free_spirit_etc

So I can photcopy the certified sticker and then make a list of what I am sending on THAT page - as proof they received THOSE documents? If they do not notify me that any of the documents I state are being sent are missing, is that "proof" that they received them? Also, do I have to request return receipt, or is the online confirmation that the certified mail was received and signed for enough evidence? Free

I KNOW I read it somewhere. I keep thinking it was in the M-21 -- Not so much a "law" but a procedure. We were concerned if we asked for an earlier effective date - that it would hold up the WHOLE dang claim until the EED got the the BVA. But the manual had said that they should fo ahead and decided what could be decided and get benefits that COULD be paid in payment status - and defer the decision on effective date. I guess you could always send that in LATER if someone finds it. Send a note asking - as you have filed for EED - you also request under ___ that they do not delay the whole claim while the effective date is being decided. On the link mountain tyme sent -- this sounded more relevant to what you were talking about -- not a NOD or reopening. According to this - if they RECONSIDER your claim based on new evidence that you send in WITHIN the one year appeal period - then your appeal period doesn't START until they issue the NEXT decision. FROM OTHER LINK Another route that may be of some interest is the "reconsideration" route. This is where a claimant has received a rating decision and may disagree with that decision, but has "new" evidence that the Rating activity was unaware of at the time of their decision, and may think that the "new" evidence might result in a more favorable decision than the prior one. In this case the claimant has the one year appeals period to send in the "new" evidence and request that the Rating Activity "Reconsider" their previous decision. The claims folder would then go back to the Rating activity to be reconsidered and the RVSR would send out a new rating decision where the "new" evidence and possibly a new rating would be discussed if warranted. A request for reconsideration generally goes faster then an appeal because the claims folder goes back to the RVSR and is worked according to the original effective date (the date of the Informal Claim of Formal Claim). One thing to keep in mind is that if you request a "Reconsideration" with "new" evidence, you must do this within the one year appeals period. If you don't, then the VA must "Re-open" the claim and you loose your original effective date. Another thing to keep in mind is that if you send in "new" evidence within the one year appeals period and it doesn't change the prior decision, the RVSR will still produce a rating decision stating such, and then your one year appeals period starts over from that rating decision again. I wasn't sure about that. Everything gets so technical - that sometimes you read one thing and think you are on the right track - and want to argue that - and explore it a little deeper - and discover that argument won't help - as they have a way to shoot it down. COnsiderig the above information on the reconsideration - You might want to just advance all three theories...lumped in. It looks like a reconsideration is kind of like a re-opened claim - except the case was never closed - as it had not been within a year of the intial decision. And I am reading the above to say the resconsideration starts a NEW start date for one year to appeal from the NEXT decision. It is not like you did NOTHING. You DID respond. I was notified ____. I responded ____. yadayayda -- Regardless of whether the RO considered my communication to be a NOD, a request for reconsideration, or a reopening of a claim - the effective date would be ___. Actually, I guess they couldn't consider it a REOPENED claim - as the claim had not been closed or abandoned yet. So it would be a NOD or reconsideration. Actually, now you have one year to submit evidence - and if they decided your case before that time, I think they have to redecide it if you send in more evidence. I am not sure if the same regualtions were in effect then. I keep looking for the effective date info - but have been busy and am not sure where I stuck it. Free

Yep. I agree. Sound like the doc is on YOUR side - and will do what he can to help you. And since he wants to help - HE might write you up something that will REALLY help. :)

Sounds like a plan, except that you can't jump rank... you gotta take each step of the process on the way - you can't just jump straight to court. It is a LONG process to GET to court. The court won't hear your claim until you have been through the entire process. Yes. You can go to court -- AFTER the NOD, the wait (sometimes a YEAR) for a Statement of Case - and another wait (real long) for them to do a DRO - and issue ANOTHER SOC - so you can APPEAL to the BVA - and WAIT again - a year, or two, or more - and have you case heard and WAIT for a DECISION - and they MIGHT REMAND it BACK to the RO - and you WAIT again - and then it goes BACK to the BVA (you are up to a few years now - or more) and IF the BVA denies you - THEN you can go the COURT. That's the only game in town that I know of to get to court. You can't jump straight there. I've seen cases where the person has WAITED and WAITED for court - and the court decides they don't have JURISDICTION to hear the case - as the person didn't exhaust the process. No matter how black and white the case. You can't just JUMP to court. They would say they don't have jurisdiction and send your case back DOWN. My husband filed when he retired - after a couple of years he FINALLY got on the docket at the BVA - and then he WAITED - and dang! The BVA said that though his medical records showed he was in the Air Force for 28 years..however many days and months -- his file was missing his DD-214. NOT my husband's fault. He had provided it to the RO SEVERAL times. But they didn't have it in his file for the BVA. THe BVA could have surely got it in a week or two and decided his claim - but NO - they remanded it BACK to the RO - to get the DD-214. My husband sent ANOTHER copy - and then had to wait another period of time to get BACK on the docket. Court would have been several years down the road. The only thing I think you MIGHT be able to do to get a change more quickly is to ask the RO to call a CUE on themselves. They can call a CUE on themselves and change the decision if they see it is the result of an obvious error. But if they are calling it the wrong thing - they might be unlikely to do that. Couple weeks / couple months are all relative terms at the VA. No matter what the error, or whose fault, it takes time to get it straightened out IF you do - sometimes YEARS - and it all has to go through each step of the process. Anyone getting discharged from the military is GRANTED ONE TIME dental work after discharge (if they didn't receive it within a certain amount of time BEFORE discharge) Black and White - when you are discharged - everything wrong with your teeth at that time - gets fixed ONE time. My husband asked for dental TREATMENT. They denied SC PAYMENT - as there was no injury. He appealed - Yes. No injury. Not asking for paymnent. Asking for my ONE TIME TREATMENT. after the dd-21 fiasco - finally several years LATER the BVA reviewed the case. They said - the guy is NOT asking for Payment - he is ASKING for TREATMENT - and remanded to the RO. The RO sent him for an exam. They again denied PAYMENT. THey ignored the part about TREATMENT. He appealed again. The BVA looked at the record and said - it looks like he might have had dental injury - He MIGHT be entitled to PAYMENT (and didn't mention the treatment). And they remanded it back to the RO again. This time the RO decided AGAIN against PAYMENT - and the BVA AFFIRMED. Though the even STATED in the decision that it was not denying the one time DENTAL TREATMENT afforded to a veteran - they did not GRANT it either. They sent it BACK to the RO who send him another letter that he wasn't entitled to TREATMENT because he was not Sc'd on dental - a WHOLE different matter. So even things that are black and white can get sucked into limbo. Free

Hi. Welcome to the group. I am sorry I can't be of much help because I don't understand the medical discharge process and how that interplays with VA disability much. Some members understand it a little better and may be able to help you more. Two weeks is record speed for the VA to do anything in my book. Many of us pay for many of their mistakes - and it takes time to get paid back. Even if they do make a mistake, they don't speed things up because of that. It's more of a take a number and stand in line type system. You could try for unemmployability - but I think that will take some time to develop and even longer to win. I think it would have to go beyond being unemployable as a welder. Good luck! Free

I didn't like the decison per se either. However the decision gives the exact regulation that tells you that they have to send you a statement of case or consider your case opened, reopened. You could use THAT Reg - I just didn't have time to look it up. Or I am sure there are OTHER decisions that are more favorable - (though the case at point was denied because the person did NOT fit the criteria of not being issued an SOC) But again, I didn't have time to look it all up - I was just trying to point you in a direction. I think what the BVA was saying that is important to YOU, is their "BUT" he didn't appeal the April decision. THAT is what you have to Beat to get the retro. I don't think that just saying your weren't notified of the decision and therefore the claim was still pending will cut it. The BVA already said that you weren't notified - but they had a BUT and did not grant you an earlier effective date. I am not sure if you didn't send in anything that could be construed as an NOD - why where they sending you on exams on a final decision? I am getting confused over the chain of events from the April denial until the Nov denial you didn't get.. Because the BVA's BUT is WITHIN that time frame. Free

