MEPSDOX



MEPS60-Second Mental Health Screen


One of our most difficult jobs in MEPS is screening for subtle mental health disorders. Many times we end up arbitrarily disqualifying an applicant based on a magic number like 4 traffic tickets, and miss an applicant that has a significant underlying behavioral problem.

What makes this so difficult is the wide, fuzzy line between normal and abnormal. Yet, these borderline applicants can potentially be a danger to others or themselves. (Suicide is one of the leading causes of death in the MEPS age group of applicants.)

Step Onein mental health screening is “fact gathering.” This step is actually a part of every MEPS physical examination. As you proceed with the history and physical, look for “triggers and “red flags in the SHSQ, 2807-1 and the 2808. While red flags are obvious signs or history of a mental health disorder, triggers are more subtle signs and usually will need further probing. The following is a quick rundown of what to look for:


SHSQ: The questions (a, b, c, d, f and l) are red flags for depression and will require further evaluation. Question “e” (SIV) is in itself disqualifying (ICD E986) and is a red flag for either a poor coping mechanism (20%) or a high degree of impulsivity (80%). The remaining questions g, h, i, j and k are all triggers for potential maladaptive behavior problems, particularly impulsivity disorders. Pearl: Studies show 3 or more “yes” answers out of these 6 impulsivity questions (f, g, h, I, j, k) do poorly in the military service. (Impulsivity is discussed in length below.)
Question l (L) can be misleading. The decision to join the military can cause some insomnia. Most of these young applicants are not working and quickly get in the habit of watching late-night TV. If they wake up in the middle of the night after once falling asleep – this may be a sign of depression.

Alcohol screening score at the bottom or the SHSQ is used for not only picking out current or potential alcoholism problems, but also as a trigger for further symptoms of an impulsivity disorder. A high score (males 4, females 3) is a red flag and needs to be thoroughly evaluated. Always question an applicant with a “0” alcohol score if he ever drank, and when did he stop – make sure it wasn’t just before their MEPS exam! Also, a borderline score (2 or 3) is not disqualifying, but should probably be notated as unhealthy or even hazardous drinking on the 2808, box 77.

2807-1: Triggers are spread throughout the questions starting with 15.a. and b. You should be mindful of unexplained dizzy or fainting spells as well as a history of headaches, all possibly being tied in with underlying poor mental health. Also, be aware of the applicant that checks multiple “yes” boxes; will he be on sick call frequently? Box 17 is a red flag box and requires comprehensive evaluation and documentation. Drug box 30.a. can be quite problematic when it shows a history of frequent usage and/or police citations. There is no magic number - a single marijuana citation could represent a significant trigger. On the other hand, we have all seen higher usage in acceptable applicants. Be wary of “additional disclosures” later in the day because “you forgot to ask me,” or an applicant that denied all drug use and a week later has a positive DAT.

2808: The physical examination includes evidence of self-injury and body modifications. This includes brands, number and content of tattoos and body piercing. Lurid tattoos need explaining, there are literally billions of patterns to choose from. SIV includes cigarette burns that “friends” did. All of these items indicate impulsivity and risk taking. Of particular importance is box 40, your clinical judgment of the applicant. What kind of person do you see sitting across from you? How does he treat you as an authority figure? What are the applicant’s presentation, mannerisms, attitude, and speech? Note minor items such as haircuts, clothes, and he fits in with other applicants. (Be aware of teenage trends.)

After screening out obvious psychiatric conditions and red-flag issues that are disqualifying, you are left with a serious of soft triggers that may be subtle, but possibly indicating serious underlying behavioral or impulsivity disorders.

There is no definite measuring stick telling you when an applicant crosses the line of what is acceptable or unacceptable behavior. For example, an applicant with guarded behavior and a glib attitude, multiple tattoos, some marijuana usage, and an old DWI citation. Is this applicant qualified? This is where a set of screening questions can be helpful. The following 5 questions are a start: (see “Interview Pointers” in Supplement.)



A suggested Skill-Set of Screening Questions:

1. Tell me about your home and parents while growing up?

Cues: Did you have a daily meal with a parent?
Did you live out of your home before age 18?
Ever runaway, even overnight? Ever homeless? Tell me about your parents, divorces,
foster parents (60% of foster kids have behavioral problems)


Probes: The ACE Score is an excellent probe, discussed in detail below. Ask them to
describe their house and neighborhood growing up.

