CREW: Department of Defense: Department of The Army: Regarding PTSD Diagnosis: 6/30/2011 - Release Pgs 242-333 DTD 27 June 2011

FOIA Release Page 242
REPLY TO
ATTENTION OF
MCHE-JA
DEPARTMENT OF THE ARMY
BROOKE ARMY MEDICAL CENTER
3851 ROGER BROOKE DRIVE
FORT SAM HOUSTON, TEXAS 78234-6200
29 July2008
MEMORANDUM FOR Commander, Great Plains Regional Medical Command, Fort Sam
Houston, TX 78234
SUBJECT: Legal Review- AR 15-6 Investigation of EACH Department of Behavioral Health
and Medical Evaluation Board
2. I have determined the following:
l(b)(5)
b. The Investigation is procedurally
sworn as directed by the Appointing Authority. (b)(S)
lb)(5)
I
I
Page 1
MCHE-DBM 28 July 2008
MEMORANDUM FOR BG JAMES K. GILMAN, COMMANDING, GREAT PLAINS REGIONAL
MEDICAL COMMAND, FORT SAM HOUSTON, TX 78234
SUBJECT: Executive Summary, 15-61nvestigation, Evans Army Community Hospital
1. This memo summarizes the findings of the investigation directed by BG Gilman under
authority of AR 15-6 to investigate an allegation that there has been institutional pressure to
compel Evans Army Community Hospital (EACH) behavioral health providers to improperly
change diagnoses, and that considerations other than established clinical criteria and judgment
have been used to affix diagnoses. The investigation was directed to examine whether there
has been organizational pressure from command or leadership at the MEDCOM or hospital
level to include the EACH command and staff, Behavioral Health department, or MEB staff.
2. Findings.
a. Finding 1: This investigation does not find deliberate institutional or organizational
pressure on EACH behavioral health providers to improperly make or change clinical diagnoses
or to render incorrect or inaccurate diagnoses pursuant to clinical or medical board evaluations.
b. Finding 2: This investigation does not find that any level of MEDCOM command, EACH
command and staff, or the EACH MEB staff and leadership have attempted to coerce or
otherwise influence the outcome of clinical evaluations conducted by EACH behavioral health
providers pursuant to clinical or medical board evaluations.
c. Finding 3: This investigation finds evidence of potential systemic pressures inherent in
Army physical disability evaluation processes that may influence MEDCOM behavioral health
providers in the course of conducting PTSD disability evaluations. These potential pressures
may lead providers to avoid making a diagnosis of PTSD on medical boards contrary to their
clinical judgment.
3. Recommendation: The existence, extent, and strength of the potential systemic pressures
indentified in Finding 3 could not be well ascertained within the scope of this investigation.
Review at additional Army military treatment facilities is recommended to determine if systemic
processes related to PTSD disability evaluations exert undue pressure on MEDCOM behavioral
health providers to avoid entering a diagnosis of PTSD on an MEB contrary to their clinical
judgment.
c(_ >=- L
~ R U C E E. CROW
COL, MS
Investigating Officer
Page 3
["},
SECTION VI- AUTHENTICATION (para 3-17, AR 15-6)
ge 7
THIS REPORT OF PROCEEDINGS IS COMPLETE AND ACCURATE. (If any voting member or the recorder fails to sign here or in Section VII below.
indicate the reason in the space where his signature should appear.)
1 I
CROW
(Recorder) (Investigating Officer) (President)
(Member) (Member}
(Member) (Member)
SECTION VII MINORITY REPORT (para 3-/3, AR 15-6)
To the extent indicated in Inclosure , the undersigned do( es) not concur in the findings and recommendations of the board.
(In the inclosure, identifY by number finding and/or recommendation in which the dissenting member(s) do(es) not concur. State the
reasons for disagreement. Additional/substitute findings and/or recommendations may be included in the inclosure.)
(Member) (Member)
SECTION VUI- ACTION BY APPOINTING AUTHORITY (para 1-3 11.Rl5-6)
The findin_ill! and recommendations of are (..... "''
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with following exceptions/

