Dr. Federoff - Independent Medical Opinion

This letter is written in response to your letter dated 24 June, 2013 in which you request an Independent Medical Opinion concerning several specific questions. It should be noted that I was not provided with the opportunity to examine the Appellant in person. Other limitations of my opinion(s) are listed later in this report.

QUALIFICATIONS OF EXAMINER

I am a licensed physician (MD) in Ontario with a specialization certification in Psychiatry (FRCPC). I have completed a sub­specialty Fellowship in Neuropsychiatry at Johns Hopkins Hospital and a sub-specialization in Forensic Psychiatry at the (then) Clarke Institute and University of Toronto. It should be noted that I have not pursued Board Certification in Neuropsychiatry (which is not offered in Canada) nor Forensic Psychiatry (which will have its first qualifying exam September 2013). My primary areas of clinical work and research is in the area of the assessment and treatment of paraphilias (which is not relevant in this case). However, I have been qualified in court as an expert in neuropsychiatry and have done IME's as part of my work as a psychiatrist. My full qualifications and expertise are outlined in my Curriculum Vitae, which is attached to this letter. The Appellant has never been my patient and I have never met him.

Top of Page

STATEMENT OF CONFIDENTIALITY

The opinions expressed in this letter are based on my review of documents provided to me solely by Ms. Kell. These documents have been kept under locked security and at Ms. Kell's request, all were returned. I have made some notations on the materials but it should be noted that not all of the highlighting in the materials and not all of the notations were made by me. I have made no copies of any of the forwarded materials.

Top of Page

LIMITATIONS OF EVALUATION

All psychiatric evaluations have specific limitations. The following in my opinion are important concerning the current letter:

1. This report is based on information provided by Ms. Kell. Ms. Kell is the only person with whom I have been in contact and I have relied on them to forward any significant materials.
2. Because I have not personally examined the Appellant, I am unable to personally diagnose him. It should be noted that I did offer to meet with him but the offer was declined.
3. I am a psychiatrist and physician. I am not an expert in oncology, neurology, or toxicology. Therefore, I am unable to offer professional expert opinions concerning issues that depend specifically on expert knowledge in those three specialties.
4. I have not interviewed any members of the Appellant's family, his friends, employers, neighbours or members of army corps.
5. Importantly, I have not interviewed anyone with any direct knowledge of the abuse the Appellant says he suffered during his military service. This is because no one has been identified.
6. I was not provided with the opportunity to review or recommend psychological or neuropsychiatric tests (other than any provided in the materials provided). It should be noted I recommended that a neuropsychologist review the materials and offer an opinion about examinations and test that would assist. I provided the name of a neuropsychologist but also indicated that I would be happy to review the opinions of any qualified neuropsychologist selected by any of the interested parties in this case.

Top of Page

SOURCES OF INFORMATION:

1. A binder titled: Major Depressive Disorder File Statement of Case. Veterans Review and Appeal Board 6/19/2013. The pages in this document are sequentially numbered as follows: 1-42 (inclusive) 54-59 (inclusive), 5, 61-69, 6, 71-79 (inclusive), 7, 81-83 (inclusive), 8, 91-99 (inclusive), 9, 1-10, 211-214 (inclusive).
2. A binder titled: Ganglioma of the Cerebellum File Statement of Case. Veterans Review and Appeal Board 6/19/2013. The pages in this document are sequentially numbered 1-50 (inclusive) page 51 is included but not numbered, 52-52, un-numbered page, 55-252 (inclusive)
3. A binder titled: Medical and Psychological Reports. Veterans Review and Appeal Board 6/18/2013. The pages in this document are sequentially numbered 4-10 (inclusive), 78- 79, 13-28 (inclusive), un-numbered page, 31-239 (inclusive), un-numbered page, 240- 292 (inclusive).
4. A binder titled: PSTD (sic) File: Statement of Case. The numbering scheme in this binder is highly inconsistent, likely because much of it consists of copied materials from the other binders.
5. A binder titled: PSTD (sic) File: Statement of Case Supplement (Part 1).
6. A binder titled: PSTD (sic) File: Statement of Case Supplement (Part 2).
7. A document signed by E. A. Giraldeau, dated 17, January 2012 concerning a teleconference held on that date.
8. Paper copies from the Forces.ca website describing the "demands of basic training".