I think they would have a hard time saying your case was closed then. I would think sending in a document asking that the decision be reconsidered and submitting a new evidence would constitute a Notice of Disagreement (if they maintain one was required). Otherwise, they considered it as NEW and MATERIAL and REOPENED your claim when they sent you to the Exam. So they either did NOT respond to your NOD by issuing a SOC, or they did NOT issue a decision (if the claim was still pending and not reopened). In any event they were wrong. But I still think it is an appeal for an earlier effective date, rather than a CUE. Good news for you if it is - as CUES sound good - but are harder to win. I think I would argue ONE side - and also explain the other. I received the decision on ____. I responded on _____ telling them I disagreed. I was not advised that my claim was reopened. However, I was sent to C&P exams after that, yet they never sent a Statement of Case on the NOD I filed with them on ____. Therefore I was not provided with any information that the claim was denied, reasons for the denial, or information of how to further appeal. My claim remains pending. If The VA did not consider the NOD I filed ____ a disagreemet with there decision, they apparently considered it New and Material Evidence - and re-opened my claim at that time, as they sent me for a C&P exam after receiving it. However, I still never received any notification from the RO about the status of my claim after that point. Therefore, I was not notified of any decision. If the RO considered my ____ communication to be a NOD, my effective date would be ___, the day I filed my orginal claim, as I never received a SOC following their receipt of my NOD. If the RO considered my ____date communication to be a request to reopen with new and material evidence, then my effective date would be ____(the date they reopened the claim) as I never received any notification of denial of my claim from the time it was reopened. ____ I would spell it out - and let them know - no matter which game they play - the end result is closely the same... with only a few months difference. Don't let them play the --well he was not issued a SOC, but that doesn't matter because they told him he can appeal in April and he didn't..blahblahblah.. Thanks for explaining. It didn't make sense that they said you did NOT disagree with the decision, yet they sent you to a doctor after that. I would argue BOTH points - to try to avoid being in BVA limbo -- If you just argue the NOD --- they will delay it forever, remand it back to the RO to see if they considered your May letter a NOD -- play it back and forth for awhile, wear you down, wear you out...hope that you don't realize if they didn't consider it an NOD that STILL doesn't put you out of the game on the re-opened claim that was not finally decided as you weren't notified (or they don't have proof that you were) (and with that much retro - they will probably be SEARCHING for a lost record for sure!!!!) But if you argue BOTH points - you let them KNOW -- You can call it or not call it whatever you want - but either shot you call - I WIN! Free

EEK! Also - I think they might go by the regulations in effect AT THAT TIME - can you get a copy of the 1977 regs? Free

http://www.ll.georgetown.edu/federal/judic...ns/02-7015.html United States Court of Appeals for the Federal Circuit 02-7015 MICHAEL D. HERNDON, Claimant-Appellant, v. ANTHONY J. PRINCIPI, Secretary of Veterans Affairs, Respondent-Appellee. Finally, Herndon argues that the board’s 1998 decision, that its 1987 decision subsumed the 1984 rating decision, constitutes a denial of due process of law under 38 C.F.R. § 20.904. The failure of the statement of the case to list termination as an issue for appeal and to cite the regulations concerning termination, however, does not rise to the level of a violation of due process contemplated by the regulation. See 38 C.F.R. § 20.904(a)(2) (2001) (“Examples of circumstances in which denial of due process of law will be conceded are: . . . (2) When a Statement of the Case or required Supplemental Statement of the Case was not provided.”). So it looks like it IS in the law - and relied on in FEDERAL courts. So the important thing is Did you get an SOC? IF so were any supplemental SOC's REQUIRED? I wouldn't just put in the EED arguement that you weren't notified of the decision - and thus it is still open. THe BVA already said it doesn't show you were notified - but that you WERE notified in April and did not pursue an appeal. So you need to address THAT Did you get an SOC in April? If so - did you disagree? And were they REQUIRED to send you a supplemental SOC? I would certainly think if they were still sending you to doctors that your case was still OPEN -- but you have to spell it out for them. They have already acknoledged you weren't notified - but said "BUT...." You have to address why the "BUT>>" is not valid. MY opinion at least.... Free

Yeah! And keep your eye on the PRIZE - the INCREASED rating! And keep focused on evidence that your condition is WORSE! more than when it started... Yes. They CAN take benefits away - but not that easily. They would have to show fraud or error or something. One note in a doctors report shouldn't be able to do it. If they could show that you were in constant treatment preservice - or on medicine for anxiety. You are PRESUMED sound unless they can SHOW BY EVIDENCE that you were not. And you already have your SC - so they can't just take it away because of one ignorant remark. I am amazed and appalled at my husband's medical records. Heck! They kept writing the wrong lung down for the cancer. Several of his reports talk about cancer in his RIGHT lung - and it was his LEFT. Actually when he was first diagnosed the base doctors told him it was SMALL CELL - so they told him it grows rapidsly and could have started post service. A YEAR later - they looked at the LAB REPORT and said - Oh..no.. it isn't small cell - it is NONsmall cell - that grows very slowly (adenocarcinoma) It probably started in the middle of your military career. (But for them to put it in writing --OH NO... ) The doctor writes - Records wrong and Pt misinformed of diagnosis. NOT small cell. Is Adenocarcinoma. Important Differences explained to patient. But most of his other reports from the base kept saying NONsmall cell. People just write whatever and act like it doesn;t affect people's lives.. But keep on keeping on - and keep your eye on the prize. If they can get you to keep arguing a side issue -- then even if you win - it doesn't matter. They'll just say "You're right. Your anxiety didn't start in childhood. But your condition isn't worse." Not to say you don't want to ammend the record. Though doing so might also call attention to it. I think you actually have the right to have attachments put in medical records. Or governmental records. I know you can with Social Security. Kind of like you can with credit reports. If they WON'T change it. You can have your disagreement filed. And then every time they send the record with the statement you disagree with - they have to also send YOUR explaination. You might want to try that - if they won't change it. Write a small statement - Something like "I disagree with Dr. ___'s report that my anxiety has been present since childhood. I admitted to him, within what I thought was a trusting therapuetic professional relationship that I had been somewhat SHY as a child. However, this has nothing to do with the type of anxiety I have experienced since being in the military. I am adding this statement because I do not want doctor __'s statement to be misconstrued. I was somewhat shy as a child. However, I never experienced ant type of clinical anxiety, nor was I diagnosed with any type of anxiety, nor was I treated for any anxiety until ____." You might want to ask the pt advocate if you can add a statement. Again - you will have to weigh whether that will make things better (by explaning things) or worse (by calling attention to something that might be overlooked anyway). And yes - I would ask for a doctor I could trust. ANd maybe the DOCTOR would change the statement to one that couldn't be misconstrued so easily. Pt. reported some shyness as a child. However pt.'s anxiety did not begin until.... But VA-wise - I don;t think they can hold it against you - because there is no proof to back it up even if they wanted to. Free

I think a CUE would have to argue about the evidence in the record back then. But if he was not notified of the decision (and given the right to appeal that decision) then the decision would NOT be final - and therefore any NEW evidence CAN be added. I don't really know how they decide what level of disability you are at one point. I THINK they have to give you whatever rating you are given BACK to the date of the orginal filing. Maybe that is ONE good thing about them always taking so long on everything - is that by the time they finally make a decision - the vet is much worse - and gets a higher rating all the way back to filing. Heck - the new vets should realize that - file when you get out and by the time you make it all the way through the system you will be bad enough to get a decent rating - and it goes back to the 500 years ago that you filed. But I think on a CUE - they would look at did the evidence in the file at the time aupport the decision. But on a non-final decision -- or open claim -- which is basically what he can argue -- the current rating goes all the way back to the date of filing.. which is why they nitpic so much on them BUT I COULD BE WRONG!!! Free

I am not getting the actual link to the pdf to work - but this one was in my notes and if FROM: http://www.cavcbar.net/ Court of Appeals for Veterans Claims Bar Association PO Box 7992 Washington, DC 20044-7992 http://www.cavcbar.net/files/12571787.pdf Later, the veteran filed a motion with the BVA to vacate its 2002 decision on the ground that there was a violation of due process in the proceedings leading to the 2002 denial of benefits. This motion was filed pursuant to Section 20.904, which provides that [a]n appellate decision may be vacated by the Board . . . at any time upon request of the appellant . . . on the following grounds: (a) Denial of due process. Examples of circumstances in which denial of due process of law will be conceded are: (2) When a Statement of the Case or required Supplemental Statement of the Case was not provided, and (3) When there was a prejudicial failure to afford the appellant a personal hearing . . .

