Personality Disorders as a Basis for Discharge and Denial of Benefits in the Military: Logical or Abusive?

ABSTRACT: The US Department of Defense specifically states that intellectual disability and personality disorders are not diseases for compensation purposes, and disabilities from them may not be service connected absent a superimposed mental disorder. In addition, the diagnosis of a personality disorder led to the discharge of 31,000 troops during the years 2001 to 2010. I review the history of these developments, and how the Diagnostic and Statistical Manual of Mental Disorders enabled these actions. In contrast, the United Kingdom and Canada do not allow such actions. Whether our approach is logical seems highly questionable, especially given the significant problems with the DSM's definitions of personality disorders, definitions at odds with the literature.

[Prospects of IT usage in the field of military psychiatry].

Development of effective information support for monitoring of internal health, based on the principles of complex diagnostics, provides the necessary tools objektive evaluation and prediction of mental health in servicemen. Effectiveness of psychiatric prophylaxys technologies depends on compliance with a number of fundamental principles, the main of which should be considered as a multidimensional assessment of mental health in servicemen and real cooperation of different specialists (commanders, specialists of medical and psychological service) for its implementation. In this case, an introduction of information and communication technologies on the basis of the district (fleet) and the Central Military Hospital, as well as other bodies of military control will be almost justified only when creating a full-fledged "information field of military psychiatry" that implements the basic principles of the monitoring system of mental health and includes necessary infrastructure. The practical implementation of this system will allow to personjfyfy medical and psychological assistance to military personnel, to improve early diagnosis of mental disorders, addictive .and suicidal behaviour, and thus increase the effectiveness throughout psychiatric prophylaxis in the army.

Salem VAMC-U.S. Army Fort Bragg Warrior Transition Clinic telepsychiatry collaboration: 12-month operation clinical perspective.

OBJECTIVE: To describe the clinical experience in the first Veterans Affairs (VA)-U.S. Army Warrior Transition Clinic (WTC) telepsychiatry operation (September 2008-August 2009). MATERIALS: Joint VA and U.S. Army records. METHODS: Analysis of intake, follow-up, and last visit records. RESULTS: One hundred twenty active-duty U.S. Army soldiers were seen (394 clinic visits). Ninety-eight soldiers had one or more combat tours, principally in Iraq and Afghanistan. Posttraumatic stress disorder was diagnosed in 50.0% of the cases by the WTC telepsychiatrists. The majority of the soldiers had medical comorbidities, especially chronic pain (75.0%), in addition to mental health problems. Several of the soldiers were recovering from trauma (20.8%) and/or surgery (23.3%), 11.7% exhibited traumatic brain injuries, and 17.5% had headaches. Disrupted relationships (74.2%) were notable for non-family members, especially military cohorts such as other persons in the same WTC squad or platoon. CONCLUSION: The observations in this report come from a cross-section of soldiers who were triaged to meet WTC admission criteria. As this is the prototype VA-U.S. Army telepsychiatry collaboration, there are no comparative data at this time. The nature of the medical and psychiatric problems treated in the military WTC represents an index of the more severe combat trauma treated on military bases from ongoing combat operations and may predict future VA-U.S. Army collaborative telepsychiatry clinic experiences.

The acceptability of 'Trauma Risk Management' within the UK Armed Forces.

BACKGROUND: Trauma-support programmes may benefit employees of organizations that routinely expose their staff to traumatic events. However, in order for such programmes to be effective, staff need to find them acceptable. AIMS: To investigate whether Trauma Risk Management (TRiM), an example of such a programme, is acceptable within a military population and whether it is viewed as complementing or replacing pre-existing personnel support systems. METHODS: Semi-structured interviews were undertaken with serving Royal Navy personnel who had served on one of six ships, which had received TRiM training some 12-18 months previously. Three hundred and thirty interview transcripts were subjected to qualitative analysis and themed categories were generated. RESULTS: The majority of personnel who were aware of TRiM were supportive of its aims. TRiM was also viewed as supplementing other personnel support measures rather than replacing them. Personnel interviewed thought that TRiM practitioners needed to be carefully selected, supported by line management and to pay particular attention to the issue of confidentiality. CONCLUSIONS: The TRiM system appeared generally acceptable to military personnel and is seen to supplement rather than replace existing mechanisms. However, these data support careful selection of potential TRiM practitioners and demonstrate the need for senior management support for the system if it is to be accepted by those who might benefit from its use.