According to Ms. Kell's letter of June 24 2013, these documents represent "all the documents which are part of the Appellant's appeal file for Post-traumatic Stress Disorder (PTSD), as well as the files concerning related disability claims for Major Depressive Disorder (MOD), and for Ganglioma of the Cerebellum (operated)."

Ms. Kell's letter also explicitly states that "No independent medical examination or neuropsychological testing is required by the Board (Appeal Panel of the Veterans Review and Appeal Board), as this option was proposed to the Appellant, but will ultimately not be pursued based on the opinion of the Appellant's treating psychologist."

As a side note, I am not sure who the Appellant's treating psychologist is. I presume it is not Dr. Vandersteen since her reports appear to have been accepted as independent reports.

Top of Page

REFERRAL QUESTIONS

The following are the specific questions posed to me by Ms. Kell in her letter dated June 24, 2013:

1. Would some, or all, of the symptoms diagnosed as PTSD (and Major Depressive Disorder) be the result of, or sequelae of, the 2002 surgery for the brain tumour? Specifically:
2. Is there a credible basis to link or attribute the diagnosis of PTSD made in 2011 to Appellant's three year history of military service between 1964 and 1967? Specifically:
   • In your opinion would participation in Basic Training, involving physical training, training in handling weapons, and training in basic combat, satisfy the DSM-IV criteria for PTSD, which requires that the individual be exposed to an extreme traumatic stressor, or an extreme traumatic event involving death, or risk of death, and/or serious injury to oneself or others?
   • Considering the facts of the case with respect to the nature of the Appellant's military service between 1964 - 1967, the pattern of the onset of his symptoms, and the timing of the diagnosis of his PTSD in 2011, is it likely, or probable, that the Appellant's psychiatric disorder(s) was caused by events or traumatic experiences that are not related to military service?
   • How, or in what manner, could the impairment of the Appellant's memory and cognitive abilities potentially affect the Appellant's ability to reliably and accurately recall or identify past traumatic experiences or traumatic events? Are there protocols or tests that should be administered by a mental health or medical professional in order to screen or identify whether other causes or events might be operative in causing a psychiatric disorder such as PTSD?
3. What is the relationship between PTSD and the Appellant's Major Depressive Disorder? Although each disorder represents a distinct psychiatric disorder under the DSM-IV, do they ultimately represent the same medical disability or impairment? Is there overlap in the symptoms of the two disorders?
4. Is it likely that PTSD and Major Depressive Disorder could be present, but not be detected, at the time of the evaluation and treatment for the ganglioglioma in 2002?

Before answering these questions, I will briefly review the information on which my opinion is partially based.

Top of Page

BACKGROUND INFORMATION

In her letter of 24 June 2013 Ms. Kell provided a succinct summary of the background issues as follows:

Ms. Kell also focused the issues to be addressed as follows:

In a footnote, Ms. Kell indicated that the issue of disability resulting from the Appellant's brain tumour (ganglioglioma) has been resolved and not an issue this report needs to address.

Top of Page

SUMMARY OF COLLATERAL INFORMATION

In the following Table I list some of the events or comments that have assisted me in composing this letter. It should not be misconstrued as a comprehensive summary of all the materials I reviewed. I do not necessarily endorse any of the comments listed in the table. The Source references refer to the three binders of materials provided and listed at the beginning of this report (often the same information is provided in several places and not all references are listed). Readers should verify for themselves that the quotes are accurate and note the source of the information (in some cases the item is quoted in another document and the validity of the source varies). Also, several of the source materials were handwritten or photocopied in a manner that made it difficult to be sure of what was being written.

Top of Page

RESPONSES TO THE REFERRAL QUESTIONS

In order to answer the questions copied below I first provide a copy the DSM-5 criteria for PTSD. I note that other commentators have understandably relied on earlier versions of the DSM (since the DSM-5 has only been available from May 2013 onward). Here are the edited DSM-5 diagnostic criteria as published by the American Psychiatric Association (2013):

Post Traumatic Stress Disorder

• Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:
  1. Directly experiencing the traumatic event(s).
  2. Witnessing, in person, the event(s) as it occurred to others.
  3. Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental.
  4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse).
  Note: Criterion A4 does not apply to exposure through electronic media, television movies, or pictures, unless this exposure is work related.
• Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred:
  1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s).
  2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s).
  3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.)
  4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
  5. Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
• Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidenced by one or both of the following:
  1. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
  2. Avoidance of or efforts to avoid external reminders (people, places. conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
• Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:
  1. Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs).
  2. Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., "I am bad," "No one can be trusted," 'The world is completely dangerous," "My whole nervous system is permanently ruined").
  3. Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others.
  4. Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame).
  5. Markedly diminished interest or participation in significant activities.
  6. Feelings of detachment or estrangement from others.
  7. Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings).
• Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:
  1. Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects.
  2. Reckless or self-destructive behavior.
  3. Hypervigilance.
  4. Exaggerated startle response.
  5. Problems with concentration.
  6. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).
• Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month.
• The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
• The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition.