I'm thinking about it and reading - and I am not coming up with CUE. You are not attacking a the decision made (that there was an error in how they made the decision) as much as arguing the claim was still pending... for earlier effective date. You are basically appealing the decision that the effective date is Nov 2001 is in error - you are not claiming that the OLD decision was in error. Because it was NOT final... A CUE can make a final decision - UNfinal But I don't think you have to do that - which is good because they really twist around on the CUES. Again - what I think will be important to go through that the BVA said about the April Notice - is what occured to keep your claim Open from April -- Free

What I am having trouble understanding: 1. They denied your claim in April 2. They contiued the denial in July because of failure to appear at exam 3. You contacted the in August and said you would report to the exam 4. You went to exam in October 5. The denied again in November but did not notify you. (or there is no evidence they did.) QUESTIONS: IF they denied your case in April - what caused them to continue the denial in July for failure to appear at exam? It doesn't make sense that they would deny you - and then send you to an exam -UNLESS you appealed. No formal appeal was required yet - but what caused them to continue the denial It looks like the Board is saying that you weren't notified in November - BUT since you didn't appeal the April decision after being told that you could - the November thing doesn't matter. Welllll YESSSSSSSS - It DOES - But what I think would HELP the case is to address THAT point - about them saying there is NO evidence you were notified in November _ BUTTTTTTTTTTTT you were notified in April and informed of your appeal rights and did not appeal. Then why in the heck did they continue the appeal in June??? Why were they sending you for an Exam --if they had ALREADY denied you in a final decision. THAT is the point that makes your case OPEN - Don't let them get by with that "well he didn't appeal the april decision" stuff to try to say you had your opportunity to appeal and didn't take it.. So what happened between the April Decision and the June decision... Free

Hmmm. I was thinking that a CUE was more that the DECISION was made in error. You aren't appealing that the decision was in error. You are appealing that as you did not receive an SOC - the decision was NOT final. Does the other case on the CUE link MENTION that it is a CUE? Actually, if there are NONCUE wasys to argue it - it might be better - because CUE cases have different standards - and they are harder to win. I would think you would be APPEALING 1. THe rating 2. THe effective date of the award, but not based on a CUE (that an error was made in the decision --even if it was) but that the decision wasn't final - and therefore still pending when you filed in 2001. And again - there is a regualation that says they are supposed to split these. Meaning if you can show enough evidence for an increased rating - they can go ahead and grant that and start paying higher -NOT holding it up over the effective date....

I'm not an expert by any means but I would add a bit of how it Affects you in with it. Diagnostic Code 5243 IVDS gives a 40% rating for forward flexion (range of motion) of the thoracolumbar spine 30 degrees or less. Mine is 25 degrees. This causes me _____. Diagnostic Code 5243-8520 20% moderate incomplete paralysis sciatic nerve, left leg, ( this is pain shooting down the legs.) The pain in my legs ____ 20% moderate incomplete paralysis sciatic nerve, right leg. On the earlier effective date I would add in a bit more on WHY you considered it open. I was thinking you stated in another post that the BVA indicated that you were not notified of the decision - but that you had been denied earlier and had not appealed. Yet they said you were denied for not appearing for an exam - and you notified them and went to the exam. Did you write ANYTHING back then that should be CONSTRUED of a notice of disagreement. I would point that out. I was notified on ___ that ____. I contacted the VA to disagree with that decision as I was willing to go to the exam. The VA responded by sending me to the exam. However, after I disagred with the decision and appeared at the exam - I was not notified of any denial. I would point out some way, any way that you had disagreed with the decision - and that you were not notified after that - But since the VA did mention it - I would spell it out - how you DID disagree - and how THEY dropped the ball. Even to point out that as the LAST action the VA took was to send you for an exam - your case was opened THEN (why would they send you to an exam if you were already denied?") and that you did not hear from the VA again. I think they might have to PAY this one. THEY messed up. Dang. I remember reading a VA court case like this. Since the guy did NOT appeal an earlier decision - the BVA did the same thing - well, since he didn't appeal THEN, he wouldn't have appealed even if notified. The court said NO NO NO - you can NOT make assumptions about what someone would or would not have done. also - there is something in the M whatever manuals about EED on claims that states that they should go ahead and process the REST of the claim and not hold it ALL up on the EED decision. I think this might be important since the EED will probably have to go to the BVA - as THEY have already assumed you wouldn't have appealed even if notified. So you might want to put in - if you can find the reg - Under ___ I request that my claim for increased rating not be delayed -- Oh heck - I'm not thinking right -- but letting them know that you know you can get the increased rating NOW - and not have the whole dang thing held up for the EED.

As for me I submitted my request in June 2007. I didn't send it by certified mail, but I know they got it as I asked for an appointment to view the C-file and a copy of the C-file in the same letter. And I got my appointment to see the C-file. I think I better follow up on my request and REMIND them that I requested a copy IN WRITING at that time. Otherwise I will get stuck on the bottom of the pile. Chicago RO rountinely tells people that it will take at least 6 months after your request to get a copy of the file. They tell you that in writing. However, the letters just say "we are still working on it..." I am thinking that might get them out of the 10 days limit - as long as they keep contacting you with their we are still working on it letters. I haven't received those though - so I think my request got lost in the shuffle. I guess I better follow up on that. Free

Not sure at all. I also deal with Chicago. My husband requested his C-file August 2006. Had not received it when he died February 2007. But he had received several letters telling him that they were working on the request. I had to RE-request it after he died. Was told last June it would take at least 6 months to get a copy or an appointment. I got to SEE it in July (1 month after asking) - They give you an hour - with someone with you> She wrote down what I wanted to get copies of to send to me. But nothing has been sent yet. I have also not received the C-file either. But there standard answer is that it takes at LEAST 6 months. We have even sent in LIMITED requests (Please send me a copy of __specific thing). We have NEVERNEVERNEVER received anything we have requested. Maybe they just don't send people copies -- So if YOU find out = PLEASE let me Know. Geez - you have a certain amount of time to appeal something - and they won't even send you the information to show you what to appeal. Free

I lit a candle for your friend. The link will take you to the candle. I didn't know his initials - so I labled his candle VET :) So click on the candle that says VET. http://www.gratefulness.org/candles/view.c...g&c=5182955

I WISH YOU ENOUGH "I wish you enough sun to keep your attitude bright. I wish you enough rain to appreciate the sun more. I wish you enough happiness to keep your spirit alive. I wish you enough pain so that the smallest joys in life appear much bigger. I wish you enough gain to satisfy your wanting. I wish you enough loss to appreciate all that you possess. I wish enough "Hello's" to get you through the final "Goodbye." ~ Bob Perks