2. Did you drop out of high school? What grade, year, age and why?

► Cues: GED? How and when?

Probes: Counseling? ADHD treatment? Special Ed? Job Corps? Home schooling? Why?
Any make-up classes or repeating school years? Any citations for truancy,
trespassing, fighting or graffiti writing?
Band member? What sports actively played in high school?
List college attempts, failures, and successes.

3. Ever been in the backseat of a police car? (Lead-in to legal problems)

► Cues: Match this with what applicant notated in Box 17 and 30a.
Ever ridden in (or driven) a car with the driver under the influence of alcohol or drugs?


Probes: Tell me about all police/legal citations: Traffic, drug, alcohol or other citations.
Any reckless driving citations, court-ordered classes or anger management?
80 mph in a 65 mph zone is worse than 40 in a 30 zone. Any legal trouble? Credit
card debt, auto repos? Ever divorced? Any children? Where are they?

4. What have you been doing between high school/GED up till now?

► Cues: A good way to approach this is by using their notation in Box 7b, (USUAL
OCCUPATION). If the wrote “college,” ask them how many credits they have.
E.g. 12 credits in 3 years, or are they closing in on finishing college? If they noted a
job, ask how long on this job. You want to know what their job history has been since
the high school benchmark.
.
Probes: Note how many years ago this was, and number of jobs, i.e. longest, shortest, ever
fired, promotions. If ever fired or not promoted, ask why – tardiness, excessive sick
days? Did boss have it in for him or were his co-workers jealous of him?
List successes in work/college.
Still live with parents, or how many different addresses during this time?
Any intimate GF/BF relationship lasting one year? Describe present “family” life.

5. What do you want to do in the service?

► Cues: Which service and type of job can be very telling. What is their vision of the future?
An aspiration of being a diesel mechanic as compared to an airborne
ranger, is this realistic or another sign of risk taking? Check their ASVAB.


Probes: Get them to talk about their view of the future, hopes and dreams, is it down-to-earth
or thrill seeking? Ask them how they see themselves in 10 years and kind of retirement
plan they have thought about.


Each MEPS examiner needs to develop their own set of mental health screening questions they use over and over until they do this almost automatically with virtually every applicant they interview. It is difficult to predict where each examiner will end up in this process. As time goes on, you will shorten, rearrange and replace some of these questions as your screening ability improves.

Here is an example of how one group of MEPS examiners ended up after one year of using these 5 questions. Two things happened. First, they learned to profile an applicant quickly as to whether more probing was indicated using the many subtle clues (triggers) including attitude, manner of speech, appearance, and any trigger items seen in the SHSQ and 2807-1. When further screening was indicated, one question became the benchmark question, “Did you graduate from high school or get your GED?” This was usually followed by, “Since then, how many jobs have you been able to get?” The answers to just these two questions plus the applicant’s demeanor often allowed the examiner to make a snap decision to go from “screening to probing” (positive screen), or to “move on,” (negative screen).

For example, if the applicant slouched into the room with “attitude,” tattoos showing, and a quick scan of his papers showed marijuana use and perhaps a DUI and a questionable cigarette burn on his arm – This profile would kick off the two questions, and most likely leading to all 5 questions. On the other hand, if the applicant were a polite “squeaky clean” 17 y/o, probably no screening questions would be asked. Learning the skill of knowing when to probe during a screen develops over time. In doing this over and over, an examiner slowly sharpens their “psychiatric instincts,” and can do this quickly, thus, the 60-second mental health screen.

As a result of this screening process, you start forming a picture of the applicant. Try placing everything into “Mental Health Buckets.” This will help organize all your findings and serve as a check of completeness – have you left out any areas?

Mental Health Buckets: (Scan the buckets – forgotten anything?)

(1) Psychiatric Bucket: Anger and assault citations, post-partum depression.
Any psychiatric history that in itself is not disqualifying is still
considered a red flag or trigger.

(2) Medical Bucket: Frequent headaches, seizure history, prior MVA/TBI, low BMI,
and psychosomatic issues – a “positive 2807-1” & frequent doctor visits.