Specify whether:

With dissociative symptoms: The individual's symptoms meet the criteria for post- traumatic stress disorder, and in addition, in response to the stressor, the individual experiences persistent or recurrent symptoms of either of the following:

1. Depersonalization: Persistent or recurrent experiences of feeling detached from, and as if one were an outside observer of, one's mental processes or body (e.g., feeling as though one were in a dream; feeling a sense of unreality of self or body or of time moving slowly).
2. Derealization: Persistent or recurrent experiences of unreality of surroundings (e.g., the world around the individual is experienced as unreal. dreamlike, distant, or distorted). Note: To use this subtype, the substance (e.g., blackouts, behavior during alcohol intoxication) or another medical condition (e.g., complex partial seizures).

Top of Page

I also include the DSM-5 list of recommended differential diagnoses. PTSD differential diagnoses are conditions that should be considered as possible alternative explanations for PTSD symptoms. Here are the ones listed in the DSM-5 (2013). It is not exhaustive:

Top of Page

I will now attempt to answer the questions in the order they were posed. Again, I would like to stress that because I have not examined the Appellant, none of my comments should be misconstrued as comments about his specific diagnoses.

1. Would some, or all, of the symptoms diagnosed as PTSD (and Major Depressive Disorder) be the result of, or sequelae of, the 2002 surgery for the brain tumour?

Answer: Symptoms due to cranial surgery and/or major depression can be attributed to either condition. The differential diagnoses published in the DSM-5 include both "Major depressive disorder" and "traumatic brain injury" (see above). To be complete, these conditions can also occur in addition to PTSD.

2. Is there a credible basis to link or attribute the diagnosis of PTSD made in 2011 to Appellant's three-year history of military service between 1964 and 1967?

Specifically:

Top of Page

The Appellant's medical records document cognitive impairment secondary to his brain tumour and brain surgery. This could include memory impairment. There is also a well documented phenomenon known as false memory syndrome in which individuals come to believe they recall something that did not actually happen. There is a large literature on this phenomenon. Again, I am not in a position to say whether or not the Appellant suffers from FMS but there are some indicators that this may explain some of the issues that have arisen. For example, he does not mention the traumatic incident which he says occurred when he was in Special Forces training (there are some notations stating he was never in Special Forces training) until he was assessed by Dr. Vandersteen in 2012. The Appellant also writes that he did not know what was wrong with himself (MD file, P. 212). If his recollection of the traumatic incident(s) occurred during a therapeutic session, it would be characteristic of the phenomenon seen in FMS.

In my respectful opinion, the Appellant would benefit from assessment by a neuropsychologist who could test for the conditions listed under the differential diagnosis listed above and in particular identify neuropsychological strengths and deficits that could be attributed to his brain tumour and subsequent treatment as well as his rehabilitation to date. While I would defer to the opinions of a neuropsychologist, typical tests such as the Luria-Nebraska or Halsted-Reitan Neuropsychological Batteries would be routine. I note that Dr. Vandersteen reported that the Appellant's MMPI test results were invalid but there was no explanation about why the Appellant produced an invalid MMPI.