HERO GOING HOME So live your life that the fear of death can never enter your heart. Trouble no one about their religion; respect others in their view, and demand that they respect yours. Love your life, perfect your life, beautify all things in your life. Seek to make your life long and its purpose in the service of your people. Prepare a noble death song for the day when you go over the great divide. Always give a word or a sign of salute when meeting or passing a friend, even a stranger, when in a lonely place. Show respect to all people and grovel to none. When you arise in the morning give thanks for the food and for the joy of living. If you see no reason for giving thanks, the fault lies only in yourself. Abuse no one and no thing, for abuse turns the wise ones to fools and robs the spirit of its vision. When it comes your time to die, be not like those whose hearts are filled with the fear of death, so that when their time comes they weep and pray for a little more time to live their lives over again in a different way. Sing your death song and die like a hero going home. Chief Tecumseh (Crouching Tiger) Shawnee Nation 1768-1813

I bet that was upsetting. And you certainly want to get another doctor because it is hard to work with a doctor you don't trust. I imagine that as you are already 10% they have already established that your anxiety did not pre-date the service, so they might not even notice the remark. The sad thing is the VA so many times ignores the obvious - and focuses on the one tiny detail out of context, that vets have to read everything with an eye for that ONE thing they can take out of context and magnify. Unfortunately, when we have to spend our time worrying about this - they can get us side-tracked spending all our energy on the side issues - that even if we do PROVE them, we do not prove our case. Your case is for an increase. That should focus on how your condition has worsened and the way it affects you. They should not be able to take away your rating based on one comment that can't be supported. EVERYONE has some anxiety in childhood. But as you did not have anxiety that required treatment - it isn't a "condition" that pre-dated the service. You might want to hold off on spending big bucks for an IMO that would just show what has already been decided once for SC (that your anxiety was caused by / started in the service). Because they could just say - Yeah. We knew that. However it isn't an INCREASE. Do what you can - and what you feel you need to - about the unfair comment in your record - but keep your eye on the INCREASE - and don't let them pull you off course. My husband was in the hospital at the end of his life, fighting for his life. He chose to remain full code (wanting EVERYTHING done to save his life) until the very end. The hospital psychiatrist wrote "denies suicidal tendencies..." NO Kidding... Sometimes I think they just have their standard phrases which they babble out onto the paper in some kind of order... Free