(3) SIV Bucket: Obvious self-harm is in itself disqualifying. However,
there are triggers strongly suggestive of self-harm
that may not be diagnosable, including brands, multiple
tattoos/or lurid content, piercings, suspicious bruising or
even multiple poorly explained bone fractures.

(4) Drug Bucket: Frequency, how recent, including any prescription drugs.
Is it part of their lifestyle? Police citations. Use DSM-IV criteria.

(5) Alcohol Bucket: SHSQ score, CAGE (see below), police citations, court-ordered
classes, rehab treatment. Apply DSM-IV criteria. Family members?

(6) Growing Up Bucket: See screening questions 1 and 2.

(7) School Bucket: see screening question 3.

(8) Job Bucket: Screening question 5.

(9) Legal Bucket: see screening question 4.

(10) Lifestyle Bucket: Stability and length of relationships, status of any children,
multiple addresses, sensation seeking - speeding and
reckless driving tickets. Wild lifestyle- party person, gambling.
Thrill seeking – extreme sports - sky diving, motorcycles.
(Devil-may-care skiers, surfers and rock climbers are linked
to addiction-prone personalities and early alcoholism)





Step Two - Forming a picture of the applicant:

The first 5 buckets are mostly a result of “fact gathering” from the SHSQ, 2807-1 and 2808. Any one of these buckets could be disqualifying in themselves, or serve as triggers to other mental health disorders.

The second set of 5 buckets are subtle trigger buckets. The problem comes when you have only a few minor non-disqualifying items in the first 5 buckets, but a hodgepodge of more subtle items in the second 5 trigger buckets.

Consolidate all of the information in your buckets into a succinct description of the applicant in Box 30a of the 2807-1.

Step Three – You have to put the applicant’s picture in the current context of what you see right today by applying the contents of a Redemption Bucket. This bucket is mostly from the screening questions 4 and 5, and bucket 10. This is an active process of putting a timeline on the various negative items in the buckets, and making a current assessment of what the applicant is today. Is the applicant more mature now? Put everything into context with time-lines and recent successes. Is it your conclusion that the applicant you see in front of you now will successfully adapt to the responsibilities and stresses of military service? This statement might be in the form of your recommendation to the waiver authority if indicated.

Consider that past behavior predicts future behavior; unless you are convinced there has been real change over time. Some consider age 26 as a marker for full brain maturity, which is why auto insurance companies have higher premiums up to this age.

Here is how the DoDI rules evaluate the second 5 buckets:

Section 28, i (1) and (2)

(1) History (demonstrated by repeated inability to maintain reasonable adjustment in school, with employers or fellow workers, or other social groups), interview, or psychological testing revealing that the degree of immaturity, instability, of personality inadequacy, impulsiveness, or dependency shall likely interfere with adjustment in the Military Services.

(2) Recurrent encounters with law enforcement agencies (excluding minor traffic violations) or antisocial behaviors are tangible evidence of impaired capacity to adapt to military service.




Time to make a decision:

● If you decide the applicant is qualified and you have enough information to
support your decision make it clear in your history note.

● If your overall picture is still a little fuzzy, with multiple soft signs (triggers) but no
big red-flags and you have doubts, consider a psychiatric consult.

● If you find the applicant is disqualified after applying section 28, i (1) and (2),
apply this DoDI rule:

“Current or history of disturbance of conduct (312), impulse control (312.3), oppositional defiant (313.81), other behavior disorders (313), or personality disorder (301)”.

Fitting your clinical impression into one of the above categories is sometimes not easy, particularly if you only have soft triggers and no red-flags. If one of the above rules clearly fits your applicant’s picture, then use it. If it does not, here are some of the ICD Barrels you can use by dumping all your mental-health buckets into the most appropriate barrel:

DoDI Mental Health Barrels: (Alphabetical order)

Behavioral Barrel: ICD 313
HS drop-out, maladaptive, future misconduct type in the service.
This is the “barrel of last resort,” when nothing below fits and you are convinced
there are too many triggers for this applicant to likely succeed in the military.