Theater Mental Health Encounter Data (TMHED): overview of study design and methods.

Research has documented higher risks for mental health problems among service members deployed to war zones, yet a research limitation has been that assessment has generally occurred often years after combat exposure. The Operational Stress Control and Readiness program integrated mental health practitioners with 1st Marine Division units serving in Iraq. This team documented mental health visits between January 2006 and January 2007 and developed the Theater Mental Health Encounter Database (TMHED). This report describes the TMHED study design, measures, and cases. Of 1336 patients (3180 patient visits), 10% were women, 75% were high school educated, 55% were mid-paygrade enlisted, and 63% were on their first combat deployment. Compared with the overall deployed population, patient percentages included higher percentages of Marines and Navy personnel but lower percentages of Army and Air Force personnel, more junior enlisted but fewer officers, and fewer college graduates. TMHED provides an unprecedented opportunity to study early psychiatric intervention in a combat zone and prospectively examines postdeployment health and career outcomes.

[Servicemen mental health monitoring in different stages of military service].

The effectiveness of psychoprophylactic work on each of military service basic stages and how to optimize it have been presented. The universal system of mental health monitoring in whole period of military service has been developed. A possibility of differentiated rapid assessment of mental status for effective monitoring of mental health has been analyzed. Some practical recommendations for the unit doctors in the principles of servicemen distribution by group of mental health level and taking the appropriate organizational decisions have been advised.

[From the history of the Kirov Evacuation Hospital N 1322 during the war].

During the Great Patriotic War in Kirov Red Army soldiers provided specialized psychiatric care. 24 June 1942 on the basis of evacohospital N 1322 was organized by the psychiatric ward. This department carries out all necessary psychiatric care until November 1945.

'Lessons learnt from America'--Reflections from a fellowship examining the prevention, recognition and treatment of operational stress injuries in U.S. Army serving personnel.

These are my personal views and reflections from a hugely rewarding experience. They are not opinions or recommendations of the MOD or any other institution I am associated with. I realise that there may be various logistical reasons why my recommendations cannot be carried out; however I do hope that some will be able to be put into place. If nothing else I gained a massive amount from my travelling fellowship and it has already had a positive impact on my own clinical work. I hope to continue to pass on what I have learnt from the fellowship for many years to come. A special thank you goes to the Winston Churchill Memorial Trust for providing me with this fantastic opportunity and everyone who helped me before and during my visit.

Support of marines and sailors returning from combat: a comparison of two different mental health models.

As Navy medicine continues to support the Global War on Terrorism, various approaches are used to attenuate combat stress casualties. This article examines two different mental health models, one employed at sea and one in the combat zone, used for active duty forces immediately after cessation of combat operations. Both models focus on screening, early prevention, and treatment implemented during the transition from the combat theater to garrison. Returning by sea provided the opportunity for greater education and decompression of combat stress as the service members transitioned back to garrison when compared to those who returned by air. It was also found that the Post Deployment Health Assessment (PDHA) did not capture as many individuals with mental health issues leaving combat theater, which identified 6% on both missions, compared to the capture rate with the Post Deployment Psychological Screener (PDPS), which identified 16-20%. Limitations, opportunities, and recommendations for future interventions are discussed.

[Capabilities of telemedicine for solving tasks of psycho-prophylactic work among military servicemen of Air Force command posts].