SubstifutiolJ]> (If the appointing authori(Y returns (fie prOCeedingS tO the inVeStigating officer Or board for JUFlfleT jJ .
0
S Or
corrective action, attach that correspondence (or a summary, if oral) as a numbered inclosure.)
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USAPAV1.20
the MEB section was not 'coercive'. He mentions in his sworn statement one other case
where he fell pressure from a dissatisfied patient to add a PTSD diagnosis which he did
-
In the audio recordind(b)(
6
) 'mplies to his patient that he claims to have given
him a diagnosis of Anxiety Disorder NOS in response to an unspecified source or
sources of pressure. During described systemic pressures
associated with medical board evaluations that were voiced by other providers as well
and are inherent in several processes of the disability system. These processes may
pressure behavioral health providers to avoid using a diagnosis of PTSD and to use an
Anxiety Disorder diagnosis instead.
MEB's require considerable time to complete but receive disproportionately low RVU
credit. Providers were being encouraged to gain more RVU's and to do more boards.
There was a pressure to get more of these done as quickly as possible. The
understanding of providers at EACH was that PTSD boards took longer to do, were
more complicated and more likely to be returned. Their personal experience seemed to
validate this as they saw more boards returned for collaborating evidence in the form of
the commander's letter needing to be reconciled or reviewed. Providers sought to do
boards as quickly as possible and with a lower likelihood of them being returned. Talk
amongst the staff was that an anxiety disorder NOS diagnosis was likely to be quicker
and be done when you sent it forward.
Another pressure described by staff involved an effort to reduce the number of
administrative separations at Ft. Carson due to previous criticism about excessive
"chapter" separations that resulted in media and congressional scrutiny. In essence
providers determined if a Soldier had deployed they would support a medical board in
lieu of an administrative separation regardless if an administrative separation was
supportable. This seemed to correlate with an increased number of MEB's being done
and a pressure to be more liberal with making a boardable psychiatric diagnosis. This
pressure was cited by multiple providers as being 'beyond local, it was Congress and the
media' and 'Monday morning quarterbacking' was felt to be pervasive.
One concern noted by providers was a pressure they perceived to be placed on Soldiers
by their commanders. There were statements from multiple providers that Commanders
were discouraging Soldiers from accessing behavioral health care. One provider noted
"green tab leaders, from platoon sergeants to battalion commanders, were increasingly
frustrated with providers when their subordinate Soldiers were classified as non-
deployable or in need of an MEB. They believed manv of these individuals were
embellishing their symptoms in order not to deploy." (b)(6) These may be the
same leaders who are asked to provide a Commander's letter to validate a Soldier's
PTSD event as well as a Commanders duty performance statement regarding a
Soldier's level of functioning. This information is used by the PEB to adjudicate level of
disability and it would be concerning if psychiatric medical boards put a Soldier in an
adversarial relationship with his or her command.
8. Recommendations. This investigation directly addressed whether there are
deliberate institutional or organizational pressures from leaders or persons in authority
that improperly impact on the diagnosing practice of behavioral health providers at
Evans Army Community Hospital. As described in detail above. the evidence obtained
8
Page 15
in this investigation does not support this conclusion and further investigation into this
matter does not appear warranted. What could not be fully addressed in this
investigation was whether systemic pressures of MEB evaluations identified at EACH
are experienced among other MTF staffs. 1n order to determine the existence, extent,
and strength of potential systemic pressures across MEDCOM, additional review would
be required.
a. Recommendation 1. Review at additional Army military treatment facilities is
recommended to determine if evaluation processes under proponency of MEDCOM
(MEB) and/or Human Resources Command (PEB/PDA) pursuant to PTSD disability
evaluations, exert improper pressure on MEDCOM behavioral health providers that
discourages them from entering a diagnosis of PTSD on an MEB contrary to their clinical
judgment. Such a review could involve a representative sample of MTF's and include
methods such as provider/staff surveys, sensing sessions, interviews, and data calls for
metrics sensitive to variance from an expected rate of PTSD diagnosis on final
adjudicated physical evaluation boards.
b. Recommendation 2. Recommended actions for EACH:
1} Education and training: Providers who are to do MEB should have a targeted
training for conducting these challenging evaluations. Many of the active duty
psychiatrists have had training through residency programs and are experienced with
MEB's. At EACH the former or current active duty providers could devise a training
program for those providers who have not had experience or formal training in the past.
Part of this training should include a vision statement or philosophy of doing MEB's. This
should include that there are no pressures to diagnose outside of what the facts,
evidence and history of the Soldier indicate should be the diagnosis. Additional training
witb regards to the PEB conducting staff assistance visits, or MTF providers visiting the
PEB could facilitate better understand by MTF providers of the PEB process.
2} Local quality control metrics should be employed to monitor trends associated
with MEB's returned from the PEB. Metrics such as the number returned and reasons
for the returns can help providers appropriately address recurring problems. This should
be in the context of providing a quality product and not as a 'pressure' to change a
diagnosis.
c r - > ~ L
BRUCE E. CROW
COL, MS
Investigating Officer
Clinical Psychologist
Chief, Department of Behavioral
Medicine
Brooke Army Medical Center
9
Page 16
SAMR
OFFICE OF THE ASSISTANT SECRETARY
MANPOWER AND RESERVE AFFAIRS
111 ARMY PENTAGON
WASHINGTON, DC 20310.0111
MAR : 1 2011
MEMORANDUM FOR UNDER SECRETARY OF DEFENSE (PERSONNEL & READINESS)
SUBJECT: Army Personality Disorder Separation Compliance Report for Fiscal Year 10
1. On September 10, 2010 the Under Secretary of Defense directed the Army to examine
compliance with DoD I 1332.14, personality disorder (PO) separations for fiscal year (FY) 1 o. In
addition, the Army was directed to provide the total number of PO separations since
September 11, 2001 including those who had served in Imminent Danger Pay Areas. In
FY201 0, 365 enlisted Soldiers were separated for PD. The Army r e v i e ~ e d 14 percent of the
records in order to satisfy the requirements set by USD (P&R). Since September 11, 2001 a
total of 7,440 enlisted Soldiers have been separated for PO and 1,759 of them servecUn
Imminent Danger Pay Areas.
2. The cases reviewed were in compliance with the requirements set forth by DoD. The Army
is taking additional steps to ensure units and leaders are aware of and complying with DoD and
Army separation and medical screening policies, and that those cases.requiring review and
endorsement by the Office of the Surgeon General (OTSG) are being properly forwarded.
Detailed analysis may be found In the enclosed report.
3. In addition to the FY1 0 compliance report, the Army was directed to provide the total number
of Soldiers who have deployed in support of a contingency operation since September 11 , 2001,
who were later administratively separated for personality disorder, without completing the
enhance screening requirements for Post-Traumatic Stress Disorder and Traumatic Brain Injury
implemented on August 28, 2008 In 0001 1332.14. Between September 11, 2001 and August
28, 2008 a total of 1 ,453 enlisted Soldiers were administratively separated from the Army for
personality disorder who had also deployed to an area designated as an Imminent Danger Pay
Area. The Army is presently obtaining current mailing addresses In order to send letters
informing them of the process to correct their discharge characterization, and how to obtain a
mental health assessment through the Department of Veterans Affairs. Once letters have been
mailed, the Army will proVide the final names to the Department of Veterans Affairs as directed.
4. My secretariat point of contact for this action Is COL Tracl E. Crawford. She can be reached
at (703) 6921296 or by email at: tracl.e.crawford@us.army.mll.
Encl
- ~ ~ - .. 1-
THOMAS R. LAMONT
Assistant Secretary of the Army
(Manpower and Reserve Affairs)
Army Personality Disorder Separation
Compliance Report for FV 2010
Background:
In 2007, The Government Accounting Office (GAO) reported that the Military
Departments were not fully compliant with DoD personality disorder (PD)
separation guidance (DoDI1332.14)
1
As a result, the Under Secretary of
Defense for Personnel and Readiness (USD (P&R)) requested that all Service
Secretaries review personality disorder separation files to determine compliance
