pollock's 
top psychiatric official Ellsbeth Richey quoted that accusation 
as really the only understanding of how these soldiers with the 
severe psychological pre-condition could get into the military, 
they simply didn't cough up the information during their 
initial screening.
    Ms. Brown-Waite. One other question, Mr. Chairman, if you 
will indulge me. I also have heard from some in the mental 
health community who are treating veterans with PTSD who are 
telling me that in an effort to save some money, that the VA 
has gone to a 13-session PTSD module. And it really is a module 
of treatment that is meant for a sexual abuse or a rape victim. 
Have you at all, anybody on the panel, also been aware of that 
phenomena?
    Mr. Kors. No.
    Ms. Brown-Waite. Okay.
    Mr. Forrester. No, ma'am.
    Ms. Brown-Waite. Mr. Chairman, I yield back the balance of 
my time.
    The Chairman. Thank you. Ms. Herseth Sandlin?
    Ms. Herseth Sandlin. Thank you, Mr. Chairman. And I too 
want to thank you for this very important hearing and thank 
each of our witnesses today for their very unique and important 
roles in bringing attention to this very serious matter. And I 
have a few statements that I think are necessary for the record 
before posing some questions based on the discussion that has 
already taken place. And I look forward to the further analysis 
that will be provided so that we can better identify how we 
target our manner of addressing this problem. I, for one, don't 
need any further evidence or analysis that this a problem. And 
if we want to focus on the numbers that is fine, but the fact 
that we have one individual and Mr. Town who was treated this 
way, whether it is 22,000 or 5,500; whether it is just from the 
Army and Marines or the Air Force and the Navy, which we should 
all acknowledge the Air Force and the Navy have contributed a 
number of servicemembers who have been in ground combat. So 
making these distinctions among the branches, making 
distinctions about what years we are talking about, whether we 
start with 2001 or 2003, I don't need any further evidence. And 
part of it is because we have to take this issue in the broader 
context of what we have been dealing with in the last few years 
that this is additional evidence that we were not prepared to 
take care of another new generation of veterans.
    So we can talk about making distinctions about years and 
about numbers and about branches, but I think we have enough 
evidence already to say that this is a problem. And the further 
analysis will shed light on how we best address effectively 
solving the problem. I also think that there has been important 
testimony here today about the broader context of society at 
large and hopefully we will make some important progress there 
by passing Congressman Patrick Kennedy's bill on mental health 
parity so that this problem can be addressed, not just in the 
military, not just in DoD installations and the VA facilities, 
but in the private insurance industry, in our public health 
programs, and the values issue of how we take care of one 
another.
    I think it speaks volumes that the Surgeon General isn't 
here today despite the invitation to join us. Mr. Town, I can 
understand why the psychiatrist that you met with at the VA was 
in tears after about 25 minutes. When you re-enlisted in Iraq, 
was that after the explosion in October of 2004?
    Mr. Town. It was before the explosion.
    Ms. Herseth Sandlin. And all of the prior screenings that 
you described, was there any screening once you were in Iraq, 
either prior to re-enlistment or after re-enlistment?
    Mr. Town. They had a screening 2 months after we got to 
Iraq. I can't be--I can't remember what it was about, but they 
had a screening for medical issues at that time.
    Ms. Herseth Sandlin. Okay. And I think that either you 
testified or Mr. Kors you did, in addition to being diagnosed 
with PTSD, Mr. Town, have you also been diagnosed with 
traumatic brain injury?
    Mr. Town. Yes, ma'am.
    Ms. Herseth Sandlin. When you met with the doctor at Ft. 
Carson, and either you can answer this or others on the panel, 
if there were concerns that the doctor, the psychiatrist, at 
Ft. Carson had about the symptoms that you were exhibiting even 
though there was no diagnosis there of PTSD, but there was 
clearly a concern on his part about redeploying you. Were there 
any other options other than the personality disorder to 
prevent Mr. Town's redeployment?
    Mr. Town. Soldiers can go through a medical board. And it 
is a little lengthy process, but you go in front of a board of 
medical doctors and they listen to your case. And they make a 
decision if you are not fit for duty or fit for duty at that 
time.
    Ms. Herseth Sandlin. And thank you for explaining that and 
I know that is a lengthier process, but there is no other 
option for a treating psychiatrist other than the personality 
disorder or the medical board process to prevent a redeployment 
in the--in the case of a servicemember who is clearly suffering 
from the affects of prior ground combat for PTSD? Is there any 
other----
    Mr. Sullivan. Well what I hear you asking for, 
Congresswoman, is there a second opinion? And the answer is I 
am not aware that there is. And one of the biggest problems 
facing soldiers unlike Specialist Town is that they have no 
advocate. It is a denial of their civil rights. It is a denial 
of their dignity as a human being, and an American soldier that 
they be provided with some assistance before being discharged 
for a medical reason, especially if it involves a brain injury 
that is clearly documented or a mental health condition.
    Denying the soldier basic due process is unconscionable 
after they have been wounded. And if I may give this analogy: 
How many people here would agree that if I was in a car wreck, 
that the attorney of the person who ran into me, and it was 
their fault of course, was at my bedside in the hospital asking 
me to sign paperwork on a settlement. We know that that is 
absolutely unethical. And what is happening in these situations 
because the soldiers don't have advocates, they are losing out 
on the due process. That needs to be fixed. Not only for the 
service, but also at VA.
    Ms. Herseth Sandlin. Thank you, Mr. Sullivan. Mr. Chairman, 
if I might ask one quick follow up question?
    The Chairman. Please.
    Ms. Herseth Sandlin. Mr. Town, or Mr. Kors I know you are 
very familiar with Mr. Town's case. Did you--you said that you 
filed five different times with the VA before they would 
actually review your case?
    Mr. Town. Yes, ma'am. I filed one a month prior to me 
getting out of service. One 2 months after and a month in 
between the next three. And the last one I filed was a month 
prior to the article being written in The Nation by Joshua. And 
that is when I got the call from VA that said, ``Hey, we have 
caught wind of--we want you to come down to Dayton as soon as 
possible.''
    Ms. Herseth Sandlin. Thank you all. Thank you, Mr. 
Chairman.
    Mr. Kors. I followed up with the VA on exactly how that 
happened. Their--the VA's explanation was pretty simple. They 
said, ``We lost it.'' We lost each of those five submissions.
    The Chairman. Thank you Ms. Herseth Sandlin. I ask 
unanimous consent to allow our colleague Congressman Patrick 
Kennedy to sit with us. He has been a leader on issues of 
mental health. Thank you for joining us. Hearing no objection. 
Ms. Brown, if you have one question before you have to go?
    Ms. Brown of Florida. Yes. Thank you. Thank you, Mr. 
Chairman for holding this hearing. And first of all let me 
thank Mr. Town for your service. Thank you very much. And I do 
have a question for you, but let me just say to Mr. Kors, it is 
important to see the media at the forefront of government. And 
when they don't do their job, this is the result, we have a 
failure in the system.
    I always know it is more than one side, but we have to get 
it out there. And all of us know the amount of casework for 
veterans we do in our offices, when the system is giving them 
the run around. And we, you know the Members of Congress, we 
stop it for individual veterans, but the system needs to be 
fixed.
    Let me say, Mr. Town, I have a question for you. Later we 
are going to hear from Colonel Crow and in his testimony he 
states that, ``Before separation soldiers have the opportunity 
to consult with an attorney.'' And they are told about their 
abilities to petition the Army Discharge Review Board or the 
Army Board of Correction or Military Records for Administrative 
Review of their cases. Did this happen with you, sir?
    Mr. Town. I did go see the Judge Advocate General (JAG). 
The process is as you go see JAG with your non-commissioned 
officer (NCO) or the person in command of you. You go over 
there, they say that you need to sign this paper, this paper, 
this paper and they give you a paper. I actually do not have 
that with me, but I will have to get that document. And it said 
what I was suppose to get when I left the Army with this 
personality disorder discharge. And it had, you know, the 
severance pay, benefits, and free, you know, the free burial. A 
whole of list, a whole page and a half of stuff. And of course 
that was all lies and that was given to me by JAG there at Ft. 
Carson.
    Ms. Brown of Florida. Okay.
    Mr. Kors. Congresswoman? The----
    Ms. Brown of Florida. Yes?
    Mr. Kors [continuing]. Army Board of Military Correction of 
Records is an interesting organization I looked into. And in 
the past year, all the cases that I reviewed, only one was 
overturned in through that Board. That was the case of William 
Woldridge who began suffering schizophrenic delusions after he 
accidentally ran over a young Iraqi girl who was pushed into 
the road. He was hauling a supply truck and she was killed. She 
was about the age of his young daughter. And later in his 
apartment in Arkansas, he was haunted by the mangled ghost of 
that girl.
    That condition was seen as the result of a pre-existing 
personality disorder and he fought it through the Army Board of 
Correction of Records. That case was pretty clear, not just 
because of the facts of the case, but also because the only 
reason it was overturned was because he had a top connection in 
Washington who worked behind the scenes at the Board to create 
that overturn.
    Ms. Brown of Florida. Thank you. And thank you, Mr. 
Chairman.
    The Chairman. Mr. Stearns?
    Mr. Stearns. Yeah. Thank you, Mr. Chairman and I thank you 
for holding this hearing. I am a little more optimistic than 
the gentle lady from South Dakota when she said the VA is not 
prepared to take care of another generation of veterans. I 
think with the money and resources that we have provided them, 
I think they are working admirably to do that. There is going 
to be cases like this and this is reprehensible what happened 
to Mr. Town. But I think when that the VA is working diligently 
and I think this case is an example where there needs to be 
improvement. Obviously, this Committee doesn't have the full 
jurisdiction. The jurisdiction is in the Department of Defense 
and that is where the hearing should be. But we welcome the 
opportunity to talk about this.
    Mr. Kors, you keep mentioning the 22,000 and Mr. Lamborn 
brought out that the 22,000 is included in that number is not 
even when the Iraq war had started in 2003. And he pointed out 
that roughly only 5,500 were actually Army/Marine combat 
veterans. Of the 22,000, do you know how many were combat 
veterans who actually served in combat?
    Mr. Kors. No. And that is another key point as well.
    Mr. Stearns. Right.
    Mr. Kors. Bob Woodruff and I asked that question to Colonel 
Ellsbeth Richey in our Nightline report and she didn't know 
either.
    Mr. Stearns. Do you think that is a relevant point?
    Mr. Kors. I think it is. And I think a full review that 
hopefully could come from a hearing like this----
    Mr. Stearns. Yeah.
    Mr. Kors [continuing]. Will determine just how many of 
those thousands of soldiers served in Iraq.
    Mr. Stearns. Colonel Bruce Crow who is coming later in this 
panel, has talked a little bit about statistics and he gave, 
for example, about 70,000 soldiers were discharged from the 
active Army, just the Army, in 2006. Of those discharged 
roughly 1,100 were separated for personality disorder of which 
roughly 300 of those individuals had served in a theater of 
combat. To the uniform civilian and contract healthcare 
professionals that care for soldiers, the thought of even one 
soldier being inappropriately discharged for personality 
disorder is disturbing.
    So I mean, that really explains how the Veterans 
Administration feels too. With that in mind, in fact, the 
acting Surgeon General, Major General Gale Pollock, has 
directed each and every one of these 300 records be reviewed by 
behavior health professionals to verify that appropriate 
actions were taken and that all health concerns were considered 
in the discharge.
    So I think the VA is well aware of this problem, and is 
trying to make efforts. Mr. Kors, I think in your statement, 
your opening statement, you indicated that perhaps the 
Secretary of Veterans Affairs had to step down and you linked 
it with Walter Reed--when you mentioned that in your previous 
sentence--and the Surgeon General Kiley resigning also. I don't 
think it is fair to say that Senator Nicholson stepped down 
because of the personality disorder discharges.
    Mr. Kors. No. No. I certainly didn't mean it----
    Mr. Stearns. But your statement here implies it and I think 
you are inappropriate to indicate that in the same sentence 
when you talk about these other people resigning.
    The Chairman. Did you say Senator Nicholson?
    Mr. Stearns. Secretary Nicholson.
    The Chairman. Thank you.
    Mr. Stearns. Thank you for the correction. Yeah.
    The Chairman. We were wondering why----
    Mr. Stearns. Right. Right. No. So I just if you would like 
in open testimony to say that is not what you implied, that 
would be appreciated.
    Mr. Kors. I don't think that the fallout from the publicity 
on this issue was certainly helpful to him, but I did not mean 
to make a one-to-one correlation.
    Mr. Stearns. Right. And I didn't think you did, so I wanted 
to make sure that you had that opportunity to disclaim that.
    Mr. Sullivan, when you made your suit, did you contact any 
VSOs to say here's the evidence, the American Legion, or any of 
the VSOs to say, what do you think? Just yes or no.
    Mr. Sullivan. I would direct that question to the attorney 
handling the suit, Gorden Erspamer at Morrison and Foerster in 
San Francisco.
    Mr. Stearns. Well aren't you the one that--you are the 
executive director of the Veterans for Common Sense. You are 
making the suit, is that correct?
    Mr. Sullivan. Yes. That is--I am not making it on my own 
behalf, the organization is.
    Mr. Stearns. Yeah, the organization. And you are the 
executive director, so you are what we call the talking head 
for the group. And with that in mind, did you ever call any 
VSO? Did you ever contact the American Legion about this suit 
or the Veterans of Foreign Wars or anybody?
    Mr. Sullivan. Again, Congressman----
    Mr. Stearns. If not, I am curious----
    Mr. Sullivan [continuing]. I already answered the question. 
If you want to ask that, you can ask the lead attorney on the 
case. Thank you.
    Mr. Stearns. Well I think the lead attorney would be a good 
one to contact, but he takes his directions, I think, from the 
organization that is making the suit, which is the Veterans for 
Common Sense. So I just think that for the suit to have to be 
extremely valid, should also encompass some of these VSOs and 
their opinions, I would say.
    Let me ask the last question. In reading the lawsuit you 
filed in Federal Court, Mr. Sullivan, it is unclear to me what 
you expected the court to do. Were you looking for an 
injunction of some kind or something else? What do you--what 
does your organization ultimately expect to happen?
    Mr. Sullivan. Thank you for asking the salient question, 
Congressman. The bottom line goal of the suit as described in 
it is very simple. If a servicemember goes to war and they come 
back wounded, injured, ill, and they need medical care, the 
country has an obligation, social contract, to provide that 
care. They don't, the veteran should not have to file 23-page 
claim form. The veteran should not have to wait endlessly for 
Health Maintenance Organization (HMO) like decisions. The 
veteran should be able to see the doctor right away. We are 
very familiar with the case of the veteran Jonathon Shulzy in 
Minnesota who tried to go VA multiple times and was turned 
away. A very disturbing case. That shouldn't happen.
    In a similar manner, the suit is looking to fix this other 
question. If a veteran is disabled and has difficulty working 
or having problems with the quality of their life and they need 
disability benefits, again the veteran shouldn't have to wade 
through endless paperwork by themselves to try to get a 
reasonable disability check so that they can put food on the 
table for their family, pay their rent, and make sure they 
don't go bankrupt or get foreclosed. It is a very solemn 
obligation our country has with that veteran. And we want to 
make sure that the veterans have their civil rights protected 
as individuals, that they get the due process that they earned. 
For example, having an attorney when they initially file a 
claim so that when they want to be able to get the healthcare 
and benefits they earned, they don't have to wait.
    These are basic, common sense, human dignity issues. And we 
can talk about numbers, Congressmen, or who is on the suit or 
who is not. The court issue right now that the backlog of 
claims is soaring. It is taking longer for veterans to get 
their disability checks. Veterans are being turned away because 
some VA facilities don't have mental healthcare. And that is 
according to VA's own top officials.
    Those two things need to be fixed, Congressman. We went 
through some of this with the gulf war where veterans were 
coming back and if we had problems trying to get care. And I 
remember working at VA and when I saw the numbers coming in on 
mental healthcare and some other disabilities, I used facts and 
numbers and what I thought was very thorough analysis to send 
up a red warning flag that the crisis had hit VA. And 
unfortunately VA did not ramp up in 2004, in 2005. And we are 
suffering the consequences now for the failure to act earlier.
    The suit will have the purpose of not allowing addressing 
this issue in court, which every American has the right to do, 
but the suit will also raise the issue in the court of public 
opinion, because at the end of the day, the people run the 
country. And if they start call their Congressmen and their 
Senators and saying, ``Lets make sure that veteran gets his 
healthcare. Lets make sure that veteran gets his disability 
benefit.'' Then we also served another purpose. And that is 
what I hope we can do what we can do with the suit.
    Mr. Stearns. Thank you, Mr. Chairman.
    Mr. Kennedy. If I could speak out of order. I believe this 
lawsuit is a catalyst to get the VA to work with community 
mental health providers to get the necessary mental health to 
our veterans yesterday and today that they can't postpone any 
longer. The VA is not at capacity right now. As you know, this 
Congress appropriated $500 million in last year's supplemental 
for mental health that the VA was not able to expend because it 
didn't have the mental health professionals to hire.
    The reason they couldn't hire them is that they weren't out 
there. They shouldn't be hiring them, they should be 
contracting out with existing mental health providers already 
in the community. But guess what? The VA doesn't want to 
contract out because the VA wants to keep everything in-house 
because they are so insular. Because no one wants to share 
their turf. And who is suffering because of this turf battle 
but the veterans. And I hope as a member of the Milcon VA 
Appropriations Subcommittee, that in the conference, that we 
get to put this Committee's authorizing language allowing for 
the VA to share resources with outside mental health providers 
into the Milcon VA Appropriations Conference Committee Report 
so that we can force the VA to contract with outside mental 
health providers, in this Conference Committee Report that will 
be coming up.
    And I thank you, Mr. Sullivan, for instigating this 
lawsuit.
    Mr. Buyer. Will the gentleman yield?
    Mr. Kennedy. Yes. Be happy to yield.
    Mr. Buyer. Mr. Kennedy, I will work with you and I work 
with Mr. Michaud. Before you came in, that was Mr. Michaud's 
point in particular to try to be persuasive to the VA to do 
more contracting of care. It shouldn't just for mental health, 
but for many other types of rehabilitative----
    Mr. Kennedy. Absolutely.
    Mr. Buyer [continuing]. Services and I will work with the 
gentleman.
    Mr. Kennedy. Absolutely. Thank you.
    The Chairman. Thank you, Mr. Kennedy and thank you for your 
leadership on this.
    Mr. Baker.
    Mr. Baker. Thank you, Mr. Chairman.
    The Chairman. We just had--Mr. Donnelly is next. And then 
you.
    Mr. Donnelly. Thank you, Mr. Chairman. And thank you Mr. 
Town for your service and to all the veterans here.
    I wanted to ask you, Mr. Town, you were diagnosed with 
traumatic brain injury, is that correct?
    Mr. Town. Correct.
    Mr. Donnelly. When you were leaving the service, what 
options did they tell you you had in regards to treatment for 
your traumatic brain injury?
    Mr. Town. Dr. Wexler, the psychiatrist that I was going to, 
he stated that when I got out the VA would take care of me.
    Mr. Donnelly. Did he tell you that there were specific VA 
centers that specialized in traumatic brain injury?
    Mr. Town. No.
    Mr. Donnelly. Okay. Did they ever indicate to you while you 
were still on active duty that you had an option to go to 
places like the Chicago Rehabilitation Institute?
    Mr. Town. No.
    Mr. Donnelly. It was pretty much just said the VA can work 
with you and good luck?
    Mr. Town. Pretty much. Yes, sir.
    Mr. Donnelly. Secondly, when did you first see the terms of 
your termination? You indicated that you worked with JAG. When 
did they first start to tell you, ``Here are the terms that you 
will go out under.''
    Mr. Town. When I saw JAG they showed me the terms of the 
benefits that I was going to receive when I left the service, 
but the day I actually left the service is when I found out 
what the real benefits were and that it was a pre-existing 
condition. That was the first time I ever found out that is was 
a pre-existing condition to me being in the military, thus 
meaning it is not service connected.
    Mr. Donnelly. Did you have a copy of what they had 
previously promised you?
    Mr. Town. Yes. I have a copy, not with me. I have to get 
that out. I will get that.
    Mr. Donnelly. And at the time you were leaving the service 
did you say, ``Hey, listen, I have got a whole different plan 
here that was promised to me.''
    Mr. Town. Yes, sir.
    Mr. Donnelly. And their response was?
    Mr. Town. That they didn't have a responce. The gentleman 
who does the final out has actually come forth and done 
interviews now. And the day I was signing out he actually gave 
me IAVA's card and said that they had been doing this injustice 
by what they were doing to the veterans that are getting out of 
the service. And suggested that I call IAVA and talk to them 
and see what I could do about this situation.
    Mr. Donnelly. So the gentleman signing you out at the time 
he was signing you out basically told you that you were getting 
a raw deal?
    Mr. Town. Yes, sir.
    Mr. Donnelly. Okay. And you showed him and you said, 
``Listen, I have been promised other terms.'' He said those 
terms are no longer applicable?
    Mr. Town. Correct. And then he showed me the paperwork that 
said I had a re-enlistment bonus that I needed to pay back. 
They were going to only let me sell back 30 days of my leave 
and all that was going to go to my debt. And then I still owed 
$3,000 to the military.
    Mr. Donnelly. And when you were first told about the terms 
that were so different from the final terms, did they give you 
any documents to sign off at, at that time, or how long before 
your final departure did you finally get the documents that 
said, ``These are the final terms. Sign here.''
    Mr. Town. That day.
    Mr. Donnelly. No 24-hour buyer's remorse?
    Mr. Town. No. It was that day.
    Mr. Donnelly. Okay. Again, thank you very much for your 
service and to all of you for being here today.
    Mr. Town. Thank you, sir.
    The Chairman. Thank you, Mr. Donnelly. Mr. Baker?
    Mr. Baker. Thank you, Mr. Chairman. First, just a brief 
report to the Ranking Member and Chairman and we still don't 
have a decision on the VA hospital replacement in New Orleans 
between the State and the VA. Just want to keep the Chairman's 
attention on that matter.
    Having said that, let me express deep concern for the 
reports of the mistreatment and negligent behavior that appears 
to have occurred on significant number of occasions. I do not 
believe one case is an acceptable outcome that results in 
someone's claims not being adequately met. But I do think it 
important to balance the hearing record to some extent in 
recognizing at least for the VA, the Committee has 
responsibility for that enterprise only in this matter. That it 
is an entity made up of significantly higher number of veterans 
being employed, almost 33 percent. There is about 220,000 
employees. That means within the walls of that agency 
describing it nationally, there are in excess of 72,000 
veterans. I cannot imagine anyone who is more dedicated to the 
adequate and fair treatment of veterans than veterans.
    Of the residual number of employees, many an excessive 
number, are lifetime people committed to serving the military 
veterans of this Nation. I would not want us to leave the 
hearing today and have the words in part of the written 
testimony the unconscionable, outrageous, intentional actions 
taken by the Department of Veterans Affairs to prevent Iraq and 
Afghanistan war veterans from receiving prompt care and 
disability compensation to be the only statement with regard to 
the performance of this agency.
    Reading from one of the witnesses own comments citing as of 
June 2007, 202,000 Iraq and Afghan war veterans have made 
disability claims. As of June 2007, 157,00 had been satisfied. 
That is a 77-percent rate of those who have applied, have 
gotten some resolution. So I say on behalf of the decent people 
trying to do the right thing with perhaps limited resources, 
yeah, we don't get it right all the time, but I am not willing 
to throw them all out on the street and say they are all a 
bunch of thugs trying to beat people out of their just due.
    I am here simply to say lets move in a measured pace; lets 
find out those who have acted in an unprofessional and 
irresponsible manner; lets provide the consequences for that 
conduct, but not at the same time disregard the service of 
those who have put their own life on the line and who are now 
serving within the agency at a number in excess of 72,000 
people.
    I yield back.
    The Chairman. Thank you, Mr. Baker. Mr. Hall?
    Mr. Hall. Thank you, Mr. Chairman. And thank you, Mr. Town 
and the rest of our panel for your presence and your testimony 
and your service.
    I would point out to my colleague, Mr. Baker, at 77 percent 
a rate of applicants who are satisfied with the result is good, 
but not necessarily in most schools considered excellent. And I 
would hope that when it comes time this September for bonuses 
to be given to those in the top brass of the VA, that they will 
be given for excellent performance, not just merely for passing 
performance.
    I have a couple of stories to relate for my district. Last 
night, there was a hearing of the CARES (Capital Asset 
Realignment for Enhanced Services) Commission at the Montrose 
New York VA Center. And I just asked my district director, has 
sent me a report, because I of course couldn't be there. And 
she said there was a lot of anger from vets as to how they are 
being treated by the VA and the process. They feel a decision 
has already been made to move service and sell off the land 
despite all their testimony and opposition. This is a facility 
in Westchester County, the most affluent county in New York; 
the most affluent county in my district; one of I think five of 
the most affluent counties in the country where there is a 
homeless population made up about 23 percent of veterans on the 
street.
    And the facilities that they are planning to close and 
possibly we understand sell off to private, you know, condos or 
townhomes along the Hudson River. It is beautiful. You can see 
why a developer would want to acquire this property. It is 
currently treating psychiatric cases and PTSD and my belief and 
that of the veterans in my district is that the taxpayer of 
this country paid for these facilities to take care of veterans 
that we are just beginning now to understand the gravity and 
the size of the problem that we are going to be dealing with 
returning veterans from the Iraq and Afghanistan wars.
    We are hearing stories of diplomats having PTSD. Of truck 
drivers for contractors having PTSD. Of families and children 
having PTSD because of the repeated stress, the repeated 
deployments and seeing on the news explosions and burning and 
bodies and not knowing if it is their daddy. When you are a 
child, it is much easier to be affected severely by these 
things than when you are a supposedly rational adult.
    I also wanted to mention the case, one of many like all of 
us who we deal with veterans cases in our districts, and we 
recently had a soldier who had just left the service and become 
a VA client, Alex Lazos who was being kept in a VA hospital for 
extended time for treatment and was about to be released. He 
had witnessed the death of an Iraqi girl in the cross fire, 
held her while she died. And then came back here and was having 
nightmares and was being told that he was okay. And that he was 
not eligible for classification. And he was given a zero 
rating. And called our office. He shouldn't have to call his 
Congressman, but he did and I am glad that the people in my 
office were capable and got him a 100 percent rating. And he is 
now getting the treatment that he needs and the medical and 
psychiatric treatment and also the disability compensation that 
he needs while he puts his life back together.
    And, you know, we are talking about people, we are talking 
about the on-going impact and expense of a war which was a war 
of choice. And the longer we stay in this war the more 
expensive it is going to be in both human and financial terms.
    I am curious to get to questions about, and maybe Mr. 
Sullivan you might know this or other panel members, how many 
of the soldiers are released so far and since 2001 or 2003, 
whatever the average is, with other than honorable discharges?
    Mr. Sullivan. Congressman, we have requested that 
information under the Freedom of Information Act. However, we 
have not received a full response. I do believe there is 
pending legislation, H.R. 1354 in the House, and in the Senate 
it is S. 117. It recognizes and honors the former Ranking 
Member of the Committee, Congressman Lane Evans. And it calls 
for a thorough set of data to be gathered by VA military. And 
it calls for extensive reports on the financial and human cost 
of the war. And of the things----
    Mr. Hall. Okay. And I----
    Mr. Sullivan [continuing]. That that bill calls for is 
information on the types of discharges.
    Mr. Hall. Thank you. My time is running out so I just 
wanted to, I am sorry to interrupt you, but noting that I 
believe it is Mr. Forrester's testimony said that 49 percent of 
Guard members, 38 percent of soldiers, and 31 percent of 
Marines are experiencing some mental health issues after 
serving in OIF/OEF. After the Vietnam War, it turned out to be 
in some cases years, decades even, before soldiers came forward 
and were diagnosed with PTSD.
    So I would guess that those numbers are going to go up. And 
I, too, would associate myself with the comments of the Ranking 
Member and Mr. Kennedy and Mr. Michaud and I believe the 
Chairman and others who will hope to use private resources that 
are available and that are coming forward and offering to help 
so that we can make sure that our veterans get help in the 
timely fashion that they deserve.
    I yield back, Mr. Chairman. Thank you.
    Mr. Kors. Congressman? If I could address the story you 
told about your constituent, it was very sad about the soldier 
who was denied, as you were remarking, after watching that 
child die. It was stories like that, that we came across in our 
year of reporting that was a tip off to myself and to the Army 
Times and to other journalist who have looked into this 
personality disorder issue. That there were questions of 
leadership here. Not just with Surgeon General Pollock, but 
down the line. I think about the review of personality disorder 
cases at Ft. Carson. When this story broke they went back, they 
said, and did a review of 56 more personality disorder cases at 
Ft. Carson. Again, in which nobody, not even the soldiers 
themselves were interviewed. They determined all of those cases 
to be properly diagnosed, but they noted to me that they could 
only find 52 of the cases. I asked the leaders at Ft. Carson 
how they knew the other four were properly diagnosed when they 
had lost or misplaced them. And they said they couldn't answer 
that question.
    The Chairman. Thank you, Mr. Hall. Mr. Buyer?
    Mr. Buyer. I am neither a doctor of psychology nor of a 
psychiatrist and I look forward to the testimony of Dr. 
Kilpatrick and Dr. Satel.
    Let me ask this question: To our reporter, I found this 
very interesting, but I just can't ever remember a reporter 
testifying before Congress and sitting on a first panel. Very 
peculiar. Is personality disorder a recognized clinical 
diagnosis?
    Mr. Kors. Yes, Congressman, it is.
    Mr. Buyer. Yeah. In your statement you said recruits who 
had a severe pre-existing condition, like a personality 
disorder, do not pass the rigorous screening process. What is 
that? What is a rigorous screening process?
    Mr. Kors. Well, I think Mr. Sullivan----
    Mr. Buyer. No, I am asking you. What is you said that 
recruits----
    Mr. Kors. Uh huh.
    Mr. Buyer [continuing]. Who have a pre-existing condition 
like a personality disorder do not pass the rigorous screening 
process.
    Mr. Kors. Uh huh.
    Mr. Buyer. What is the rigorous screening process?
    Mr. Kors. Soldiers coming into the Army undergo a rigorous 
physical and psychological screening process. Precisely what 
tests are done in that screening, I think that is something 
that others in the panel could better answer.
    Mr. Buyer. Did you, have you served in the military?
    Mr. Kors. No, sir.
    Mr. Buyer. Do you know what you are talking about when you 
say a rigorous screening process? What are you talking about?
    Mr. Kors. Well the doctors I spoke to and the soldiers and 
the veterans leaders all describe that initial screening as 
rigorous. And went over precisely how they were screened.
    Mr. Buyer. You give an emphatic conclusory statement. 
``Recruits who have a severe pre-existing condition like 
personality disorder do not pass the rigorous screening process 
and are not accepted into the Army.'' That is a black and white 
conclusive statement. Yet, you have no personal experience nor 
you can give this Committee testimony about what a rigorous 
screening process is.
    Mr. Kors. Congressman----
    Mr. Buyer. I--no.
    Mr. Kors [continuing]. I don't think there is anybody in 
this room----
    Mr. Buyer. I am going to----
    Mr. Kors [continuing]. Who would argue with the fact that 
the Army's screening process is rigorous.
    Mr. Buyer. Basic training is a matriculation process of 
militarization. Is that what you are referring to as a rigorous 
screening process? I don't know what you are referring to.
    Mr. Kors. The process you underwent----
    Mr. Buyer. No, no. I am asking the reporter. You can't 
reach for a life-line. You give an emphatic statement to this 
Committee. I just want to know what you are relying on. So you 
are not relying upon any personal experience, nor can you 
explain to this Committee what a rigorous screening process is.
    I will just go to the next question. Let me go to, you give 
this statement, ``Commanders pressuring doctors for 
diagnosis.'' Who? What and where? What commander pressured 
doctors for diagnoses? What commander pressured a doctor? Where 
did that occur? When did it occur? Who is the commander and 
what was the doctors name?
    Mr. Kors. Congressman, I am not at liberty to reveal their 
name. A lot of these people who came forward were extremely 
scared that their careers were at stake. I have been asked in 
most cases to keep them in the background.
    Mr. Buyer. So you make an allegation to this Committee 
about commanders pressuring doctors for diagnoses, but you will 
not give the name of a commander; you will not give the name of 
a doctor and you have no factual basis then to submit to the 
Committee?
    Mr. Kors. I----
    Mr. Buyer. I will ask the next one.
    Mr. Kors. I don't think----
    Mr. Buyer. ``Every person who lied about the personality 
disorders discharge. Every person has lied about the 
personality disorder discharge benefits.'' That is your quote. 
Who? Who lied? What person lied to an individual? Tell me the 
person's name, when and where did it occur? Help this 
Committee.
    Mr. Kors. You are talking about the doctors.
    Mr. Buyer. You are saying every person lied about 
personality disorder discharge benefits. What doctor did that? 
Give me a name.
    Mr. Kors. I will, but first let me just go back and----
    Mr. Buyer. No. Give me a name with regard to this question. 
What doctor lied about this?
    Mr. Kors. Congressman, I would like to answer your 
questions.
    Mr. Buyer. Please----
    Mr. Kors. I would like to answer your question.
    Mr. Buyer. All right.
    Mr. Kors. I think every journalist relies on those who 
speak off the record. I don't think I could do a story like----
    Mr. Buyer. All right. So I am not going to get an answer 
from you then.
    Mr. Kors. I don't think we could do a story--no, I will.
    Mr. Buyer. Let me ask this one:
    Mr. Kors. Doctor Mark----
    Mr. Buyer. An example of a doctor presenting--yes, you also 
said you gave examples of doctors presenting persuasive 
scenarios to why a soldier should accept a personality 
discharge. You are not going to give that doctor's name either 
I suppose?
    Mr. Kors. I certainly will.
    Mr. Buyer. So you answered a northeast fort clinical----
    The Chairman. Mr. Buyer, he said he would answer the 
question. So give him a chance to answer the question.
    Mr. Kors. I will give the doctor----
    Mr. Buyer. Hold on just a second. Hold on. Let me get in 
the last one and then you can go.
    Mr. Kors. All right.
    Mr. Buyer. You also mentioned a northeast fort clinical 
chief, ``. . . get them to Iraq or find a pre-existing 
condition.'' So also tell me what is the name of that Fort and 
who is the clinical chief?
    Mr. Kors. Again, I am not going to volunteer his name or 
his location. But you asked about----
    Mr. Buyer. Well then let me just say this, Mr. Chairman, 
what is really challenging when we have a reporter testify 
before a Committee is that the reporter then gets to speak, use 
this type of syllogism to a Committee. They get to speak in 
generalities as the major premise and we don't know with regard 
to the credibility or embellishments. As a minor premise they 
get to use innuendo and the results then at times can be 
reckless indictments.
    The Chairman. It sounds very much like a Congressman I know 
too.
    Mr. Buyer. That is very challenging. Well the mirror looks 
pretty good.
    [Applause.]
    Mr. Buyer. Well, Mr. Chairman, then the mirror looked 
pretty good this morning to you.
    Let me just say this: I am just saying I have a challenge 
here because we have a reality. The reality is what disturbs me 
the most is not the fact that there are individuals who may be 
diagnosed with a pre-existing condition. What bothers me is 
that, if the individual wasn't discovered somewhere along the 
process when they go to war, then they come back with problems, 
and with the next panel we will be able to get with the actual 
doctors, that is what is most important here. These doctors, 
because what is bothersome to me as a soldier is, once that 
person goes to a war zone and they come back, we shouldn't be 
saying that this was a pre-existing condition.
    But I am not a doctor. But I am just saying that bothers me 
immensely.
    The Chairman. Thank you.
    Mr. Buyer. With that I yield back.
    Mr. Kors. Mr. Chairman? If you give me 30 seconds to answer 
his question----
    The Chairman. Please.
    Mr. Kors [continuing]. I would be happy to do that.
    Let's divide this into two sections. No amount of pressure 
you put on me will move me to reveal my off-the-record 
anonymous sources. That is not going to happen.
    Second, you asked for a name of a doctor. I would be happy 
to volunteer one that came up repeatedly in my reporting. Dr. 
Mark Wexler at Fort Carson, he was Specialist Town's doctor and 
several others. And I know the group, Veterans of America, 
represented here also encountered many cases with him also 
encountered many cases with him. If you are really interested 
in specific cases with Dr. Mark Wexler named here in this 
Committee, I am sure Jon will be happy to tell you precisely 
how that one specific doctor behaved.
    The Chairman. Thank you. We are going to have to recess in 
a few minutes for votes. I was going to again thank the panel 
and say how chilling your testimony was, how compelling. 
Specialist Town, your description of having to sell back leave 
to make up for your bill is just absolutely disgraceful, just 
disgraceful. We have put you in a war where you were brain 
injured. We tried to diagnose you to avoid any later cost for 
benefits and for treatment and then we give you a bill for the 
privilege of all of that. That was very chilling.
    What is even more chilling is the questioning by the 
Ranking Member. We have a problem here. Everybody, almost 
everybody said whatever the numbers are, whatever--we have a 
problem here. Nobody was questioning, I would say to Mr. Baker, 
nobody was questioning the commitment of people either in the 
VA or the military. But the system is leading to this 
situation. The system is leading to this. No matter how good 
the individuals are, how committed--I have been told by a 
doctor, Mr. Buyer, and I am not going to reveal his name here 
because he thought he would be fired, that he was told by his 
commanders to diagnose people with PTSD and get them out. I 
asked him to testify. He was fearful of that.
    So we don't have to go beyond what we have here, as Ms. 
Herseth Sandlin said. We have the evidence right here. It is 
incumbent upon us to act and to act very quickly and that is 
why I called this hearing even though we have joint 
responsibility here. We have people like Specialist Town who 
are suffering because they served their Nation. That should not 
be, that should not be an option for this Nation.
    And we thank you for being here. You are going to help us 
correct this. We are going to work on this system and we are 
going to make sure that those who serve, that we have repaid 
them with the care and the honor and the dignity that they 
deserve.
    We will recess. I will--this panel can be dismissed. We 
will go into panel two when we return from the votes.
    [Recess.]
    The Chairman. I apologize for the intermission. We just 
can't avoid it.
    Panel two, you have also had the advantage of listening of 
panel one, so I hope that you can take that testimony into 
account in your oral testimony. Your written statement will be 
made a part of the record.
    Professor Shea is an expert, I am told, in distinguishing 
between personality disorder and PTSD. And I hope we can hear 
from you, Dr. Shea.
    Dr. Shea. Thank you, Mr. Chairman. I am honored at the 
opportunity to----
    The Chairman. Is your microphone turned on? Make sure the 
microphone is right in front of you.