The article is devoted to using of telecommunicational technologies for prophylaxis, diagnostics and treatment of psychic disorders by military servicemen of specialbuildings of command post of Air Force. Were defined main tasks of using telecomunicational net for improvement of psychic reliability of military operators during a combat duty. Was proposed a scheme of using forces and facilities of medical service in organization of psycho-prophylactic work with using telemedical technologies, was proved necessity of creation of coordination counsel in telemedicine.

Leadership in 21st century military healthcare: what did clinical psychologists ever do for us?

Psychology is integral to the concepts and practice of leadership. Leadership models often have their roots in psychological paradigms, making it intrinsically easy for psychologists to grasp and apply them alongside clinical models. Psychologists' 'second-order' skills have been used to good effect in the changing landscape of military mental healthcare: modelling adaptive responses to change, understanding the non-conscious aspects of relationships in hierarchical organisations, working with systems, the ability to diagnose situational requirements and act accordingly, drawing on a range of psychological theories and leadership styles. The clinical psychologist as a professional who can help others 'reframe' a situation or experience is key to their leadership role within healthcare settings, 'enabling others to achieve shared purpose in the face of uncertainty'. The contribution that clinical psychology has made to leadership in Defence over the past 20 years will be illustrated by personal accounts from 'experts by experience'.

Neuropsychology and clinical health psychology in the UK Ministry of Defence.

Neuropsychological testing has been used in a wide range of applications across military settings, including the selection of personnel to engage in covert operations, battlefield assessment and rehabilitation following blast exposure, traumatic brain injury, other neurological conditions and assessment of malingering. Over recent decades, military psychologists have helped to shape the advances in assessing and remediating the psychological sequela that is associated with operationally related neurological and other physical injuries. This paper will present an overview of some of the neuropsychological and related services within the UK Armed Forces, which are provided to service personnel with traumatic brain and other physical injuries.

Military psychologists and cultural competence: exploring implications for the manifestation and treatment of psychological trauma in the British armed forces.

This paper considers the manifestation and treatment of psychological trauma in the military. The article describes how military psychologists conceptualise psychological trauma within the culture of the Armed Forces (AF), which is reflected in the process of acquiring what has been referred to as cultural competency. Psychologists in this context acquire an understanding of the manner in which the psychological and organisational systems and culture of the military affect the presentation of psychological trauma, including post-traumatic stress disorder (PTSD). The paper outlines core psychological features of military life, including some of the ways in which the AF functions effectively as an adaptable fighting force. This highlights, for example, the potential for stigma within and between military personnel who experience mental health difficulties. The article proceeds to examine aspects of help-seeking in military mental healthcare, how symptoms can present at different stages in a deployment process, and the consequences that such problems can cause for military conduct and performance. Psychological care in the military is structured within an occupational mental health ethos, in which psychologists fulfil a range of clinical, organisational and leadership roles. These dynamics are explored with examples of care pathways and clarity on evidence-based interventions for trauma and PTSD in those experiencing military-related psychological injuries. Two vignettes are then offered to illustrate how some of these interventions can be used psychotherapeutically in addressing symptoms pertaining to hyperarousal, hypervigilance, guilt and shame.

Combat stress casualties in Iraq. Part 2: psychiatric screening prior to aeromedical evacuation.

TOPIC: Exposure to combat-related trauma is a leading cause of posttraumatic stress disorder. Deployed military mental health practitioners serve important roles in the assessment, diagnosis, and aeromedical evacuation of psychiatric patients from the combat zone. PURPOSE: To review the role of military mental health professionals working with psychiatric patients at a combat hospital and aeromedical staging facility in Iraq. SOURCE OF INFORMATION: Military operating instructions, existing theoretical and research literature, and personal experiences of the authors while deployed to Iraq. CONCLUSIONS: Psychiatric screening can help reduce risk in potentially unstable mental health patients prior to aeromedical evacuation. Civilian nurse psychotherapists and advanced practice psychiatric nurses will be needed to provide psychiatric follow-up care for the large number of military veterans returning from combat.