Conduct Barrel: ICD 312 (Already failed in the service)
Misconduct, DD 214 RE-3 – will automatically be reviewed by waiver authority.
VA studies show that 95% of returning soldiers from deployments have some
degree of PTSD including higher alcohol and drug abuse. This category implies
“recurrent” misconduct and is essentially a personality disorder

Emotional Mess Barrel: ICD 301.83 (Borderline Personality Disorder)
Extreme up & down emotions in adolescence, difficult social life, some signs of
potential drinking problems, a teenage parent, ran away from home. You will see
psychosexual conditions (302) that may belong in this barrel.

Fuzzy Psychiatric Barrel: ICD 796.9 (Generally unfit for service)
You can’t put your finger on it, but you are sure this
applicant will not be successful in the military.Future “platoon screw-up.”

Immaturity Barrel: ICD 301.6
Mama’s boy, dependent personality, never had a good job

Impulsivity Barrel: ICD 312.3 (Impulse-control disorder)
Does things on a whim which gets them into trouble. Childhood temper tantrums,
frequently in principal’s office, shoplifting, compulsive gambler, assault/property
destruction citations including road rage, history of a boxer fractures. Court-ordered
anger management classes. If you cannot formally make the diagnosis of IED, but
have enough triggers to come close to it, use this barrel.

Personality Disorder Barrel: ICD 301
Maladaptive, HS dropout, loses jobs due to jealous peers or boss having it in for him,
Prone to violence and even criminality. Never learns from past mistakes.

This particular group of barrels is neither official nor complete by any means, and there is overlapping. But this scheme might help you find the best ICD label for your findings. Write a complete summary and recommendation to the waiver authority since no one knows the applicant better than you do at this point. Make them see what you see.

Summary:This entire screening process is to encourage you to develop what psychologists call a skill set, a short list of the questions that you can use to effectively and quickly screen for mental-health disorders. There are 3 basic steps:

(1) Fact Gathering (2) Forming a picture of the applicant (3) Redemption Bucket

(Below is supplemental information on Interviewing Pointers, TIPS, ACES, CAGE, and Understanding Impulsivity)

Supplemental Information:


Interview Pointers:

(1) Make applicant comfortable, be friendly and casual, but be direct, looking them in the eye.

(2) Explain that all applicants are asked the same questions at least twice in MEPS, now
and again in a pre-enlistment interview later in the day. If something is not divulged
now, they could be sent back after the PEI to repeat this interview.

(3) You have to assure them that anything they tell you is strictly confidential and
private.

(4) Start with open-ended, less personal questions and progress to more probing
questions. (Try to not ask “yes or no” questions)

(5) Remain nonjudgmental and acknowledge the applicant’s thoughts and feelings.
One psychiatrist in MEPS uses the phrase, “Help me to understand…”

(6) REMEMBER, reluctant answers are probably hiding something…
Consider noting “reluctant historian” or even “poor veracity,” e.g. 1/4 in your notations.


● How many TIPSIf there are over 3 Tattoos, or even 1 Intimate piercing or a total of 6 or more Piercings, studies show this is suggestive of a high level of impulsivity with increased drug abuse, arrests and binge drinking.Note age of first cigarette-alcohol-marijuana use & first tattoo (Any of these before age 13 is a trigger for sensation seeking and impulsivity)


How many Aces do you have? - ACE Score: Adverse Childhood Events

This is a list of 9 items that a child may grow up experiencing before age 18. All are considered to be childhood traumatic circumstances or events that will significantly affect their mental health. One of the key emotions seen in borderline personality disorders as well as suicidal behavior is the feeling of abandonment as a young child.

1.Recurrent physical abuse (hitting, slapping, spanking)
2.Recurrent emotional abuse (always verbally abusing the kid)
3.Contact sexual abuse
4.An alcohol and/or drug abuser in the household
5.An incarcerated household member
6.Someone who is chronically depressed, mentally ill, institutionalized, or suicidal in the house
7.Mother is treated violently (father or boyfriend slaps or abuses the kid’s mother)
8.One or no parents (divorced, foster parents, lives with aunty or grandparents)
9.Emotional or physical neglect (never hugged, complimented or awarded for outstanding things)

Calculate the ACE ScoreThe ACE Score uses a simple scoring method to determine the extent of each applicant’s exposure to childhood trauma. Exposure to one category (not incident) of ACE, qualifies as one point. The total points give you the ACE score. An ACE score of 5 is associated with a high risk of alcohol/drug abuse. A score of 7 or higher is associated with a high risk of depression and suicide.


