Trust but verify, the briefing says, urging doctors to contact platoon sergeants or officers to back up testimony from their patients.
VA memos from that time period are even more explicit in their emphasis on patients feeling helpless in a single event.
Mere service in combat zone (is) not enough to support a diagnosis of PTSD, a 2006 VA briefing says.
A person must have been exposed to a traumatic event in which the person experienced or witnessed an event that involved actual or threatened death or serious injury, it says.
Both of the earlier VA and Army PTSD guidance documents were obtained by the nonprofit Citizens for Responsibility and Ethics in Washington. The organization pursued them through the Freedom of Information Act after learning of complaints at an Army hospital in Colorado where doctors felt pressured not to diagnose PTSD.
The organization submitted another FOIA request for the Armys most recent PTSD guidance and for investigations into patient complaints at Madigan. The Army denied the request, as it has done for similar appeals from The News Tribune, The Seattle Times and public radio station KUOW.
Army leaders say they resolved issues at Madigan, but they have declined thus far to describe any changes theyve made aside from curtailing the widespread use of forensic psychiatrists at the hospital south of Tacoma.
Forensic psychiatrists are commonly used in court cases to make an objective opinion about a defendants state of mind.
At Madigan, the forensic doctors sometimes gave PTSD diagnoses to patients who came to them with diagnoses for less serious conditions. They also looked for service members who embellished their combat records to obtain benefits, and occasionally caught soldiers in lies, according to Madigan documents The News Tribune obtained last year.
Four years ago, Army leaders endorsed Madigans forensic psychiatrists as an example of best practices in military medicine because the extra research they carried out resulted in a higher degree of diagnostic accuracy.
Their ascendency crashed at Madigan early last year when an Army inspector general obtained a briefing that urged doctors to consider the long-term costs to taxpayers of a PTSD diagnosis, suggesting the Army would pay out $1.5 million in benefits over a soldiers lifetime for that diagnosis.
Some doctors in the hospital had already expressed concerns that the forensic psychiatrists drive to root out fraud and malingering was causing Madigan to mistreat patients who should have received help.
The new Army guidelines move toward a more broad-minded view of PTSD.
There really has been a big change, said one Madigan doctor who spoke on the condition of anonymity out of concern for his career.
Others bristle at the suggestion they downgraded diagnoses to save money.
Our interest was in diagnostic accuracy, not in monetary issues, said Juliana Ellis-Billingsley, a forensic psychiatrist who resigned last year when she became convinced the Army was fixing diagnoses to appease political leaders.
Senior Army officers insist Madigan was the only military hospital to rely on forensic psychiatrists so extensively.
Yet the second Defense Department memo obtained by The News Tribune maintains a role for them in behavioral health medicine.
The memo, signed by Assistant Secretary of Defense Jonathan Woodson, says doctors should continue to consult with forensic psychiatrists or forensic psychologists in certain cases.
Where profound symptom embellishment or malingering seems manifest, consider consultation with experts in such matters, such as forensic psychiatrists or forensic psychologists, reads Woodsons Aug. 24 memo.
Ellis-Billingsley said that guidance resembles her former purpose at Madigan.
Army Medical Command spokeswoman Maria Tolleson said the service still has a limited number of forensic behavioral health specialists. She said they no longer participate in disability evaluations as they did at Madigan. Instead, theyre consulted in legal cases and certain administrative hearings.
The Army in November announced that it changed diagnoses for 267 former Madigan patients, including 150 who received PTSD diagnoses. Their cases were considered under the new Army guidelines.
Woodson wrote that differences in diagnoses should be expected even among experienced behavioral health specialists.
Diagnostic variance among highly competent clinicians is inevitable, he wrote. Clinical diagnosis is both an art and a science.