Thanks to both of you! I learn something new every day! :) Free

http://www.warms.vba.va.gov/admin21/guide/...iciansguide.doc Chapter 14 - POST-TRAUMATIC STRESS DISORDER (PTSD) 14.1 What is PTSD? PTSD is a mental disorder that is a specific type of anxiety disorder that may result from a traumatic event such as combat, rape or other personal assault, natural disaster, accident, or other traumatic experience. DSM-III established the diagnosis of PTSD and set forth clear diagnostic criteria. DSM-IV provided revised diagnostic criteria. While this chapter plus the examination worksheets for PTSD provide considerable guidance on the diagnosis and assessment of PTSD, for more comprehensive information, see the booklet: “VA Practice Guideline for Post-Traumatic Stress Disorder Compensation and Pension Examinations.” 14.2 What causes PTSD? Research and clinical observations have demonstrated that the etiology is complex. The most relevant etiologic variables in the delayed and chronic forms are: a. Quantity and quality of traumatic stressors encountered. b. General psychosocial conditions prevailing in a war zone, e.g., unit integrity, tactical and strategic coherence of military operations, and clarity of purpose in the war. c. Homecoming experiences post-war, particularly adequacy of military, family, and community opportunities for debriefing and readjustment. d. Pre-existing traumatic incidents (make people more vulnerable to PTSD). e. Inherited biological factors 14.3 Why is establishing rapport at the onset of the interview critical? Since accurate diagnosis requires extended discussion of experiences, which may have been extremely traumatic, veterans, whether they have had little or no treatment or extensive treatment, may react strongly to the history taking and review of memories of the war or other stressor. Sensitivity, tact, and on-going assessment of the level of arousal are required. Opportunities for therapeutic interview may need to be assured. Repression, denial, and general haziness of memories are often hurdles in obtaining an adequate military history many years after service. Because of cultural and individual factors, some veterans may find it difficult to be forthcoming with the examiner. For these reasons, and the inherently painful quality of the traumatic material, it is crucial that the examiner place emphasis on avoiding an authoritarian role, avoiding judgmental interventions, and establishing rapport through an initial focus on current life experiences or other discussion which encourages comfort in the interview. It is often useful for both parties to discuss and become comfortable with the fact that the examiner may not have experienced the events lived through by the veteran. Such clarification of the initial status of both parties, though time-consuming, may ultimately produce the most accurate clinical data. 14.4 What are recommended guidelines for assessing trauma exposure? a. Objective. The objective of trauma assessment is to document whether the veteran was exposed to a traumatic event, during military service, of sufficient magnitude to meet the DSM-IV stressor criterion, described below. DSM-IV Stressor Criterion (A) The person has been exposed to a traumatic event in which both of the following have been present: 1. The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others 2. The person's response involved intense fear, helplessness, or horror. Compensation and pension examinations routinely address PTSD resulting from combat exposure. However, many other forms of military-related stress are sufficient to induce PTSD and should be reviewed among veterans applying for service-connected disability benefits. Non-combat forms of military-related trauma that are not uncommon include sexual assault or severe harassment; non-sexual physical assault, duties involved in graves registration or morgue assignment; accidents involving injury, death, or near death experiences; and experiences associated with peace-keeping deployments that meet the DSM-IV stressor criterion described above. Note. Adverse psychological reactions are often associated with stressful events that have the quality of being unpredictable and uncontrollable. Additionally, stressors that result in bodily injury, threat to life, tragic loss of a significant other, or involvement with brutality or the grotesque heighten risk for subsequent PTSD. Exposure to assaultive violence, particularly of a criminal nature, is more likely to induce PTSD than random "acts of God." It is known that severity of the stressor, in terms of intensity, frequency, and duration, is the most important trauma characteristic associated with subsequent development of PTSD. Factors surrounding the trauma incident, such as absence of social support for the victim, may also influence the degree to which a stressful event is experienced as psychologically traumatic, and may contribute to its potential for inducing psychiatric symptoms. b. Sources of information used in trauma assessment include: 1. VA Claims File 2. DD-214 3. medical records from VA, Department of Defense, and other health care facilities 4. statements from collaterals or others who have information about the veteran's trauma exposure and its behavioral sequelae 5. evidence of behavior changes that occurred shortly after the trauma incident 6. statements derived from interview of the claimant. c. Guidelines for interview assessment of trauma exposure. Initial examinations conducted for purposes of establishing a diagnosis of PTSD require clinician assessment of trauma exposure and documentation of findings. Provided below are guidelines: 1. Orientation of the claimant to trauma assessment. For initial examinations, explain to the claimant that it is necessary to obtain a detailed description of one or more traumatic events related to military service. Further, it is helpful to orient him/her to the fact that, although trauma assessment is brief (20-30 minutes), it is likely to cause some distress. The veteran should be advised that trauma assessment is a mutual and collaborative process, and that he/she is not required to answer in depth some questions, if it is too distressing to do so. 2. Documentation of trauma-related information. A detailed narrative description of the traumatic episode must be recorded in the report, including: a) the objective features of the traumatic event :) date and location of the stressor(s) c) names of individuals who witnessed or were involved in the traumatic incident d) individual decorations or medals received e) the veteran's subjective emotional reaction during and after the trauma and his/her behavioral response f) the veteran's perception of perceived consequences of the traumatic event, including abrupt changes in behavior g) names of health care facilities where trauma-related injuries were treated. 3. Suggested interview queries. Assessment of one or more personally relevant traumas proceeds after sufficient rapport has developed and some cursory details regarding the context of the trauma situation(s) have been gathered (e.g., branch of the military served in; events leading up to the traumatic situation). Provided below are questions that may then be asked of the veteran, if appropriate to the context of the trauma situation: Stem or lead inquiry: The Clinician Administered PTSD Scale (CAPS) strategy for assessing the stressor criterion is recommended for the initial inquiry about trauma exposure. This strategy involves the following sequence of orienting procedures and questions: Orienting statement: "I'm going to be asking you about some difficult or stressful things that sometimes happen to people. Some examples of this are being in some type of serious accident; being in a fire, a hurricane, or an earthquake; being mugged or beaten up or attacked with a weapon; or being forced to have sex when you didn't want to. I'll start by asking you to look over a list of experiences like this and check any that apply to you. Then, if any of them do apply to you, I'll ask you to briefly describe what happened and how you felt at the time. Some of these experiences may be hard to remember or may bring back uncomfortable memories or feelings. People often find that talking about them can be helpful, but it's up to you to decide how much you want to tell me. As we go along, if you find yourself becoming upset, let me know and we can slow down and talk about it. Do you have any questions before we start?” Administration of trauma exposure checklist: The CAPS 17-item trauma exposure checklist may be administered as a preliminary means of identifying exposure to different traumatic events. Detailed inquiry should follow positive endorsement of traumatic events, in order to clarify objective features of the stressor, using questions suggested below as appropriate: Were you wounded or injured? Did you witness others being killed, injured or wounded? Were you exposed to bodies that had been dismembered? About how many times were you exposed to [the traumatic event]? Was somebody important to you killed or seriously hurt during this situation? During the trauma, did the perpetrator coerce you into doing something against your will? (sexual assault) During the trauma, did the perpetrator threaten to injure you or kill you if you did not comply with their wishes? Did you believe there would be any other negative consequences to you if you did not comply with their intentions? (sexual assault) What did other people notice about your emotional response? What were the consequences or outcomes of this event? Did you receive any help, or talk to anyone, after this event occurred? Questions assessing subjective response to the stressor: Suggested inquiries for assessing subjective reactions to trauma exposure (DSM-IV criterion A.2) include: At the time the trauma was occurring, did you believe your life was threatened? Did you think you could be physically injured in this situation? At the time this occurred, how did you feel emotionally (fearful, horrified, helpless)? Were you stunned or in shock so that you didn't feel anything at all? Did you disconnect from the situation, like feeling that things weren't real or feeling like you were in a daze? Can you recall any bodily sensations you may have had at the time? Suggested inquiries if no events are endorsed on the CAPS trauma exposure checklist: Has there ever been a time in the military when your life was in danger or you were seriously injured or harmed? What about a time when you were threatened with death or serious injury, even if you weren't actually injured or harmed? What about witnessing something like this happen to someone else or finding out that it happened to someone close to you? What would you say are some of the most stressful experiences you had during the military which still upset you today? 