The 49-year-old veteran explained that he suffered from paranoia in crowds, nightmares and unrelenting flashbacks from the Iraq war. He said he needed his handgun to feel secure and was worried that he would shoot somebody.
The symptoms were textbook post-traumatic stress disorder.
But Robert Moering, the psychologist conducting the disability examination at a Veterans Affairs hospital in Tampa, Fla., suspected the veteran was exaggerating. Hardly anybody had so many symptoms of PTSD so much of the time.
As disability awards for PTSD have grown nearly fivefold over the past 13 years, so have concerns that many veterans might be exaggerating or lying to win benefits. Moering, a former Marine, estimates that roughly half of the veterans he evaluates for the disorder exaggerate or fabricate symptoms.
Depending on severity, veterans with PTSD can receive up to $3,000 a month tax-free, making the disorder the biggest contributor to the growth of a disability system in which payments have more than doubled to $49 billion since 2002.
“It’s an open secret that a large chunk of patients are flat-out malingering,” said Christopher Frueh, a University of Hawaii psychologist who spent 15 years treating PTSD in the VA system.
Diagnosing PTSD can be difficult in the best of circumstances. Experts have long debated how to define the condition.
Assessing PTSD becomes even more difficult in a VA system that gives veterans a financial incentive to appear as sick as possible, former and current VA mental health clinicians said. The number of veterans on the disability rolls for the disorder has climbed from 133,745 to more than 656,000 during the past 13 years.
The veteran Moering evaluated was already receiving $1,600 a month in disability pay for PTSD and various joint problems. But he wanted to increase it.
Moering said he could not determine whether the veteran was feigning entirely or simply stretching the truth.
“This is the dilemma we face,” Moering said. “How can a disability rater honestly rate this veteran?”
Government policy in cases without a clear answer is to give the veteran the benefit of the doubt. The VA left his disability rating intact.
As the number of cases has climbed, so has debate over their legitimacy.
A 2007 study of 74 Arkansas veterans with chronic PTSD, most of them from the Vietnam War, concluded that more than half were exaggerating symptoms. Other research has found little evidence of malingering.
After serious trauma, most people experience symptoms of the disorder. But the nightmares, concentration problems and heightened state of alert usually go away in a few weeks. In a minority of cases, certain combinations of symptoms persist. That’s PTSD.
Because the diagnosis relies mainly on what patients report, it is easy to exaggerate.
In online forums, veterans trade tips on how to behave in their disability evaluations. Common advice: Dress poorly and don’t shower, refuse to sit with your back to the door, and constantly scan the room.
The motivation behind such advice is not always clear. It may be aimed at helping veterans get what they deserve from a system that many see as rigged against them. Exaggeration can also be a sign of distress itself.
Though VA investigations have exposed scams — including disability recipients who never served in the military — the department has focused on making the system friendlier to veterans. It dropped its requirement to support each case of war-related PTSD with records of the underlying trauma, and veterans are now taken at their word.
After the changes, the number of new PTSD claims rose 60 percent to more than 150,000 a year, and approval rates jumped from 55 percent to 74 percent.
The shift raised new concerns.
In a 2014 paper, Arthur Russo, a VA psychologist in Brooklyn, argued that the disability system is prone to “collusive lying,” in which veterans fake mental illness and clinicians go along with it.
Gail Poyner, an Oklahoma City psychologist, said she was dismissed in 2010 from a company the VA hired to conduct disability exams because she insisted on giving veterans tests to determine whether they were exaggerating.
“It’s political,” Poyner said. “It’s not prudent to suggest that people who have served our country are not being honest.”
The VA issued a statement to The Times saying it encourages examiners “to conduct comprehensive, accurate and thorough evaluations” and to use their clinical judgment in deciding whether to test for malingering.