THE PROBLEM OF MISDIAGNOSIS

I.     Misdiagnosis Is Common

When I wrote my Ph.D. thesis, the Committee’s one concern was that I go back and include the misdiagnosis of traumatic stress. I had no idea how prevalent this is in the V.A., especially. I devoted an entire chapter in my dissertation on this issue. I will forego that whole section and give you the hi-lights of why this is a troubling topic. 

At the top of the list for me is that combat stress is not a mental health issue. It is a physical or physiological set of problems created by continual traumatic stress. In all the years I’ve been seeing psychiatrists, that is since late 1997, only one doctor has made any reference to the changes that take place to the various parts of the brain, such as the amygdala (enlarges 6%), and the hippocampus (shrinks 7%). The chemicals and electrical circuitry are adversely affected during combat. The neurobiology, biology, sympathetic, and parasympathetic nervous systems of a veteran’s brain are often transformed radically when under continual stress. All of these components combined conspire to modify a person’s thought processes and behavior. The research is mountainous and growing each year. But for the VA, it’s as if none of this matters, and the brain accepts what comes and is not affected to any negative degree. 

I believe it’s crucial to discuss this topic with patients and families upfront before symptoms reach terminal velocity and more marriages come apart. Much good could come from the parties involved knowing how combat traumatic stress occurs, what to expect from it and why.

II.     Reasons for Misdiagnosis

On the website, P.T.S.D.: National Center for P.T.S.D., combat trauma is defined this way, “P.T.S.D. is a mental health problem that some people develop after experiencing or witnessing a life-threatening event, like combat, a natural disaster, a car accident, or sexual assault.” Notice nothing is stated about brain transformation or even hinted at as a way of understanding traumatic stress. I think some people believe that veterans can and should be de-programmed after returning from combat. 

Other reasons for misdiagnosis of combat trauma are beginning to appear. Lexa W. Lee believes the numbers are alarming. She writes, “More than 25% of Veterans’ Administration (V.A.) charts may show false-positives or -negatives in post-traumatic stress disorder (P.T.S.D.) diagnoses, according to a study presented here March 26 at the Anxiety Disorders Association of America 31st Annual Conference (ADAA).”

Researchers conducted random P.T.S.D. evaluations on two hundred sixty-eight soldiers and Marines who served in Operation Enduring Freedom and Iraqi Freedom. Forty-nine percent were females, seventy-nine percent were white, forty-seven percent were married, 21 percent were single, nineteen percent were divorced, and nine percent were cohabiting. Each veteran received a self-report questionnaire asking about “combat exposure, substance abuse, stressful life events, social support, sleep difficulty, anger, functional impairment, and suicide risk.” The research revealed that over 25 % of the diagnoses were wrong. Further refinement of the numbers was conducted in 2006 by Bruce Dohrenwend, who found that “When he had culled the poorly documented diagnoses, he found that the 1988 rate was 9 percent, and the lifetime rate just 18 percent.” 

Richard McNally worked the numbers of diagnosed cases, and the numbers came down. Dobbs writes, “If you included only those suffering ‘clinically significant impairment’ — the level generally required for diagnosis and insurance compensation in most mental illness — the rates fell yet further, to 5.4 percent at the time of the survey and 11 percent lifetime. It was not 1 in 3 veterans that eventually got P.T.S.D., but 1 in 9 — and only 1 in 18 had it at any given time. The N.V.V.R.S., in other words, appears to have overstated P.T.S.D. rates in Vietnam vets by almost 300 percent.”

The larger numbers can be attributed, according to Washington University researcher Elizabeth Loftus, to false memory. For Loftus, one in four adults lost their way in a shopping mall as a child. Two years later, over two-thirds of the veterans remembered one event that they had not mentioned a month after rotation home. Twenty-four percent described three incidents they forgot after returning. McNally believes these memories point to “late-onset” P.T.S.D., which seems to explain their depression, anxiety, as well as other such disorders. McNally’s understanding of this rules out P.T.S.D.

These studies show that when people witness an event yet later come into contact with new and misleading information about it, their recollections often become distorted.

Dr. “Norma Perez” works at a U.S. V.A. hospital. She wrote a candid email and sent it out to many V.A. clinical employees:

“Given that we are having more and more compensation seeking veterans, I’d like to suggest that you refrain from giving a diagnosis of P.T.S.D. straight out. Consider a diagnosis of Adjustment Disorder, R/O P.T.S.D."

“Additionally, we don’t or have time to do the extensive testing that should be done to determine P.T.S.D.”