STATEMENTS OF TRACIE SHEA, PH.D., PSYCHOLOGIST, POST TRAUMATIC 
    STRESS DISORDER CLINIC, VETERANS AFFAIRS MEDICAL CENTER 
PROVIDENCE, RI, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT 
OF VETERANS AFFAIRS (ON BEHALF OF HERSELF); DEAN G. KILPATRICK, 
 PH.D., DISTINGUISHED UNIVERSITY PROFESSOR, DIRECTOR, NATIONAL 
CRIME VICTIMS RESEARCH AND TREATMENT CENTER, MEDICAL UNIVERSITY 
     OF SOUTH CAROLINA, AND MEMBER, COMMITTEE ON VETERANS' 
 COMPENSATION FOR POST TRAUMATIC STRESS DISORDER, INSTITUTE OF 
MEDICINE AND NATIONAL RESEARCH COUNCIL, THE NATIONAL ACADEMIES; 
 AND SALLY SATEL, M.D., RESIDENT SCHOLAR, AMERICAN ENTERPRISE 
                           INSTITUTE

                STATEMENT OF TRACIE SHEA, PH.D.

    Dr. Shea. Thank you. Mr. Chairman, I am honored at the 
opportunity to provide testimony to the Committee on issues 
related to post traumatic stress disorder and personality 
disorders.
    I come before this Committee not as a representative or 
spokesperson for the Department of Veteran Affairs, but as a 
mental health researcher who has conducted 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 
views or policy.
    The Committee has requested my testimony regarding PTSD and 
personality disorders in context of servicemembers and 
veterans. I am just going to start to quickly review what the 
definition of a personality disorder is, according to our 
official diagnostic manual. Personality disorder is defined as 
an enduring pattern of inner experience and behavior that 
deviates markedly from the expectations of the individual's 
culture. It is manifested in cognition--that means ways of 
thinking and perceiving--interpersonal functioning, meaning 
relationships, impulse control and affect, in other words, the 
range of the emotions and the expressions of feelings.
    Now, what is important here is that for a diagnosis to be 
made, there are several requirements that need to be met. First 
of all, you need to see persistence of the behavioral pattern 
over time and it also needs to be present in multiple 
situations, not circumscribed situations. Second, its onset 
should have begun--its onset needs to have started by late--at 
least by adolescence or early adulthood. So this is not 
something as we understand personality disorders officially in 
our diagnostic system that would show up in later adulthood.
    Third, there needs to be evidence of significant distress 
or impairment in functioning associated with this pattern of 
behavior. Fourth, and this is also important to the current 
topic, the pattern of behavior should not or cannot be better 
accounted for as a manifestation or a consequence of another 
mental disorders. And I will come back to that. Fifth, the 
pattern is not due to the direction physiological effects of a 
substance such as drug or alcohol or medication or a general 
medical condition, and certainly, traumatic brain injury would 
be an example of that.
    Since the onset of personality disorders occurs by late 
adolescence or early adulthood, there should be evidence of the 
behavior pattern prior to adulthood. You would not expect a 
history of very solid, good, psychosocial functioning prior to 
adulthood in an individual with a personality disorder. You 
would expect problems to have shown up.
    It is really critical to rule out other mental disorders 
that might be responsible for the kind of behaviors you may see 
in making a clinical diagnosis of personality disorder. 
Following traumatic experiences, persistent or repeated 
traumatic stressors, it is particularly important to determine 
if those behaviors may be due to PTSD. And this is a statement 
that our diagnostic manual, the DSM-4 explicitly states, and I 
quote, ``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.'' So as a 
clinician, you really need to note that and look for that.
    Exposure to severe and prolonged trauma can result in 
behaviors that look like personality disorders. There are 
criteria such as outbursts of anger, irritability and anger, 
feeling extremely detached and socially withdrawn, having a 
very restricted range of affect or a very volatile affect. 
These are all features that are associated with PTSD but look 
like personality disorders.
    There is even a diagnosis in the International 
Classification of Diseases that is called ``enduring 
personality change after catastrophic experience'' and this 
diagnosis is used in cases of persistent change in personality 
following extreme stress. Features of this International 
Classification of Diseases diagnosis include, again, changes 
after exposure to severe trauma, hostility, distressful 
attitude toward the world, social withdrawal, constant feeling 
of feeling empty or hopeless, persisting feeling of ``being on 
edge'' or being threatened without any external cause, in other 
words, showing up in increased vigilance and irritability, and 
a permanent feeling of being changed or being different from 
others.
    Again, you see these features often, I have often in my 
work with veterans, seen features like this that can be linked 
back to the trauma. The critical distinction is, again, whether 
they represent change in personality following exposure to 
severe traumatic stress in terms of what diagnosis you would 
give the individual.
    I also want to say that despite the fact that I am focusing 
here today on the distinction between personality disorders and 
PTSD, they are not mutually exclusive. They can co-exist. An 
individual with a personality disorder can develop PTSD and 
that happens. So it is not an either/or situation.
    VA psychologists, which I am also, in addition to my 
academic work, conduct assessments for service-connected 
disability applications. These, what are referred to what they 
call compensation and pension exams, follow established 
guidelines and cover psychosocial functioning and symptoms of 
mental disorder that are 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 in these 
exams.
    Most of the exams that I personally have conducted have 
been to establish service connection for PTSD. And essentially 
they require a detailed questioning of symptoms of PTSD as well 
as other mental disorders, and again, with a focus on the 
timing of the onset of the problems. If there is a pattern of 
maladaptive behavior existing prior to military service, it is 
again important to determine whether there has been a change in 
connection with military service. Diagnoses reflect--diagnoses 
will reflect a personality disorder if present, but in my 
personal experience, this has been rare.
    I thank you for this opportunity to testify and I will be 
pleased to answer any questions you may have. Thank you.
    [The prepared statement of Dr. Shea appears on p. 87.]
    The Chairman. Thank you, Dr. Shea.
    Dr. Dean Kilpatrick is Distinguished University Professor 
at the Medical University of South Carolina and Director of the 
National Crime Victims Research and Treatment Center and also a 
member of the Committee on Veterans' Compensation for PTSD of 
the Institute of Medicine and National Research Council for The 
National Academies.
    Thank you for joining us.

             STATEMENT OF DEAN G. KILPATRICK, PH.D.

    Dr. Kilpatrick. Good afternoon, Mr. Chairman, Mr. Ranking 
Member and other Committee Members. Thank you for the 
opportunity to testify on behalf of the Committee on Veterans' 
Compensation for post traumatic stress disorder. As was just 
mentioned, this Committee was convened by the National Research 
Council and the Institute of Medicine. Its work was requested 
by the Veterans Administration which provided funding for this 
study.
    Our Committee recently completed a report entitled, ``PTSD 
Compensation and Military Service,'' that addresses some of the 
topics under discussion today. I am pleased to share with you 
the content of that report, the knowledge I have gained as a 
clinical psychologist and researcher on traumatic stress, and 
my experience as someone who previously served as a clinician 
at the VA for approximately 10 years.
    I will begin with some background information about post 
traumatic stress disorder, although from hearing the testimony 
and the questions today, I think the Committee understands post 
traumatic stress disorder pretty well. So I think I will just 
summarize that it is a disorder that, while it first was 
identified in 1980 in the DSM-III, the symptoms that have been 
described after people experience traumatic events including 
war have really been around for centuries. And so, even though 
the diagnosis is new, the pattern of behavior that people 
experience is not new.
    Our Committee's review of the scientific literature and the 
VA's current compensation practices identified several areas 
where changes might result in more consistent and accurate 
ratings for disability associated with post traumatic stress 
disorder. Excuse me.
    There are two primary steps in the disability compensation 
process. The first is a compensation and pension, or C&P, exam. 
Testimony that our Committee heard indicated that clinicians 
often feel pressured to severely constrain the time they devote 
to conducting a PTSD C&P exam. In fact, one clinician mentioned 
that it was not uncommon to take as little as 20 minutes to do 
such an examination. The protocol, however, that has been 
identified by a best practices manual developed by the National 
Center for PTSD of the VA indicated that it really should take 
maybe 3 hours or even more in complicated cases.
    So our Committee believed that the key to a proper 
administration of the VA's compensation and pension examination 
program is a very thorough C&P examination conducted by an 
experienced mental health professional. Most of the problems 
and issues with the current process can be addressed by 
providing the time and resources necessary for a thorough 
examination. The Committee also recommended that a system-wide 
training program be implemented for clinicians who conduct 
these examinations in order to promote uniform and consistent 
evaluations.
    The second step in the compensation and pension process is 
the rating of the level of disability associated with service-
connected disorders identified in the clinical examination. I 
think the for the purpose of this hearing today, it is 
important that it not only be something that occurred during 
service, but if you had something preexisting that was 
aggravated by something that happened in service, that that 
also should be part of the evaluation.
    The Committee found that the criteria used to evaluate the 
level of disability resulting from service-connected PTSD were, 
at best, crude and overly general. They were not specifically 
designed to measure disability associated with PTSD. Our 
Committee recommended that new criteria be developed and 
applied that specifically address PTSD symptoms and that are 
grounded firmly in the standards set out for mental health 
professionals doing these evaluations.
    As a part of this effort, the Committee suggested that the 
VA take a broader and more comprehensive view of what 
constitutes PTSD disability. In the current scheme, 
occupational impairment, the ability to work, drives the 
determination of the rating level. Under the Committee's 
recommended framework, the psychosocial and occupational 
aspects of functional impairment would be separately evaluated 
and the claimant would be rated on the dimension upon which he 
or she is most affected.
    The Committee believes that special emphasis on 
occupational impairment in the current criteria unduly 
penalizes veterans who may be capable of working, but 
significantly symptomatic or impaired in other dimensions. So, 
for example, a veteran might be able to work pretty well by 
overcoming the PTSD symptoms, but might have a lot of trouble 
in his family life and relationships with other people. Thus, 
if you just focus on occupational impairment, you may, in fact, 
create a disincentive to work, which is a very important 
element in recovery.
    Determining ratings for mental disabilities for PTSD is 
more difficult than for some other disorders because there is a 
subjective component to it in that it is mostly a symptom-based 
disorder. To provide, or to promote, rather, more accurate, 
consistent and uniform PTSD disability ratings, the Committee 
recommends that the VA establish a specific certification 
program for raters who deal with PTSD claims and provide the 
training to support that, and then also to recertify raters. 
Rating certification should foster greater confidence in 
ratings decisions and in the decisionmaking process.
    To summarize, the Committee identified three major changes 
that are needed to improve the compensation evaluation program 
for veterans with PTSD. First, the C&P exam should be done by 
mental health professionals who are adequately trained in PTSD 
and who are allotted adequate time to conduct the exams. 
Second, the current VA disability rating system should be 
substantially changed to focus on a more comprehensive measure 
of the degree of impairment, disability and clinically 
significant distress caused by PTSD. Third, the VA should 
establish a certification program for raters who deal with PTSD 
claims.
    Our Committee had numerous other recommendations, as you 
can tell by the size of this report. I have just sort of hit 
the high points here. And they are detailed in the body of the 
report. I believe that the report has been distributed to the 
Committee as a part of my testimony. And I would thank you very 
much for your attention and would be happy to answer any 
questions.
    [The prepared statement of Dr. Kilpatrick appears on p. 
89.]
    The Chairman. Thank you so much.
    Dr. Sally Satel is with the American Enterprise Institute 
(AEI).