and address any identified issues. In January 2009, the Army was directed to
provide a report on compliance for PO separations occurring in FY2008 and
FY2009. While Improvements towards compliance had occurred, it was
determined that compliance reporting should continue through FY2012 for all
Services. In addition to the FY201 0 compliance report, the Army was directed to
provide the total number of PO separations since September 11 , 2001 including
those who had served in imminent danger pay areas. This report Is a review of
the FY201 0 PD separation records.
To ensure continued compliance with the DoDI and 10 U.S.C 1177, the Army
Surgeon General (OTSG) I Commanding General, United States Army Medical
Command (USAMEDCOM), issued guidance on June 9, 2010 to all Regional
Medical Commands outlining screening requirements for Post-Traumatic Stress
Disorder (PTSD) and Traumatic Brain Injury (TBI) for all Soldiers considered for
administrative separation who require a mental status evaluation, have been
deployed, and who have been diagnosed as experiencing PTSD or TBI or who .
otherwise reasonably allege the influence of such a condition in support of OUSD
(P&R) Directive-Type Memorandum (DTM) 10-022, issued later on August 30,
2010. In addition, the Army completed policy updates to AR 635-200 on April 27,
2010 and has completed additional policy revisions for clarification to be
published in the next update of AR 635200. Furthermore, on February 22, 2011,
the OTSG/CG, USAMEDCOM issued updated policy guidance to all Regional
Medical Commands regarding required review and endorsement by OTSG of
separation actions for PO and other designated physical or mental conditions
when the member had been deployed to an imminent danger pay area. The
Army is also currently drafting an All Army Activities (ALAAACT) message
reiterating Army policy concerning required screening requirements for PO and
other administrative separations to ensure compliance with OTSGIMEDCOM
policy memo 1101 0.
1
Additional Efforts Needed to Ensure Compliance with Personality Disorder Separation
Requirements." GA009-31 released October 31,2008.
ASA M&RA (MP) FOUO!LIMDIS 1
The Office of the Deputy Assistant Secretary of the Army for Military .Personnel
(DASA-MP) coordinated with both Human Resources Command (HRC) and
(OTSG) to cqmplete the FY201 0 report.
PO Separations Since September, 2001
Sep
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Total
Total
Separations 42 731 972 959 1018 1071 1066 641 575 365 7440
Deployment
Experience 1 55 143 214 191 302 336 211 157 149 1759
Methods:
Collection of Da.ta:
In order to obtain losses from the Army due to PO In FY1 0, the Army queried the
Army's loss files by Separation Program Designator Code (SPD) for both
paragraph 513 (Personality Disorder for Soldiers with less than 24 months of
service) and 5-17 (Other Designated Physical or Mental Conditions). Because
Soldiers can be separated for multiple reasons under paragraph 5-17
(Adjustment Disorder, Personality Disorder for Soldiers with 24 or more months
of service, enuresis, sleepwalking, dyslexia, severe nightmares, claustrophobia,
transsexualism/gender transformation, and other disorders manifesting
disturbances of perception, thinking, emotional control or behavior) losses under
paragraph 517 were then sent to OTSG to Identify those separated based upon
a primary diagnosis of PD. In FY1 0, the Army administratively separated 365
enlisted Soldiers for Personality Disorder pursuant to AR 635200, paragraph 5-
13 and 517 of which a total of 149 enlisted Soldiers had deployed to an
imminent danger pay area. 14% of all Personality Disorder records were
reviewed for compliance (e.g., 51 files).
Data Analysis:
The Military Personnel Office developed a spreadsheet to collect the data
needed to detennlne compliance. Patient identification was redacted by using
only the last 4 digits of the Soldier's social security number as a record I D.
Records were reviewed for the presences of the following documents: (1) Service
Member received formal counseling and was afforded adequate opportunity to
improve his/her behavior prior to being separated on the basis of PD; (2) Service
Member's PO diagnosis was made by a psychiatrist or Ph.D. level psychologist;
{3) The PO diagnosis included a statement or judgment from the psychiatrist or
Ph.D. level psychologist that the Service Member's disorder was so severe that
the Service Member's ability to function effectively in the military environment
was significantly impaired; (4) Service Member received written notification of his/
ASA M&RA (MP) FOUO/LIMDIS 2
her impending separation based on PO diagnoses; (5) Service Member was
advised that the diagnosis of a PO does not qualify as a disability. For Service
Members separated on the basis of a PO who served in imminent danger pay
areas: {1) Service Member's PO diagnosis was corroborated by a peer
psychiatrist or Ph.D. level psychologist or higher level mental level professional;
(2) Service Member's PO diagnosis addressed PTSO or other mental illness co-
morbidity. (Note: In accordance with 00011332.14, paragraph 3.a. (8)(d),
unless found fit for duty by the disability evaluation system, a separation for PO is
not authorized if Service- related PTSD is also diagnosed.); (3) Service-
Member's PD diagnosis was endorsed by The Surgeon General of the Military
Department concerned prior to discharged.
Each of the required compliance areas was scored as either present (receiving a
1) or absent in the record (receiving a 0}. To be counted as present in the
record, a stand-alone document had to be found. Only the actual supporting
documentation was counted. All records were reviewed twice to ensure that no
data was missed.
Findings:
DocumentDiion required for all PO Separations files: In FY10, there were 365
total enlisted separations from the United States Army due to a clinical diagnosis
of personality disorder. The Army reviewed 14% of these records, exceeding the
10% requirement set by USO (P&R).
Adciitiona! Criteria for SeiVice Members 1 ~ v h o served in an Imminent Danger Pay
Arr:;a: OTSG reviewed personality disorder separation packets between 01 Oct
09 and 30 Sep 10 and found that they were consistent with the requirements set
forth by DoD meeting 100% compliance.
Discussion:
While the cases reviewed were consistent with the requirements set forth by
DoD, the Army is taking additional steps to ensure units and leaders are aware of
and complying with DoD and Army separation and medical screening policies,
primarily that those cases requiring review and endorsement by OTSG are being
properly forwarded.
Corrective Plan of Action:
The United States Army will continue to educate the field regarding screening
requirements including higher level review at the level of the Office of The
Surgeon General, when required, and is publishing revisions to AR 635-200 to
clarify these requirements. The Army also plans to publish an All Army Activities
message (ALARACT) as well as a senior leadership 'sends' message to leaders
asking for their assistance to ensure compliance.
ASA M&RA (MP) FOUO/LIMOIS 3
The Army is also exploring options to enable the internal Army tracking of all
separations under AR 635-200, paragraph, 5-17, Other Designated Physical or
Mental Conditions. Reasons for separation under paragraph 5-17 (adjustment
disorder, personality disorder for members with 24 or more months of active
service, chronic airsickness, chronic seasickness, enuresis, sleepwalking,
dyslexia, severe nightmares, etc.) are all categorized under a Separation
Program Designator (SPD) code broadly assigned to all paragraph 5-17
separations. Because of this, the only way to analyze trends that may then
influence changes in policy, is to individually examine each 5-17 separation file to
account for the actual reason for separation which is very time consuming and
manpower intensive.
Service Members Deployed in Support of a Contingency
Operation Since September 11, 2001 and Later Administratively
Separated for Personality Disorder:
In addition to the FY2010 compliance report, the Army was directed to provide
the total number of Service members who have deployed in support of a
contingency operation l:!ince September 11 , 2001 who were later administratively
separated for a personality disorder, regardless of years of service, without
completing the enhanced screening requirements for Post-Traumatic Stress
Disorder (PTSD) and Traumatic Brain Injury (TBI) Implemented on August 28,
2008 in DODI1332.14.
Between the period of September 11, 2001 and August 28, 2008 a total of 1 ,453
enlisted Soldiers were administratively separated from the Army for personality
disorder who had also deployed to an area designated as an Imminent Danger
Pay Area. The Army is utilizing the template letter provided by OSD, with slight
modifications, to contact and inform these former members of the process to
correct their discharge characterization process and how to obtain a mental
health assessment through the Department of Veterans Affairs. The Army is
presently obtaining current mailing addresses and identifying any of these
members who may now be deceased. Once letters have been mailed to each of
these former members, the final names will be forwarded to the Department of
Veterans Affairs as directed.
ASA M&RA (MP) FOUO/LIMDIS 4
OFFIC{: cy niE:As$1$TAz'JTS&:f:l.E1lll..l:{'(