● CAGE Questionnaire (as originally published)
1. Have you ever felt you should Cut down on your drinking?
2. Have people Annoyed you by criticizing your drinking?
3. Have you ever felt bad orGuilty about your drinking?
4. Have you ever had a drink first thing in the morning to steady your nerves or to
get rid of hangover (Eye opener)?

Scoring: 1 point for each “yes,” two or more “yes” answers is significant.

The CAGE questions have to be used appropriately in both the way you ask the questions and when you ask. One suggestion is if there is a high SHSQ alcohol score, do not tell the applicant, but causally ask the questions as rephrased below or in your own phrasing. Question 4 is probably not practical in most MEPS applicants. By the time they need an eye opener; they already have a disqualifying alcohol abuse problem. It is suggested you omit the question 4, or perhaps, determine if they need a drink on a daily basis?

1. Has anyone in your family ever been a little worried about your drinking?
2. Do you get a little irked if someone does say something about your drinking?
3. What do you think about your drinking?
4. Do you look forward in the afternoons to get home to have a drink/beer?

There is an occasional applicant with a high SHSQ score that actually brags about putting down a 6-pack. The CAGE questions would not faze him. This type of applicant is high risk for future abuse problems.

You will see some applicants that have borderline use of alcohol, e.g. SHSQ score of 3 with perhaps a citation (DUI or DWI). While this may not be disqualifying, it is unhealthy alcohol drinking or even hazardous drinking and you might consider noting this on line 77:

“50. Unhealthy (hazardous) alcohol drinking NCD”
Understanding Impulsivity


An Oversimplified Reference for all MEPS Non-Psychiatrists

Recently there has been a lot of talk about screening applicants for impulsivity traits and disorders. In the last annual CMO meeting (2011), we heard that applicants with three or more incidents of impulsivity checked on their SHSQ, do poorly in the military. Most of us do not have psychiatric training, and many find it hard to understand impulsivity.

This review is a deliberate oversimplification. It may not be scientific or fit into the DSM-IV criteria, but at least it will help us to become more aware of how we might better screen for impulsivity problems.

Impulsivity is a knee-jerk reaction - doing something on the spur of the moment without thinking about it. We all do it, but to varying degrees, and therein lies the essence of impulsivity. Think of it as your Impulsivity Thermostat; the higher it’s set, the more impulsivity you have, very similar to being hyperthyroid. Supermarkets learned this long ago by stacking piles of liquid soap bottles on sale at the front door that a shopper has to walk around. This catches the impulsive people who will buy them on the spot.

Where does this impulsivity thermostat setting come from? Neurobiologists are researching for the exact neurotransmitter gene site causing an imbalance of serotonin/dopamine in the neuron synapse. Meanwhile, let’s realize we all have it, only some more than others.

Too much of anything is not good. Hyperthyroidism can turn into thyrotoxicosis, and high levels of impulsivity can be mentally toxic. Bad things happen to people’s behavior with high levels of impulsivity. The comedienne, Flip Wilson famously said, “The devil made me do it.” Well, that devil is impulsivity.

Here the discussion digresses into two distinct topics: (1) Impulsivity + psychiatric disorders (2) Impulsivity alone.

(1) Impulsivity’s affect on other psychiatric disorders:There are hundreds of references in the literature discussing the effect of impulsivity on other psychiatric conditions such as ADHD and Impulsivity Personality Disorders and Impulsivity Self-cutters and impulsivity, and a lot of other mental health disorders. Here is a simple way to look at the relationship between impulsivity and psychiatric disorders: If a runner has a mildly weak ligament in his knee, it might not ever cause any knee problems, but if that same runner develops flat feet, then the flat feet might cause the knee ligament to tear and cause pain. Any orthopedic surgeon will tell you that most knee pain is caused by an abnormality of the feet. Impulsivity is the pes planus of psychiatry.