Combat stress casualties in Iraq. Part 1: behavioral health consultation at an expeditionary medical group.

PURPOSE: We review the role of military mental health professionals in consulting with inpatient medical patients and staff at a combat hospital and aeromedical evacuation staging facility in Iraq. CONCLUSIONS: Behavioral health consultation with medical and surgical patients during hospitalization and prior to aeromedical evacuation can help identify patients with combat stress exposure that may require future mental health follow-up. PRACTICE IMPLICATIONS: Extensive use of civilian mental health practitioners including nurse psychotherapists and psychiatric nurse practitioners will be needed to provide psychiatric care for the large number of U.S. veterans who return from deployment with combat stress related disorders.

U.S. Army Social Work Care Manager Program: an initial program analysis.

Since the Global War on Terror, the U.S. Army has been transforming to meet national security needs. The transformation includes Army mental health programs serving soldiers and their families. These programs must be relevant to the needs of soldiers and their families and effective at maintaining the force throughout the Global War on Terror. The Army Social Work Care Manager Program was initiated in July 2003 to enhance mental health support for combat veterans and their families. This study provides an initial assessment of this program. A seven-item provider questionnaire was administered to 66 care managers (N=66) to obtain an initial assessment of their utilization and satisfaction. Findings from 33 (n=33) respondents revealed diverse usage across and within installations and modest satisfaction with their jobs. Additionally, the biggest challenges care managers faced were resourcing and supervision. Recommendations for additional research, policy, and practice are provided in this study.

Assessing the effectiveness of the British Army's mental health service.

The Ministry of Defence's commitment to modernizing and improving mental health (MH) care for Armed Forces personnel has resulted in considerable changes to frontline services. The last remaining United Kingdom (UK) military psychiatric hospital closed on 1 April 2004 with the move to a clear, integrated care pathway between primary healthcare, military departments of community mental health (DCMHs) and secondary healthcare. The Army's eight UK DCMHs provide a patient-centred, occupational MH service grounded in the military MH philosophy of local, easily accessible, effective treatment (O'Brien, 1998). These MH services have been exposed to significant media interest and this article will attempt to quantify the correct state of affairs through patient, customer and staff satisfaction surveys. Clinical groups in the customer survey recorded a satisfaction rate of 87%, the staff survey 72% and the patient survey 94%. The Army has excellent access to specialist MH support and a common theme emerging in these surveys is the perception that the MH teams provide a high quality of service. The three surveys provide valuable direction to improve patient care and highlight strengths such as 97% of patients receiving appointments compatible with their duties.

Do military uniform and rank impact on the therapeutic relationship between military mental health clients and clinicians?

OBJECTIVE: to measure the perceptions of military staff of the impact of wearing military uniform on the therapeutic relationship with mental health clients. METHOD: a brief questionnaire was distributed to all military clinicians in Departments of Community Mental Health to measure their attitudes. RESULTS: there was a 67.9% (n=70) response rate regarding the impact of uniform on the therapeutic relationship. 20% of responses were positive, 31% negative, 37% mixed and 12% gave no answer. CONCLUSION: there was no clear pre-existing literature on this issue. Overall, the wearing of uniform appeared to be perceived positively positive. There is a need to assess clients' points of view in future studies.

Multiple-role dilemmas for military mental health care providers.

Military psychologists and psychiatrists frequently face ethical quandaries involving boundary crossings, or extratherapy contact, and multiple relationships. A multiple relationship is defined as necessarily engaging psychotherapy patients in nonclinical roles, such as coworker, superior officer, neighbor, or friend. In contrast to their civilian counterparts, military mental health professionals must often engage patients in many different contexts and roles. In this article, we consider the distinctive features of mental health practice in the military and offer military providers several practice guidelines for avoiding harm to patients in military settings. This article is also designed to enhance sensitivity to multiple-role risks among nonpsychiatric providers.