4. Recommended Instruments for Trauma Assessment. The following instruments are useful in assessing objective features of trauma exposure. They should be administered only to clients who resemble the appropriate criterion group on which the instruments were developed. Responses to these instruments may be used as a stimulus for further interview inquiry or to guide the interview. Some instruments (e.g., the Combat Exposure Scale) provide sufficient information to make gross assessments of whether the individual was exposed to a "high," "moderate," or "low" degree of trauma. While helpful, use of these instruments is never sufficient, and must be accompanied by a narrative description of unique details of the veteran's traumatic experience. a) For infantryman and other ground troop personnel: Combat Exposure Scale B) For females serving in a war zone: Women’s Wartime Stressor Scale c) For Gulf War veterans: Desert Storm Trauma Exposure d) For veterans exposed to sexual assault: Brief Screening Questionnaire for Sexual Assault 14.5 How is PTSD assessed? a. Objective. Assessment of PTSD for compensation and pension purposes should: 1. establish the presence or absence of a diagnosis of PTSD 2. determine the severity of PTSD symptoms 3. establish a logical relationship between exposure to military stressors and current PTSD symptomatology. Thorough assessment of PTSD requires inquiry into the presence/absence of all 17 symptoms of the disorder, together with associated features articulated in DSM-IV. Objective and standardized assessment of PTSD will be enhanced by using a structured diagnostic interview schedule, as well as psychometric tests specially designed for PTSD assessment. Below is a recommended minimum core battery of PTSD measures to be used in compensation and pension settings, based on their established reliability and validity, ease of administration, and the fact that no fee is charged for their use. DSM-IV Diagnostic Criteria for PTSD A. The person has been exposed to a traumatic event. B. The traumatic event is persistently re-experienced in one (or more) of the following ways: 1. Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. 2. Recurrent distressing dreams of the event. 3. Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated). 4. Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event. 5. Physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event. C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following: 1. Efforts to avoid thoughts, feelings, or conversations associated with the trauma. 2. Efforts to avoid activities, places, or people that arouse recollections of the trauma. 3. Inability to recall an important aspect of the trauma. 4. Markedly diminished interest or participation in significant activities. 5. Feeling of detachment or estrangement from others. 6. Restricted range of affect (e.g., unable to have loving feelings). 7. Sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span). D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following: 1. Difficulty falling or staying asleep. 2. Irritability or outbursts of anger. 3. Difficulty concentrating. 4. Hypervigilance. 5. Exaggerated startle response. E. Duration of the disturbance (symptoms in Criteria B, C, and D) is more than 1 month. F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Specify if: Acute: if duration of symptoms is less than 3 months Chronic: if duration of symptoms is 3 months or more Specify if: With Delayed Onset: if onset of symptoms is at least 6 months after the stressor. b. Diagnostic interview assessment of PTSD. The CAPS is a structured clinical interview designed to assess the 17 symptoms of PTSD corresponding to DSM-IV criteria. The CAPS has a number of advantages over other diagnostic interview methods for PTSD, including 1. the use of explicit behavioral anchors as the basis for clinician ratings 2. separate scoring of frequency and intensity dimensions for each PTSD symptom 3. measurement of associated clinical features 4. assessment of the impact of PTSD symptoms on social and occupational functioning 5. ratings of the validity of information obtained. The CAPS requires approximately one hour to administer, although it can be customized and abbreviated by eliminating less relevant components. However, sites with limited clinical resources may consider using other interview-based diagnostic instruments for PTSD, which are somewhat briefer. These instruments include PTSD symptom Scale Structured Interview for PTSD Structured Clinical Interview for DSM-IV Anxiety Disorders Interview—Revised PTSD Interview. Although a modest amount of timesaving may result from using these alternative instruments, the information gleaned from them is typically not as comprehensive and, unlike the CAPS, there may be a charge associated with their use. 14.6 What is the recommended time allotment for completing examination? This guideline is designed to enhance the objectivity, reliability, and accuracy of PTSD examinations conducted in compensation and pension settings. Although the administration of the recommended assessment instruments requires additional clinician time, it is expected to result in improved quality and increased veteran satisfaction. Approximately three to four hours are required to conduct a comprehensive initial compensation and pension examination for PTSD. This includes 90 minutes for interview assessment of trauma stress exposure and PTSD symptoms plus an additional hour to complete other portions of the examination. An additional 1.5 hours is required for review of psychological testing materials and preparation of a report of findings. (These time estimates may be adjusted downward, depending on the availability of an independent social-industrial survey completed by a social worker.) 14.7 What mental health professionals are qualified to conduct Compensation and Pension examinations for PTSD? Professionals qualified to perform PTSD examinations should have doctoral-level training in psychopathology, diagnostic methods, and clinical interview methods. They should have a working knowledge of DSM-IV, as well as extensive clinical experience in diagnosing and treating veterans with PTSD. Ideally, examiners should be proficient in the use of structured clinical interview schedules for assessing PTSD and other disorders, as well as psychometric methods for assessing PTSD. Board certified psychiatrists and licensed psychologists have the requisite professional qualifications to conduct compensation and pension examinations for PTSD. Psychiatric residents and psychology interns are also qualified to perform these examinations, under close supervision of attending psychiatrists or psychologists. 14.8 What standardized psychometric tests are useful in PTSD? Psychometric assessment of PTSD provides quantitative assessment of degree of PTSD symptom severity. Judgments about symptom severity can be made by comparing an individual’s scores against norms established on reference samples of individuals who are known to have or not have PTSD. Cutting scores have been established for the psychometric measures of PTSD recommended here, based on their high sensitivity and specificity in discriminating individuals with PTSD from those without PTSD. Data from psychometric tests never serve as a “stand alone” means for diagnosing PTSD. Rather, the psychometric measures recommended here should be used to supplement and substantiate findings gleaned from interview assessment and other sources of data. The following psychometric instruments are recommended for inclusion in disability evaluations for PTSD: 1. Mississippi Scale for Combat-Related PTSD - for combat-exposed populations 2. PTSD Checklist - for individuals exposed to combat and non-combat trauma Alternatives include: 1. MMPI PTSD subscales 2. Impact of Event Scale—Revised 3. Penn Inventory 4. PTSD Stress Diagnostic Scale 5. Trauma Symptom Inventory. Additionally, many instruments (e.g., MMPI) exist for quantifying extent of symptoms of other disorders that often co-occur with PTSD, and should be considered for use as resources permit. The MMPI and MMPI-2 include scales known as “validity scales” that are elevated in people who are trying to exaggerate their symptoms. Use of the MMPI and MMPI-2 may help the evaluator determine test-taking style of the veteran (i.e., defensive, overendorsing, underendorsing). Cutoff scores for utilizing the MMPI-2 to assess validity of PTSD diagnosis have been reported in a number of research studies. In addition, MMPI-2 cutoff scores for specific PTSD scales (i.e., PK, PS) have been shown to be effective at assessing PTSD. 14.9 What is the differential diagnosis of PTSD? a. Personality Disorders. These disorders do not usually emerge without early signs in adolescence, and are rare in individuals with successful military careers. Therefore, the diagnosis of primary personality disorder requires the usual evidence of existence of these pathological traits prior to military duty. Certain features may be due either to personality disorder or to PTSD. These include: General alienation. Reluctance to talk to professionals. Violent outbursts and assaults. Intolerance or distrust of authority. Dysfunctional patterns of living. PTSD sometimes occurs concomitantly with a personality disorder. In this case careful assessment must be made of the etiology of specific symptoms and behaviors recorded. The more severe cases of PTSD may be confused with borderline personality because of regression to splitting mechanisms and severity of behavioral disruptions. Clear assessment of the childhood, adolescent, and pre-military young adult histories will indicate whether or not the pre-military picture is consistent with borderline problems. b. Substance Abuse. Substance abuse may pre-exist PTSD or may occur as a result of PTSD. Only a detailed examination of the history of the substance abuse, its relation or non-relation to PTSD symptoms and stressors, and an adequate examination of the history for such stressors, will permit a differentiation. c. Depression. However, depression may also be an associated feature of PTSD. Clinical reports and research suggest that depression is prominent in some cases as a manifestation of the stress disorder or as a result of impacted grief and mourning. Major depressive disorder, especially in women, can be a risk factor for increasing likelihood for PTSD. d. Schizophrenia. It is not uncommon to find cases of PTSD misdiagnosed as schizophrenia during the period prior to 1980. Presence or absence of formal thought disorder is often a helpful distinguishing feature. In severe cases of PTSD, the re-experiencing of traumatic events (flashbacks) seems to have hallucinatory quality. However, these may be distinguished from schizophrenic hallucinations by determining the content and noting whether it involves a repetition of the traumatic experiences. The constriction of affect sometimes seen in PTSD may resemble the flattened affect of schizophrenics. One distinguishing feature is that PTSD patients usually express considerable pain over their constricted affect and contrast it to their pre-war state, whereas schizophrenics manifest less dissatisfaction with the lack of emotions. 14.10 How can a stressor be documented? a. Validity of history. The diagnosis of PTSD is contingent on the experiencing of traumatic stressors. At times, the examiner may have questions about the degree of distortion or fabrication in the interview. The clinical picture of PTSD is relatively easy to fabricate on a superficial level but very difficult to fabricate in depth. Thus, the more detailed the history taking, the greater the validity. b. Documentation of traumatic experiences. 1. A study by the Social Work Service may assist in gathering information about a buddy or officer who might be contacted to help confirm or deny crucial statements about military operations or other events in specific localities. 2. Documentation from family, friends, and teachers concerning changes in the individual from pre- to post-service status may be helpful. Worksheet - INITIAL EVALUATION FOR POST-TRAUMATIC STRESS DISORDER (PTSD) Name: SSN: Date of Exam: C-number: Place of Exam: A. Identifying Information age ethnic background era of military service reason for referral (original exam to establish PTSD diagnosis and related psychosocial impairment; re-evaluation of status of existing service-connected PTSD condition) B. Sources of Information records reviewed (C-file, DD-214, medical records, other documentation) review of social-industrial survey completed by social worker statements from collaterals administration of psychometric tests and questionnaires (identify here) C. Review of Medical Records: 1. Past Medical History: a. Previous hospitalizations and outpatient care. b. Complete medical history is required, including history since discharge from military service. c. Review of Claims Folder is required on initial exams to establish or rule out the diagnosis. 