Although impulsivity is not the cause of a personality disorder, the presence of a high level of impulsivity in a personality disorder may cause that person to become an aggressive violent criminal. Conversely, with little or no impulsivity, he might only be a smooth con artist. A little like comparing Dickens’s “The Artful Dodger” to the Zodiac killer.

ADHD is another example. There are two traits merged in ADHD, inattentive daydreamers and the hyperactivity kid and various combinations in the same kid. High impulsivity will cause the hyperactive aspect of ADHD to develop an Oppositional Defiant Disorder (ODD) or a Conduct Disorder (CD) 35 to 40% of the time. New research is now showing a small number of ADHD kids without any ODD/CD are likely to develop clinical depression, I am willing to bet this will turn out to be the daydreaming ADHD kids without any impulsivity.

So far it is clear that impulsivity with ADHD (hyperactivity + impulsivity), as well as personality disorders + impulsivity can cause extremely aggressive behavior in both of these conditions. How about bipolar disorders?

A bipolar disorder has up and down phases of manic and depression. Isn’t this strikingly similar to ADHD with inattentive types getting depressed, but hyperactive + impulsivity types going over the edge? Here is what one researcher, Dr Timothy Wilens at Massachusetts General Hospital found in one study: “It's been hard to tell whether one person can have both ADHD and bipolar disorder. Hyperactivity looks a lot like what bipolar patients experience during manic phases. And the manic phase of bipolar disorder looks a lot like simple hyperactivity.” Huh? The cause of the hyperactive-manic aspects in both ADHD and bipolar disorders is IMPULSIVITY. In fact, psychiatrists say it is impossible to meet the DSM-IV criteria for a manic episode without highly impulsive behavior.

OCD (Obsessive-Compulsive Disorders) is beginning to be called obsessive-compulsive spectrum disorders because there is such a wide range of symptoms from mild to severe. Severe OCD conditions are being merged with impulse-control disorders (comorbid kleptomania, compulsion shopping, and IED) because of their high level of impulsivity. In other words, what milder obsessions or compulsions these patients may have, they become more severe with impulsivity.

Chronic drug and alcohol abuse is linked to high levels of impulsivity. If they stacked narcotics at the front door of that supermarket, all the highly impulsive shoppers passing by would become drug addicts. Studies show that multiple drug/alcohol abusers have a much higher level of impulsivity than single drug abuser. And, single drug abusers have a higher level of impulsivity than nonusers. Research models show that substance abuse, suicidal behavior and impulsivity are all linked together through very complicated mechanisms. The severity is proportional to a person’s level of impulsivity. How do we learn where to draw this line in our applicants?

Where is all of this going? High levels of impulsivity have a profoundly bad effect on nearly all of the various behavioral and mental health disorders seen in our MEPS applicants. If we could assess impulsivity level in applicants, we could more accurately predict their future success in the military. At the moment, psychiatrists are working to develop reliable impulsivity scores; meanwhile, MEPS examiners need to be more aware of impulsivity problems. We need to learn how to assess them clinically in our day to day mental health screening.
(2) Impulsivity alone: This topic is impulsivity without any underlying psychiatric disorders, but overtime may emerge and be diagnosable as a Borderline Personality Disorder (BPD). This is “pure impulsivity unleashed” so to speak. This is seen at a very young age in the form of temper tantrums and later periods of sulking and moodiness. All adolescents go through “adolescence” where they will slam the door or not talk at the dinner table. But a teenager with an early borderline personality disorder may get angry, slam a door and then proceed to cut himself or overdose on pills. (Affective outbursts) Another teen with BPD may feel sad and lonely and proceed to abuse alcohol and drugs. They may also engage in promiscuous sex, which may result in teenage pregnancy. It is nearly impossible to make the diagnosis of BPD before age 18 since their personalities have not fully matured. In MEPS, determining a detailed ACE score should clearly show circumstances for feelings of abandonment. They are the kids that run away from home, or cut themselves over a breakup with a heartthrob. And, if they are in MEPS, they may be “running away” again, or maybe their parents are trying to get rid of them.
As these teenagers get older, their impulsivity can often become more emotional and erratic. They become very maladaptive in all of their relationships, family, school and jobs. Researchers working with them describe a continuous state of emotional chaos, swinging from extremes of depression, anger, and anxiety, and even suicidal. The DSM-IV has defined a Borderline Personality Disorder (ICD 301.83) and lists a dizzying array of criteria. Some researchers say that “emotionally unstable personality disorder” is a better term.