1 1 Mi'!f PE'ilTAGdli .
i:l'c W11)..f11
MEMORANDl;JMFORTHE UNDER SECRETARY OF DEFENSE, PERSONNEL
AND Rf.=jiJDINESS
SUBJECT: Administrative Se;paratlon of Stildiers with Post Traumatic Stress Disorder
(PTSD) or rraumatic Brain Injury (T8l)
1. As requested, thls letter proVfdes Information to addrass the concer,ns of SenEJtors BOI1d
1
Grassley, 8rownbaci( and Leahy. The Army Is dedlcatad to ensuring that all Soldiers \\1th
physical and mental conditions caused by wartime servioo receive the care they d$SSf\ri:l.
The enclosure otitilnes me numbar ofSotd!eis discharged In Fiscal Years 200S..2010 fc,i
Personality Disorder, Adjustment Disorder, and Other Physical or Mental Cdnditiotrs, and
how many have,deplqyed to an Imminent Danger Pay Area. Pleas,e realize that there are
complexities lhvolved beyond the numelic.al data, and that the Amly has taken actlons'to
ensure these So! diem were appropriately :screened for PTSD and TBi.
2. In 2008 and 2007, public cbncsm l!las raised that moroeSoJdiers ret1,1mlng trom combat
tours had been discharged from the military for Personality Disorders$ but were .
suhs,s;quently suffering from PTSD or TBI refated io thelr combat experiences. The Army
Issued policies to address mase concerns, and fmplemented the requirement for higher '
level review of administrative separations for Pe-rsonality Disorder at Office of The Surge\ln
General and scre&lng for PTSD and TBI. TI1s Army also lssued guidance outlining
procectures forPTSO and TB! screening forat! Soldiers ct::insldere\:1 for admlnlstrstlv'e
separation vtho require<! a mental status evaluation, or who had been deptoyoo to an
lmiliinant Danger Pay Area.
3. In at.Cordanee \VltlrOSD gt)idancer the Army Is reView ofat least'10
pef<ient .. ofall PersonalityGlrordar saparatlonsforflscaLyear 2010. Adqitlonally;.\>ie arel
identifying Soldiers who. eplpyld to r;tn tmmi.nal'\t Danger Pay Area wf1o were
Pisordersinoo.20011n <>rderto Inform them Of the process to correct t.rye1r
discharge characteriiatlcn and how to obtaln mental health assessment through the
Department of Veterans Affa1rs.
4. _MyPOC for this action isJ(b)(6)