2. Present Medical History - over the past one year. a. Frequency, severity and duration of medical and psychiatric symptoms. b. Length of remissions, to include capacity for adjustment during periods of remissions. D. Examination (Objective Findings): Address each of the following and fully describe: History (Subjective Complaints): Comment on: Preliminary History (refer to social-industrial survey if completed) * describe family structure and environment where raised (identify constellation of family members and quality of relationships) * quality of peer relationships and social adjustment (e.g., activities, achievements, athletic and/or extracurricular involvement, sexual involvements, etc.) * education obtained and performance in school * employment * legal infractions * delinquency or behavior conduct disturbances * substance use patterns * significant medical problems and treatments obtained * family psychiatric history * exposure to traumatic stressors (see CAPS trauma assessment checklist) * summary assessment of psychosocial adjustment and progression through developmental milestones (performance in employment or schooling, routine responsibilities of self-care, family role functioning, physical health, social/interpersonal relationships, recreation/leisure pursuits). Military History * branch of service (enlisted or drafted) * dates of service * dates and location of war zone duty and number of months stationed in war zone * Military Occupational Specialty (describe nature and duration of job(s) in war zone * highest rank obtained during service (rank at discharge if different) * type of discharge from military * describe routine combat stressors veterans was exposed to (refer to Combat Scale) * combat wounds sustained (describe) * CLEARLY DESCRIBE SPECIFIC STRESSOR EVENT(S) VETERAN CONSIDERED PARTICULARLY TRAUMATIC. clearly describe the stressor. Particularly if the stressor is a type of personal assault, including sexual assault, provide information, with examples, if possible. * indicate overall level of traumatic stress exposure (high, moderate, low) based on frequency and severity of incident exposure (refer to trauma assessment scale scores described in Appendix B). * citations or medals received * disciplinary infractions or other adjustment problems during military NOTE: Service connection for post-traumatic stress disorder (PTSD) requires medical evidence establishing a diagnosis of the condition that conforms to the diagnostic criteria of DSM-IV, credible supporting evidence that the claimed in-service stressor actually occurred, and a link, established by medical evidence, between current symptomatology and the claimed in-service stressor. It is the responsibility of the examiner to indicate the traumatic stressor leading to PTSD, if he or she makes the diagnosis of PTSD. Crucial in this description are specific details of the stressor, with names, dates, and places linked to the stressor, so that the rating specialist can confirm that the cited stressor occurred during active duty. A diagnosis of PTSD cannot be adequately documented or ruled out without obtaining a detailed military history and reviewing the claims folder. This means that initial review of the folder prior to examination, the history and examination itself, and the dictation for an examination initially establishing PTSD will often require more time than for examinations of other disorders. Ninety minutes to two hours on an initial exam is normal. Post-Military Trauma History (refer to social-industrial survey if completed) * describe post-military traumatic events (see CAPS trauma assessment checklist) * describe psychosocial consequences of post-military trauma exposure(s) (treatment received, disruption to work, adverse health consequences) Post-Military Psychosocial Adjustment (refer to social-industrial survey if completed) * legal history (DWIs, arrests, time spent in jail) * educational accomplishment * employment history (describe periods of employment and reasons) * marital and family relationships (including quality of relationships with children) * degree and quality of social relationships * activities and leisure pursuits * problematic substance abuse (lifetime and current) * significant medical disorders (resulting pain or disability; current medications) * treatment history for significant medical conditions, including hospitalizations * history of inpatient and/or outpatient psychiatric care (dates and conditions treated) * history of assaultiveness * history of suicide attempts * summary statement of current psychosocial functional status (performance in employment or schooling, routine responsibilities of self care, family role functioning, physical health, social/interpersonal relationships, recreation/leisure pursuits) E. Mental Status Examination Conduct a brief mental status examination aimed at screening for DSM-IV mental disorders. Describe and fully explain the existence, frequency and extent of the following signs and symptoms, or any others present, and relate how they interfere with employment and social functioning: * Impairment of thought process or communication. * Delusions, hallucinations and their persistence. * Eye Contact, interaction in session, and inappropriate behavior cited with examples. * Suicidal or homicidal thoughts, ideations or plans or intent. * Ability to maintain minimal personal hygiene and other basic activities of daily living. * Orientation to person, place and time. * Memory loss, or impairment (both short and long-term). * Obsessive or ritualistic behavior which interferes with routine activities and describe any found. * Rate and flow of speech and note any irrelevant, illogical, or obscure speech patterns and whether constant or intermittent. * Panic attacks noting the severity, duration, frequency and effect on independent functioning and whether clinically observed or good evidence of prior clinical or equivalent observation is shown. * Depression, depressed mood or anxiety. Impaired impulse control and its effect on motivation or mood. * Sleep impairment and describe extent it interferes with daytime activities. * Other disorders or symptoms and the extent they interfere with activities, particularly: mood disorders (especially major depression and dysthymia) substance use disorders (especially alcohol use disorders) anxiety disorders (especially panic disorder, obsessive-compulsive disorder, generalized anxiety disorder) somatoform disorders personality disorders (especially antisocial personality disorder and borderline personality disorder) Specify onset and duration of symptoms as acute, chronic, or with delayed onset. F. Assessment of PTSD * state whether or not the veteran meets the DSM-IV stressor criterion * identify behavioral, cognitive, social, affective, or somatic change veteran attributes to stress exposure * describe specific PTSD symptoms present (symptoms of trauma re-experiencing, avoidance/numbing, heightened physiological arousal, and associated features [e.g., disillusionment and demoralization]) * specify onset, duration, typical frequency, and severity of symptoms G. Psychometric Testing Results * provide psychological testing if deemed necessary * provide specific evaluation information required by the rating board or on a BVA Remand. * comment on validity of psychological test results * provide scores for PTSD psychometric assessments administered * state whether PTSD psychometric measures are consistent or inconsistent with a diagnosis of PTSD, based on normative data and established "cutting scores" (cutting scores that are consistent with or supportive of a PTSD diagnosis are as follows: PCL > 50; Mississippi Scale > 107; MMPI PTSD subscale a score > 28; MMPI code type: 2-8 or 2-7-8) * state degree of severity of PTSD symptoms based on psychometric data (mild, moderate, or severe) * describe findings from psychological tests measuring problems other than PTSD (MMPI, etc.) H. Diagnosis 1. The Diagnosis must conform to DSM-IV and be supported by the findings on the examination report. 2. If there are multiple mental disorders, delineate to the extent possible the symptoms associated with each and a discussion of relationship. 3. Evaluation is based on the effects of the signs and symptoms on occupational and social functioning. NOTE: VA is prohibited by statute, 38 U.S.C. § 1110, from paying compensation for a disability that is a result of the veteran’s own ALCOHOL OR DRUG ABUSE. However, when a veteran’s alcohol or drug abuse disability is secondary to or is caused or aggravated by a primary service-connected disorder, the veteran may be entitled to compensation. See Allen v. Principi, 237 F.3d 1368, 1381 (Fed. Cir. 2001). Therefore, it is important to determine the relationship, if any, between a service-connected disorder and a disability resulting from the veteran’s alcohol or drug abuse. I. Diagnostic Status Axis I disorders Axis II disorders Axis III disorders Axis IV (psychosocial and environmental problems) Axis V (GAF score - current) J. Global Assessment of Functioning (GAF): NOTE: The complete multi-axial format as specified by DSM-IV may be required by BVA REMAND or specifically requested by the rating specialist. If so, include the GAF score and note whether it refers to current functioning. A BVA REMAND may also request, in addition to an overall GAF score, that a separate GAF score be provided for each mental disorder present when there are multiple Axis I or Axis II diagnoses and not all are service-connected. If separate GAF scores can be given, an explanation and discussion of the rationale is needed. If it is not possible, an explanation as to why not is needed. (See the above note pertaining to alcohol or drug abuse, the effects of which cannot be used to assess the effects of a service-connected condition.) DSM-IV is only for application from 11/7/96 on. Therefore, when applicable note whether the diagnosis of PTSD was supportable under DSM-III-R prior to that date. The prior criteria under DSM-III-R are provided as an attachment. K. Capacity to Manage Financial Affairs Mental competency, for VA benefits purposes, refers only to the ability of the veteran to manage VA benefit payments in his or her own best interest, and not to any other subject. Mental incompetency, for VA benefits purposes, means that the veteran, because of injury or disease, is not capable of managing benefit payments in his or her best interest. In order to assist raters in making a legal determination as to competency, please address the following: What is the impact of injury or disease on the veteran's ability to manage his or her financial affairs, including consideration of such things as knowing the amount of his or her VA benefit payment, knowing the amounts and types of bills owed monthly, and handling the payment prudently? Does the veteran handle the money and pay the bills himself or herself? Based on your examination, do you believe that the veteran is capable of managing his or her financial affairs? Please provide examples to support your conclusion. If you believe a Social Work Service assessment is needed before you can give your opinion on the veteran's ability to manage his or her financial affairs, please explain why. L. Other Opinion: Furnish any other specific opinion requested by the rating board or BVA remand (furnish the complete rationale and citation of