At the heart of this turmoil are 3 characteristics: fear of abandonment, unstable pattern of relationships, and self-image, all revved up with unbridled impulsivity. They are “stably unstable” and predictably unpredictable.” Their personal relationships are best described as “I hate you-don’t leave me.” This is a disorder of emotional instability with high levels of impulsivity running amuck.

Although the DSM-IV lists the criteria to make the diagnosis, it appears that impulsivity that slowly emerges into BPD is a spectrum in severity, and the MEPS examiner may have to make a determination long before any psychiatrist might formally make the diagnosis.

Borderline personality disorders slowly burn out as their brain matures roughly starting in their mid-20s up to their 40s. However, while this “fuel of impulsivity” burns out, the emotional outbursts and affective disorders (up and down depression and anxiety) do not, they may smolder along for years.

BPD is not uncommon, but it is undiagnosed. It is present in about 6% of the patients in a primary care practice, and over 60% are females. Most are initially diagnosed after being hospitalized for a suicide attempt or self-cutting episode.

The Rage of Impulsivity: This is pure impulsivity that suddenly rockets into a violent, sometime assaultive rage. Our mother’s called it, “flying off the handle.”

In applicants, the only sign you may see is a previously court-ordered anger management class in conjunction with an assault citation. Also, look for it in any property damage or domestic abuse police citations, or road rage incidents. A boxer’s fracture may be a tip.

The DSM-IV formally makes the diagnosis by a history of three typical anger episodes. (See IED worksheet in the Supplement.) You are likely going to find it difficult supporting this diagnosis, although it is present in 6% of people, mostly males. It is a diagnosis of exclusion after ruling out such things as ADHD, BPD, PD and substance abuse disorders (particularly alcohol abuse). There is overlapping with some OCD disorders as listed above. If there are enough disturbing signs of poor anger control with violent outbursts, use the Impulse-control disorder (312.2) to disqualify the applicant, even if the DSM-IV criteria for IED is not met. Remember the first part of the Stanley Kubrick’s movie, Full Metal Jacket (1987). Don’t let this applicant get by you.

Which applicants commit suicide?Suicide is not due to impulsivity, but applicants with high impulsivity are more likely to commit suicide, this is aggressive impulsivity turned inward. Although there are many other factors and variables, there does appear to be two basic potential suicidal behavior types – those with high serotonin and those with low serotonin. Probably the common type in applicants is the high-impulsivity low-serotonin types. These are the applicants with all the signs of high impulsivity - self-injurious behavior, runaways, high-school drop-outs, teenage pregnancy, multiple drug and alcohol use/abuse, and eating disorders. Then there are the low-impulsivity high-serotonin types manifested by moody depressive- personalities, including inattentive ADHD daydreamers. More to come on this in a future review.

Conclusion: The umbrella of impulsivity covers the entire brain, wreaking havoc on every behavior function with its 5HP (serotonin) dysregulation. It is easier to see when there is diagnosable psychiatric axis I or II disorder involved. On the other hand, determining disqualifying impulsivity without any Axis I or II disorders is difficult. This makes it even more dangerous. MEPS examiners always have to be on the lookout for the tell tale signs of subtle but pathological impulsivity. Triggers may be spread out all over the place – SHSQ, 2807-1, 2808, including the applicant himself. In the end, it turns out to be only you, the MEPS examiner’s own psychiatric instincts that can manage this task. Some of the items (triggers) to constantly scan for are abrasive attitudes, dress and mannerisms in your office tattoos piercings school suspensions kicked out of the house foster parentshigh school dropout Job Corps →Self-mutilation many jobs been fired multiple traffic tickets arrests substance abuse high SHSQ alcohol score counseling previous history of ADHD, ODD or CD military service misconduct and now you have to make a decision.

FACT: Past performance predicts future performance, and three or more signs of impulsivity do poorly in the military.

The first step in making the diagnosis of impulsivity is thinking about it. Sherlock Holmes, 1887.