. -HI'
Encl
w.. .
- '
.
'd-,. ' ' ' ... ' ' "'- '
TH 'ii/M R. MONT
. secretary of the Army
npower and Reserve Affairs)
INFORMATION PAPER
SAMR-MP
25 October 2010
SUBJECT: Screening of Personality and Adjustment Disorder Discharges
1. References:
a. Letter from Senator Bond et al. to Secretary Gates, 15 October 2010.
b. Department of Defense Instruction 1332.14, Enlisted Administrative Separations,
28 August 2008.
c. Memorandum, USD-PR, subject: Continued Compliance Reporting on
Personality Disorder (PD) Separations, 10 September 2010.
d. Army Regulation 635-200, Active Duty Enlisted Separations, Rapid Action
Revision Issue Date: 27 April 2010.
e. OTSG/MEDCOM Policy Memo 09-056, Guidance for Administrative Separation
for Personality Disorder (PD) or other Behavioral Conditions, 22 July 2009.
f. OTSG/MEDCOM Policy Memo 1 0-040, Screening Requirements for Post-
Traumatic Stress Disorder (PTSD) and mild Traumatic Brain Injury (mTBI) for
Administrative Separations of Soldiers, 9 July 2010.
2. On 15 October 2010, Senators Bond, Grassley, Brown back and Leahy wrote to
Secretary Gates expressing their concerns about screening of Personality and
Adjustment Disorder discharges. They requested data on the number of Soldiers
discharged under Chapters 5-13 and 5-17 and the number of those that have deployed.
OSD further requested information regarding actions taken, or underway; to ensure that
Service members who deployed to an Imminent Danger Pay area, who were diagnosed
with either Adjustment Disorder, Personality Disorder, or Other Designated Physical or
Mental Condition and were discharged in Fiscal Years 2008-2010 did not have Post
Traumatic Stress Disorder (PTSD) or Traumatic Brain Injury (TBI). Actions taken or
underway include:
a. In 2006 and 2007, public concern was raised that the Army was discharging
some Soldiers returning from combat for personality disorder who were also suffering
from PTSD and/or TBI related to their combat experiences. To address these concerns,
the United States Army Medical Command (MEDCOM) issued policy in August 2007 to
their Regional Medical Commands directing Office of the Surgeon General (OTSG)
higher level review of administrative separations based upon a diagnosis of personality
disorder including whether or not PTSD, TBI and/or other co-morbid mental illness may
have been a significant contributing factor to the diagnosis. In May 2008, MEDCOM
1
SAMR-MP
issued additional policy requiring PTSD and TBI screening prior to Soldiers being
considered for administrative separation.
b. In August 2008, the Department of Defense (DoD) mandated similar
requirements (DoDI1332.14) regarding separations on the basis of a personality
disorder to include:
(1) A Psychiatrist or PhD-level Psychologist must diagnose the personality
disorder.
(2) A peer or higher-level mental health professional must corroborate the
diagnosis.
(3) Diagnosis must be endorsed by the Surgeon General of the Military
Department concerned.
(4) The diagnosis must consider whether PTSD, TBI and/or other co-morbid
mental illness may have been a significant contributing factor to the diagnosis.
c. In February 2009, Army policy was updated implementing the above DoD
requirements.
d. On 25 July 2010, pursuant to the provisions mandated by section 512 of Public
Law 111-84, National Defense Authorization Act for Fiscal Year 2010 and 10 U.S.C.
1177 and 1553, the Under Secretary of Defense for Personnel & Readiness issued
policy via Directive Type Memorandum 10-022, requiring a medical exam evaluation for
Post-Traumatic Stress Disorder (PTSD) or Traumatic Brain Injury (TBI) prior to
administratively separating Service members, under conditions other than honorable,
who had deployed overseas in support of a contingency operation during the previous
24 months. On 30 Aug 10, the Assistant Secretary of the Army for Manpower &
Reserve Affairs responc;led to OUSD (P&R) that OTSG Policy Memorandum 10-040,
dated 9 June 2010, included procedures ensuring compliance with requirements
promulgated in OUSD DTM 10-022.
e. OTSG Policy Memorandum 10-040, outlines procedures for PTSD and TBI
screening for all Soldiers considered for administrative separation who require a mental
status evaluation, or who have been deployed overseas in support of a contingency
operation, and who are diagnosed by a physician, clinical psychologist, or psychiatrist
as experiencing PTSD or TBI or who otherwise reasonably allege, based on their
service while deployed, the influence of such a condition. OTSG Policy Memorandum
09-056 provides guidance for administrative separation for Personality Disorder and
other behavioral conditions. A revision of the that policy, currently in staffing, will
2
SAMR-MP
require review and endorsement of all Soldiers who have deployed that are being
processed under Chapter 5-17.
f. In accordance with OSD guidance, the Army is conducting a review of at least 10
percent of all Personality Disorder separations for fiscal year 2010. Additionally, we are
currently identifying Soldiers separated for Personality Disorder in order to inform them
of the process to correct their discharge characterization and how to obtain mental
health assessment through the Department of Veterans Affairs.
4. Social Security Numbers of Soldiers with Chapter 5-13 and Chapter 5-17 discharges
for fiscal years 2008,2009, and 2010 were obtained from the Total Army Personnel
Database. These records were then forwarded to the Patient Administration Systems
and Biostatistics Activity to identify those Soldiers with a diagnosis of Personality
Disorder or Adjustment Disorder. They were also forwarded to the Personnel
Contingency Cell to determine if the Soldier had deployed. Comparison of these
databases yielded the following information:
a. Number of Adjustment Disorder (AD) discharges (Chapter 5-17).
(1) FYOB 2,032
{2) FY09 2,427
(3) FY1 0 2,033
b. Number of AD discharges who had deployed to an Imminent Danger Pay (IDP)
area.
(1) FYOB 346
(2) FY09 475
(3) FY10 767
c. Number of Personality Disorder {PO) discharges (Chapter 5-13 < 24 months
of service; Chapter 5-17 with 24 or more months of service).
(1) FYOB 641
(2) FY09 575
(3) FY10 365
3
SAMR-MP
d. Number of PD discharges who had deployed to an IDP area.
(1) FY08 211
(2) FY09 157
(3) FY1 0 149
e. Number of Condition, Not Disability discharges (Chapter 5-17 minus PDs
w/24 or more months of service).
(1) FY08 3,654
(2) FY09 3,501
(3) FY10 3,154
f. Number of Condition, Not a Disability discharges who had deployed to an
IDP area.
(1) FY08 724
(2) FY09 561
(2) FY1 0 1,003
4
PRESENTATION DOCUMENTATION FORM
As a requirement of the accrediting bodies of the Office ofthe Surgeon General, the following information regarding your
presentation is a prerequisite for approval of continuing education credits. NOTE: One form per lecture if different topics.
Title and Date of Presentation:
PTSD Disability Determination: Expectations and Reality
N!>mP nUnstJ:n.ctnr!
(b)(6)
I
Time Allocated for presentation:
!l!!!!!!:
Teaching Methods to be Used (Check all that apply) :
~
Discussion Slides Overhead Panel Presentation
Small Group Interaction Other, please specify
Brief Narrative Description: Provide 3 5 sentences regarding your presentation. This narrative should answer the questions
"What will health providers, either nurses or physicians, learn from this presentation that will enhance their professional
knowledge, skills and/or abilities?" and "How will this be accomplished?"
Initiating a Medical Evaluation Board (MEB) for a soldier with combat-related PTSD is a complicated and time-intensive
procedure that relies on appropriate documentation in both mental health and non-mental health levels of the system. Until
recently, the Physical Disability Agency (PDA) has issued few guidelines as to what they need in an MEB, and have never
issued guidelines pertaining to what they do NOT need. An unstated component in the system is that disability compensation
often depends on how much work the psychiatrist puts into the MEB. This presentation will provide an overview of how the
Physical Disability Evaluation System (PDES) determines disability compensation and what is considered "ideal" for an MEB.
113 adjudicated PTSD case files were reviewed to contrast the "ideal" with the "reality" of what a typical Army psychiatrist
documents in MEBs.
Objectives: Must provide 3 objectives. Utilize verbs that are clearly behavioral and measurable, such as describe, discuss,
explain, recite, etc. Do not use terms such as understand better, have a clear appreciation for, etc.