“Also, there has been some incidence where the veteran has a C & P, is not given a diagnosis of P.T.S.D., then the veteran comes here and we give the diagnosis and the veteran appeals his case based on our assessment.”

“This is just a suggestion for the reasons listed above.”

Year old stories detail the misdiagnosis of P.T.S.D. among military personnel discharged for “Personality” Disorders. None of these discharges are honorable, so the misdiagnosed persons are released with NO BENEFITS including Department of Veterans Affairs; medical, educational, vocational rehabilitation, On-The-Job Training OR Department of Defense disability! 

Of course, the patients themselves can also have ulterior motives for applying for compensation. Evil people scam the system because they don’t care about anyone but themselves. T.B.I. (Traumatic Brain Injury) and those with P.T.S.D. can receive a misdiagnosis since these two issues “share extremely similar symptoms, therefore either could be easily misdiagnosed as a result.”

One British psychiatric journal suggested, “Future research should include interview methodology in studies on P.T.S.D. after severe traumatic brain injury, and further investigate differential diagnoses and confounding factors to standardize assessment with this population. Although self-report measures can be used for screening, they can mislead if used for diagnosis of P.T.S.D. after traumatic brain injury.”

The clinical implications of this information are:

1.  A structured interview is necessary for a diagnosis of P.T.S.D. after severe traumatic brain injury

2. A questionnaire self-report can be useful to screen for P.T.S.D. symptoms after traumatic brain injury 

3. The true incidence of P.T.S.D. after severe brain injury has yet to be determined

I conclude this chapter on misdiagnosis with one of two cases of intentional misdiagnosis by the V.A. This story reveals the depth of the problems at the Veterans Administration Mental Health Department. I received the following letter from a fellow veteran with whom I served in Vietnam.

"Several years ago I asked my V.A. doctor, a good man but what I would call naïve, to give me a referral to Neurology so I could be screened for TBI. He did. Or he said he did at least and I believe him. After not getting any notification for approximately ten (10) days I called the doctor and spoke with his nurse. She told me that all Neurology appointments at the ___________ _____________ VAMC—one (1) of the very best in the nation—had to be approved by Mental Health, so I should call there. I did and was told there was no referral for Neurology on file. I spoke with my doctor and after looking at his computer he gave me a ‘confused’ look and told me I never asked for a referral to Neurology.

"Based on my experience working for the federal government in _________ _____________ I knew immediately what happened. His computer, a central server system, was ‘washed’ and the referral was deleted. That kind of thing happened to me several times while I was working for an unrelated government agency in Washington, D. C.—reports and E-Mails I was working on were deleted. Why? The problem, at least with the VA, is funding.

"Funding is based on the number of patients, as well as the severity of injuries/illnesses/conditions, a department such as Mental Health and Neurology sees. So if a patient is diagnosed with P.T.S.D. then Mental Health gets funding and TBI funding goes to Neurology. As a result, with the request for a Neurology referral at the V.A.M.C. in ______________________, Mental Health didn’t want to share their funding since I had already been diagnosed with P.T.S.D.

"I went to a civilian doctor and asked for a referral to a Neurologist since I had adequate insurance—Medicare and secondary insurance. The Neurologist is taking very good care of me. I no longer go to the VA. After previous experiences, this incident was ‘the straw that broke the camel’s back’ and now I see civilian doctors only.

"I don’t blame the doctors, I blame the bureaucrats. By the way, I quit seeing the Mental Health people, in both _______ _____________ and ___________________, several years earlier because

1) Their continued push to diagnose veterans with P.T.S.D. as substance abusers so they could charge the veteran’s civilian insurance for substance abuse—AA—since substance abuse can never be service-related.

2) Push people out of individual therapy and into ‘group grope’ so they can get more money for their program since they get funding based on the number of people they see and they can see more people in groups.

Of course, some veterans do ‘scam’ the VA.

This next testimony is quite illuminating from the wife of an Afghanistan Veteran.

“Your only option is to take him to the V.A. in Cheyenne, WY, miss,” the V.A. helpline operator tells me. My husband of all of three months had become a shell of his former self overnight. He had gone from a hardworking, compassionate, independent man to someone whose hands tremor so badly he can’t tie his own shoes and has night terrors so vivid he is often hoarse the next morning.

"I coax my husband—let’s call him DJ—into the car the next morning. The dirt roads on the way are now what I know as a “trigger.” Anytime something hits the bottom of the car, DJ braces for impact and sometimes calls me by a battle buddy’s name. We arrive to wait in the ER waiting room for several hours until a caseworker is available to assess him. She quickly decides that residential psychiatric treatment is the best solution and that he is in luck: there is a V.A. almost 500 miles away from home, and a plane will arrive within the hour to take DJ to the facility.