medical texts or treatise supporting opinion, if medical literature review was undertaken). If the requested opinion is medically not ascertainable on exam or testing please state WHY. If the requested opinion can not be expressed without resorting to speculation or making improbable assumptions say so, and explain why. If the opinion asks "... is it at least as likely as not..", fully explain the clinical findings and rationale for the opinion. M. Integrated Summary and Conclusions - Describe changes in PSYCHOSOCIAL FUNCTIONAL STATUS and QUALITY of LIFE following trauma exposure (performance in employment or schooling, routine responsibilities of self care, family role functioning, physical health, social/interpersonal relationships, recreation/leisure pursuits) - Describe linkage between PTSD symptoms and aforementioned changes in impairment in functional status and quality of life. Particularly in cases where a veteran is unemployed, specific details about the effects of PTSD and its symptoms on employment are especially important. - If possible, describe extent to which disorders other than PTSD (e.g., substance use disorders) are independently responsible for impairment in psychosocial adjustment and quality of life. If this is not possible, explain why (e.g., substance use had onset after PTSD and clearly is a means of coping with PTSD symptoms). - If possible, describe pre-trauma risk factors or characteristics that may have rendered the veteran vulnerable to developing PTSD subsequent to trauma exposure. - If possible, state prognosis for improvement of psychiatric condition and impairments in functional status. - Comment on whether veteran is capable of managing his or her financial affairs. Signature: Date: Worksheet - REVIEW EXAMINATION FOR POST-TRAUMATIC STRESS DISORDER (PTSD) Name: SSN: Date of Exam: C-number: Place of Exam: A. Review of Medical Records B. Medical History since last exam: Comments on: 1. Hospitalizations and outpatient care from the time between last rating examination to the present, UNLESS the purpose of this examination is to ESTABLISH service connection, then the complete medical history since discharge from military service is required. 2. Frequency, severity and duration of psychiatric symptoms. 3. Length of remissions from psychiatric symptoms, to include capacity for adjustment during periods of remissions. 4. Treatments including statement on effectiveness and side effects experienced. 5. SUBJECTIVE COMPLAINTS: Describe fully. C. Psychosocial Adjustment since the last exam 1. legal history (DWIs, arrests, time spent in jail) 2. educational accomplishment 3. extent of time lost from work over the past 12 month period and social impairment. If employed, identify current occupation and length of time at this job. If unemployed, note in COMPLAINTS whether veteran contends it is due to the effects of a mental disorder. Further indicate following DIAGNOSIS what factors, and objective findings support or rebut that contention. 4. marital and family relationships ( including quality of relationships with spouse and children) 5. degree and quality of social relationships 6. activities and leisure pursuits 7. problematic substance abuse 8. significant medical disorders (resulting pain or disability; current medications) 9. history of violence/assaultiveness 10. history of suicide attempts 11. summary statement of current psychosocial functional status (performance in employment or schooling, routine responsibilities of self care, family role functioning, physical health, social/interpersonal relationship, recreation/leisure pursuits) D. Mental Status Examination Conduct a BRIEF mental status examination aimed at screening for DSM-IV mental disorders. Describe and fully explain the existence, frequency and extent of the following signs and symptoms, or any others present, and relate how they interfere with employment and social functioning: 1. Impairment of thought process or communication. 2. Delusions, hallucinations and their persistence. 3. Eye Contact, interaction in session, and inappropriate behavior cited with examples. 4. Suicidal or homicidal thoughts, ideations or plans or intent. 5. Ability to maintain minimal personal hygiene and other basic activities of daily living. 6. Orientation to person, place, and time. 7. Memory loss, or impairment (both short and long-term). 8. Obsessive or ritualistic behavior which interferes with routine activities and describe any found. 9. Rate and flow of speech and note any irrelevant, illogical, or obscure speech patterns and whether constant or intermittent. 10. Panic attacks noting the severity, duration, frequency, and effect on independent functioning and whether clinically observed or good evidence of prior clinical or equivalent observation is shown. 11. Depression, depressed mood or anxiety. 12. Impaired impulse control and its effect on motivation or mood. 13. Sleep impairment and describe extent it interferes with daytime activities 14. Other disorders or symptoms and the extent they interfere with activities, particularly: a. mood disorders (especially major depression and dysthymia) b. substance use disorders (especially alcohol use disorders) c. anxiety disorders (especially panic disorder, obsessive-compulsive disorder, generalized anxiety disorder) d. somatoform disorders e. personality disorders (especially antisocial personality disorder and borderline personality disorder) E. Assessment of PTSD 1. state whether or not the veteran meets the DSM-IV stressor criterion 2. identify behavioral, cognitive, social, affective, or somatic symptoms veteran attributes to PTSD 3. describe specific PTSD symptoms present (symptoms of trauma re-experiencing, avoidance/numbing, heightened physiological arousal, and associated features [e.g., disillusionment and demoralization]) 4. specify typical frequency, and severity of symptoms F. Psychometric Testing Results 1. provide psychological testing if deemed necessary. 2. provide specific evaluation information required by the rating board or on a BVA Remand. 3. comment on validity of psychological test results 4. provide scores for PTSD psychometric assessments administered 5. state whether PTSD psychometric measures are consistent or inconsistent with a diagnosis of PTSD, based on normative data and established "cutting scores" (cutting scores that are consistent with or supportive of a PTSD diagnosis are as follows: PCL - not less than 50; Mississippi Scale - not less than 107; MMPI PTSD subscale a score greater than 28; MMPI code type: 2-8 or 2-7-8) 6. state degree of severity of PTSD symptoms based on psychometric data (mild, moderate, or severe) 7. describe findings from psychological tests measuring other than PTSD (MMPI, etc.) G. Diagnosis: 1. The Diagnosis must conform to DSM-IV and be supported by the findings on the examination report. 2. If there are multiple mental disorders, delineate to the extent possible the symptoms associated with each and a discussion of relationship. 3. Evaluation is based on the effects of the signs and symptoms on occupational and social functioning. NOTE: VA is prohibited by statute, 38 U.S.C. 1110, from paying compensation for a disability that is a result of the veteran's own ALCOHOL OR DRUG ABUSE. However, when a veteran's alcohol or drug abuse disability is secondary to or is caused or aggravated by a primary service-connected disorder, the veteran may be entitled to compensation. See Allen v. Principi, 237 F.3d 1368, 1381 (Fed. Cir. 2001). Therefore, it is important to determine the relationship, if any, between a service-connected disorder and a disability resulting from the veteran's alcohol or drug abuse. Unless alcohol or drug abuse is secondary to or is caused or aggravated by another mental disorder, you should separate, to the extent possible, the effects of the alcohol or drug abuse from the effects of the other mental disorder(s). If it is not possible to separate the effects in such cases, please explain why. H. Diagnostic Status Axis I disorders Axis II disorders Axis III disorders Axis IV (psychosocial and environmental problems) Axis V (GAF score - current) I. Global Assessment of Functioning (GAF): NOTE: The complete multi-axial format as specified by DSM-IV may be required by BVA REMAND or specifically requested by the rating specialist. If so, include the GAF score and note whether it refers to current functioning. A BVA REMAND may also request, in addition to an overall GAF score, that a separate GAF score be provided for each mental disorder present when there are multiple Axis I or Axis II diagnoses and not all are service- connected. If separate GAF scores can be given, an explanation and discussion of the rationale is needed. If it is not possible, an explanation as to why not is needed. (See the above note pertaining to alcohol or drug abuse.) J. Capacity to Manage Financial Affairs Mental competency, for VA benefits purposes, refers only to the ability of the veteran to manage VA benefit payments in his or her own best interest, and not to any other subject. Mental incompetency, for VA benefits purposes, means that the veteran, because of injury or disease, is not capable of managing benefit payments in his or her best interest. In order to assist raters in making a legal determination as to competency, please address the following: What is the impact of injury or disease on the veteran's ability to manage his or her financial affairs, including consideration of such things as knowing the amount of his or her VA benefit payment, knowing the amounts and types of bills owed monthly, and handling the payment prudently? Does the veteran handle the money and pay the bills himself or herself? Based on your examination, do you believe that the veteran is capable of managing his or her financial affairs? Please provide examples to support your conclusion. If you believe a Social Work Service assessment is needed before you can give your opinion on the veteran's ability to manage his or her financial affairs, please explain why. K. Other Opinion: Furnish any other specific opinion requested by the rating board or BVA remand (i.e., furnish the complete rationale and citation of medical texts or treatise supporting opinion, if medical literature review was undertaken). If the requested opinion is medically not ascertainable on exam or testing please state WHY. If the requested opinion can not be expressed without resorting to speculation or making improbable assumptions say so, and explain why. If the opinion asks "... is it at least as likely as not..", fully explain the clinical findings and rationale for the opinion. L. Integrated Summary and Conclusions 1. Describe changes in PSYCHOSOCIAL FUNCTIONAL STATUS and QUALITY of LIFE since the last exam (performance in employment or schooling, routine responsibilities of self care, family role functioning, physical health, social/interpersonal relationships, recreation/leisure pursuits) 2. Describe linkage between PTSD symptoms and aforementioned changes in impairment in functional status and quality of life. Particularly in cases where a veteran is unemployed, specific details about the effects of PTSD and its symptoms on employment are especially important. 3. If possible, describe extent to which disorders other than PTSD (e.g., substance use disorders) are independently responsible for impairment in psychosocial adjustment and quality of life. If this is not possible, explain why (e.g., substance use had onset after PTSD and clearly is a means of coping with PTSD symptoms). 4. If possible, state prognosis for improvement of psychiatric condition and impairments in functional status. 5. Comment on whether veteran is capable of managing his or her financial affairs. Signature: Date: