The U.S. Military. Robert A. Seegmiller, Ph.D. ABPP-CN Director, Postdoctoral Fellowship in Clinical Neuropsychology Brook Army Medical Center

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1 The U.S. Military Robert A. Seegmiller, Ph.D. ABPP-CN Director, Postdoctoral Fellowship in Clinical Neuropsychology Brook Army Medical Center

2 Military Disability Evaluations: "Fitness for Duty" and "Return to Duty" Medical Evaluation Boards (MEB) / Physical Evaluation Boards (PEB) Temporary Disability Retirement List (TDRL) Role of Mental Health providers as consultants to the boards: providing reports with diagnostic impressions, and assessment of degree of impairment and impact on military duty performance Focus on Traumatic Brain Injury (TBI) and Post-traumatic Stress Disorder (PTSD) Potential conflict or dual role for military mental health providers who serve as both therapist (advocate) and evaluator.

3 Evaluations typically include: Review of Medical Records Consideration of Premorbid Functioning (ASVAB) Clinical Interview and Behavioral Observations Information from Collateral Sources Psychological/Neuropsychological Testing Always in cases involving reported TBI Not always in cases involving PTSD

4 Rationale for use of PVTs/SVTs Self-report of cognitive functioning is notoriously unreliable. Little correlation between subjective memory complaints and objective findings on standardized tests Qualitative analysis of effort is tenuous at best PVTs/SVTs are used to objectively assess validity of data: Can data gathered during evaluation be used to make accurate diagnoses and appropriate recommendations? If PVTs/SVTs "failed," important to consider why? Performance and symptom validity should be considered whenever disability evaluations (involving potential secondary gain) are conducted

5 Rationale for use of PVTs/SVTs (continued) Dangers of NOT using PVTs/SVTs: misdiagnoses (most likely over-diagnoses) leading to inappropriate recommendations, treatment, disability ratings and compensation misattribution (reported symptoms attributed to TBI, not the real source of problems) Iatrogenic disorders or "diagnosis threat": Increased risk of prolonged disability, post concussion syndrome PVT failure is associated with lower self-reported community participation. PVTs may serve as an indicator of patients' functioning in the community. (Lippa et al., 2014)

6 High rates of PVT/SVT failures in military disability/compensation evaluations Russo (2012) 38 veterans referred for NP evals following positive VHA Comprehensive TBI evaluations; 68% WMT failure Armistead-Jehle & Buican (2011) 280 service members with history of mtbi; 38% WMT failure Armistead-Jehle (2010) 45 Veterans referred for NP evals after scoring positive on VHA TBI screens; 58% failed MSVT

7 Military policies regarding the use of SVTs/PVTs Recognized by most providers as important (Psychologists > Psychiatrists and Social Workers) OTSG/MEDCOM Policy Memo : Optimal Use of Psychological/Neuropsychological Assessment (21 Sep 2011 thru 21 Sep 2013) "Psychological and neuropsychological assessments are valuable tools in quantifying patient deficits, clarifying diagnoses, informing treatment, and in making decisions regarding a Soldier's continued fitness for military service." "Certain clinical tests in use by neuropsychology are designed to evaluate level of effort on the part of the test taker. Poor effort on cognitive symptom validity measures means only that the data is not valid to be fully interpreted, and invalid data can be due to a range of causes other than malingering."

8 Military policies regarding the use of SVTs/PVTs (continued) No recommended or prohibited PVTs/SVTs No mandated or universal standards. Left to each provider's comfort and discretion. Differences of opinion between military providers on use and interpretation of PVTs/SVTs Common PVTs: Stand alones: WMT, MSVT, TOMM, VSVT, Dot Counting Test, b Test Embedded PVTs: e.g., RBANS Effort Index, Reliable Digit Span, CVLT Forced Choice Recognition, Wechsler Memory Scale-III/IV Common SVTs: MMPI-2/MMPI-2-RF, PAI

9 "Risks" associated with the use of SVTs/PVTs in the military Concern about "malingering" diagnoses, which are discouraged but not prohibited Potential for creating adversarial relationships (distrust, assumptions of dishonesty). Primary role of mental health providers is to be supportive Risk of offending "wounded warriors" with genuine complaints Those who feign or exaggerate impairment may be angry when presented with findings. Complaints (IG, Congressional) are unpleasant and take a lot of time Concerns about misinterpretation and misuse: Diagnosing "poor effort" or malingering on the basis of a single test score. Concern about "false positives" "Malingering" can be prosecuted as a UCMJ violation (Article 115). Can become a legal "headache" and slow down separation/discharge process

10 Determining validity of PTSD is more difficult than determining validity of TBI PTSD primarily diagnosed on the basis of self-reported symptoms Not only self-reported symptoms, but on suggested symptoms (e.g., checklists) which significantly increase symptom reporting PTSD symptoms often impossible to objectively evaluate Cognitive PVTs may be helpful for assessing PTSD and other psychiatric symptom exaggeration Strong association between failure on cognitive PVTs and elevated self-reported PTSD symptoms on a selfreport measure, Glywasky et al., (2010)

11 Psychological and contextual factors best account for SVT failures Jones, Ingram & Ben-Porath (2012) 501 military members primarily seen for combat mtbi SVT failure was associated with significant linear increases in all of the over-reporting MMPI-2-RF validity scales and most of the substantive scales. Context matters! Disability evaluations vs. Aeromedical evaluations Failure rates: 74% of TDRL evaluations 7% Aeromedical evaluations Significantly more compensation-seeking patients failed PVTs than non-compensation seeking patients

12 Evidence of symptom exaggeration must be interpreted cautiously OTSG/MEDCOM Policy Memo : Policy Guidance on the Assessment and Treatment of Post-Traumatic Stress Disorder (10 Apr 12 thru 10 Apr 14) "Poor effort on psychological/neuropsychological tests does not equate malingering, which requires proof of intent, per OTSG/MEDCOM Policy In addition, this diagnosis requires the signatures of two credentialed care providers, including a supervisor, Department Chief, or Deputy Commander for Clinical Services"

13 USAMEDCOM Behavioral Health Training Day, 12 June 2012 "BH (Behavioral Health) providers on the whole do support the patient/soldier on face value and advocate in every way for them, however we lose credibility with both medical personnel and line units when we fail to properly investigate and obtain collateral information" "The MEB/IDES (Integrated Disability Evaluation System) process is not a workman's comp type program in which the injured party has the obligation to prove their injury." "We cannot assume there is purposeful secondary gain or malingering. Army BH professionals diagnose and treat and should not be in an adversarial role with patient in terms of disability processes." "We must approach with a Soldier-centered focus that provides Soldiers the benefit of the doubt"

14 So what is the role of psychological tests, including PVTs & SVT, in the military? "You are not detectives" But we are professionally and ethically bound to conduct comprehensive, objective, and valid assessments