Describe the system for documenting and adjudicating cases of PTSD disability

Summarize symptoms or dysfunctions that affect disability determination based on a chart review of 113 cases

Establish realistic guidelines for psychiatrists in documenting PTSD cases for disability adjudication
Content Outline: Provide a basic outline with major headings. This outline should correspond to your objective(s). If you
wish to provide a more detailed outline for note taking, you should use an additional piece of paper. A comprehe11sive outli11e
is required prior to the presentation in a camera-ready format, aUowinlf room for notetakinlf
I. The Current Burden of combat-related PTSD in the Army
A. Epidemiology
B. Costs
II. Overview of the Physical Disability Evaluation System (PDES)
A. Guiding regulations
B. V ASRD rating system
1. Monetary values and corresponding disease severity
c. The Medical Evaluation Board (MEB)
D. The Physical Evaluation Board (PEB)
E. U.S. Army Physical Disability Agency (USAPDA)
II. Ideals for a psychiatrist documenting PTSD disability
A. Documentation of symptoms
B. Commanders' statements
c. Occupational dysfunction in the military and civilian environments
III. Case review of 113 PEB packets and adjudicated cases
A. Statistics on how much compensation is given out at the varying disability levels
B. Statistics on what symptoms were documented by psychiatrists for the MEB
c. Statistics on what types of occupational dysfunctions were documented by psychiatrists for the MEB
D. Statistics on how much collateral information was included in MEBs
E. Associations between content of the MEBs and the fmal disability determination
F. Conclusions concerning which factors do and do NOT play a role in determining disability
G. Conclusions concerning the objectivity and subjectivity of the system
H. Recommendations to mental health providers for achieving the best outcome for their disabled patients

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Objectives
Describe the system for documenting and
adjudicating cases of PTSD disability
Summarize symptoms or dysfunctions that
affect disability determination based on a
chart review of 113 cases
Establish realistic guidelines for .
psychiatrists in documenting PTSD cases
for disability adjudication
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Step #1 -- MEB
Medical Evaluation Board (MEB) is
performed by a psychiatrist "When a
soldier reaches maximum benefit of
medical care for a condition which may
render the soldier unfit for further military
service soldiers shall be referred for
evaluation within 1 year of the diagnosis of
their medical condition."
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Step #1 -- MEB
The soldier may or may not be rated as
meeting medical retention standards.
The MEB is documented on paper (the
Narrative Summary, or NARSUM).
The NARSUM and other documents are
submitted to the PEBLO.
The PEBLO forwards the packet to the
PEB.
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Step #2 -- PEB
Physical Evaluation Board (PES) evaluates the -
MEB and decides whether the soldier is unfit for
duty or not.
Once determined unfit, the PES is required by
law to rate the disability using the Veterans
Affairs Schedule for Rating Disabilities (VASRD).
Ratings can range from 0 to 1 00 percent rising
in increments of 10.
3 PEBs exist
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Step #3 -- USAPDA
U.S. Army Physical Disability Agency
(USAPDA, or simply PDA)
Manages and provides appellate review
for the Army's disability system.
Headquartered at Walter Reed.
Oversees the three PEBs.
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Step #4 -- APDAB
If the PDA changes the findings of the
PEB and the soldier non-concurs and
submits a rebuttal, the case is forwarded
to the U.S. Army Physical Disability
Appeal Board (APDAB)
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Fitness for Duty
The standard for determining fitness is whether the
medical condition precludes the soldier from
reasonably performing the duties of his or her
office, grade, rank, or rating.
There is no requirement that a soldier must be
able to perform in every condition or under every
circumstance.
Deployability may be used as factor
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Disposition
Those found unfit for duty have four
possible dispositions:
1 . separation without benefits
2. separation with severance pay
3. temporary duty retirement list (TDRL)
4. permanent duty retirement list (PDRL)
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Factors Affecting Disposition
whether the soldier can perform in his or her
MOS;
the rating percentage;
the stability of the disabling condition;
and years of active service in the case of pre-
existing conditions.
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Separation without Benefits
The unfitting disability
-existed prior to service (EPTS)
-was not permanently aggravated by military

serv1ce
- and the member has less than 8 years of
active service
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Separation with Severance Pay
The soldier
- Has less than 20 years of active federal

serv1ce
- and has a disability rating of less than 30
percent
-With a 10% rating, the soldier receives 1 0% of
twelve month's basic pay multiplied by the
time in service
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Permanent Retirement (PDRL)
-The disability is determined permanent and
stable
-and rated at a minimum of 30 percent
-or the soldier has 20 years of active federal

serv1ce
- The soldier with a 30% rating will receive 30%
of their base pay
- OR receive their normal retirement pay
(whichever is higher)
-There is no "double-dipping" of pay
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Temporary Retirement (TDRL)
Same as PDRL except that the disability is
not stable for rating purposes,
Soldier will be re-assessed yearly to
monitor for changes in disability (and
therefore the disability rating)
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Relevance to PTSD Cases
Most soldiers get a 10% rating, a few get a
30% rating, and <1% get a 50% rating
Most junior soldiers will get separation with
severance pay
Senior soldiers will be placed on TDRL
Those separated with severance pay may
still apply to the VA for monthly disability
payments
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PTSD
One of the few psychiatric conditions for which a
specific etiology (cause) is believed to be known
The "cause," however, is necessary but not
sufficient for the diagnosis.
Other factors are essential in addition to the
requisite stressor
Adjudicators must be cautious in assuming that
PTSD exists on the basis of only one factor.
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Guidelines from the PDA
The PDA has released two documents on
this subject:
-"Issues in Adjudication of Cases Involving
Posttraumatic Stress Disorder" - Fall 2004
-"Guidance for Preparing Psychiatric Reports
on Soldiers Going Through the Physical
Evaluation Board Process" - Fall 2005
-Both are written by David T. Armitage,
COL(RET)
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The Forensic Standard
The MEB is akin to a Sanity Board, in that
the adjudicators are looking for collateral
information to support the patient's
statements and dispel any question of
malingering or exaggeration for secondary
gain (money, separation from the military,
or avoidance of domestic duties).
The adjudicators at the PDA are often
M.D. and J.D.
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The Traumatic Event
Exact use of DSM-IV criteria, particularly
in regards to presence of the traumatic
event and reaction to the event
- Use of collateral information to prove the
event or the reaction may be used
- Using vague descriptions such as "he reacted
to combat situations with fear'' are inadequate
-The reaction may be simply dissociation
-A reaction approximating "disgust" or
"nauseating" is not sufficient
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The Traumatic Event
- Use "common sense" in deciding if an
event is "severe" enough to cause PTSD
Common sense may include the
"reasonable person" test: would other
reasonable soldiers in the same
circumstances have had the same
reaction?
Ex: a soldier hearing artillery fire miles
away is overwhelmed by fear
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Symptoms
The PDA does not explicitly state that DSM-IV
criteria for the symptom clusters of re-
experiencing, avoidance, and hyperarousal must
be met. It is implied, however.
"Double-counting" of symptoms is prohibited,
due to the potential for "pyramiding" of benefits.
"Laundry-lists" of DSM-IV symptoms are viewed
as carrying little weight
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Collateral Documents
Include any documents you use with the
NARSUM
Emails with soldier's unit members
Personnel records (award citations)
Assignment orders
Medical records
Police reports/sworn witness statements
Statements by the family
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Impairment
Spheres of impairment may include the
military work environment, the social
sphere, and tasks that may be used in the
civilian occupational world
Military and social impairment do n-ot
impact the disability rating unless they can
be tied into the civilian impairment
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Military Dysfunction
The usu;al reason for initiating the MEB is
that the soldier is unfit for duty
State how he is unfit
The disability rating is not based on the
military impairment - symptoms may
better outside of military environment
However, the military impairment may be
used to extrapolate civilian impairment
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Social Impairment
Social impairment may be used as a
symptom to prove the presence of PTSD
Tying it into civilian impairment is useful
for the adjudicators
Ex. - the soldier cannot work with anyone
due to severe anger or isolating behavior
. Ex. - use of alcohol/drugs to self-medic.ate
causes stigmatization or legal problems
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Civilian Impairment
a ~ k . a . "civilian and industrial adaptability"
Determine if the symptoms will impact an
aspect of work outside of the military
The PDA believes that nightmares and
insomnia rarely impact work performance
to a significant degree
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Considerations for Civilian
Impairment
1. Remember locations, work-like
procedures, and instructions
2. Maintain concentration to complete tasks
in a timely manner
3. Communicate with others about work
4. Being civil toward boss or coworkers
5. Sustain an ordinary routine without

superv1s1on
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Impairment
6. Work with/near others without being
distracted by them
7. Make simple work-related decisions
8. Work without excessive rest periods
9. Seek help when appropriate
1 0. Adapt to changes at work
11. Awareness of hazards, use of
precautions
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Impairment
Other factors may include:
- Job stability, type of job, schooling
-Time commitment for outpatient
treatment or repeated inpatient stays
( esp. due to suicidality or substance
abuse)
-Non-compliance issues
-Competency to manage finances
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Impairment
Commander's Performance Statement--
contains many specifics about work
dysfunction ..
The PDA loves this statement
Statements that the soldier cannot work
due to a profile are useless
- Commander should focus on what s/he has
the soldier doing instead of their normal

miSSIOn
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Personality Disorders
The PDA states that personality traits and
maladaptive styles should be discussed,
and their impact on dysfunction noted
There are pros and cons to this approach
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Depression and Anxiety
The PDA is looking to see if any other
diagnoses better account for the soldier's
military dysfunction, particularly
adjustment disorders.
For instance, the presence of "tolerable"
combat stress reactions followed by onset
of a new stressor such as impending
divorce or a new, hostile platoon sergeant.
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Substance Abuse
Primary substance abuse by itself is not a
compensable condition
Substance abuse caused by or
aggravated by PTSD should not result in
less compensation
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Occupational Therapy
An OT consult may be useful in finding
ways to describe civilian impairment or
ability to manage one's finances
Allen Cognitive Level (ACL) is a well-
researched modality, given in 15 minutes,
and is a given to all inpatients on some
inpatient wards.
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Malingering
Malingering may be suggested by:
- Recitation of DSM-IV criteria
- Vague descriptions of symptoms such as nightmares;
combat-induced nightmares usually involve combat,
as opposed to non-combat PTSD nightmares
- Inability to state how PTSD affects their daily
functioning
- Hyperarousal not in evidence
- Reporting static symptoms - PTSD usually fluctuates
A comment concerning the absence of these
items may be helpful to dispel doubt
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One Word= One Rating
Possibilities in the civilian and industrial
adaptability section:
. - "Mild" = 1 Oo/o
-"Definite" = 30%
- "Considerable" = 50%
- "Severe" = 70%
-"Total"- 100%
Your opinion may or may not be weighed
heavily
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VASRD Classification
Full remission at 0 percent.
(a) Symptom free.
(b) No medication.
(c) No medical supervision.
(d) Work record acceptable or better.
(e) Satisfactory social adjustment.
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Mild at 10 percent.
(a) Displays minimal signs or symptoms with
probing.
(b) May require medication or psychotherapy,
especially during
times of stress.
(c) Adequate job adjustment.
(d) Adequate social adjustment.
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Definite at 30 percent.
(a) Does not require hospitalization.
(b) Displays some signs or symptoms of mental
illness on examination.
(c) Usually requires medication and or
psychotherapy.
(d) Usually there is job instability.
(e) Borderline social adjustment.
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Considerable at 50 percent.
(a) Intermittent hospitalization.
(b) Overtly displays some signs or symptoms of
mental illness.
(c) Requires constant medications or
psychotherapy.
(d) Extreme job instability.
(e) Significant social maladjustment.
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Severe at 70 percent.
(a) Usually financially mentally competent and capable of
cooperating in PEB proceedings but occasionally may be
incompetent.
(b) Usually hospitalized, but often in care of next-of-kin or guardian.
(c) Actively psychotic, but may have intermittent contact with
reality.
(d) Requires supervision approximately 50 percent or more of the
time.
(e) Some potential to be harmful to self or others.
(f) Unemployable.
(g) M_inimal social adjustment.
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Total at 100 percent.
(a) Usually mentally incompetent to handle financial
affairs and to participate in PEB proceedings.
(b) Usually hospitalized, rarely in care of next-of-kin or
guardian.
(c) Actively psychotic, totally out of contact with reality.
(d) Requires constant supervision and- care.
(e) Significant potential to be harmful to self or others.
(f) Unemployable.
(g) Incapable of any social adjustment.
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PTSD that Existed Prior to Service
(EPTS)
Permanent versus temporary service
aggravation.
Natural progression of the EPTS
condition.
"EPTS, not permanently service-
aggravated" means no benefits will be
awarded (this. is less than a Oo/o r ~ t i n g )
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PTSD
1 March 2003 to 8 Aug 2005
- 850 cases with PTSD as a diagnosis
-0% 39 cases
- 1 0% 549 cases
- 30% 202 cases
-50% 6 cases
- EPTS 54 cases
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Methods
Reviewed the PDA files of 113 PTSD
cases between Nov 2004 and March 2005
Data considered by the PDA in their
determination was tabulated, including
NARSUM and collateral information from
other providers, commanders, coworkers,
and family members
Internal PDA emails/memos were read
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Findings
Search for any associations between
types of data and the amount of disability
awarded
Paint of picture of what types of data are
commonly being included by Army
psychiatrists in their MEBs for PTSD
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Collection of Data
A table of data was collected from each
file, including:
Disability Percentage
Demographics
Axis I, II, and Ill
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Collection of Data from MEB
Nature of Trauma
DSM-IV PTSD criteria A, B, and C
Social, Civilian, and Military-specific
dysfunction, and degree of detail
Treatment response
Other MEB for physical injury
Psychiatric and trauma history
Appearance on mental status exam
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Collection of Other Data
Use of collateral information from progress
notes, inpatient records
Use of psychological testing
Collateral information from family,
coworkers, and command
Verification of the trauma details via letters
from commanders
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Description of the Population
Disability awarded (from Dec 2004 to
March 2005):
0% -- two files
1 0% -- 92 files
30% -- 18 files
50% -- 1 file
32 files could not be located
Average of 41 new c a s ~ s per month
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Axes 1-111
67% of the files had PTSD as the only
Axis I diagnosis
25% had one additional Axis I diagnosis
8% had three or more Axis I diagnoses
2o/o had an Axis II diagnosis
32% received a MEB for a separate Axis
Ill dx
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2
Input from Other Providers
Large majority of the files lacked medical
documentation other than the MEB itself
F
O
I
A

R
e
l
e
a
s
e

P
a
g
e

3
1
3
Nature of the Trauma
83% of the MEBs described the trauma(s).
The rest did not mention anything other
than "soldier was in Iraq"
39% of the soldiers suffered physical
injuries from a trauma
63% were directly at risk of being harmed
during an incident.
F
O
I
A

R
e
l
e
a
s
e

P
a
g
e

3
1
4
Nature of the Trauma
71% described mental trauma from
viewing disturbing sights. More than half
listed multiple sights.
33/o of the MEBs described the soldier's
response to the trauma. Most of those
who received physical injuries were
knocked unconsciousness simultaneously
F
O
I
A

R
e
l
e
a
s
e

P
a
g
e

3
1
5
Duration of Symptoms
Most did not list the duration of symptoms
Duration was extrapolated from dates of
return from deployment and date of MEB
dictation
The median duration was 6 months
The longest duration reported was 24
months
F
O
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A

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a
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3
1
6
Specific symptoms
14% (36 out of 113), documented the
DSM-IV-required number of symptoms for
re-experiencing, avoidance, and
hyperarousal
Factoring in Criterion A, only 18 MEBs
( 16o/o) met PTSD by DSM-IV
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F
O
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R
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3
1
8
Symptom Stats
Least commonly reported:
Inability to recall - 3.5%
Foreshortened future- 13.3%
Restricted affect - 19%
Psychological distress to cues- 26.5%
F
O
I
A

R
e
l
e
a
s
e

P
a
g
e

3
1
9
Association with Criteria A,B,C,D?
There was no association between the
level of documentation of DSM-IV criteria
A, B, C, or D with the disability
determination
F
O
I
A

R
e
l
e
a
s
e

P
a
g
e

3
2
0
Dysfunction
28% of the MEBs did not mention any type
of impairment in social, civilian-
occupational, or military abilities in the HPI
section
12% contained some sort of "positive"
comment that an impairment should
improve with time
F
O
I
A

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e
a
s
e

P
a
g
e

3
2
1
Dysfunction
62o/o (71 files) mentioned some sort of
social dysfunction
17o/o (21 files) mentioned some sort of
civilian occupational dysfunction
42% ( 4 7 files) mentioned some sort of
military dysfunction
F
O
I
A

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P
a
g
e

3
2
2
Associations with Dysfunction?
Specific dysfunction categories showed no
association
Absolute number of negative dysfunctions
did show an association
The soldier with 50/o disability had 4 types
of negative dysfunction documented
The 2 soldiers with 0% disability had no
negative dysfunctions documented
F
O
I
A

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e
l
e
a
s
e

P
a
g
e

3
2
3
________ ,_
Treatment Response
61% of the MEBs listed a poor tx
response. 27% made no comment
whatsoever.
3 files in the 30% disability category had
no treatment response documented
11 files in the 10% disability category
received 1 0% despite having a positive
treatment response
F
O
I
A

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e
l
e
a
s
e

P
a
g
e

3
2
4
----------
MEB for other injury
32% (36 files) received a primary MEB for
a physical injury due to the trauma.
In these cases, the PTSD was considered
an Addendum to the primary MEB
24 received 1 0% disability; 2 received
30/o
F
O
I
A

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a
s
e

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a
g
e

3
2
5
Psych/trauma History
24% of the soldiers had some sort of
psychiatric history .
12% had a history of childhood trauma
No association with percent disability
~
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CJ) ro
co
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z

F
O
I
A

R
e
l
e
a
s
e

P
a
g
e

3
2
7
Psychological testing
12% of the soldiers received psych testing
F
O
I
A

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e
l
e
a
s
e

P
a
g
e

3
2
8
Collateral information
5 files had letters from coworkers
59% had a letter from a commander about
the soldier's dysfunction. Most were
nonspecific, and were written after the
soldier had been placed on a profile for
.PTSD
F
O
I
A

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e
l
e
a
s
e

P
a
g
e

3
2
9
Collateral information
26 (23%) of the files contained verification
that the trauma occurred.
5 of those 26 contained 2 letters of
verification
F
O
I
A

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P
a
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3
3
0
Conclusions
Disability determiners generally accept the
diagnosis of PTSD even if insufficient
criteria are documented
Predictions of the degree of dysfunction in
the civilian sector is the most important
criterion in determining disability, in
accordance with the regulations
F
O
I
A

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s
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a
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e

3
3
1
Conclusions
Determination of 30% or greater disability
may depend on other factors not
examined here:
- Nature of treatment failure
-Types of treatment required for maintenance
- Specific nature of dysfunctions
- Documents other than narrative summary
- Discussions between USAPDA determiners
F
O
I
A

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s
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P
a
g
e

3
3
2
Conclusions
Psychiatrists performing MEBs should
concentrate on incorporating the context of
the illness (the exact impairments) for the
soldier if they wish to maximally benefit
their MEB patients
(/)
c
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-
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0

CREW: Department of Defense: Department of The Army: Regarding PTSD Diagnosis: 6/30/2011 - Release Pgs 242-333 DTD 27 June 2011

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CREW: Department of Defense: Department of The Army: Regarding PTSD Diagnosis: 6/30/2011 - Release Pgs 242-333 DTD 27 June 2011

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