                 STATEMENT OF SALLY SATEL, M.D.

    Dr. Satel. Thank you, Mr. Chairman and Congressman Buyer 
and Committee Members. Thank you again for the invitation to be 
here. I am a psychiatrist and I formerly worked with veterans 
at the West Haven VA in Connecticut and currently I am at AEI.
    Just one word about the Chapter 5-13 discharges that were 
spoken about so much earlier. They raised two main questions. 
The first, of course, has been exhaustively discussed and the 
attention it is getting is very much deserved. It is the 
question of whether military evaluators are erroneously 
ascribing impairments caused by active duty to preexisting 
personality disorder.
    The second question is a mirror image of the first, that is 
to say it involves situations in which personality disorder 
discharge is indeed accurate. We don't know what the 
distribution is between misapplications and accurate ones, 
however. But clearly, some soldiers are going to fall into that 
personality disorder category; there is a chance, though, that 
he or she has gotten too far into his tour of duty by the time 
that diagnosis is made.
    So the question becomes whether the military's screening 
procedures and ongoing evaluations are adequate to identify 
these problem personnel, in a timely manner. And that issue may 
sound like a military issue, but it has relevance for Veterans 
Affairs as well. After all, it is those individuals, men and 
women with pre-military evidence of severe misconduct or those 
who have become disciplinary problems early in active duty are 
particularly vulnerable to developing psychiatric impairment 
under the strain of combat. And upon discharge, they may turn 
to the VA mental health facilities for long-term care for 
treatment--treatment of psychiatric conditions that might have 
otherwise been prevented with proper screening.
    Now, if and when they get to the VA, I really don't worry 
so much that clinicians are going to misdiagnose PTSD as 
personality disorders. And in fact, it seems to be the case 
that Chapter 5-13 discharges often reflect an administrative 
decision than a clinical confusion. But in any case, the core 
symptoms of post traumatic stress disorder and neuropsychiatric 
impairments like traumatic brain injury are distinguishable 
from preexisting personality disorder. And I don't think there 
is much debate about that at all.
    Yet, even though they are distinguishable, as Dr. Shea 
mentioned, there is no question that the two problems can occur 
together in the same patient. In fact, one of the most striking 
observations made by VA psychiatrists since the mid 1980's is 
that the longer a patient suffers with PTSD, the more likely he 
is to also have evidence of personality disturbance. And I use 
the word personal disturbance and not personality disorder, 
which as we know, is a preexisting, pre-military phenomenon, 
because what looks like a personality disorder, may actually be 
a character change induced by the experience living with 
symptoms of PTSD for many years.
    Now, remember, so much of this research has been done on 
Vietnam veterans and so many of them--I don't have numbers, but 
I would venture to say it is the vast majority--did not come 
forward for help for at least 5 years after returning home, and 
sometimes 10 and 15 years later. There was no outreach at the 
time. PTSD wasn't even an official diagnosis recognized by the 
American Psychiatric Association until 1980. And the National 
Center for PTSD didn't exist until 1989.
    So by the time those veterans, those Vietnam veterans, did 
come to the attention of the VA, their conditions had often 
festered and become quite complicated. And as I mentioned 
before, living with pervasive anxiety, nightmares and other 
sleep disturbances can lead to intense anger, chronic mistrust, 
depression, substance abuse and social isolation, the kinds of 
features that contribute significantly to disability, these are 
also features that make it very hard to treat a patient who has 
suffered them for 10 and 15 years and also to determine which 
is the dominant disability, the symptoms of chronic PTSD or the 
maladaptive behaviors, the personality disturbances, that it 
induced.
    So the vital lesson here is that new veterans, the young 
men and women now returning from Iraq and Afghanistan, must get 
treatment as early as possible. That is when combat induced 
stress syndromes are going to be most responsive to care and 
also when there are ripe opportunities to address the 
considerable burdens of readjustment. Financial problems, 
family and marital issues, occupational dislocation, these are 
enormously important. They are not psychiatric conditions. They 
are social problems. And they are burdens that can make a huge 
difference in how well veterans cope and return to civilian 
life and also the extent that they can cope with mental 
distress. Distress, which I should emphasize, will most likely 
resolve over time, and will respond well to the treatment if 
care is provided early.
    Certainly, some veterans will continue to suffer profoundly 
even with treatment and won't be able to resume a productive 
life. That is what compensation is for. I hope and predict they 
will be a small minority. With early and competent treatment, 
however, there is good reason to be optimistic that the vast 
majority of veterans returning from Iraq and Afghanistan will 
do well. They will be changed by the war. How could someone not 
be? But most will not be permanently damaged.
    Thank you very much.
    [The prepared statement of Dr. Satel appears on p. 91.]
    The Chairman. We thank all of you for helping us understand 
this better. Mr. Michaud.
    Mr. Michaud. Thank you, Mr. Chairman.
    Just a couple of questions. You heard the testimony earlier 
where it was Jon Town who said that he was screened before he--
when he went into the service, screened when he went to Korea, 
screened when he went to Iraq. There was no indication that he 
had a personality disorder, and actually, I think he was even 
screened once he got into Iraq. Then when he came out, he had 
personality disorder.
    I would like to ask each of the three panelists, is it 
possible that you can miss so many different types--so many 
different screenings in that process? I guess I will start with 
Dr. Satel.
    Dr. Satel. Well, I would be very--I would be quite 
skeptical that you could miss it at that many levels. At 
enlistment, it is often hard to predict who will not succeed 
and I know that screening has been a very confounding process 
for the military family for years. Since World War II it has 
been questionable. I understand, however, this is just from my 
reading, not from my personal experience, that there are an 
increased number of so-called moral waivers being given out and 
these are for people who have known felonies. Multiple felonies 
should certainly raise a red flag.
    But, you know, those who have a personality disorder that 
hasn't manifested in gross ways like for example, as an arrest 
record, at enlistment, may well show maladaptive behavior as 
they progress through active duty. Imagine a cardiac stress 
test. Boot camp and early deployment are often the 
psychological equivalent. And if you have a fragile 
personality, a tendency toward maladaptive coping, it would be 
very surprising to me if that didn't rise to the surface during 
intense phases of duty.
    I would predict that someone with a serious preexisting 
problem in relating to others would not progress too far 
through the system before coming to the attention of peers and 
command. That is my opinion.
    Mr. Michaud. Yes. Doctor.
    Dr. Kilpatrick. Well, I would just add that in the case 
where someone is, you know, injured in combat, that PTSD would 
certainly come to mind a lot quicker than personality disorder 
as the explanation for change in behavior.
    Dr. Shea. I would just add that I think it is possible to 
miss mild personality disorders, but I think it doesn't--that 
is not so much the issue. I think the issue is, is there a 
change? Is the behavior that is being used as a basis for the 
diagnosis of personality disorder, does it represent a change 
following the experience in military service? And if so, then 
it is not preexisting in that sense. It could be exacerbated or 
it could be new onset. Thank you.
    Mr. Michaud. And my second question, I think Dr. Kilpatrick 
brought it up, but for the other two--I haven't read the report 
which I will definitely be reading. How long would it take if 
someone is to evaluate someone either before they go into the 
service or after they come out to adequately detect whether it 
is a personality disorder or whether they have PTSD? And I 
think it was Dr. Kilpatrick that said you can't do it in 20 
minutes or something like that. What is the normal timeframe 
for someone to go through that process?
    Dr. Kilpatrick. Well, the VA deserves an enormous amount of 
credit for their National Center for PTSD which developed a 
model protocol that is not a one-size-fits-all, but gives some 
basic parameters for doing these compensation and pension 
examinations. It suggests the types of information that should 
be gathered which includes information about pre-service 
functioning and sources of social support, as well as 
evaluating the level of combat and exposure to other war zone 
stressors and to evaluate all of these things.
    And I believe that they did not set an exact time limit, 
but approximately 3 hours, but I mean basically the notion that 
we are saying is, if you make a 20 minute examination, you are 
more likely to miss something. If you do a more comprehensive 
evaluation and basically get it right the first time, then 
maybe veterans will have a better view of the fairness of that 
evaluation because of its thoroughness.
    And secondly, you are just more likely to get it right 
which will maybe save money down the line because there are 
appeals. And people who do not feel like they have had their 
sort of ``day in court'' in terms of a fair evaluation and a 
thorough evaluation may, in fact, later be more likely to 
appeal these, which again, takes a lot of resources.
    Mr. Michaud. Does Dr. Shea and Dr. Satel, do you agree with 
what Dr. Kilpatrick just said?
    Dr. Shea. I do. I just would like to add, I mean I have 
done many, many of these exams in the VA in my role as a 
clinical psychologist at the VA and I can say that you always 
want more time because the issues can be complex. You don't 
want to cut the veteran off. You want to hear the full story. 
You want to get as much detail as you can.
    You also are realistically working within time limits. I do 
not think you can do this exam in 20 minutes. Personally, I try 
my best to get them done, interview time an hour, the whole 
process, including going over the chart, dictating a report, I 
don't think I have ever done in under 2 hours. I have spent 3 
to 4 hours on complicated cases. You just do that if you have 
to.
    The other point I would say is that individuals vary quite 
a bit in terms of how difficult or easy they are to interview. 
Some people are very good reporters and those interviews move 
quite smoothly. They are able to articulate what their 
experiences are in a way that makes it easy. Other people are 
more difficult.
    Dr. Satel. Just one quick point. One of the reasons it can 
take 3 to 4 hours--20 minutes is so brief it is mind boggling--
is because, depending on the case, one has to spend a fair 
amount of time interviewing spouses and collateral sources of 
information, employers, and previous physicians, and so on.
    The Chairman. Thank you.
    Mr. Buyer.
    Mr. Buyer. Thank you very much. I may have to step out 
soon. We have a briefing from Secretary Shalala and former 
Senator Dole on the Commission's findings. So I want to thank 
you for your submitted testimony. I had a chance to read it. I 
wish you had been the lead panel. You could have helped us 
immensely. And I think what I take from this hearing is there 
is a good reason why reporters don't testify.
    We rely upon one's testimony to be factually based and 
there was a lot of free wheeling going on. And so your 
testimony is very important to us because we have to make 
policy decisions based on what is happening out there. There is 
this impression and the allegation that has been made, almost 
an embellishment, that we have this large number, 22,000--one 
of my colleagues even made the conclusion that I wrote down 
that they are diagnosed incorrectly. That it is all made up. 
And so a pretty strong impression is being placed out there and 
that is why I had to ask the reporter is it, in fact, a 
disorder? Is it a clinical diagnosis? I am glad he said yes.
    The challenge for us is that we in the VA, we are the 
receiver of whatever the DoD does. So I am curious about your 
counsel to us, as we also oversee the armed services in our 
other capacities as Members of Congress. Is it in the country's 
best interest for us to say to DoD that you cannot discharge a 
soldier because of a personality disorder? What is your opinion 
with regard to that? Please, we will go right down the line.
    Dr. Shea. I will say that that is a--I think that is a 
quite difficult question personally for me to address, because 
I think there are very complex issues involved in that that 
have to do with military needs that I am not aware of. What I 
would say is that I think it is critical that the evaluation 
that is made be very comprehensive, second opinions be allowed, 
that records from prior history be gathered, that every effort 
is made to determine what the consequences of the service were 
so that the person can receive adequate treatment and receive 
adequate benefits to which they are entitled.
    Mr. Buyer. Thank you. Dr. Kilpatrick.
    Dr. Kilpatrick. Well, I would say--I would echo that and 
agree with it and say that it is a difficult thing. But I think 
we need to be very careful because when you say personality 
disorder, that has a very pejorative term to it, I mean whether 
in fact it is true or not. And so I guess in any case, what you 
have done, the military has either accepted someone in who has 
a preexisting personality disorder that was not captured, or 
may have been, in fact, aggravated by, you know, something that 
happened in service, may be misdiagnosed as a, you know, 
personality disorder when it is a change in personality 
functioning as a function of having PTSD or other war zone 
related-problems.
    So obviously there are some people who it takes a while to 
get caught up to and particularly severe antisocial behavior 
people who may not be fit for service. On the other hand, we 
need to be, I think, very careful about describing people who 
may not be fit for service right now, but who actually might be 
fit for service if their PTSD was treated. And so, I mean, it 
is a difficult situation, but summarily deciding if they are 
not getting along well now, that must be that they have a 
personality problem and therefore we are going to kick them out 
of service which then has some implications for their VA 
benefits later, including access to services, you know, can be 
problematic.
    Mr. Buyer. Well, that is problematic and also rather 
callous if, in fact, that is why it is being done. I mean I do 
recall even being a JAG on active duty with regard to--as a 
lawyer for the hospital whereby the clinicians actually counsel 
the commanders. You know, this allegation that the commanders 
are putting pressure upon the docs, it is usually the docs 
saying to the commanders ``do not put a weapon in this guy's 
hand.'' Usually it is the counsel coming back to the commanders 
and telling the commanders what to do, that is what my 
experience has been.
    Dr. Satel, do you have any opinion based off of the 
testimony of the other two?
    Dr. Satel. I certainly agree with what my colleagues have 
said. I suppose when you hear the word ``personality 
disorder,'' that should be a signal that a careful, what we 
call differential diagnosis process, has to be instituted. And 
if everything else is ruled out and you are left with someone 
who is just unfit because they cannot adapt to the norms of the 
military, you have to certainly act on that. You don't want 
someone who is incapable of cooperating with others, of 
following orders, disrupting group morale. Also, as I said, 
such individuals are often at a higher risk for developing 
combat stress syndromes.
    But remember, if a soldier is behaving erratically, 
impulsively, defiantly or bizarrely, the first thing is to make 
sure we are not talking about traumatic stress injuries or 
bipolar illness or early schizophrenia. New onset of 
schizophrenia was one of the cases described earlier today. But 
if not, and this is someone who is just not psychologically 
equipped to conform to the rigors of the military, then that 
needs to be dealt with. But most important is to rule out other 
explanations for inappropriate actions on the part of the 
individual.
    Mr. Buyer. Doctors, I appreciate your testimony. I am just 
a layperson and I look at my 27 years experience in the 
military. I have recognized in that crucible of basic training 
and AIT, that certain things can apply certain stressors, 
whereby people--you will be able to recognize certain behaviors 
or conduct. And then they get referred to the hospital for some 
type of treatment or end up with diagnosis.
    The concern I think that the Chairman has and myself and 
other Members of the Committee is we would think that many of 
these things could be identified early on, and that an 
individual would actually go to war and that is when the so-
called a preexisting condition is then discovered, and they are 
discharged after they come back home. Even as a layperson, as a 
military guy, something doesn't fit here, doesn't seem right to 
me.
    And I read in your testimonies, both of you--all three of 
you are--in agreement that you can have a preexisting disorder, 
but you can also have PTSD; is that correct?
    Dr. Kilpatrick. Yes.
    Dr. Shea. Yes.
    Mr. Buyer. Okay. So your testimony about careful analysis 
is with regard to the DoD. When they make this discharge 
determination, and when the VA receives it, the VA has to 
examine this judgment with a rebuttal presumption, and be able 
to come in and challenge what DoD has done. Would that--would 
you agree with that? In other words, we shouldn't just accept--
--
    Dr. Satel. Yes.
    Mr. Buyer. We shouldn't accept that the VA should also have 
the ability to have their own second opinion with regard to the 
benefits, especially for these individuals that come back after 
war. Would you all agree with that?
    Dr. Satel. Yes, I would.
    Dr. Shea. Yes.
    Mr. Buyer. All right. Thank you very much.
    Dr. Kilpatrick. And part of the problem is, is that people, 
a lot of people with PTSD will develop alcohol problems. They 
will have impulse control problems which may mimic some of the 
personality problems that are disturbing to people. So that is 
why the diagnosis is important, because something can be done 
for the PTSD.
    Mr. Buyer. Okay. Thank you very much.
    The Chairman. We thank the panel. The panel was in total 
agreement, while you were out of the room, Mr. Buyer, that they 
were quite skeptical that personality disorder would not be 
found out whether it is early screening or basic training or 
beginnings of combat or whatever, that they would not find that 
and have to do that post-deployment would be very unusual at 
the very least.
    Given that judgment of yours, I mean, Dr. Shea, were you 
surprised at the testimony on the first panel which seemed to 
indicate that many, many of these combat veterans were being 
diagnosed with personality disorder? Did that surprise you at 
all?
    Dr. Shea. The particular cases that I heard and have read 
about, yes, I am stunned by those particular cases, from what I 
have read. They don't--it sounds like an inaccurate procedure. 
I can say that. I mean I think it is hard to speak to the other 
cases because we simply don't know the details.
    The Chairman. Right. I understand. But I mean the numbers 
in the testimony that we have had seems to say that. If a 
veteran comes to you for a C&P examination, does the fact that 
they have been diagnosed with personality disorder by the 
military have any sway with you? Is it harder for them to even 
get that far in the disability process and how would that 
affect your evaluation?
    Dr. Shea. Well, let me say for the first part, I would 
defer that to Dr. Katz who is on the next panel because he is 
much more familiar with the eligibility requirements and how 
that process works than I am.
    In terms of lending it to me, and if I see--I would look 
very carefully at the medical records. I would look very 
carefully at any documentation that was provided. I would look 
at treatment records. I would probe for those--but most 
importantly, what I would be doing is looking for symptoms of 
post traumatic stress disorder if that was the basis of the 
evaluation. I would have it in the back of my mind that this 
person had been diagnosed with a personality disorder, but I 
would be looking for, again, what specific behaviors and 
symptoms have onset and what was the relationship to the 
traumatic stressors. What kind of traumatic stressors did they 
experience and what--can they link these symptoms of PTSD to 
those? And that would be my concern. I would frankly be less 
concerned about the personality disorder unless I thought that 
I had to be careful not to make a mistake in diagnosing----
    The Chairman. It was implied by their testimony that it is 
hard even to get to that point. Again, you don't know about 
that. You want me to ask Dr. Katz; is that what you are saying?
    Dr. Shea. Yeah. I am not totally familiar with all of the 
eligibility requirements for getting there. But I know we see 
people who have prior diagnoses with personality disorder. So I 
know that they can be seen by the VA, but I don't know of 
anybody else.
    The Chairman. And what--is there any generalization you can 
make? In your evaluation, have you overturned all of those, or 
some of them, or none of them? Was there a PTSD diagnosis from 
you in contradiction to the personality disorder diagnosis?
    Dr. Shea. Well, we are not typically asked to comment on 
the previous diagnosis.
    The Chairman. Right. But you give some sort of diagnosis.
    Dr. Shea. Yes.
    The Chairman. I was just wondering, were all of them given 
PTSD diagnosis or none of them or half of them? I mean----
    Dr. Shea. Oh, you mean--excuse me----
    The Chairman. For those who had a personality disorder that 
you can recall, a diagnosis from the military, how, in general, 
do you diagnose them?
    Dr. Shea. I have not had any compensation exams that have 
come to me in recent times that have listed military diagnosis 
separation due to personality disorder. So I just haven't had 
that come up.
    The Chairman. I thought you said that you have seen those, 
so you know they can get in.
    Dr. Shea. Well, I know through the years I have treated 
many, many veterans, a lot of Vietnam veterans, as well as some 
of the more recent Iraq veterans. And those veterans I may not 
be doing comp and pen exams. I am just treating them. And I 
know that they have a history in----
    The Chairman. So you haven't given a C&P exam to anybody 
who had a personality disorder? So for all you know, they may 
have been screened out before you got there. I mean----
    Dr. Shea. That is a possibility. Yeah.
    The Chairman. Or just, you know, the luck of the draw that 
you----
    Dr. Shea. Yeah. I can't speak to that.
    The Chairman. Okay.
    Dr. Shea. That is right.
    The Chairman. Well, we thank all of you for being here. We 
thank you for helping us understand this better and we will ask 
the third panel to come forward.
    I have diagnosed a personality disorder on schizophrenia in 
your changing of the nameplates. So you are trying to confuse 
us also, right? You are not really Dr. Katz. Okay. I think we 
should discharge you immediately from the VA.
    Thank you for being here. Dr. Ira Katz is the Deputy Chief 
for Patient Care Services for Mental Health in the Veterans 
Health Administration, Department of Veterans Affairs, 
accompanied by Ron Aument, Deputy Under Secretary for, 
Benefits, Veterans Benefits Administration (VBA), and Paul 
Hutter, Executive in Charge in the Office of General Counsel.
    Dr. Katz, you have the floor.

 STATEMENTS OF IRA R. KATZ, M.D., PH.D., DEPUTY CHIEF PATIENT 
       CARE SERVICES FOR MENTAL HEALTH, VETERANS HEALTH 
     ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS; 
  ACCOMPANIED BY RONALD R. AUMENT, DEPUTY UNDER SECRETARY FOR 
BENEFITS, VETERANS BENEFITS ADMINISTRATION, U.S. DEPARTMENT OF 
 VETERANS AFFAIRS; PAUL J. HUTTER, EXECUTIVE IN CHARGE, OFFICE 
 OF GENERAL COUNSEL, U.S. DEPARTMENT OF VETERANS AFFAIRS; AND 
 COLONEL BRUCE CROW, CHIEF, DEPARTMENT OF BEHAVIORAL MEDICINE, 
BROOKE ARMY MEDICAL CENTER, FORT SAM HOUSTON, TX, AND CLINICAL 
 PSYCHOLOGY CONSULTANT TO THE ARMY SURGEON GENERAL, DEPARTMENT 
            OF THE ARMY, U.S. DEPARTMENT OF DEFENSE

             STATEMENT OF IRA R. KATZ, M.D., PH.D.

    Dr. Katz. Hello, Mr. Chairman and Members of the Committee. 
I, too, was moved by what I heard from the first panel, as 
everyone in the room must have been. I want to, before 
beginning my prepared presentation, comment about the issues 
that were raised in the last panel. The VA's evaluation, 
whether it is an evaluation for purposes of treatment planning 
or compensation and pension evaluation, is a de novo evaluation 
that is independent and unbiased, evaluating the patient before 
us and not bound or in any way determined by prior evaluations 
in DoD. The VA evaluation is patient-centered----
    The Chairman. But somebody has to come forward for that. 
And if they were told, for example, by the Army that they 
weren't eligible for the VA based on personality disorder, they 
may never show up to you, right? You would give them a de novo 
exam if they showed up. But if they don't show up, you 
obviously can't do it?
    Dr. Katz. Right. We work hard to promote access and to de-
stigmatize mental health to promote access.
    I want to speak about the issue that was raised in the 
previous panel about the fact that multiple diagnoses are the 
rule and about how VA applies the principles that PTSD 
frequently coexists with other mental health conditions. I 
would like to request that my written testimony be submitted 
for the record.
    The Chairman. Certainly.
    Dr. Katz. As of the end of the first half of 2007, almost 
720,000 servicemen and women have separated from the Armed 
Forces after service in Iraq or Afghanistan and over a quarter 
million have sought care in VA. About 95,000 received at least 
a preliminary mental health diagnosis and among these, PTSD was 
experienced by about 45,000 or 48 percent of those with a 
mental health condition. It is the most common of the mental 
health conditions, but it is not the whole story, and 
depression is a close second.
    The average veteran with a mental health problem received 
about 1.9 separate diagnoses. Multiple diagnoses, as was 
suggested, is the rule, not the exception. There can be several 
reasons for this. First, injuries of the mind, like injuries of 
the body, can be nonselective, depending upon psychological, 
physiological or genetic vulnerabilities. The same stress or 
trauma could give rise to multiple conditions. It can produce, 
for example, PTSD and depression or PTSD or a panic disorder.
    Second, the disorders can occur sequentially. Some veterans 
with PTSD may try to treat their own symptoms with alcohol and 
wind up with a diagnosis related to problem drinking. Third, 
some preexisting mental health conditions, like milder 
personality disorders, could be quite compatible with 
occupational functioning even in the military, but they may 
increase a person's vulnerability to stress-related disorders 
like PTSD.
    VA has intensive programs to ensure that mental health 
problems are recognized, diagnosed and treated. There is 
outreach to bring veterans into our system and once they 
arrive, there is extensive screening for mental health 
conditions. Specifically, VA screens all new returning veterans 
for PTSD, depression, traumatic brain injury and problem 
drinking. The prompts for these screens are built into our 
electronic medical records.
    The Chairman. I am sorry. Dr. Katz, did you say--who does 
the screening? Did you say--I didn't hear that sentence.
    Dr. Katz. Usually it is the first provider that sees the 
returning veteran----
    The Chairman. No, is it the VA?
    Dr. Katz [continuing]. Usually the primary care provider.
    The Chairman. I am sorry. Was it the VA or the military did 
you say?
    Dr. Katz. VA definitely screens everyone who comes to us 
for the----
    The Chairman. Right. But you didn't say everyone who comes 
to us in that sentence. You said every veteran is screened. 
There is a crucial distinction between every veteran is 
screened and every veteran who comes to us is screened.
    Dr. Katz. I agree. We work hard----
    The Chairman. I want to know what you said.
    Dr. Katz. We work hard at outreach to get people to us----
    The Chairman. I understand. But I bet you haven't gone to 
those 22,500 and tried to get them in and see what is going on 
with them.
    Dr. Katz. We have gone to almost all of the post-deployment 
health reassessment sessions to really work----
    The Chairman. Did you call in the 22,500 people who have--
--
    Dr. Katz. No, sir.
    The Chairman. So that is what I would call outreach.
    Dr. Katz. For those who screen positive for mental health 
conditions, the next step is comprehensive diagnostic and 
treatment planning evaluation. If someone screens positive for 
symptoms of PTSD, we are, of course, interested in whether or 
not they have PTSD. But we are also interested in whether or 
not they have depression or panic disorder or problem drinking 
or other problems. Regardless of the specific diagnosis, we 
treat the person, not his or her label.
    Clinical science regarding PTSD had advanced dramatically 
since Vietnam. There is a firm evidence base for several 
classes of treatment for PTSD, both medication based and talk-
therapy based. Specifically, several anti-depressants have been 
found effective and safe for the treatment of PTSD and many 
other medications are being studied.
    Two specific forms of cognitive behavior therapy, prolonged 
exposure therapy and cognitive processing therapy, appear to be 
even more effective than medications and VA has currently 
developed training programs to make these treatments more 
available in all of our facilities.
    In addition, there is increasing evidence for the 
effectiveness of psychosocial rehabilitation treatments to help 
veterans with residual symptoms function in their family, 
community and on the job, even if they have symptoms left after 
other treatments.
    When patients have more than one condition, and most do, 
clinicians must evaluate the severity of the conditions and the 
patient's preferences. Plans must allow for combinations or 
sequences of treatment as appropriate following clinical 
practice guidelines.
    VA also employs evidence-based strategies for beginning 
PTSD and substance abuse treatment simultaneously when they 
both occur. It may be difficult to diagnose personality 
disorders in the face of PTSD or other mental health 
conditions. For veterans with relevant symptoms, the clinical 
approach in VA is to treat PTSD first. A subsequent step would 
be to evaluate what symptoms or impairments remain and to plan 
treatments accordingly.
    In summary, treatment for PTSD and other mental health 
conditions can work. For veterans with multiple conditions, 
there must be a multi-stage process beginning with an evidence-
based intervention for the most severe of the patient's 
conditions. Treatment begins with the most severe and continues 
until the person recovers and beyond.
    Thank you for this opportunity to testify. I and my 
colleagues will be pleased to answer any questions you may 
have.
    [The prepared statement of Dr. Katz appears on p. 95.]
    The Chairman. Thank you, Dr. Katz.
    Colonel Bruce--is it Crow or Crou?
    Colonel Crow. Crow.
    The Chairman. Crow, is Chief of the Department of Behavior 
Medicine at the Brooke Army Medical Center and is with us today 
as the Clinical Psychology Consultant to the Army Surgeon 
General.
    We have your written statement, Colonel. If you can respond 
to the first panel as opposed to going through what you guys 
are doing. You know, all you guys are doing everything right. 
As Dr. Katz said, he was affected by the first panel. I hope 
you were. I would like you to respond to it in your statement. 
If you think they are wrong, tell us. If you think they are 
right, what are we going to do about it?
    Colonel Crow. Well, Mr. Chairman, I actually have a oral 
statement that is a little bit different, a little bit shorter 
than my written testimony. I would like to read that, if I may.
    Ms. Brown-Waite. Mr. Chairman, I want to make sure that his 
written statement is going to be entered into the record.
    The Chairman. All written statements will be made a part of 
the record.
    Ms. Brown-Waite. And he does have the opportunity----
    The Chairman. He can do whatever he wants. I would ask him 
to--we put the VA and the DoD as the last panel instead of the 
first panel, as has been the practice here, because after the 
first panel goes, they all walk out and they don't listen to 
the citizens and the stakeholders. So now they have had a 
chance--and I appreciate your sitting through that--to hear. 
And it seems to me if I were in their position, I would say 
well, they don't know what they are talking about, we do this, 
or yes, they are right and here is what we are going to do to 
fix it. They have this opportunity and if they choose to pass 
it up, well, we will try to get to these matters in questions. 
But I would say that that is not the most responsive way to be.
    You have the floor, Colonel.

                STATEMENT OF COLONEL BRUCE CROW

    Colonel Crow. Mr. Chairman and Congressman Buyer who is not 
here, thank you for the opportunity to address the 
distinguished Members of this Committee. I am Colonel Bruce 
Crow, the Clinical Psychology Consultant to The Army Surgeon 
General and Chief of the Department of Behavioral Medicine at 
Brooke Army Medical Center in San Antonio, Texas.
    The soldiers of the U.S. Army deserve the very best mental 
healthcare available. We know there is a stigma against seeking 
mental health services in our society and in the military, 
which is made worse if soldiers don't trust us as mental health 
providers. The Army has highly qualified psychiatrist, 
psychologists and social workers who are uniform or work as 
civil service or contract employees. We are helping thousands 
of soldiers and their family members every day deal with 
problems of living. We are expected to do our job well and to 
improve our system when we find problems.
    Questions have been raised about whether Army psychiatrists 
and psychologists have been negligent for misdiagnosing 
soldiers with personality disorder instead of correctly 
recognizing symptoms of PTSD or traumatic brain injury. This 
would be wrong and should not happen. The ethics and standards 
of our professions dictate that our patients receive accurate 
diagnoses and appropriate treatment.
    I strongly believe our providers have the best interests of 
soldiers at heart. Our obligation is to our patients first and 
above all else. We are committed to reviewing our clinical 
procedures related to making a diagnosis of personality 
disorder pursuant to administrative separation under Army 
regulation. If there are problems with this process, they need 
to be fixed.
    The Acting Surgeon General of the Army, Major General 
Pollack, has initiated a review of the administrative, medical 
and mental health records for nearly 300 soldiers who served in 
combat and were subsequently discharged for a personality 
disorder. This initial review will include the 295 soldiers 
separated from the Army in 2006 who had served in Iraq and 
Afghanistan and had received a separation for personality 
disorder. There were an additional 791 soldiers discharged for 
personality disorder who had not served in combat, for a total 
of 1,086 personality disorder separations in 2006.
    For the period 2001-2006, the Army separated a total of 
5,631 soldiers due to a personality disorder. A much smaller 
portion of that number have served in combat. I may add, I 
don't think the numbers would tell us whether or not we should 
be concerned about a problem. One is too many and we should 
look to see if there is a problem.
    This review will be conduced by a team of senior mental 
health providers looking at compliance with the procedures, 
quality of clinical documentation and whether there are 
indicators that these soldiers had conditions that should have 
been referred for medical board evaluation. The results of this 
review will help determine whether additional reviews should be 
conducted. We expect to have results by early September with 
release to the Senior Army and DoD leadership and then to 
Congress.
    The Army has designed an administrative separation process 
that is intended to provide checks and balances so that 
soldiers are treated fairly and correctly. It would be 
absolutely unacceptable for our mental health providers to 
participate in any way of a misuse of this process.
    We have made many improvements to the Army mental health 
system in the past few years and we believe we provide the 
highest quality, most comprehensive, and most responsive mental 
healthcare of any military in the world. We know there is more 
work to do and more to learn about the psychological effects of 
combat on our soldiers. Every soldier is important to us. 
Especially important are those who need our help dealing with 
traumatic stress or recovery from a brain injury.
    We are dedicated to making our system better and we welcome 
the opportunity to demonstrate our commitment to the highest 
qualify of psychological care for our deserving warriors and 
their families.
    [The prepared statement of Colonel Crow appears on p. 96.]
    The Chairman. Thank you, Colonel.
    I will start the questioning with Mr. Michaud. But just 
given some of the charges that we have heard and some of the 
history, I would say that it is great that you are doing this 
review now. It is a little late, but I am glad you are doing 
it. I think it should be done by an outside panel, an 
independent panel. I don't trust you to tell me what you all 
did, because you are going to tell me it is right. We all know 
that. So why bother?
    Let's get an outside review. I am going to try to put that 
into legislation because you should not be reviewing these kind 
of charges that are based on--you are going to get the 
information from the same people who are being charged with 
negligence and you are going to ask them, well, was it right? 
We know what these reviews are. You reviewed the first stack, 
Surgeon General Pollack did, and every one was perfectly right. 
They didn't ask a soldier. They didn't ask anybody else. They 
just asked the doctor who gave the diagnosis so why should we 
trust this review?
    Mr. Michaud.
    Mr. Michaud. Thank you, Mr. Chairman.
    My first question is for Dr. Katz. If you were asked to 
review someone who--a case that someone had a personality 
disorder, to do a thorough and thoughtful review, what would 
you do in that situation?
    Dr. Katz. The first thing I would do is look for everything 
else besides the personality disorder. We have effective and 
safe evidence treatments for many psychiatric disorders. The 
evidence and effectiveness for treatments of personality 
disorders is lagging somewhat behind. So as a physician and 
someone wishing to help, I would want to make sure that I have 
looked for and excluded all other more treatable conditions 
before making the diagnosis of a personality disorder.
    Mr. Michaud. Would you also want to talk to the individual?
    Dr. Katz. That goes without saying. I assumed you were 
talking about an examination of the patient.
    Mr. Michaud. Well, getting back to the question I brought 
up earlier where Surgeon General Pollack was asked to do a 
thorough and thoughtful--or do a review without--and she did. I 
mean they did and they never talked to the individual. So that 
is why I was kind of curious. If you are to do a thorough 
review, what would the process be? And I agree with your 
comments. If you were to do one, then it would seem to me you 
would have to talk with the individual involved.
    Colonel, the Chairman had mentioned about--and you 
mentioned, you are doing a review of the process and the 
Chairman had mentioned about having an independent review 
process. In light of everything that is going on, particularly 
with Walter Reed, and I have heard my constituents who said 
that they were asked to be redeployed even though they had what 
they thought were PTSD problems, but still they were told that 
they had to go back over there. What is your thought about 
having an independent review of this process? Would you object 
to that?
    Colonel Crow. No, sir, not in general. I mean if there are 
questions about the quality of work done by us, and it is 
more--there would be more confidence in a review by an external 
group of experts, I don't think fundamentally there would be an 
objection to that. I think when this idea was conceptualized by 
our Surgeon General, the idea was this is something that we 
could do, we can do immediately. We have access to the records. 
But if the level of concern is such that you want to have a 
high degree of confidence and not an appearance that it an in-
house and potential conflict of interest, I don't think there 
would be an objection to that.
    Mr. Michaud. Okay. When someone goes into the military, we 
heard from the first panel that there is a rigorous process 
that an individual has to go through. When you have active-duty 
members, then you have the Guard and Reserves. What is 
happening over in Iraq and Afghanistan, what process, or is 
there a reevaluation for the Guard and Reserve members to go 
through that rigorous process before they are asked to be 
deployed over in Iraq?
    Colonel Crow. Well, sir, the process was described as 
rigorous. I would not describe it that way at all. In terms of 
the initial processing into the military for medical 
processing, it is basically a self-report questionnaire and the 
psychiatric questions, they really have to do with is there a 
history of certain kinds of serious psychiatric conditions, 
depression, psychiatric hospitalization, suicidal behavior and 
so forth. There is not direct----
    The Chairman. Colonel, did you--excuse me for interrupting. 
Did you just say the Army of the United States of America takes 
troops into active duty without any rigorous medical 
evaluation? Is that what you just said?
    Colonel Crow. Sir, there is not rigorous psychological 
evaluation. There is----
    The Chairman. So you are saying a rigorous psychological 
evaluation. Go on to one of the--in a combat situation which we 
know is incredibly difficult and causing trauma and you can sit 
there and say that the Army of the United States of America 
does not have any rigorous psychological evaluation. That is 
incredible. I just want to make sure I heard it right.
    I am sorry, Mr. Michaud. You still have more time.
    Mr. Michaud. Thank you.
    I guess the distinction, what I would like to know, 
Colonel, is where a big portion of the men and women who are 
fighting over in Iraq and Afghanistan are from the Guard and 
Reserves, and a lot of these folks haven't--are up there and 
they really haven't had that ongoing military experience like 
the active duty force. So I am just trying to figure out since 
a good portion are over in Iraq, is there anything that the 
Department of the Army is doing to make sure that before they 
ship them to Iraq and Afghanistan that they are able to deal 
with the issue. And actually, I heard from the earlier panel 
that there is a rigorous process. So that is why I asked if 
they had to go through that rigorous process to make sure that 
they are able to do the job that they have to do.
    Colonel Crow. Sir, I think the way that I would 
conceptualize it is the presumption is that someone who has 
enlisted in the Army is able to withstand the duty demands. 
Once they have cleared the basic training, that they are able 
to perform in their duty. And unless it is determined 
otherwise, then the presumption would be that they are fit for 
duty.
    We do have two sets of screenings that are directly related 
to deployment. At the point of redeployment, there is what is 
called a post-deployment health assessment. So all soldiers who 
have been to deployment and are returning are asked a series of 
health questions that do include some questions about 
psychological functioning. And 90 to 120 days following return 
from deployment, there is an assessment called a post-
deployment health reassessments for all military, Guard, 
Reserve, as well as active component, that asks about health 
status, as well as more extended questions about psychological 
functioning that are more sensitive to things like depression 
and post traumatic stress.
    The Chairman. Ms. Brown-Waite.
    Ms. Brown-Waite. First of all, I want to thank you all for 
being here today.
    And Dr. Katz, if there are this 20 some thousand who had 
been diagnosed and dismissed by the military with personality 
disorders, do you know where they are so that they can be 
helped? Is there any coordination going on now that we know 
that there may be a problem in the system? Do you know where 
these people are?
    Dr. Katz. I do not. There is increasing communication and 
list sharing to match people up. We are good at tracking those 
who were discharged via a medical evaluation route, those with 
polytrauma and other related severe injuries, visible or 
invisible. But those who are discharged via more ambulatory 
routes are followed primarily through the PDRHA and beginnings 
of liaison with VA there and by community outreach and 
education.
    Ms. Brown-Waite. PDRHA, tell me what that is.
    Dr. Katz. Post Deployment Health Reassessment that the 
Colonel was speaking about. These are evaluations that are 
conducted by DoD with co-participation from VA, primarily Vet 
Center staff, usually peer outreach people to try to make 
contact.
    Ms. Brown-Waite. What about those that DoD has released 
with a diagnosis of personality disorder? Is there any way that 
you could reach them? Is there the sharing of the information? 
In other words, Colonel Crow, if someone is released from DoD 
with a personality disorder diagnosis, is that--do you ever do 
followup?
    Colonel Crow. No, ma'am. Followup of their living situation 
or----
    Ms. Brown-Waite. Followup of their mental health needs.
    Colonel Crow. No, ma'am.
    Ms. Brown-Waite. And obviously they are not eligible for 
the VA because they have been discharged because of a diagnosis 
of a prior condition.
    Dr. Katz. No. That is really not the case.
    Ms. Brown-Waite. Okay.
    Dr. Katz. They are very much eligible for VA care and 
benefits.
    Mr. Aument, do you want to talk about the benefits side and 
I will talk about care?
    Mr. Aument. Certainly. In fact, I think it is worth 
clarifying that, as long as there is an honorable discharge or 
a general discharge, anything other than dishonorable 
conditions, a diagnosis of personality disorder does in no way 
disqualify a veteran from receiving disability compensation or 
VA healthcare eligibility.
    We would go through precisely the same evaluation process 
if a veteran came to us seeking disability compensation for 
PTSD. We would go through precisely the same process evaluating 
that claim that we would for any other veteran who came to us 
with that type of a claim.
    The Chairman. Would you yield for 1 second?
    Ms. Brown-Waite. As long as the panel isn't going to be 
attacked, sir.
    The Chairman. Okay. Would you--do you know how many people 
who come to the VA with this personality disorder discharge 
have come to the VA for help? Do you know?
    Mr. Aument. No, I do not, Mr. Chairman.
    The Chairman. Do we keep that information?
    Mr. Aument. No, we would not, Mr. Chairman. In fact, that 
information is not even reflected on their DD214. We would have 
to go through and actively review their service medical records 
and somehow capture that information for future use. And quite 
frankly, if it is not relevant to a determination of PTSD, we 
would have no reason to collect that information.
    Ms. Brown-Waite. Let me ask another question reclaiming my 
time. Would a Benefits Delivery at Discharge (BDD) physical 
with VA and DoD practitioners evaluate a servicemember to 
understand the history and possibly the exacerbation of mental 
health conditions, new or old?
    Mr. Aument. Do you want to take that, Doctor, or do you 
want me to----
    Dr. Katz. Any reliable and valid evaluation should include 
those components.
    Ms. Brown-Waite. But I think I am asking do they.
    Mr. Aument. It depends upon what type of conditions have 
been claimed. For benefits delivery at discharge, we conduct 
the examinations that are relevant to the disabilities that are 
being claimed as part of that process. For example, if there 
has been no PTSD or other mental disorder disability that has 
been claimed, it is unlikely that we would conduct any 
extensive mental health examination.
    Ms. Brown-Waite. I see that my time is up. Let me ask one 
other question. Is part of the problem that the young man who 
testified earlier, Jonathan Town, where he submitted the 
information multiple times, is part of the problem that the 
computer system has different programs to it? I know I 
experienced this when trying to help a constituent and got a 
very helpful person on the line from VA disability and he said 
well, I knew the paperwork was there because the constituent 
sent it in three times. I send it in once and he said let me go 
to this program, let me go to this program, let me go to this 
program. There were four different programs.
    So perhaps that was part of the problem, because I know I 
was being told that constituent's paperwork wasn't there when I 
knew it was there. He had sent it in several times. My office 
sent it in registered mail with return receipt. So we knew they 
had it. Is that part of the problem?
    Mr. Aument. I think in this case, Congresswoman, that is 
probably the heart and soul of the problem. What you are 
identifying here is a processing shortcoming on VBA's part in 
this particular case, that we are certainly accountable for. 
But I don't believe it was anything having to do with this 
particular condition, just probably some sloppy service on our 
part.
    Ms. Brown-Waite. Well, this happened--this happened 3\1/2\ 
years ago. So I am asking you have you gotten--have you 
improved the computer tracking system at all?
    Mr. Aument. Yes.
    Ms. Brown-Waite. Tell me how.
    Mr. Aument. Part of the processing changes that have been 
made has been to upgrade the claims processing system starting 
from the very time that a claim is received, Congresswoman. We 
have not completed that process. It is part of the replacement 
of the compensation and pension payment and processing system. 
It is the effort that is called Vetsnet, which, has a little 
troubled history, but I believe we are on track now for 
improving that and providing better service to veterans.
    Ms. Brown-Waite. Let me ask you one other question. If 
today an application is made for a disability, how many 
different programs could that information be entered into? It 
was 4, 3\1/2\ years ago. How many today?
    Mr. Aument. I would say today, a receipt of a claim for 
disability compensation would be entered in no more than two 
systems, probably only one, but no more than two.
    Ms. Brown-Waite. And that is system-wide?
    Mr. Aument. That is correct.
    Ms. Brown-Waite. Okay. All right. Thank you. I yield back.
    The Chairman. But Specialist Town's applications were not 
3\1/2\ years ago. They were far more recent and he said only on 
the fifth one when he had a lot of publicity did he ever get 
notice.
    Let me ask a few questions and make a few observations. The 
first panel shocked me. You guys shocked me even more.
    Colonel, you came into my office yesterday to explain to me 
this wonderful chain teaching approach of PTSD. And we are 
going to educate the whole Army about this. And you said the 
whole basis of this chain teaching is that support has to come 
from the top so everybody knows it. And yet the implication of 
what you said earlier was that to the Army, psychological stuff 
is hardly very important. You said there is a high probability 
they will adapt. We don't have to worry about it.
    What kind of signal is that sending if the physical and the 
mental--you have not parity whatsoever in your own mind. So how 
can a soldier ever understand what PTSD is if at the very top 
you are not understanding these issues?
    Colonel Crow. Sir, I could comment about the chain 
teaching. What we were wanting to describe is that we recognize 
that stigma for seeking mental health services is a barrier to 
care. We recognize----
    The Chairman. And did you say anything today that would 
remove that stigma? You said they will adapt. Real men adapt. 
Real women adapt. Don't worry about this stuff with the 
psychological thing. You went through basic training and you 
are going to be a soldier. That is what you said today. So how 
does that get rid of the stigma?
    Colonel Crow. Sir, I didn't intend to give that 
connotation.
    The Chairman. The implication----
    Colonel Crow. I think the question had to do is whether 
there is rigorous----
    The Chairman. Yes, and you dismissed it. You said we just 
assumed that they are going to adapt to the conditions after 
basic training. That is what you said. So clearly, it is not 
important to you and that is what people get. And if they have 
something, well, you better not admit it.
    I have talked to soldiers and marines who filled out the 
questionnaire about on entrance, on separation, that they are 
supposed to self report about any medical conditions. They told 
me when they submitted their questionnaire, their commander or 
whatever said you have go redo this. You cannot admit any of 
this psychological stuff. They will keep you here another 6 
months. You want to go home. Change your questionnaire.
    We have soldiers getting out of there that are slipping 
through the cracks that have no evaluation for either brain 
injury or for PTSD. You are sending back for second and third 
deployments people who have brain injury and PTSD. If I was in 
your position, Dr. Katz or Mr. Aument, and heard what I heard 
at the beginning, I would have shocked this Committee and said, 
you know, if there are 22,500 people that have been diagnosed, 
maybe wrongly according to the testimony, with personality 
disorder, let's go find them all, not just 10, not just 259. 
Let's go after the 22,000.
    The Army is a great record keeper, right? We could find 
them. You say you have outreach. I don't know--I doubt if you 
are going after--I would take a sample of these by the way and 
we may have to do this in legislation, take a sample of the 
22,000, maybe 1,000 and find out what is going on with them, 
bring them to the VA. Don't just wait for them to come in.
    We are responsible for them. We sent them into war. We sent 
them into whatever we sent them to, whether they are in combat 
or not. We have an obligation to them. And you all sit here and 
say well, we have outreach and no, we don't know how many of 
those personality disorders come in.
    And Mr. Aument, you said everybody knows that they could 
come in and we will do a de novo review. It doesn't have any--
none of what they had before affects us. But if you are a 
soldier and you were told at age 20 that you are not eligible 
for VA benefits, as these guys had papers that told them that, 
and you cannot show up because you had a preexisting condition, 
what are the odds that they are going to show up? I think 
pretty small, although let's find out. Let's go after--let's 
take 5 percent of that 20,000 and find out. Did all 1,000 come 
in?
    If you told me you went after 1,000 and they are all now 
getting adequate treatment at the VA, I wouldn't be talking 
like this. But I doubt that is the fact. But prove me wrong.
    Anyway, given the fact that both the military and the VA 
heard this testimony, which is very, very shocking, that there 
is a systematic and a policy-driven misdiagnosis of PTSD as 
personality disorder to get rid of the soldier early, to 
prevent any expenditures in the future which are calculated in 
the billions of dollars, I would take that pretty seriously if 
I were you guys and say something about that. But, you said you 
are affected, but nobody said well, let's go look at those 
22,000. Maybe these guys are wrong. We are only basing it on a 
few people.
    Well, find out. I mean these are pretty serious, pretty 
serious allegations. And if we had doctors' names and one was 
listed and I have some that have told us that they were 
misdiagnosing, it seems to me that you should go find that out, 
Colonel Crow. You are just going to look at 300 records and 
everything will be fine. Maybe there will be one or two.
    There is something going on in your organization that is 
wrong and it is hurting our young men and women. It has to hurt 
your effectiveness as a fighting force. I mean for all I know, 
we are doing so bad in Iraq because you are sending all these 
brain injured kids back to the second deployment. I mean that 
could account for how terrible the effort is we are doing.
    But we have got a lot to do here. And if I heard one thing 
from either organization, that you took it seriously and wanted 
to do something about it and we are going to ask the Congress 
to give us the money to go after these 20,000--why don't you 
ever ask us that? I didn't hear anything like that.
    Dr. Katz. Well, we are grateful for the money we have 
received, including the supplemental funding and----
    The Chairman. Yes, but nobody asked for that. We asked for 
it.
    Dr. Katz. And are using them to improve access, capacity 
and quality to make VA mental health services----
    The Chairman. Well, that is a generalization. I want to 
know, I want you to tell me that we are going to look at 1,000 
of these 20,000 PD diagnoses and figure out what happened to 
them, working with the Army, get their names and addresses, go 
after them. That would show me you cared about access.
    All these generalizations don't tell me anything because I 
have people coming into my office every day--and Ms. Brown-
Waite talks about specific soldiers coming in, who tell us they 
can't get--they have called the VA. They think they have PTSD 
and they have got to wait for three, four, or 5 weeks to call 
back. Now, we know people have committed suicide in that 
interval.
    But everybody says we are outreaching. Soldiers come into 
our office or call us. They cannot get the help they need. They 
are dissuaded from coming in and, when they come in, there is a 
limited number of sessions they can have and on and on. So 
something is wrong.
    Dr. Katz. We will take your suggestion for these specific 
outreach and followup studies----
    The Chairman. Thank you.
    Dr. Katz [continuing]. And determine what can be done with 
existing records
    Ms. Brown-Waite. Mr. Chairman?
    The Chairman. Yes, ma'am.
    Ms. Brown-Waite. First of all, I have not told you people 
came into my office on PTSD issues.
    The Chairman. No. You talked about specific cases.
    Ms. Brown-Waite. I have talked about specific cases, yes, 
including one this morning. I just wanted the record to be made 
clear. And I think that perhaps the record may not also be 
clear about the conversation with Colonel Crow. That is not the 
testimony that he gave here today. It may have been what he 
said in your office. But your assessment of his saying oh, they 
will be all right, that is not the testimony that he gave here 
today.
    The Chairman. If you read the transcript of his testimony, 
he said, and we can take down his words and see it right now, 
but we won't. He said, when asked about the rigorous 
examination and I said you mean you don't have a rigorous 
examination? He said, well, I was speaking mainly of the 
psychological. And then in answer to a question from Mr. 
Michaud, he said that--not exactly quoting, but something to 
the effect that we assume that they will adjust after basic 
training to the, to the war situation, right? I mean that is 
what I heard. Is that what you heard or something like that?
    Mr. Michaud. Yes. We would have to look at the record 
because I couldn't hear.
    The Chairman. And besides, if he said completely different 
words and that is what this poor little Congressman heard, then 
he is not communicating correctly and we gave him a chance to 
change it. But he gave the impression, and I am sure it is in 
the transcript, that the psychological evaluation was not as 
rigorous and was not as important because a real soldier will 
adjust.
    And that is the whole problem we have.
    Ms. Brown-Waite. I don't believe he said important.
    The Chairman. That is why these people on panel one came to 
us, because we don't have an understanding of these issues and 
we don't have treatment of them and we have a systematic 
effort, apparently, to try to get rid of them without having 
more problems. They don't follow them. They took them into the 
Army. It seems to me we have some obligation there. And we 
don't follow them up or anything. They are back who knows 
where.
    So I hope that we can look at some of those personality 
disorder evaluations. Thank you, Dr. Katz for saying that. And 
we are going to either--the Surgeon General asked for an 
independent evaluation or we will put it in legislation. But if 
you think that we are going to believe an evaluation of 259 
cases, whichever ones you happen to pick, I will tell you now I 
am not going to believe it.
    So why bother? Let's have an independent evaluation and we 
will try to deal with it.
    Mr. Michaud.
    Mr. Michaud. Yeah, I just--I would have two quick 
questions, but I don't know if Mr. Rodriguez had any questions. 
But my two quick questions actually, one for Dr. Katz is, you 
talked about taking care of our veterans. Quick question, what 
do you do with someone who is a veteran who is employed by a 
company like Blackwater who is currently over in Iraq and 
Afghanistan but they might be a Priority 8 veteran but they 
need help with traumatic brain injury or PTSD? Would you take 
that individual into the VA system? And I don't need an answer 
today if you can't----
    The Chairman. What if they are not a veteran and they have 
been injured in the war?
    Mr. Michaud. So that would be my question for them. The 
additional follow-up question to the Colonel would be, you had 
mentioned earlier that every soldier is important to you. Some 
of the concerns that I have heard from the men and women who 
have been over in Iraq, who have come back from Iraq, when you 
look at the ratings, if everyone is really important when you 
look how you deal with the disability ratings, it is different 
than the VA.
    You look at the injury, as I understand it, whereas the VA 
looks at an individual as a human being, as a whole person. And 
that is why we are seeing a disparity in ratings. And when you 
are reviewing this process, hopefully that you would look at 
the soldier as an individual, and yes, they might have lost a 
limb over in Iraq, but yes, they also might have caused other 
problems such as PTSD or TBI. So hopefully that review process 
will look at an individual as a whole person, similar to what 
the VA does.
    Dr. Katz. We will respond to the question about the 
veteran/contractor for the record.
    [The following was subsequently received:]

          VA would provide care to a veteran who serves as a contractor 
        in either Iraq or Afghanistan, if the veteran is already 
        enrolled in the VA health care system. If the veteran is not 
        enrolled in the VA health care system, the veteran could apply 
        for enrollment, and VA would make an enrollment decision based 
        upon applicable eligibility factors.
          If the veteran had no other qualifying eligibility factor 
        such as a service-connected disability, recipient of a Purple 
        Heart award and income under the applicable VA means test 
        threshold or determined to be catastrophically disabled, the 
        enrollment restriction for new priority 8 veterans would apply.

    The Chairman. Mr. Rodriguez, do you have a concluding 
comment or question?
    Mr. Rodriguez. I haven't had a chance to----
    The Chairman. Oh, I am sorry. I apologize for missing you. 
I am sorry.
    Mr. Rodriguez. And I apologize. I didn't get a chance to 
listen to the panel either, to the whole panel. I know Dr. Katz 
well, you know. So good seeing you again.
    I don't know how many of you actually listened to the 
initial testimony. As we look at the numbers of 22,000, I would 
presume, and I want you just to comment on it, that that is 
disproportional in terms of the diagnosis for that specific 
diagnosis. Would that be accurate in saying that, that that is, 
you know, if there are 22,000?
    Dr. Katz. There have been 720,000 individuals discharged or 
separated from the military after service in Iraq and 
Afghanistan.
    Mr. Rodriguez. Seven hundred and----
    Dr. Katz. Twenty thousand.
    Mr. Rodriguez. Okay.
    Dr. Katz. Two-hundred fifty thousand have come to the VA 
for care.
    Mr. Rodriguez. So 22,000--usually there is a percentage out 
there for, I guess, one-half percent or a percent of the 
population falls into schizophrenia, what other percentages--so 
is that something that is out of the, you know----
    The Chairman. How many of those 250,000 were diagnosed by 
the VA with personality disorder?
    Dr. Katz. I could get back to you about that. That is not 
one of the diagnoses we follow most closely.
    [The following was subsequently received:]

          From October 1, 2001 to March 31, 2007, 252,095 OEF/OIF 
        veterans were either evaluated or treated at VA medical 
        centers. Of that number, 2,316 OEF/OIF veterans were seen for 
        personality disorders (ICD-9 CM, 301).
          It is important to note the ICD diagnoses used in this 
        analysis to obtain the number of OEF/OIF veterans seen for 
        personality disorders were obtained from computerized 
        administrative data. Although diagnoses are made by trained 
        healthcare providers, it may include provisional diagnoses 
        before confirmation by specialists, diagnostic tests, and a 
        followup evaluation.

    Mr. Rodriguez. Yeah. I was just wondering----
    The Chairman. Because you are not looking for it. You told 
us you are looking for PTSD. They are looking for personality 
disorder----
    Mr. Rodriguez. Yeah, because I think--I just wonder where 
there is a disproportional number in that population of that 
specific diagnosis. That is the only reason I was asking.
    Secondly, we know that--and it also brings some concerns. 
And I know the Colonel and I am familiar with Brooke Army 
Medical Center. They do great work there. Do we know in terms 
of the data that we have now if there is a disproportional 
number may be coming out of Fort Carson or other areas with 
that diagnosis or do we know that for a fact, or we don't have 
that information?
    Colonel Crow. No, sir. You are raising some very good 
questions in terms of prevalence rates of the diagnosis, let's 
say, of personality disorders in general. How have they--
variance stayed constant over time, before war, after war, 
given the different demographics of the soldiers that are 
coming in. There would be a lot of questions, I think, that 
could help answer whether or not there seems to be a variance 
at this point in time with making that diagnosis.
    Mr. Rodriguez. But see, there is a pattern that maybe from 
some areas or some psychiatrist doing, going in that direction 
versus others, in terms of their decisionmaking.
    I would also be concerned--and you mentioned it also that 
if there is one that we misdiagnosed that is one too many. And 
so of the ones that we have dishonorably discharged, and I 
don't know if we have those figures, if they were due to self-
medication, because I know that sometimes when they are ill, 
there is a tendency to self-medicate and maybe get illegal 
drugs. And I know that that is grounds for dishonorable 
discharge.
    And I am curious now whether there are some people under 
that category that could have been ill and were not caught and 
now find themselves dishonorably discharged as a result of 
trying to self-medicate. Do we have any idea?
    Colonel Crow. No, sir. I am now thinking of a way that we 
would be able to answer that.
    Mr. Rodriguez. We would have to go after the discharge--
they were dishonorably discharged, to get a grasp to see if 
there is any, you know, because if we have made mistakes in 
diagnosing, and I know full well that someone may be seriously 
ill and we misdiagnosed, then we could have also, that person 
could easily have gone to try to self-medicate in the process 
of doing that and then find themselves, even though they might 
have had a great record with the military, find themselves 
dishonorably discharged as a result of that.
    And so I would be concerned if there is just one who 
deserves to have, not to have fallen into that category. I 
wonder if you have any comments on that. Have we ever done any 
assessments of that?
    Dr. Katz. We have seen the press reports about that 
happening and are very concerned about those tragedies. There 
are processes in VA for appealing less than honorable 
discharges to reclaim eligibility for benefits.
    Mr. Rodriguez. The Chairman said, you know, we are in a 
situation and we hear the report. I guess the frustration is if 
we don't hear anything, we are not going to come up with a plan 
as to what is best to get to it unless we hear that, and the 
report tells us that no, everything was above board. But if 
not, what would you recommend under those circumstances having 
heard the allegations?
    Colonel Crow. Well, sir, I think if the question is, is the 
Army and perhaps the other military services doing an accurate 
job of diagnosing personality disorders as they are 
administratively separated, I think there would be some other 
indicators that we could look at. One of the things that I had 
mentioned in my oral statement was there is supposed to be 
checks and balances in this process. And one of the balances, 
if you will, is a review by a legal officer to make sure that 
procedures were followed, that the soldier who is being 
separated understands the nature of the separation, agrees with 
it, understands their benefits.
    That is not a medical procedure. I don't know if there are 
suspicions or problems with that balance. Part of the problem 
may be complaints by soldiers that this is not working well. I 
really wouldn't know that. But I think that would be another 
potential indicator.
    Mr. Rodriguez. Yeah, because I know that that particular 
diagnosis automatically disqualifies the personality disorder, 
basically indicating that--now, the other diagnosis of 
schizophrenia, we haven't heard anything on that. But that 
onsets also early adult and it is under pressure that it 
reveals itself. Do we have any data on those individuals?
    Dr. Katz. Among those who have come to VA for clinical 
care, among the 250,000, the number of those who have served in 
OIF or OEF who have come back with a psychosis is really quite 
small, under 2,000.
    Mr. Rodriguez. Yeah. And in the regular population, that is 
about 1 percent or less. So that seems--I don't know what the 
numbers are. So is that about appropriate?
    Dr. Katz. It is a percent or less that have a psychosis. 
There are other psychoses besides schizophrenia, but one would 
expect that the people with early onset, the most severe forms 
of schizophrenia would not be in the military.
    Mr. Rodriguez. Okay. Thank you very much.
    The Chairman. Thank you. Do you have any final thoughts, 
Ms. Brown-Waite?
    Ms. Brown-Waite. Mr. Chairman, I would ask that the record 
be reflected for the true statement that Colonel Crow made. I 
just want to make sure that there is no misinformation out 
there. I just think that that would be appropriate.
    The Chairman. That is part of the--this is officially 
transcribed. So all his words will be in the record, as will 
mine.
    Mr. Kennedy----
    Ms. Brown-Waite. I just wish that there could be some way 
that your words and your interpretation could be indicated 
that--because I think that there was a very clever weaving of 
what he said and how you interpreted it. And that concerns me.
    The Chairman. Well, thank you for saying I am so clever.
    But Mr. Kennedy, do you have any final thoughts?
    Mr. Kennedy. Thank you. Yes, Mr. Chairman. I just wanted to 
point out once again, as a Member of the Veterans' 
Appropriations Subcommittee, that, you know, we are looking 
forward to doing a Conference Committee and looking to address 
the immediate--you know, we are talking all about these 
problems, but we have got all these veterans out there 
suffering right now. And we have got to get help to them right 
away. There is a lot of talk going on, but we need action.
    And we need to make sure that we get these services out to 
them as soon as possible without delay and we need to do it 
this year posthaste and I hope in this Conference Committee 
that we can take this authorizing language that this Committee 
has been working on on the contracting out and put--set aside 
dollars for the Veterans Integrated Service Networks (VISNs) to 
specifically use to contract out for mental health services and 
other services with local community health providers to obtain 
the services desperately needed by these veterans, that they 
are not now currently getting and due to the fact that the need 
is so great and the capacity is so limited within the VA.
    And the intransigence it seems as though that there is, 
within the VA, to want to share, you know, to go outside itself 
to--and I know there is this insular attitude. I don't know if 
any of you could talk to me about where that comes from. I know 
it is kind of a sacred cow. I mean I am hearing it--I hear it 
from my VSOs. They don't even want to hear me talk about any 
contracting out of VA services because God forbid, you know, 
anything but the VA provide services to veterans.
    But I am telling you this. My veterans don't care where 
they are getting their services now. That World War II 
generation wanted to be with the World War II generation. Korea 
wanted to be with the Korean generation. But after that, these 
new veterans, they don't care where they get their care. They 
want their care. Okay? And they don't care if they are with 
their fellow veterans. They want to make sure they get their 
care.
    I just as soon we take a gold card and give it to every vet 
that comes back and say you go out there and you get your care. 
This notion that we are now trying to protect these sacred cows 
so as to--and in the process letting our poor veterans go out 
there and in the middle of all of this have to wait in line 
and, you know, fight for what should truly already be theirs to 
me is just something that is inexplicable.
    But maybe you guys could shed some light on this issue to 
me. You understand the issue, and I think we all do, that there 
is a cohort of veterans from an earlier age that all love to be 
together because of that sense of common experience, that there 
is that bonding. They like to be together. But there is a new 
generation of veteran that frankly wants to just get their 
healthcare, get their benefits and get on with their lives, 
that isn't as consumed with this notion of where they get it. 
They just want to get their healthcare.
    And maybe you can answer me why there is this sacred cow 
and why we can't get these VISNs to give up their sacred 
territory about contracting out with community mental health 
providers, per se.
    Dr. Katz. Mr. Kennedy, I would like to respond by saying I 
have admired your advocacy, knowledge and passion for the 
mental health issues for many, many years. All of us in the 
mental health professions are very, very glad you are here.
    I think that what we are protective and paternal about 
isn't our turf, but the quality of care, as well as access to 
care. And we would very much appreciate the chance for 
technical discussion with you about how to optimize both access 
and the quality of care.
    Mr. Kennedy. Well, let's work on appropriate language. But 
one thing I think that would be a conflict is if a local VISN 
director has to make a choice of deciding where to put the 
money and they are going to take that budget and that budget is 
going to be chosen as to whether they are going to take their 
money out of their hide and spend it on a community mental 
health center or not, where are they going to spend it. They 
are going to spend it within their own budget to make ends meet 
as opposed to, you know, take a chance that looking at this 
local community health center that does great work down the 
way.
    Now, that local community health center has certified 
mental health professionals. Now, frankly, the experience of 
these veterans run the gambit. Now, granted, you have the post 
traumatic stress disorder and the VA has certain expertise. And 
in fact, we are studying some of that in my district that is 
some of the most cutting edge in the PTSD area. But there is a 
great deal of work in substance abuse, in marital counseling, 
in a whole host of areas that frankly, you know, there is 
plenty of room where the VA doesn't need to be--where they can 
be maximizing the use of these mental health professionals.
    When you have got over 40 percent of the Guard and 
Reservists right now suffering from PTSD, I would think that 
you would err on the side of caution of getting them access to 
some kind of mental health professional rather than saying hey, 
we want the perfect to be the enemy of the good. I don't think 
we want the perfect to be the enemy of the good, because 
frankly, even if a mental health provider is not an expert in 
PTSD, it doesn't mean that they don't have the kind of training 
that they need to deal with trauma, because trauma itself is 
not something that they aren't ill-equipped to deal with in 
general.
    So let's work together on this because with the magnitude 
of this problem, we can't wait. We both agree that waiting is 
not the answer. Failure, you know, is not a solution, as they 
said in Apollo 13, because we know that delay here makes this 
problem worse, not better. And I thank you for your work and 
your concern about this.
    And maybe I could ask, one of the problems I heard about at 
my local VA hospital was that if not asked about whether an 
Army, a Guard Reservist was being treated for PTSD, they would 
be called back up. That was specific to my VA in Providence. My 
PTSD supervising doctors told me that they were--saw some of 
their patients being sent back to Iraq and as a matter of 
policy, the Navy specifically prohibited, but the Army did not. 
They said that the Army, if they did not specifically ask 
whether they were treating someone for PTSD, that the VA did 
not have to volunteer that information. Is that true?
    Dr. Katz. VA's policy is to share information without 
significant barriers for those with whom we share clinical 
care. The redeployment decision is a command authority 
administrative decision and VA's policy on sharing clinical 
information for administrative command authority reasons is to 
require that the veteran consent to VA sending the information 
to DoD.
    We are concerned that there may be cases for whom that 
exposes veterans to risk, but we are concerned that without a 
consent provision we may not be recognizing the rights of 
people who may want a military career and respond to treatment 
to continue their military careers. It is a tough tightrope in 
balancing rights and responsibilities.
    Mr. Kennedy. Well, what it seems to me is, they are 
concerned that they can't say that I am getting treatment 
because they know the military is going to say goodbye and 
their military career is going to be over. Whereas, if they 
said no, I am getting treatment, the military would say okay, 
you can stay in the military, but here are some other options 
for you in the military.
    That is what I think is not--is the missing piece here. 
Instead, what we have is, we have the military saying, you 
know, don't ask, don't tell. And in the process, we may have 
someone who comes back into the unit that may be a threat to 
the unit if they are not properly treated, if they are not safe 
to themselves and to the unit.
    I mean you have basically said, if they are not--you are 
balancing on the one hand the individual's needs with the 
unit's needs, correct? So how do you do that?
    Dr. Katz. VA's policy is to provide this information to DoD 
with the veteran's consent. And our assumption is that the 
Department of Defense examines people about to be redeployed 
for mental health and other physical conditions that could 
limit their effectiveness.
    Mr. Kennedy. Right. Well, my--the thing is, my PTSD doctor 
in Rhode Island said that they were--he was actively treating 
PTSD Guard and Reservists who were on medical leave, 
Reservists, okay, so that they were called up again and he 
wasn't consulted as to whether they should be called back into 
active service and so they went back to Iraq and presumably 
they joined their unit and presumably they were fit to join 
their unit and they weren't a threat to the security of the 
unit or themselves.
    But it is interesting that that is--that that fine point 
has not been worked out. I believe in protecting the private 
confidentiality of the soldier. But I also believe in the 
safety of the unit and I don't think that in order to protect 
the privacy of the soldier we need to sacrifice the safety of 
the unit, and I don't believe that the soldier's future career 
needs to be jeopardized.
    I think that there ought to be other options for that 
soldier to pursue. That is the big conundrum, that there is 
this notion that if they reveal that somehow they have sought 
treatment, that they somehow have no other--their options are 
limited, absolutely limited from then on, which, of course, as 
we know, is not true. So that I think is where the stigma comes 
in.
    Colonel Crow. I would like to make a comment. I am not sure 
that it will really address what you are saying. But I think 
the assumption has been made throughout the course of the day 
that once diagnosed with post traumatic stress disorder it is 
sort of a end of the line----
    Mr. Kennedy. Right.
    Colonel Crow [continuing]. Kind of connotation, and that is 
not the case as we see it.
    Mr. Kennedy. Right.
    Colonel Crow. What we know is, we have soldiers who are 
diagnosed with post traumatic stress disorder who continue to 
do their job. They want to do their job. They want to stay on 
active duty and perform. So there is not an automatic 
disability associated with post traumatic stress disorder.
    We also know that the models of treatment that have been 
developed came from a different population at a time when we 
didn't know very much about PTSD and we believe that it is 
extremely important to rapidly develop, to the extent that we 
can, models of treatment that allow us to provide interventions 
close to the time that the traumatic event and the symptoms 
appear. That is not a situation that we had in Vietnam. It is a 
situation that we do have now as an opportunity. However, the 
professions and the science had not matured to the point where 
we have off-the-shelf capability to do that. That does need to 
be developed.
    We are extremely grateful that there has been a 
considerable sum of money that will be provided to the 
Department of Defense to help both with research, as well as 
new clinical programs that I think will help quite a bit.
    I also think it would be remiss to leave the impression 
that the mental health providers in the Army or Department of 
Defense don't know what they are doing. We have extremely well-
qualified and extremely well-trained individuals. If there are 
problems with individuals who are outside the variance of 
clinical practice, by all means, that needs to be correct. But 
we have dedicated professionals. We have strong ethics within 
the Army of taking care of soldiers and trying to do what is 
right. And I think that needs to be recognized and not 
overlooked.
    The Chairman. Thank you. Thank you, Colonel Crow.
    Mr. Kennedy. If I could, Mr. Chairman, we don't have enough 
of them.
    Colonel Crow. That is true.
    Mr. Kennedy. We don't have enough of them and we also have 
had an ethic of ``pull yourself up by your bootstraps,'' too 
much of that ethic recently from the political establishment in 
this town as of the last few years that, you know, believe in 
God and country and you will make it through. And that, my 
friends, has been what has been wrong with this. If you believe 
in God and country, you will be all right. If you don't, that 
is, you know, you have got some moral deficiency here.
    That is what we have got to get over. This is a real 
disease, a real effect of war and it is not some moral failing 
of the person and not some character defect and unfortunately, 
so much of the--there has been so many mixed messages coming 
from political leadership at the VA and from the 
Administration, whether it be other administration--Justice 
Department, through the politicization of those other 
departments, and so forth, that have sent these messages out 
that I think has made it very difficult for people who have 
been trying to seek care, to go out there and think that it is 
all right for them to seek care.
    Thank you, Mr. Chairman.
    The Chairman. Thank you, Mr. Kennedy. Thank you for your 
leadership on this.
    We thank the panel for being here and this meeting is 
adjourned.
    [Whereupon, at 3:06 p.m., the Committee was adjourned.]



                            A P P E N D I X

                              ----------                              

                 Prepared Statement of Hon. Bob Filner
             Chairman, Full Committee on Veterans' Affairs
    Thank you all for coming here today. The purpose of this hearing is 
to examine: (1) how the VA addresses Personality Disorders; and (2) the 
recent report by the Institute of Medicine on VA PTSD claims.
    Let me start by saying that this is a real issue. Estimates are 
that about one-third of Iraq and Afghanistan veterans may show signs of 
PTSD. A national report last year said that the number of veterans 
seeking help at VA walk-in Vet Centers for PTSD rose from 4,500 to over 
9,000 between October 2005 and June 2006.
    Mental health issues, however, are not confined to OIF/OEF 
veterans. There are many older veterans who have yet to be properly 
treated or diagnosed. Until recognized in the early eighties, PTSD was 
considered a temporary ``war neurosis.'' For servicemembers who didn't 
recover, the default diagnosis was to search for an underlying 
Personality Disorder.
    My concern is that this country is regressing and again ignoring 
legitimate claims of PTSD in favor of the time and money saving 
diagnosis of Personality Disorder. For instance, in the last 6 years, 
the military has discharged over 22,500 servicemembers due to 
Personality Disorders. Unfortunately, this Committee does not have 
oversight responsibility for DoD; however, I have asked them to be 
present today because they can provide insight on the initial mental 
health treatment of our veterans.
    Providing veterans with the correct medical diagnosis is key for a 
variety of reasons ranging from receiving proper treatment to 
eligibility for military and veterans benefits.
    Once a servicemember is diagnosed with a Personality Disorder, he 
or she has a much more difficult time receiving benefits and treatment 
at the VA. I want to know how the VA deals with veterans who have been 
labeled with a Personality Disorder.
    Does the burden fall on the veteran to prove that he or she doesn't 
have a Personality Disorder? Will such a diagnosis prevent the veteran 
from receiving health care once initial VA coverage ends? What extra 
barriers does this veteran face?
    I am also very interested in learning more about the May 7th PTSD 
Compensation and Military Service Report, which addressed the current 
status of the VA's PTSD claims process. The Report was completed by a 
Committee of preeminent professionals in the mental health field and 
was paid for by the VA.
    The Report offered numerous recommendations on how the VA could 
improve its PTSD claims process. I want to hear the VA's opinion on 
whether they can implement the many suggestions offered in the Report. 
Or, is this Report going to wind up like so many others before it--on a 
dusty shelf somewhere in the vast VA?
    In closing, I want to say that our servicemembers who come back to 
the states from serving in OIF/OEF should not be forced to fight a 
second battle to receive a proper medical diagnosis and the benefits 
and medical care they deserve. One battle in a lifetime is more than 
enough.

                                 
                Prepared Statement of Hon. Corrine Brown
         a Representative in Congress from the State of Florida
    Thank you, Mr. Chairman for calling this hearing today to discuss 
the relationship between PTSD and Personality Disorders and treatment 
at the VA.
    PTSD has been called many names through to many wars. From 
``soldier's heart'' in the Civil War, to ``shell shock'' in World War I 
and ``combat'' or ``battle fatigue'' in World War II.
    Other terms used to describe military-related mood disturbances 
include ``nostalgia,'' ``not yet diagnosed nervous,'' ``irritable 
heart,'' ``effort syndrome,'' ``war neurosis,'' and ``operational 
exhaustion.''
    Yet the name is not important for the disease, but how those 
affected are treated.
    The men and women in our military are risking their lives to defend 
the freedom of this country and for us to throw them away after their 
operiational usefulness has ended is inhuman and un-American.
    I am reminded of the words of the first President of the United 
States, George Washington, whose words are worth repeating at this 
time:
    ``The willingness with which our young people are likely to serve 
in any war, no matter how justified, shall be directly proportional as 
to how they perceive the veterans of earlier wars were treated and 
appreciated by their country.''
    I look forward to hearing the testimony of those panelists here 
today and learn how to best help those who have bravely served our 
Nation in war.

                                 
          Prepared Statement of Hon. Stephanie Herseth Sandlin
      a Representative in Congress from the State of South Dakota
    Thank you, Chairman Filner for holding this hearing to review 
assertions that Post Traumatic Stress Disorder claims are being 
misclassified as pre-existing personality disorders and also to review 
the May 7, 2007, report from the Institute of Medicine and National 
Research Council on the Department of Veterans' Affairs PTSD disability 
rating system.
    I also would like to thank all of today's witnesses. I look forward 
to hearing your testimony.
    Like the rest of my colleagues on this Committee, lam committed to 
the quality health care that our servicemembers and veterans deserve 
and were promised, including honest and fair medical evaluation and 
treatment.
    Mr. Chairman, thank you again for holding this hearing. I look 
forward to working with you to resolve these problems and other 
problems associated with the Department of Veterans' Affairs and 
Department of Defense's PTSD disability rating systems.

                                 
                Prepared Statement of Hon. Cliff Stearns
         a Representative in Congress from the State of Florida
    Mr. Chairman,
    Thank you for holding this important hearing on Post Traumatic 
Stress Disorder (PTSD) and Personality Disorders among returning 
servicemembers from areas of conflict. I am pleased we are holding this 
hearing today, and look forward to participating in this discussion.
    PTSD is the most prevalent mental disorder among returning 
Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) 
servicemembers. The hallmark characteristics of PTSD include 
flashbacks, nightmares, intrusive recollections or re-experiencing of 
the traumatic event, avoidance, and numbing. When such symptoms last 
under a month, they are typically associated with acute stress 
disorder, not PTSD. In order for a diagnosis of PTSD, symptoms have to 
persist for at least a month and cause significant impairment in 
important areas of daily life. However, some studies indicate that more 
than 80% of people with PTSD also experience a major depressive or 
other psychiatric disorder. Therein lies the difficulty in accurately 
evaluating a patient has suffering from PTSD, or a Traumatic Brain 
Injury (TBI) or as having a personality disorder. I am pleased that 
beginning in 2005, the Veterans Health Administration created 
``Returning Veterans Education and Clinical Teams'' in medical centers 
to help, educate, evaluate, and treat returning veterans with mental 
health and psychosocial issues. These programs collaborate with other 
VA Medical Center PTSD, substance abuse and mental health programs, and 
with polytrauma teams, TBI and primary care services, as well as with 
Vet Centers in an attempt to provide comprehensive treatment. By the 
end of this year, the VA anticipates that it will have 90 of these 
programs operational throughout the country.
    While the treatment for PTSD is improving in the VA system, we are 
here today to ensure that all those who need such mental health 
services are correctly identified, getting the appropriate treatment, 
and able to receive the appropriate compensation for their disability. 
A recent report from the Institute of Medicine regarding PTSD 
compensation was very interesting and raised some good points. I was 
interested by the Institute's finding that the VA's current approach 
using the Global Assessment of Functioning (GAF) scale when evaluating 
severity of PTSD for compensation and disability claims was inaccurate 
and needed to be re-evaluated. In fact, the report states that the GAF 
scale is, ``only marginally applicable to PTSD because of its emphasis 
on the symptoms of mood disorder and schizophrenia and its limited 
range of symptom content.'' In particular, the Institute advocates that 
the system should look at the veterans' everyday life and social 
interactions and not solely upon the impact upon the veterans' 
employability.
    Among some of the Institute's recommendations was the suggestion 
the VA use only experienced mental health professionals to diagnose 
patients claiming to suffer from the disorder, rather than standard 
claims processors. The variation among evaluations spans sometimes from 
a 20-minute conversation to the recommended full 3-hour evaluation. 
Standardization among these evaluations is imperative to ensure 
patients are diagnosed and treated correctly. To that end, VA leaders 
should align their guidelines to those set by the American Psychiatric 
Association, and implement certification procedures for workers dealing 
with PTSD claims.
    I feel it is important to note that the focus of this Committee 
hearing should be on the VA claims process and criteria for PTSD 
claims. While there have been publicized reports of problems with the 
screening and discharge processes at the Department of Defense, the 
jurisdiction and problem before this Committee is how the VA processes 
and evaluates claims from veterans asserting PTSD for service-connected 
disability status. It is a complex issue involving many psychiatric 
components, and I look forward to our panels of witnesses shedding 
light on the intricacies in these diagnoses for us today.
    Thank you.

                                 
              Prepared Statement of Hon. Ginny Brown-Waite
         a Representative in Congress from the State of Florida

    Thank you, Mr. Chairman,
    I appreciate all of the witnesses, and I especially would like to 
thank all the healthcare professionals present here today. Your 
involvement and expertise helps this Committee ensure we are meeting 
the healthcare needs of the men and women that have so bravely served 
their country in the Armed Forces.
    The men and women of our military not only face grave physical 
danger while on the battlefield but in some cases experience life 
altering traumatic events that effect their ability to lead a normal 
life when they come home. Today's hearing draws attention to a report 
by the Institute of Medicine on how the VA handles claims of post 
traumatic stress disorder. Post traumatic stress disorder is a serious 
medical condition and our veterans should receive the care they need to 
live a healthy and productive life.
    Once again, I welcome you to the hearing and look forward to 
hearing your thoughts on the issue before us today.

                                 
              Prepared Statement of Hon. Harry E. Mitchell
         a Representative in Congress from the State of Arizona

    Thank you, Mr. Chairman. I am very pleased that this Committee is 
addressing the issue of service-members who have been denied treatment 
of their PTSD due to a determination of a preexisting personality 
disorder. This topic is one which needs all the attention we can give 
it. While I understand that this situation is happening in our Armed 
Forces, I believe that Congress as a duty and responsibility to shed 
light on this deplorable situation.
    It has always amazed me that it is somehow acceptable to treat 
people suffering from ``unseen'' mental injuries any differently than 
if they had a visual wound or impairment.
    I look forward to hearing from our panelists and to working with 
this Committee to do everything in our power to make sure that this 
practice stops.
    Mr. Chairman, I ask that we continue to follow up with these 
soldiers when they transition to our jurisdiction in the Veterans 
Affairs system to make sure that they get the services they need while 
this egregious policy is being rectified.

                                 
                Prepared Statement of Jason W. Forrester
                Director of Policy, Veterans for America

    Chairman Filner, Ranking Member Buyer, Members of the Committee:
    It is an honor to be here today.
    Veterans for America--formerly the Vietnam Veterans of America 
Foundation--focuses solely on meeting the needs of America's newest 
generation of servicemembers, and veterans. We work very closely with 
the Department of Defense, Members of Congress, the media, active-duty 
troops and veterans to identify the unique challenges facing today's 
military.
    Much of our work is investigative. Members of VFA have visited 
every major demobilization site in the United States and abroad. 
Specifically, our work at Ft. Carson, Colorado--where we first met 
Specialist Town--and our current work at Camp Pendleton, California, 
has prompted considerable media attention and congressional action, and 
has helped identify trends and areas where our country is failing our 
servicemembers.
    We also work closely with veterans trying to navigate the mammoth 
VA bureaucracy. However, given the distressing disconnect between VA 
and the DoD, the greatest service that VFA can provide here today is to 
highlight the trends we have identified and are working to correct 
within DoD and to offer some ideas regarding how the VA can help in the 
process of ensuring that those who have served in Iraq and Afghanistan 
get the assistance they deserve.
    It is important for VA to understand the unique situations and 
experiences of the nearly one million servicemembers from Iraq and 
Afghanistan who are still on active duty--and who will be in the VA 
system sooner or later.
    It is our hope that once the VA has a greater understanding of the 
specific needs of today's military and a greater understanding of the 
deficiencies within DoD that the VA can help those who were failed 
before they became veterans.
    The DoD's Mental Health Task Force's report found that 49% of Guard 
members, 38% of soldiers, and 31% of Marines are experiencing some 
mental health issues after serving in Iraq and Afghanistan. The Task 
Force recognized that programs within DoD did not adequately reflect 
the increasing demand. These shortcomings are caused partly by a lack 
of resources. In addition, stigma is a significant hurdle blocking 
treatment. In the Task Force report, DoD characterized PTSD as a 
``signature'' wound of wars in Iraq and Afghanistan.
    Our investigative work supports these findings and demonstrates the 
immense challenge of implementing solutions across the military.
    At Ft. Carson, we found soldiers who had been diagnosed with 
chronic PTSD who were only receiving 1 hour of individual therapy a 
month. Often, these soldiers saw a new therapist each visit. In an 
attempt to compensate for this deficiency, many soldiers were 
prescribed medicines to help them deal with their PTSD. It was not 
uncommon for us to meet soldiers on over 15-20 different medications at 
once.
    At Ft. Carson, we worked with soldiers who, having clearly 
indicated on their Post-Deployment Health Reassessment (PDHRA) that 
they were having difficulty readjusting to life post-deployment, were 
not receiving the treatment they need. In some cases, these soldiers 
have been redeployed only to have their wounds compounded by further 
exposure to conflict. In other cases, undiagnosed and untreated PTSD 
led soldiers to turn to drugs and alcohol.
    The civilian medical community has long recognized that alcohol and 
drug use is a symptom of PTSD, and, fortunately, many in the military 
also recognize this. That said, this reality poses a significant 
challenge for our military and has had unfortunate consequences for our 
servicemembers. The maintenance of discipline is the top priority for 
the military and the pressure to bring together units to be deployed is 
immense. The combination of these two factors have inhibited adequate 
treatment of the behavioral manifestations of PTSD.
    At Ft. Carson, many soldiers addicted to alcohol and drugs have 
been referred to the Army Substance Abuse Program (knows as ASAP), as 
Army regulations dictate. While this program can be very beneficial to 
soldiers who have only drug and/or alcohol addictions, it does not help 
soldiers with service-connected PTSD. It is policy within DoD not to 
treat soldiers with drug and/or alcohol addictions for their PTSD until 
their addictions have been addressed. There are no dual-track PTSD and 
substance abuse programs within the DoD. We have worked with several 
soldiers who have suffered greatly from this deficiency and, in some 
cases, we have managed to get them help within VA facilities that offer 
dual-track care.
    We also have seen many cases other where soldiers with PTSD have 
been other-than-honorably discharged--losing any hope of treatment for 
their service-connected injuries.
    Many of the same issues are found at Camp Pendleton. The Marine 
Corps still has not identified adequate approaches for dealing with 
behavioral issues associated with mental health challenges. As a result 
of our work, VFA believes that the stigma associated with mental health 
is greater in the Marine Corps than in the Army. The Marine Corps often 
confines Marines with behavioral issues to the brig. In the brig, 
Marines are still given their medications, if they were lucky enough to 
have received a diagnosis. However, they receive no therapy and are 
left to deal with the consequences of their service-connected injuries 
alone.
    These problems within the DoD have created considerable challenges 
for the VA. VA needs to recognize this challenge by creating new 
programs designed for this generation of servicemembers. Since PTSD is 
so prevalent--and dual-track treatment options within DoD for mental 
health issues and substance abuse are absent--VA must increase the 
number of dual-track alcohol/substance and PTSD programs. VA must also 
create new programs for Iraq and Afghanistan veterans with unique 
needs--such as women and Guard and Reserve members.
    VA can help greatly with the issue of stigma by increasing its 
outreach to servicemembers and their families on bases and within 
military medical facilities. Today's servicemembers need to know that 
PTSD is an injury and that they deserve every opportunity to recover. 
PTSD is not a sign of weakness. It is a proven medical reality of 
sustained exposure to combat.
    Finally, another distressing trend that we identified at Ft. Carson 
was the prevalence of pre-existing personality disorder discharges for 
soldiers with service-connected mental health problems. From 2001-2006, 
the Army discharged over 5,600 soldiers for pre-existing personality 
disorders; over 22,500 have been discharged for this reason across all 
the services. A personality disorder diagnosis often requires 
servicemembers to repay their re-enlistment bonuses and denies them 
their combat-related disability pay.
    Some within the Army's personnel system have argued that 
personality disorder discharges are an easy way out for the Army and, 
unfortunately, for soldiers who are tired of reprimands and suffering. 
That said, the consequences of such a dismissal are severe, including 
denial of VA benefits due to the disorder's ``pre-existing'' nature.
    At Ft. Carson, we met numerous soldiers who had been diagnosed with 
a pre-existing personality disorder discharge--often in under an hour--
regardless of the fact that they were deemed fit when they entered the 
service and regardless of the fact that they had been diagnosed with 
PTSD post-deployment to Iraq and/or Afghanistan.
    Pre-existing personality disorder discharges remove the burden from 
our society to help the servicemember deal with their service-connected 
injuries. It is unacceptable to ask an American to sacrifice for this 
country and not treat and recognize the consequences of their service.
    In May of this year, as a result of our work at Ft. Carson, a 
congressional staff-delegation returned to Ft. Carson where they met 
with the soldiers and family members who we have been helping. This 
visit prompted a GAO investigation into mental health treatment in the 
military, and it led to 31 senators sending a letter to Secretary Gates 
calling for a moratorium on pre-existing personality disorder 
discharges.
    While we are hopeful that this moratorium will come into effect 
immediately, it still would not address the problem of those who have 
already been inappropriately discharged.
    This problem presents a great opportunity for VA leadership.
    The VA has no obligation to treat a veteran with a pre-existing 
personality disorder discharge since the discharge implies that their 
injuries are not service-connected. That said, these veterans can still 
visit Vet Centers. However, they do not have immediate access to 
adequate medical care. This being the case, the VA should create a 
streamlined process for face-to-face medical evaluations for those with 
pre-existing personality disorder discharges.
    We owe these veterans a second chance to get much needed help for 
their service-connected injuries.
    This concludes my prepared statement. I would be pleased to answer 
any questions.

                                 
            Prepared Statement of Jonathan Town, Findlay, OH

    On January 20, 1961 a Veteran who was being sworn in as our 
president said during his inaugural speech ``Ask not what your country 
can do for you, ask what you can do for your country''. Since January 
2001 over 22,000 people have answered this call and served in the 
United States armed forces only to be chaptered out of the military 
with a Personality Disorder discharge. It has become a debate if it was 
done to save the military money or to help out with military war time 
and deployment strength. Regardless of the reason, it is an outrage 
that these servicemembers, including myself and their families have 
been put through this.
    I would like to tell you my story. I served 4\1/2\ honorable years 
at Fort Knox, Kentucky as an administration specialist. I was then 
given orders for ``Permanently Change of Station'' to Korea. After 
arriving in Korea I was told that the unit I was assigned to had just 
received its deployment orders to Iraq. In August, 2004 the ``STEEL'' 
battalion (which I now was part of) deployed to Ramadi, Iraq. On 
October 19, 2004, I was running mail for our battalion when incoming 
rounds started exploding across the street from where my vehicle was 
parked. While running for shelter in our S-1 shop's office, a 107mm 
rocket exploded 3 feet above my head leaving me unconscious on the 
ground. After regaining consciousness, I was taken to the battalion's 
aid station where I was treated for various wounds including a severe 
concussion, shrapnel wound in my neck and bleeding from my ear. I was 
given quarters for the rest of the day and went back to work the next 
day. This is when everything started to go downhill health-wise for me. 
Throughout the next 9 months, while continuing to serve my country, I 
battled severe headaches, bleeding from my ear, and insomnia. We 
finally got the word that we were headed home and I thought I would 
finally be able to get some assistance for the medical issues I was 
going through. After a few days back in the United States, I realized a 
new battle for me was taking place. My ability to adjust to loud 
noises, large groups of people, and forgetting what had happened to my 
unit and myself while we were in Iraq was going to be yet another 
battle.
    About 45 days after coming back stateside to Fort Carson, Colorado 
I was finally able to see a psych doctor. The first few meetings with 
the doctor were good and it seemed like he actually cared about helping 
me get through my issues if it were possible. Then word came down that 
our unit was going to be redeployed. The next time I went to see the 
doctor he informed me that he was going to push a personality disorder 
chapter and explained why. The doctor said ``You have the medical 
issues that call for a medical board but the reason I am going to push 
this chapter is because it will take care of both your needs and the 
Army's. You will be able to receive all of the benefits that you would 
if you were to go through a medical board; get out of the military; and 
focus on your treatment to get better. For the military they can get a 
deployable body in to fill your spot''. I told him that if this is what 
he thought was best for the military and my family that he could do 
what he needed to do. I never realized that everything that was said to 
me during that day were all lies.
    I went through the ``final out process'' to leave the military. The 
day that I was signing out I was told by the ``final out'' personnel 
that I would not receive any severance pay or benefits and that I 
actually owed the military $3,000. I do not know everyone in this room 
but I think that if you where to work your heart out for a company or 
agency only to be told that you owed them money when you went to leave 
you would obviously think something is wrong. If it weren't for my 
family taking us in and supporting us both financially and emotionally 
and for new friends helping us, I don't know where my family and I 
would be right now. The last 9 months have been spent trying to get 
assistance both medically and financially through the Veterans 
department; getting the word out to the public about what is happening 
to my fellow servicemen and myself; and trying to get my family and 
myself back on our feet. I'm now receiving treatment and disability pay 
from the VA. I am fortunate because there are many, many injured 
military personnel that still have not gotten to this point.
    I think the government should fix the Personality Disorder 
discharge issue and the time it takes a servicemember to receive the 
start of their disability from the time they leave the armed forces. 
The Chapter 5-13 Personality Disorder discharge should be completely 
taken out of any DOD regulation or if the military really wants a way 
to get servicemembers out of the service (that do not have over 6 
months of active service or have not been deployed overseas) then it 
needs to be written that way in the regulations. It is 100% wrong to be 
able to use this discharge for any servicemember that has been on 
active service for a substantial amount of time; who has fought in a 
war or who has served in a war zone for their country.
    An idea I have heard about I could fix how long a servicemember has 
to wait till they finally start receiving disability after leaving the 
armed forces. The servicemember starts his or her disability paperwork 
and process at the station where the he or she is currently stationed 2 
months prior to getting out of the service. The servicemember should 
not be able to final out from their branch of the military until he or 
she is either granted or denied their disability claim. By going 
through this route, it will allow the servicemember to receive their 
first disability check immediately after their last paycheck from the 
armed service. The Department of Defense should work ``hand in hand'' 
with the Veterans Department to assist the soldiers in need.
    In closing I want to state that I did not have a personality 
disorder before I went into the Army as they have stated on my 
paperwork. I have post traumatic stress disorder and traumatic brain 
injury now due to injuries from the war. I shouldn't be labeled for the 
rest of my life with a personality disorder and neither should my 
fellow soldiers who also incorrectly received this label. I would like 
to ask the Committee and panel Members to thoroughly think about the 
ideas I have mentioned to fix some of the issues we as veterans are 
facing. Please help those who have helped their country.
    Thank you.
                                 
        Prepared Statement of Joshua Kors, Reporter, The Nation
                       and Contributor, ABC News

    Good morning. I've been reporting on personality disorder for the 
last 10 months, and I'm here today to talk about the 22,500 soldiers 
discharged in the last 6 years with that condition.
    A personality disorder discharge is a contradiction in terms. 
Recruits who have a severe, pre-existing condition like a personality 
disorder do not pass the rigorous screening process and are not 
accepted into the Army.
    The soldiers I interviewed this year passed that first screening 
and were accepted into the Army. They were deemed physically and 
psychologically fit in a second screening as well, before being 
deployed to Iraq, and served honorably there in combat. In each case, 
it was only when they came back physically or psychologically wounded 
and sought benefits that their pre-existing condition was discovered.
    Discharging soldiers with a personality disorder prevents them from 
being evaluated by a medical board and getting immediate medical care. 
This can be life-threatening for our soldiers. A good example is Chris 
Mosier, who served honorably in Iraq, where he watched several of his 
friends burn to death in front of him. After that, he developed 
schizophrenic-like delusions. He was treated at Ft. Carson for a few 
days, then discharged with a pre-existing personality disorder. He 
returned home to Des Moines, where he left a note for his family saying 
the Iraqis were after him there in Iowa, then shot himself.
    Surgeon General Gale Pollock agreed to review a stack of 
personality disorder cases. After 5 months, she produced a memo saying 
her office had ``thoughtfully and thoroughly'' reviewed the cases, 
including Jon Town's, and determined all of them to be properly 
diagnosed. With further reporting, I discovered that as part of that 
``thoughtful and thorough'' 5-month review, Pollock's office did not 
interview anybody, not even the soldiers whose cases she was reviewing. 
Some of those soldiers said they called the Surgeon General's office 
offering information about their ailments. Their efforts were rebuffed.
    The one thing the Surgeon General's office did do was contact a 
doctor at Ft. Carson, where many of the personality disorder diagnoses 
were made, and ask him whether his doctors got it right the first time. 
That doctor said yes, his staff's original diagnoses were correct, and 
Pollock shut down the review at that point.
    The Surgeon General's office denied that for many months, insisting 
that the review was conducted by a panel of health experts who were not 
involved in the original diagnoses. This wasn't a case of one man 
reviewing his own work, they said. But eventually it did come out that 
the only reviewer was Col. Steven Knorr, who as Chief of Behavior 
Health at Ft. Carson, oversaw many of the personality disorder 
diagnoses and, in his capacity as a psychiatrist, was reportedly 
involved in creating many of them as well.
    When the problems with Walter Reed became public, the Pentagon took 
two actions: it accepted the resignation of Surgeon General Kevin 
Kiley, and it hired the public relations firm LMW Strategies with a 
$100,000 no-bid contract to put a positive spin on those problems. This 
past week, as these personality disorder discharges became public, VA 
Secretary Nicholson stepped down. And today Surgeon General Pollock 
will sit before you.
    As a journalist, it's not my role to make any recommendations, but 
I do want to share with you the hopes of the wounded veterans I spoke 
to this year, which is a hope that someone be held responsible, and 
that officials go back through the 22,500 cases and seek out the 
thousands of Jon Towns who are waiting there, struggling right now 
without benefits or the media spotlight.
              Personality Disorder Discharges (2001-2006)

----------------------------------------------------------------------------------------------------------------
                    Year                        Army            Air Force           Navy             Marines
----------------------------------------------------------------------------------------------------------------
   2001                                               805       Unavailable             1,389               443
----------------------------------------------------------------------------------------------------------------
   2002                                               734             1,523             1,733               460
----------------------------------------------------------------------------------------------------------------
   2003                                               980             1,496             1,316               328
----------------------------------------------------------------------------------------------------------------
   2004                                               988             1,307             1,253               414
----------------------------------------------------------------------------------------------------------------
   2005                                             1,038               928             1,176               475
----------------------------------------------------------------------------------------------------------------
Nov. 2006                                           1,086             1,085             1,076               442
----------------------------------------------------------------------------------------------------------------
  Totals:                                           5,631             6,339             7,943             2,562
----------------------------------------------------------------------------------------------------------------
Source: Department of Defense
* Navy numbers are for fiscal, not calendar, year.


    TOTAL (2001-Nov. 2006):  22,475

    Total for 2001: 2,637 (which includes the Air Force's one 
unavailable year)
    Total for 2002: 4,450
    Total for 2003: 4,120
    Total for 2004: 3,962
    Total for 2005: 3,617
    Total for 2006: 3,689

                               __________
                               [GRAPHIC] [TIFF OMITTED] T7475A.001
                               

                               __________
                     Press Release / March 27, 2007

    ``Post Traumatic Stress Disorder (PTSD) is real. The Army's 
leadership--up and down the chain of command starting with the Acting 
Secretary of the Army and the Vice Chief of Staff of the Army--are 
actively involved in getting the entire Medical Evaluation Board and 
Physical Evaluation Board process right. The Army has no greater 
obligation to its returning `Wounded Warriors' than to provide them 
with the absolute best medical care possible; and if we come up short, 
then the Army will react immediately to remedy the problem.
    Leaders from the Office of the Army Surgeon General had the cases 
Mr. Robinson brought to them thoroughly evaluated and reviewed. While 
we cannot address individual medical cases in this venue, it was 
determined that the behavioral health providers did thorough 
assessments and appropriately referred the soldiers for substance abuse 
and behavioral health treatments. A more detailed response is being 
provided to Mr. Robinson.
    The behavioral health officers at the Army hospital at Fort Carson 
reviewed the Chapter 5-13 cases in soldiers who were diagnosed with 
PTSD. The data demonstrated that there were no soldiers separated under 
Chapter 5-13 in the last 4 years who should have undergone a medical 
evaluation board. It should be noted that a personality disorder 
diagnosis does not necessarily mean that a medical evaluation board is 
needed. It indicates that a soldier has personality traits that are not 
compatible with military service.
    Soldiers who are separated under Chapter 5-13 receive honorable 
Discharges and, if they have served 6 or more years on active duty, 
they are eligible for separation pay. Additionally, it is Army policy 
not to separate a soldier for a personality disorder under Chapter 5-13 
if that disorder amounts to a disability. If the disorder amounts to a 
disability, the soldier should be separated under the disability 
evaluation procedures of AR 635-200.
    Further, it is certainly possible that there are cases where 
soldiers with symptoms of Post Traumatic Stress Disorder or Traumatic 
Brain Injury are not diagnosed or treated. We are grateful each time 
someone raises a concern. Nothing is more important than insuring that 
these men and women are provided the best possible health care.
    We understand that many wounded and injured soldiers, who have 
supported the Global War on Terror, as well as their families, continue 
to endure hardships. The Army is committed to providing the best 
possible medical care for the men and women who have volunteered to 
serve this great nation and has recently launched the Wounded Soldier 
and Family Hotline: 1-800-984-8523.
    The purpose of the hotline's call center is twofold: to offer 
wounded and injured soldiers and family members a way to seek help to 
resolve medical issues and to provide an information channel to senior 
Army leadership so they can improve how the Army serves the medical 
needs of our soldiers and their families.''
    Lieutenant Colonel Bob Tallman, Spokesman for the U.S. Army

                                 
                  Prepared Statement of Paul Sullivan
             Executive Director, Veterans for Common Sense

    Chairman Filner and Members of the Committee, thank you for 
inviting Veterans for Common Sense to testify about ``PTSD and 
Personality Disorders: Challenges for the VA.'' VCS is a non-profit 
organization based in Washington, DC focusing on issues related to 
national security, civil liberties, and veterans' benefits.
    My testimony focuses on offering solutions to the many 
unconscionable, outrageous, and intentional actions taken by the 
Department of Veterans Affairs and by the Administration to prevent our 
Iraq and Afghanistan war veterans from receiving prompt medical care 
and disability compensation for PTSD. My testimony is based on more 
than 15 years' of experience as a veterans' advocate and as a VA 
project manager.
    There are two common sense standards VA should meet. First, when a 
war veteran needs mental healthcare, our Nation must provide it 
immediately from a certified mental healthcare professional so the 
veteran can avoid a broken family, lost job, drug abuse, alcoholism, 
crime, homelessness, and suicide.
    Second, when a veteran needs disability compensation for a mental 
health condition, our Nation must provide it immediately, without 
endless bureaucratic hassles, so the veteran can put food on the table, 
pay the rent, and take care of his or her family.
    When the Department of Defense discharges a servicemember who 
fought honorably in combat for a personality disorder, then the 
military is breaking its own rules. DoD regulations state that if a 
servicemember was in combat, then the military is generally prohibited 
from using a personality disorder diagnosis.
    DoD's actions have serious consequences. A veteran discharged for a 
personality disorder is usually denied access to VA healthcare and 
disability benefits based on VA regulations that prohibit providing 
services for a pre-existing condition.
    In light of the military's inappropriate discharges, what can 
Congress and VA do now to begin to resolve this fiasco? VCS will 
describe the scope of PTSD among Iraq and Afghanistan war veterans, and 
then VCS will offer solutions. More than 1.6 million of our fellow 
Americans have deployed to the two war zones.
    As of December 2006, about 686,000 are now veterans eligible for VA 
healthcare and benefits. A staggering 36 percent, or 229,000 veterans, 
were already treated at VA medical facilities. Of those treated, more 
than one-third, or 84,000 veterans, were diagnosed and treated for a 
mental health condition, including more than 20 percent, or 45,500, for 
PTSD.
    As of June 2007, more than 202,000 Iraq and Afghanistan war 
veterans have already filed disability compensation claims against VA. 
Of the 157,000 claims approved by VA, more than 19,000 veterans are 
service-connected for PTSD. The PTSD claims will continue to rise as 
the number of PTSD patients rise, especially when the deployed veterans 
exhaust their 2 years' of free healthcare.
    When all of our troops return home, at the current rate, VA faces 
nearly 600,000 potential mental health patients, including 320,000 
diagnosed with PTSD. The number will grow as hundreds of thousands more 
of our servicemembers deploy for a third or fourth combat tour in an 
escalating war that surrounds our troops with 360-degree combat 24 
hours per day, where our troops switched from being the predator to 
being the prey. The number of claims will also continue to rise, 
including those for PTSD.
    VCS urges Congress to adopt nine new policies so that more of our 
war veterans with PTSD don't fall through the cracks--the period of 
time between when a servicemember discharges from the military and the 
new veteran begins receiving all of his or her healthcare and 
disability benefits.
    Failure to reduce the stigma and delay in providing healthcare and 
benefits will most likely result in a social catastrophe among many of 
our returning Iraq and Afghanistan war veterans--including broken 
families, lost jobs, stigma, drug abuse, alcoholism, crime, 
homelessness, and suicide. Many of these consequences are preventable. 
Please act now and take advantage of this quickly closing window of 
opportunity.
Proposed Solutions to Personality Disorder and PTSD Crisis
    First, VCS urges Congress to order the Department of Defense to 
immediately stop discharging war veterans with a personality disorder 
diagnosis. If the military allowed the servicemember to enlist, then a 
personality disorder diagnosis should be given only in cases of fraud 
after providing the servicemember with full due process. Congress 
should also order the military to conduct a review of all personality 
disorder discharges for veterans deployed since September 11, 2001. 
Congress should also order VA to review applications for healthcare and 
disability compensation where VA denied access based on a personality 
disorder.
    Second, Congress should order DoD and VA to establish a policy to 
reduce the stigma against people with mental health conditions. 
Military studies confirm this stigma hinders many of our war veterans 
from seeking mental healthcare. America can and should welcome our 
veterans home with full and prompt access to mental healthcare.
    Third, VCS urges Congress to demand full enforcement of Public Law 
105-85, the law requiring all servicemembers to be examined for 
physical and mental health conditions before and after deployment. This 
law implements a critical lesson learned from the gulf war, when the 
military failed to examine our troops before and after deployment. The 
military's negligence resulted in a lack of information about gulf war 
illnesses among more than 100,000 Desert Storm veterans that still 
stump scientists today.
    Fourth, Congress can enact legislation creating a presumption of 
service connection for PTSD for veterans who deployed to a war zone 
since September 11, 2001, who are diagnosed with PTSD. A deployment 
since September 11, 2001, should be considered as combat under 38 USC 
1154. A presumption makes it easier for VA to adjudicate the claim, and 
results in faster medical treatment and faster disability compensation 
payments for veterans. Congress should also explore automatically 
approving all VA claims at a modest rate within 30 days, for a period 
up to 1 year, for deployed veterans' claims. VCS supports this bold 
recommendation initially made by Harvard Professor Linda Bilmes.
    Fifth, Congress should enact legislation significantly expanding 
VA's highly successful Vet Centers and allowing VA readjustment 
counselors to provide mental health services to active duty 
servicemembers, either at existing facilities or at new offices on 
military bases. This expanded service might first be targeted at 
military installations that have shortages of mental healthcare 
providers and bases expecting large redeployments from the war zones. 
This way, the supply of mental health professionals can meet expected 
and significant surges in demand. Congress should also consider 
allowing families to participate in the readjustment counseling process 
at Vet Centers.
    Sixth, Congress should enact S. 1606, which was added to the 
National Defense Authorization Act in the Senate. This bill directs DoD 
to streamline policies and reduce the number of veterans falling 
through the cracks. The most important part of the bill, in our view, 
is the provision mandating that DoD provide free medical care for 
veterans discharged for a medical condition at less than 30 percent. 
Based on the series of government Accountability Office reports over 
the past 10 years, this legislation should be amended to mandate that 
DoD provide VA immediate access to full military and medical records 
immediately after a veteran's discharge so that VA can expedite medical 
treatment and claims processing.
    Seventh, Congress should enact S 1354, which directs VA to define 
the war zones, collect data, and prepare cost and benefit use reports 
about the Iraq and Afghanistan wars. This proposal mandates ``truth in 
government'' so Congress and the public are fully and regularly 
informed about the human and financial costs of the two wars. This 
proposal will also tremendously improve VA planning and budgeting. 
Without consistent and timely reports for the expanding Iraq and 
Afghanistan war population, VA may once again fall $3 billion short and 
be unable to provide medical care to veterans.
    Eighth, in a related matter, VCS urges Congress to enact S 849 so 
that VA and DoD comply with all Freedom of Information Act requests in 
a complete and timely manner. VA routinely delays or denies our FOIA 
requests about the Iraq and Afghanistan wars. VA's stonewalling unduly 
hinders VCS from providing fact-based advocacy. VCS used DoD and VA 
documents obtained under FOIA to assist Harvard Professor Linda Bilmes 
with estimating the cost of the two wars for VA at between $350 billion 
and $700 billion over 40 years. VCS also obtained obscure DoD reports 
confirming the two wars caused more than 65,000 casualties, defined as 
a person who is dead, wounded, injured, or ill (DoD and the press 
routinely mislead the public by providing the incomplete count of 
25,000 casualties). VCS also publicized the fact that VA statistics 
reveal that National Guard and Reserve are half as likely to file VA 
disability claims than Active Duty. However, the National Guard and 
Reserve are twice as likely to have their claim denied.
    Ninth, Congress and VA should consider a package of PTSD-related 
reforms:

      VA should set clear timeliness standards to screen and 
provide care for PTSD.
      VA should outsource current demand for PTSD treatment to 
the private sector, so veterans receive timely care, until such time as 
VA can hire permanent staff.
      VA must accept a PTSD diagnosis from private professional 
psychiatrists. If VA disputes the non-government diagnosis, then VA 
should approve the PTSD claim until the claim decision is final so that 
the veteran receives prompt medical care.
      VA must update the outdated and incomplete PTSD rating 
schedule to take into consideration quality of life issues raised 
recently by the Institute of Medicine. The rating schedule should be 
veteran-friendly and be based upon the latest medical and scientific 
findings.
      VA must require all claims adjudicators to receive prompt 
and intensive training on PTSD claims. This high-priority item should 
be accomplished quickly because of the escalating claims backlog and 
the reasonable expectation of hundreds of thousands of more PTSD 
claims.
      VA must be held accountable when VA makes mistakes. When 
a veteran wins a case based on appeal or remand, then VA should be 
required to pay back interest and penalties. Without accountability, VA 
will continue to inappropriately delay and deny veterans PTSD claims.
Background Describing VA's Crisis
    Sadly, Mr. Chairman, the current VA political leadership failed our 
veterans as the VA claims backlog grew 50 percent in the past 3 years. 
In a bitter irony, VA handed out $3.8 million in cash bonuses to top VA 
political leaders while the overall situation deteriorated at VA. More 
veterans are waiting much longer to receive disability compensation 
payments. In response to the outcry over the bonuses, VA said it wanted 
to retain top executives who could earn more outside government. In our 
view, bonuses are for exemplary performance only. Public service is an 
honor, not an ATM machine.
    Due to the current poor political leadership, VA's doctors and 
claims staff are unable to provide either immediate treatment or prompt 
payments because of inappropriate interference by VA political 
appointees. In effect, VA's political appointees locked VA's doors and 
blocked access to healthcare and disability benefits. If not for the 
intervention of Congress in May to appropriate $1.8 billion in 
emergency funds to hire more doctors and claims adjudicators, VA's 
crisis would continue worsening.
    In early 2005, while working at VA, I briefed political appointees 
and executives at VA headquarters about the sharply escalating mental 
health and PTSD disability claims among Iraq and Afghanistan war 
veterans. I personally advised several VA executives, including Ruth 
Whichard, Mike McLendon, Jack McCoy, Ronald Aument, Lois Mittelstaedt, 
and several others, that the claims situation was worsening as the two 
wars deteriorated and the number of eligible veterans continued 
growing. I advised them, in writing, that more claims processors be 
hired to meet the steeply rising demand, especially the even faster 
rise in mental health and PTSD claims. I provided several e-mails 
documenting these briefings to your staff in March 2007.
    After my briefings, top VA political appointees shamefully broke 
faith with our veterans. Instead of hiring more physicians and claims 
processors to meet the growing demand, top VA political appointees 
fought against our war veterans and locked the doors.
    At one briefing in 2005, a political appointee since fired for his 
role in the lap top theft scandal, Mike McLendon, revealed that the 
Bush Administration was fighting against our war veterans. At one 
meeting, McLendon said there were too many PTSD claims, the veterans 
were filing them too soon after returning home, our veterans were too 
young to be filing claims, and it costs VA too much money to assist 
them. McLendon went further with a factually incorrect and highly 
offensive statement that if our returning Iraq and Afghanistan war 
veterans simply ``believed in god and country, then they would not come 
home with PTSD.'' I immediately advised my supervisor about this 
incident, and I also advised your staff about it in early 2006.
    After my several briefings to political appointees in 2005 warning 
them of the current problem, VA launched a systematic effort to block, 
hinder, restrict, and otherwise prevent our newest generation of combat 
veterans from receiving the mental healthcare they need and that they 
earned. In effect, VA locked the doors to cover their refusal to 
prepare for the surge in returning Iraq and Afghanistan war veterans 
with PTSD.
VA's Four Anti-PTSD Policies Adopted in 2005
      VA ordered a re-evaluation of 72,000 previously approved 
PTSD claims rated at 100 percent. If implemented, VA's policy would 
have further increased the 600,000 claim backlog by shifting VA claims 
adjudicators away from working on new claims to work on already 
approved claims. Luckily, Congress intervened and stopped VA from 
implementing this outrageous policy. In the one thousand PTSD claims VA 
reviewed, VA found zero cases of fraud.
      VA instituted a ``second signature'' requirement for 
approving new claims for PTSD at 100 percent. This VA policy would have 
also increased the backlog by requiring additional work for each claim 
by a second VA employee. Luckily, veterans groups raised the alarm and 
VA suspended this policy. Congress should legislate a termination of 
this policy.
      VA contracted with the Institute of Medicine for the 
stated purpose of validating the diagnosis of PTSD. VA's hidden purpose 
was to narrow the definition of PTSD so that fewer veterans would 
qualify for VA healthcare or VA disability benefits, thus blocking 
future claims and saving VA money. Luckily for our veterans, IOM 
validated the serious nature of PTSD.
      VA again contracted with IOM for the stated purpose of 
validating PTSD disability payment amounts. VA's hidden purpose was to 
reduce the amount of money paid to veterans suffering from PTSD, thus 
saving VA money. Fortunately for veterans, IOM responded with a report 
saying VA should consider quality of life issues when determining a 
veteran's level of disability.

    When viewed together, these four anti-PTSD policies sent a signal 
to veterans, veterans' groups, and Congress that VA would fight against 
PTSD claims filed by Iraq and Afghanistan war veterans. We will never 
know how many veterans stopped fighting VA and then needlessly suffered 
from broken families, lost jobs, alcoholism, drug abuse, crime, 
suicide, and homelessness.
    Under the guise of saving taxpayer money, VA's 23-page claim form 
and Byzantine claims process serve to inappropriately reduce the number 
of eligible and entitled veterans receiving assistance for mental 
healthcare and disability benefits, especially for PTSD.
    As a result of these and other anti-veteran policies recently 
adopted by VA, VCS was given no other choice than to file suit against 
VA in Federal Court this week. VCS hopes to bring attention to the 
plight of our returning war veterans with mental health conditions, 
especially those misdiagnosed with personality disorder and thus denied 
VA healthcare and disability benefits.
    America must not repeat the social catastrophe after the Vietnam 
War and gulf war, where veterans faced enormous road blocks when 
seeking healthcare and disability benefits. Veterans are citizens, too, 
deserving of full civil rights, equal access, and due process when 
dealing with our government when we return home from war.
    Allow me to close with this very sharp warning that the U.S. 9th 
Circuit Court of Appeals issued last week in its ruling against VA for 
resisting payments to Vietnam War veterans suffering from chronic 
lymphocytic leukemia due to Agent Orange poisoning.
    ``What is difficult for us to comprehend is why the Department of 
Veterans Affairs . . . continues to resist the payment of desperately 
needed benefits to Vietnam War veterans who fought for their country 
and suffered grievous injury as a result of our government's own 
conduct. . . .
    ``These young Americans who risked their lives in their country's 
service and are even today suffering greatly as a result are deserving 
of better treatment from the Department of Veterans Affairs than they 
are currently receiving. . . .
    ``We would hope, that this litigation will now end, that our 
government will now respect the legal obligations it undertook in the 
consent decree 16 years ago, that obstructionist bureaucratic 
opposition will now cease, and that our veterans will finally receive 
the benefits to which they are morally and legally entitled.''
    [Attachments to Mr. Sullivan's testimony are being retained in the 
Committee files and include the following:]

    1.  VA Benefits Activity, Veterans Deployed to the Global War on 
Terror, Prepared by VBA Office of Performance Analysis & Integrity, 
June 25, 2007;
    2.  VA Facility Specific OIF/OEF Veterans Coded with Potential PTSD 
Through 2nd Qt FY 2007;
    3.  Analysis of VA Health Care Utilization Among U.S. Southwest 
Asian War Veterans, Operation Iraqi Freedom, Operation Enduring 
Freedom, VHA Office of Public Health and Environmental Hazards, April 
2007;
    4.  Study by Linda Bilmes, John F. Kennedy School of government, 
Harvard University, entitled ``Soldiers Returning from Iraq and 
Afghanistan: The Long-term costs of Providing Veterans Medical Care and 
Disability Benefits,'' January 2007 http://www.mofo.com/docs/pdf/
PTSD070723.pdf; and
    5.  Complaint filed against VA written by Gordon Erspamer, Esq., of 
Morrison & Foerster: http://www.mofo.com/docs/pdf/PTSD070723.pdf

                                 
                Prepared Statement of Tracie Shea, Ph.D.
          Psychologist, Post Traumatic Stress Disorder Clinic
             Veterans Affairs Medical Center Providence, RI
  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 servicemembers 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 Servicemembers 
        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.

                                 
            Prepared Statement of Dean G. Kilpatrick, Ph.D.
                   Distinguished University Professor
     Director, National Crime Victims Research and Treatment Center
            Medical University of South Carolina, and Member
 Committee on Veterans' Compensation for Post Traumatic Stress Disorder
          Institute of Medicine and National Research Council
                         The National Academies

    Good morning, Mr. Chairman and Members of the Committee. My name is 
Dean Kilpatrick and I am Distinguished University Professor in the 
Department of Psychiatry and Behavioral Sciences and Director of the 
National Crime Victims Research and Treatment Center at the Medical 
University of South Carolina. Thank you for the opportunity to testify 
on behalf the Members of the Committee on Veterans' Compensation for 
Posttraumatic Stress Disorder. The committee was convened under the 
auspices of the National Research Council and the Institute of 
Medicine. These institutions are operating arms of the National Academy 
of Sciences, which was chartered by Congress in 1863 to advise the 
government on matters of science and technology. The work of the 
Committee was requested by the Department of Veterans Affairs, which 
provided funding for the effort.
    Our Committee recently completed a report entitled PTSD 
Compensation and Military Service that addresses some of the topics 
under discussion in this hearing. I am pleased to be here today to 
share with you the content of that report, the knowledge I've gained as 
a clinical psychologist and researcher on traumatic stress, and my 
experience as someone who previously served as a clinician at the VA.
    I will begin with some background information on posttraumatic 
stress disorder. Briefly described, PTSD is a psychiatric disorder that 
can develop in a person after a traumatic experience. Someone is 
diagnosed with PTSD if, in response to that traumatic experience, he or 
she develops a cluster of symptoms that include:

      reexperiencing the traumatic event as reflected by 
distressing recollections, memories, nightmares, or flashbacks;
      avoidance  of anything that reminds them of the traumatic 
event;
      emotional numbing  or feeling detached from other people;
      hyperarousal  as reflected by trouble sleeping, trouble 
concentrating, outbursts of anger, and having to always be vigilant for 
potential threats in the environment; and
      impairment  in social or occupational functioning, or 
clinically significant distress.

    PTSD is one of an interrelated and overlapping set of possible 
mental health responses to combat exposures and other traumas 
encountered in military service. Although PTSD has only been an 
official diagnosis since the 1980's, the symptoms associated with it 
have been reported for centuries. In the U.S., expressions including 
shell shock, combat fatigue, and gross stress reaction have been used 
to label what is now called PTSD.
    Our committee's review of the scientific literature and VA's 
current compensation practices identified several areas where changes 
might result in more consistent and accurate ratings for disability 
associated with PTSD.
    There are two primary steps in the disability compensation process 
for veterans. The first of these is a compensation and pension, or C&P, 
examination. These examinations are conducted by VA clinicians or 
outside professionals who meet certain education and licensing 
requirements. Testimony presented to the Committee indicated that 
clinicians often feel pressured to severely constrain the time that 
they devote to conducting a PTSD C&P examination--sometimes to as 
little as 20 minutes--even though the protocol suggested in a best 
practice manual developed by the VA National Center for PTSD can take 3 
hours or more to properly complete. The Committee believes that the key 
to proper administration of VA's PTSD compensation program is a 
thorough C&P clinical examination conducted by an experienced mental 
health professional. Many of the problems and issues with the current 
process can be addressed by consistently allocating and applying the 
time and resources needed for a thorough examination. The Committee 
also recommended that a system-wide training program be implemented for 
the clinicians who conduct these exams in order to promote uniform and 
consistent evaluations.
    The second primary step in the compensation process for veterans is 
a rating of the level of disability associated with service-connected 
disorders identified in the clinical examination. This rating is 
performed by a VA employee using the information gathered in the C&P 
exam. The Committee found that the criteria used to evaluate the level 
of disability resulting from service-connected PTSD were, at best, 
crude and overly general. Our Committee recommended that new criteria 
be developed and applied that specifically address PTSD symptoms and 
that are firmly grounded in the standards set out in the Diagnostic and 
Statistical Manual of Mental Disorders used by mental health 
professionals. As part of this effort, the Committee suggested that VA 
take a broader and more comprehensive view of what constitutes PTSD 
disability. In the current scheme, occupational impairment drives the 
determination of the rating level. Under the Committee's recommended 
framework, the psychosocial and occupational aspects of functional 
impairment would be separately evaluated, and the claimant would be 
rated on the dimension on which he or she is more affected. The 
Committee believes that the special emphasis on occupational impairment 
in the current criteria unduly penalizes veterans who may be capable of 
working, but significantly symptomatic or impaired in other dimensions, 
and thus it may serve as a disincentive to both work and recovery.
    Determining ratings for mental disabilities in general and for PTSD 
specifically is more difficult than for many other disorders because of 
the inherently subjective nature of symptom reporting. In order to 
promote more accurate, consistent, and uniform PTSD disability ratings, 
the Committee recommends that VA establish a specific certification 
program for raters who deal with PTSD claims, with the training to 
support it, as well as periodic recertification. Rater certification 
should foster greater confidence in ratings decisions and in the 
decisionmaking process.
    To summarize, the Committee identified three major changes that are 
needed to improve the compensation evaluation process for veterans with 
PTSD:

      First, the C&P exam should be done by mental health 
professionals who are adequately trained in PTSD and who are allotted 
adequate time to conduct the exams.
      Second, the current VA disability rating system should be 
substantially changed to focus on a more comprehensive measure of the 
degree of impairment, disability, and clinically significant distress 
caused by PTSD. The current focus on occupational impairment serves as 
a disincentive for both work and recovery.
      Third, the VA should establish a certification program 
for raters who deal with PTSD clams.

    Our committee also reached a series of other recommendations 
regarding the conduct of VA's compensation and pension system for PTSD 
that are detailed in the body of our report. I have provided copies of 
this report as part of my submitted testimony.
    Thank you for your attention. I will be happy to answer your 
questions.

                                 
                Prepared Statement of Sally Satel, M.D.
            Resident Scholar, American Enterprise Institute

    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.
                               Background
    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 servicemembers. 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.'' \1\
---------------------------------------------------------------------------
    \1\ AR 635-200 Active Duty Enlisted Administrative Separations 
http://gidischarges.org/odpmc/army/index.html, accessed July 23, 2007.
---------------------------------------------------------------------------
    *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.\2\
---------------------------------------------------------------------------
    \2\ 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.
---------------------------------------------------------------------------
    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.\3\ Those waivers may be officially overlooking exactly the 
behaviors that are symptoms of personality disorders.
---------------------------------------------------------------------------
    \3\ 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.
---------------------------------------------------------------------------
    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 4-year followup 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.\4\
---------------------------------------------------------------------------
    \4\ 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.
---------------------------------------------------------------------------
    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.\5\ 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.
---------------------------------------------------------------------------
    \5\ 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.
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Possible explanations of co-occurrence:
    1.  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).\6\
---------------------------------------------------------------------------
    \6\ 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
---------------------------------------------------------------------------
    2.  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.
    3.  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.\7\
---------------------------------------------------------------------------
    \7\ Weisberg, JN. ``Studies Investigating the Prevalence of 
Personality Disorders in Patients with Chronic Pain.'' In Personality 
Characteristics of Patients With Chronic Pain. Eds: Gatchel R, Weisberg 
N. Washington, DC: American Psychological Association, 2000.
---------------------------------------------------------------------------
       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.\8\ In the absence of prospective studies or baseline information 
on individuals it is difficult to distinguish between these scenarios.
---------------------------------------------------------------------------
    \8\ 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.
---------------------------------------------------------------------------
    4.  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.
    5.  PD alone: see below.\9\
---------------------------------------------------------------------------
    \9\ 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.
    a. 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.
    b. 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).
---------------------------------------------------------------------------
       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.\10\ 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.\11\ 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.\12\
---------------------------------------------------------------------------
    \10\ ``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
    \11\ Dunn NJ, Yanasak E, Schillaci J, Simotas S, Rehm LP, Souchek 
J, Menke T, Ashton C, Hamilton JD. ``Personality disorders in veterans 
with posttraumatic stress disorder and depression.'' Journal of 
Traumatic Stress. 17(1) (February 2004), pp. 75-82; 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) (April 2000), pp.255-270.; Rosenheck R. 
``Malignant post-Vietnam stress syndrome.'' American Journal of 
Orthopsychiatry. 55 (1985), pp. 166-176;Hyer L, Woods MG, Bruno R, 
Boudewyns P. ``Treatment outcomes of Vietnam veterans with PTSD and the 
consistency of the MCMI.'' Journal of Clinical Psychology. 45(4) (July 
1989), pp. 547-542; Mazzeo SE, Beckham JC, Witvliet Cv C, Feldman ME, 
Shivy VA. ``A cluster analysis of symptom patterns and adjustment in 
Vietnam combat veterans with chronic posttraumatic stress disorder.'' 
Journal of Clinical Psychology. 58(12) (December 2002), pp. 1555-1571.
    \12\ 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
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    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.
                                Summary

    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.

                                 
             Prepared Statement of Ira R. Katz, M.D., Ph.D.
      Deputy Chief Patient Care Services Officer for Mental Health
  Veterans Health Administration, U.S. Department of Veterans Affairs

    Good morning Mr. Chairman, thank you for this opportunity to speak 
about multiple diagnoses and specifically about the principle that Post 
Traumatic Stress Disorder (PTSD) frequently coexists with other mental 
health conditions.
Multiple Mental Health Problems
    As of the end of the first half of FY 2007, almost 720,000 service 
men and women have separated from the armed forces after service in 
Iraq or Afghanistan, and over 250,000 have sought care in VA. About 
95,000 received at least a preliminary mental health diagnosis. Among 
these, PTSD, experienced by over 45,000 or 48 percent is the most 
common.
    The average veteran with a mental health problem received 
approximately 1.9 diagnoses. There could be several reasons. First, 
injuries of the mind, like injuries of the body can be non-selective. 
Depending upon psychological, physiological, or genetic 
vulnerabilities, the same stress and trauma can give rise to multiple 
conditions, for example PTSD and depression or panic disorder. Second, 
the disorders may occur sequentially. Some veterans with PTSD may try 
to treat their own symptoms with alcohol and wind up with a diagnosis 
related to problem drinking. Third, some pre-existing mental health 
conditions like milder personality disorders may be quite compatible 
with occupational functioning, even in the military, but may increase 
vulnerability to stress-related disorders like PTSD or depression.
How Does VA Deal With This Problem
    VA has intensive programs to ensure that mental health problems are 
recognized, diagnosed, and treated. There is outreach to bring veterans 
into our system, and once they arrive, there is screening for mental 
health conditions. For those who screen positive for mental health 
conditions, the next step is a comprehensive diagnostic and treatment 
planning evaluation. In this, the question is about what is causing the 
veteran's suffering or impairment, and what can be done about it. If 
someone screens positive for symptoms of PTSD, we are interested in 
whether or not they, in fact have PTSD. But we are also interested in 
whether or not they have depression, or panic disorder, or problem 
drinking, or other problems. Which do we treat? We treat them all. Or 
more significantly, we treat the person, not his or her labels.
    Clinical science has advanced dramatically since the Vietnam War. 
We now know how to diagnose PTSD, and how to treat it. Accordingly, we 
are hopeful that we can prevent the lasting suffering and impairments 
that occurred after that war. There is a firm evidence-base for several 
classes of treatment for PTSD, both psychopharmacological or medication 
based and psychotherapeutic or talk/behavior based. Specifically, 
several of the antidepressants that act on the neurotransmitter 
serotonin have been found to be effective and safe for the treatment of 
PTSD, and many other medications are currently being studied. Two 
specific forms of cognitive behavioral therapy, prolonged exposure 
therapy and cognitive processing therapy appear to be even more 
effective than the medications, and VA is currently developing high 
throughput training programs to make them increasingly available within 
our medical centers, clinics, and Vet Centers. In addition, there is 
increasing evidence for the effectiveness of psychosocial 
rehabilitation. For veterans for whom there may be residual symptoms 
after several evidence-based treatments, treatment is available to help 
them function in the family, in the community, or on the job.
Given That There Are a Number of Effective Treatments, How Do We Decide 
        Which to Provide?
    Actually, the question should be which to offer first and which 
comes next. The first treatments are usually offered on the basis of 
both the provider's judgment and the patient's preference. However, we 
monitor treatments and outcomes, and if the first doesn't work, we 
modify it.
    What happens when patients have more than one condition? The choice 
of what to treat first depends on the severity of the conditions, the 
provider's judgment, and the patient's preferences. Plans must allow 
for combinations or sequences of treatments, as appropriate following 
Clinical Practice Guidelines or other sources of guidance.
    There may have been a time in the past when coexisting conditions 
may have been barriers to care, when it was hard to treat people with 
PTSD and alcohol abuse because PTSD programs required people to be 
sober, and substance abuse programs required them to be stable. This no 
longer occurs. In fact, there are now evidence based strategies for 
beginning PTSD and substance abuse treatment simultaneously. One 
approach, called Seeking Safety was developed in the VA, and is being 
disseminated broadly.
    It may be difficult to diagnose personality disorders in the face 
of PTSD or other mental health conditions. For patients with relevant 
symptoms, the clinical approach in VA is to treat the PTSD first. A 
subsequent step would be evaluate what symptoms or impairments remain, 
and to plan treatments accordingly.
    The message I want to deliver in this hearing is that treatment for 
PTSD can work. For veterans or others with multiple conditions, 
treatment may be a multistage process beginning with an evidence based 
intervention for the most severe of the patient's conditions, and 
continuing in a way that depends upon the outcome. Overall, the message 
should be cautiously optimistic.
    Thank you for this opportunity to testify. I will be pleased to 
answer any questions you may have.

                                 
                Prepared Statement of Colonel Bruce Crow
                Chief, Department of Behavioral Medicine
         Brooke Army Medical Center, Fort Sam Houston, TX, and
       Clinical Psychology Consultant to the Army Surgeon General
           Department of the Army, U.S. Department of Defense

    Mr. Chairman, Congressman Buyer, and distinguished members of the 
Committee, thank you for the opportunity to discuss the behavioral 
health status of the brave men and women in your Army. The Army 
leadership recognizes the profound impact the combat environment has on 
the mental and emotional well-being of soldiers and their families. 
Last week, the Army kicked-off an unprecedented awareness campaign to 
educate more than one million Active, Reserve and National Guard 
soldiers over the next 90 days about Post Traumatic Stress Disorder 
(PTSD) and Traumatic Brain Injuries (TBI). Development and 
implementation of this chain teaching program has been one of the 
highest priorities for both the Secretary and Chief of Staff of the 
Army. The presentation and materials were vetted throughout the Army, 
not only in the medical channels, but through the leadership and 
soldier focus groups as well.
    Coincidentally, today at the Pentagon over 200 General Officers and 
Senior Executive Service civilians are participating in this PTSD and 
mild TBI Chain Teaching Program. The presentation is a combination of 
briefing slides and video clips. Commanders and leaders use an 
accompanying script to ensure the material is presented accurately and 
consistently throughout the Army. Let me briefly highlight what we are 
attempting to achieve:

      First, leaders and soldiers throughout the chain of 
command, to include the Army Chief of Staff, must take care of 
themselves and their buddies. Knowing how to recognize symptoms of PTSD 
and TBI and being aware of the available treatment options are the 
first steps toward addressing these issues.
      Second, seeking mental health treatment should not be 
perceived as a sign of weakness. Rather it should send a powerful 
signal of strength and personal courage. We are aware that mental 
health treatment carries with it a certain stigma. Soldiers must 
understand that seeking treatment for PTSD is no different than being 
treated for medical conditions such as hypertension. Untreated 
psychiatric conditions have an impact on soldier readiness and well-
being. The Army is committed to providing the very best treatment 
possible.

    Shifting gears, I'd like to briefly address personality disorders, 
as I know this has been a topic of much discussion within the media and 
the halls of Congress. As the clinical psychology consultant to the 
Army Surgeon General, I am deeply distressed to hear that some of our 
soldiers feel they have been wrongly separated from the Army for 
personality disorders. I have heard some alarming numbers thrown around 
in the media and would like to set the record straight. About 70,000 
soldiers were discharged from the Active Army in 2006. Of those 
discharged, 1,086 were separated for personality disorder, of which 295 
of those individuals had served in a theater of combat. To the 
uniformed, civilian, and contract health care professionals that care 
for these soldiers, the thought of even one soldier being 
inappropriately discharged for personality disorder is disturbing. With 
that in mind, the Acting Surgeon General, Major General Gale Pollock, 
has directed each and every one of those 295 records be reviewed by 
behavioral health professionals to verify that appropriate actions were 
taken and that all health concerns were considered in the discharge. 
That extensive record review is currently underway.
    Another misconception is that separating a soldier for personality 
disorder is simply an administrative decision made by a member of the 
Chain of Command to do away with problem soldiers. Separation on the 
basis of personality disorder is authorized only if a diagnosis is made 
by a psychiatrist or doctoral-level clinical psychologist with the 
required DoD professional credentials and privileges. The disorder must 
be so severe that the member's ability to function effectively in a 
military environment is significantly impaired. Existing military 
clinical quality assurance processes such as routine peer review of 
provider records also reduce the likelihood of provider deviation from 
the community standard of care. To protect their legal rights, every 
soldier pending separation for a personality disorder is afforded the 
opportunity to consult with an attorney prior to separation. 
Additionally, former soldiers who believe that they were improperly or 
unfairly separated may petition the Army Discharge Review Board or the 
Army Board for Correction of Military Records for administrative review 
of their cases. Legal counselors advise soldiers of this right prior to 
their separation.
    As mentioned, a Personality Disorder is a diagnosis that must be 
made by a psychiatrist or Ph.D. level clinical psychologist. There are 
actually ten different specific personality disorders, each with a set 
of characteristic behaviors. One common characteristic that is shared 
by all individuals with a personality disorder is that they have 
extreme difficulty modifying their problem behaviors and generally do 
not respond well to psychological treatment. These problem behaviors 
are typically disruptive to a military unit and are often associated 
with discipline problems. When they are judged to be unlikely to change 
or respond to clinical treatment, these behaviors can form the basis of 
an administrative separation.
    When a soldier is referred by their Commander to a psychiatrist or 
psychologist for a personality disorder evaluation, it is typically 
because there have been behavior problems that have not responded to 
counseling and other remedial efforts by the chain of command. The 
psychiatrist or psychologist basically looks for three things: 1) 
whether there is a diagnosis of a personality disorder; 2) whether 
there is a favorable prognosis for psychological treatment; and 3) 
whether there is a diagnosis that should be considered for a medical 
evaluation board. If the evaluation concludes that a personality 
diagnosis is warranted AND there is poor prognosis for treatment or 
change in behavior AND there is no psychiatric diagnosis that would 
lead to a medical board, the soldier's commander is informed that the 
soldier may be further processed for administrative separation because 
of personality disorder.
    Although soldiers suffering from a psychiatric disorder, such as 
PTSD, can sometimes exhibit behaviors that are similar to individuals 
with a personality disorder, the diagnoses can be distinguished by 
behavioral health professionals. Psychiatric diagnoses made by military 
providers are based on the same criteria used in the civilian health 
care sector, and codified in the 4th edition of the Diagnostic and 
Statistical Manual (DSM-IV). All psychiatric diagnoses include 
observable behaviors coupled with significant psychological distress or 
impairments in social or occupational functioning.
    I mentioned earlier that the Army's Surgeon General's Office will 
conduct a review of nearly 300 records of soldiers who had deployed to 
a combat theater and were subsequently separated due to personality 
disorder. This review has already been initiated and is being conducted 
by a team of senior mental health providers. The team will review 
mental health records, administrative records, and medical records to 
determine if appropriate procedures were followed and whether 
improvements are needed in the way clinical evaluations for personality 
disorder are conducted as part of the administrative separation 
process. If lessons can be learned that will improve the quality of 
these clinical evaluations, we want to know and are interested in 
making this information available to our Army behavioral health 
providers.
    In 2006 the Army diagnosed 9,500 OIF/OEF deployed soldiers with 
PTSD, including some who had deployed in previous years. We recognize 
that for some soldiers, symptoms will emerge after a period of time, 
perhaps years following their combat deployment. Findings from our 
Mental Health Advisory Teams tell us that between 15 to 20% of deployed 
troops report symptoms of post combat stress. As the war continues and 
soldiers incur multiple deployments we expect the number of soldiers 
suffering from PTSD and presenting for treatment to rise. 
Correspondingly, as these soldiers leave military service, the number 
of veterans seeking treatment is also expected to grow. As our 
education and training efforts are fully implemented, we hope that the 
stigma of seeking care will decrease, which could lead to an increased 
demand for services in both the military and veteran populations.
    When it comes to diagnosis and treatment of PTSD, the Armed Forces 
and the VA have some of the most experienced providers in the world. 
Even though our Army psychiatry and psychology training programs 
include comprehensive training in PTSD, we are working in collaboration 
with the VA's National Center for PTSD to develop additional training 
and tools for our behavioral health providers. We have also begun 
providing training in PTSD to primary care providers, nurses and social 
workers working in our Warrior Transition Units. A pilot program titled 
RESPECT-MIL also provides behavioral health training to our primary 
care providers and enhances their ability to identify, treat, and refer 
patients with mental health concerns. This pilot was so successful at 
Fort Bragg that we are pushing it across the Army to 15 additional 
installations this year. At the Surgeon General's office we established 
a Behavioral Health Proponency Office to oversee and coordinate 
behavioral health programs across the entire command.
    A major challenge we are facing involves recruiting and retaining 
active duty and civilian mental health providers. To address staffing 
shortfalls, the U.S. Army Medical Command recently committed over $50 
million to hire more than 200 behavioral health professionals to fill 
requirements across the Army. By bringing on more providers, we intend 
to increase access to mental health services and increase our outreach 
capability.
    I want to assure the Congress that the Army Medical Department's 
highest priority is caring for our Warriors and their Families. Like 
most of my colleagues, I am here because I believe in supporting 
soldiers for what they do every day in defense of our country and our 
way of life. I will do everything in my power to ensure soldiers and 
their Families receive the best health care available.
    Thank you for holding this hearing and thank you for your continued 
support of the Army Medical Department and the Warriors that we are 
honored to serve.

                                 
                     Statement of Hon. Jeff Miller
         a Representative in Congress from the State of Florida

    Thank you, Mr. Chairman.
    It is abundantly clear how prevalent the issue of mental health is 
with not only veterans returning from the Global War on Terror. This 
Committee has given a great amount of attention to traumatic brain 
injury, but equally serious is post traumatic stress disorder.
    PTSD has proven to be as dangerous an enemy as any; there is no one 
specific symptom defining it. It can derive from a range of causes, and 
the disorder itself can act itself out in a range of manners. On top of 
that, a veteran might not know that he or she has it, and therefore not 
seek treatment. While the medical community strives to diagnose PTSD 
among our active and former servicemembers as early and accurately as 
possible, it must be understood that it is still a developing science.
    I look forward to today's testimony and the input the panel members 
will provide. This Committee remains dedicated to seeing that the 
Department of Veterans' Affairs provides the best treatment possible to 
those in need.