• In your opinion, would participation in Basic Training, involving physical training, training in handling weapons, and training in basic combat, satisfy the DSM-IV criteria for PTSD, which requires that the individual be exposed to an extreme traumatic stressor, or an extreme traumatic event involving death, or risk of death, and/or serious injury to oneself or others?
  1. According to the DSM-5 criteria, PTSD is a condition due to: "directly experienced traumatic events (that) include, but are not limited to, exposure to war as a combatant or civilian, threatened or actual physical assault (e.g., physical attack. robbery, mugging, childhood physical abuse), threatened or actual sexual violence (e.g., forced sexual penetration, alcohol/ drug-facilitated sexual penetration, abusive sexual contact, noncontact sexual abuse, sexual trafficking), being kidnapped, being taken hostage, terrorist attack, torture, incarceration as a prisoner of war, natural or human-made disasters, and severe motor vehicle accidents" (p. 274). The events described in the question do not appear to be in the same category of events as those listed in the PTSD criteria. While basic training and even special forces training is undoubtedly stressful, there is a qualitative difference between the type of stress that causes PTSD and the type of stress endured in military training. Importantly, there is also a difference in terms of the context of the stress. Stress causing PTSD is typically unpredicted, of unknown duration and perceived as personally life-threatening. Canadian Forces military training, according to the documents reviewed, has none of the characteristics of PTSD inducing stress. In addition, Canadian military service training is entirely voluntary.
  2. Basic training is designed to prepare recruits for the demands of warfare. This includes reducing vulnerability to developing PTSD. It would make no sense for a military training program to induce PTSD in its own soldiers before deployment.
  3. Most graduates from military training do not have PTSD.
• Considering the facts of the case with respect to the nature of the Appellant's military service between 1964 -1967, the pattern of the onset of his symptoms, and the timing of the diagnosis of his PTSD in 2011, is it likely, or probable, that the Appellant's psychiatric disorder(s) was caused by events or traumatic experiences that are not related to military service?
  1. The exact traumatic incident(s) are not described in the materials provided. Dr. Vandersteen describes aspects of the standard special forces training but the Appellant describes abuse by a supervisor.
  2. There is no documentation of specific PTSD symptoms or complaints until applications for disability on the basis of exposure to Agent Orange, Major Depression, and sequelae of the successful treatment of a cerebellar tumour were exhausted.
  3. The first mention of anxiety or "nervousness" was in a doctor's note dated April 7, 1982.
  4. There are multiple documented events that could explain the symptoms described by the Appellant including: discharge from the military, traumatic events in the RCMP, divorce, unemployment, brain tumour, brain surgery, "massive" pulmonary embolism, and/or unsuccessful applications for disability.
• How, or in what manner, could the impairment of the Appellant's memory and cognitive abilities potentially affect the Appellant's ability to reliably and accurately recall or identify past traumatic experiences or traumatic events? Are there protocols or tests that should be administered by a mental health or medical professional in order to screen or identify whether other causes or events might be operative in causing a psychiatric disorder such as PTSD?

Top of Page

1. What is the relationship between PTSD and the Appellant's Major Depressive Disorder?

Without examining the Appellant I am unable to confirm or refute any specific diagnoses. Major depression is listed in the DSM-5 criteria as a condition that should be considered in the differential diagnosis or as a comorbid disorder when considering a diagnosis of PTSD.

Although each disorder represents a distinct psychiatric disorder under the DSM­IV, do they ultimately represent the same medical disability or impairment?

Answer: No. They are distinct conditions that may occur together or separately.

Is there overlap in the symptoms of the two disorders?

Answer: Yes.

Top of Page

2. Is it likely that PTSD and Major Depressive Disorder could be present, but not be detected, at the time of the evaluation and treatment for the ganglioglioma in 2002?

Answer: Regretfully, the answer is probably "Yes". Neurosurgical teams are highly specialized and focused on completing complex surgical procedures as expeditiously as possible. A thorough investigation of possible psychiatric problems would not be routine. I was somewhat surprised by the absence of baseline and follow-up testing of the Appellant's neuropsychiatric status. Given the Appellant's pattern of not always fully disclosing problems (e.g. his reported history of abuse) even a psychiatric examination might not have detected either diagnosis. The problem is further compounded by comorbid medical problems that could disguise either diagnosis including a brain tumour, and a "massive pulmonary embolism".

This completes my review of the materials and my answers to the questions posed.

As I final comment I would be remiss if I did not add a final impression of the Appellant based on a review of the materials and his own writings. A theme in his writings is a sense that he is not being heard. He also indicates a sense of not being properly acknowledged for the service he has given to his country both through his military service and volunteer work with the RCMP. He clearly holds Canada's Armed Forces in high esteem. He has been deemed disabled on several occasions (see Table above) due to documented medical conditions, especially his brain tumour. In my respectful opinion, regardless of the final determination of the hearing, the Appellant's substantial contributions to his country and community should be acknowledged. He should also be encouraged to seek independent assessment and treatment from a mental health practitioner familiar with the unique needs of soldiers with neuropsychiatric disabilities, regardless of their cause.