"The next day I receive a call late at night from a woman named Norma Jean, a nurse on “the unit.” In hushed tones she tells me to come to the V.A. as soon as possible; she can’t tell me what is going on but says to get there the next morning. I pack my bag and am on the way at sunrise.

"When I arrive I find out that the admitting psychiatrist diagnosed DJ with Post Traumatic Stress Disorder. No surprise there. Then I found out the psychiatrist DJ has been assigned to decided after a five-minute assessment that DJ has bipolar disorder and has been placed on a two medication cocktail. On my way out of “the unit,” Norma Jean stops me in a side hallway and recommends I look up bipolar disorder in the DSM. I do so and see DJ doesn’t fit the symptoms at all for bipolar 1 or 2.

"DJ has a meeting every morning with the psychiatric team. His symptoms are not improving, and he is becoming increasingly agitated and unresponsive. Anytime he or I mention that he isn’t reacting well to the medication the psychiatrist doubles his current dosage. After a few days of visiting DJ on the unit, I find out that every single one of DJ’s psychiatrist’s patients has the same diagnosis and the same medication, and each time any of them says they aren’t feeling right their meds are doubled. One soldier that this psychiatrist sees has been mute for several months. None of the patients in the unit has family who still keeps in touch; at that point, I’m the only non-staff member who is ever there.

"My gut says something isn’t right. I push to have DJ reassessed by a different psychiatrist. The process takes several days because clinicians rarely in the office or on vacation, but finally, I manage to schedule an appointment with the head of the psychiatric department. She agrees to have DJ reevaluated and asks me to sit in the hall for a moment. DJ’s current psychiatrist’s office is near hers, the door is wide open, and I hear every detail of his explanation about how I am a “yappy cur” who needs to be quiet. When I go back into the head of psychiatry’s office, I let her know that I understand his current psychiatrist is livid, but that Doctors really shouldn’t scream patient information where everyone can hear. She is embarrassed and assures me the psychiatrist will be taken off DJ’s case immediately.

"In the ten minutes the conversation takes place, DJ’s psychiatrist enters the unit, hands DJ pills, and tells him to take them. He then makes him sign an “Against Medical Advice” (AMA) release form. I find DJ in the parking lot, he thinks he is slaying dragons. I take him back inside and demand to know what in the world is going on. The head of psychiatry says that since DJ signed the AMA form, he cannot be evaluated until he admits himself back under the same psychiatrist’s care. DJ of course refuses. I have no idea what to do. We are told to go home.

"DJ and I make it back to Colorado. Dropping cold turkey off of as high of a dosage of medication that he is on has disturbing side effects: he hallucinates; he throws up; he has a fever. On his first night home, he injures my wrist during a night terror.

"It took two years and nine suicide attempts for DJ to finally get help through the V.A. system. He has had plenty more deplorable doctors; one shrieked at me how, “That’s the V.A. way.  If you don’t like it, leave,” when DJ had a life-threatening reaction to a medication. Now, when I advocate for DJ’s and other’s care, I remember her lesson that near-fatal medical policies are the V.A.way. Instead of leaving, though, I do my best to make sure poor treatment at home doesn’t kill soldiers who survived deployment."

I can say much more about this disappointing topic, but you get the picture. We live in a broken, dangerous world. The V.A.Mental Health system needs more than its philosophical, man-centered worldview. Researchers regularly use words and phrases about cranial studies such as “this may be the reason for,” “we believe,” “our theory thus far is,” “supposedly,” “we think,” “the research suggests,” “we don’t understand why,” “perhaps,” “this might be the reason for,” and so many more uncertainties when dealing with the brain. 

I believe the God who has made Himself known in His creation, including man's conscience. God created mankind in His image, and therefore, He has written His law on their hearts. Unfortunately, we prefer to repress that knowledge. God knows more about the brain, its workings, and what is wrong with it due to sin than the most brilliant researchers and physicians. God doesn’t make guesses. He knows everything there is to know about everything instantaneously. He can’t learn anything since He possesses all knowledge. 

The V.A.’s mental health system and its professionals have not diagnosed their patient’s most lethal problem: sin. But since God doesn’t exist in the V.A.'s Mental Health Department, the professionals working there remain free to bandage their patient’s “terminal spiritual cancer” with the gauze of atheistic and humanistic psychology. But more about that as we move through the material below.