ptsd Va C & P Service Clinicians Guide

[free_spirit_etc]

http://www.warms.vba.va.gov/admin21/guide/...iciansguide.doc

Chapter 13 - MENTAL DISORDERS

13.1 What general information should be provided in examinations for mental disorders?

Information required for a disability evaluation of a psychiatric disorder (or an alleged psychiatric disorder) is essentially no more extensive than a discerning examiner would want for his/her own use in an adequate understanding of a patient. The evaluation requires a report that sets forth a clear and complete word picture of the patient as a whole person, what he/she is like, and how able he/she is to take care of himself/herself and earn a living. The examination worksheets describe the specific requirements for a disability examination for mental disorders. This material supplements them. Specifically, the examination report should include:

a. Complaints in a veteran’s own words, recorded between quotation marks. The presenting problems, when symptoms began, their course (chronological evolution).

b. Information covering behavior, attitudes, and general health prior to onset of present illness.

c. A detailed military history: Where served, combat, when, wounds, decorations, names of units where served.

d. A description of the symptoms, subjective and objective, upon which the diagnosis is based.

e. An occupational history as it relates to the veteran’s adjustment to his/her work: Pre-service social, employment, and educational history.

f. A definitive diagnosis or diagnoses, based on whole history and current examination. (If the diagnosis of a psychosis is made, always qualify by stating “active,” “in full remission”, or “in partial remission.”) Terminology and the basis of the diagnosis must conform to the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association (DSM-IV); otherwise the report will be returned. The report should explain how the veteran meets the DSM-IV diagnostic criteria for the mental disorder(s) diagnosed.

g. An opinion as to mental competency.

h. A discussion of social functioning.

i. A complete multiaxial assessment should be provided in all cases.

13.2 What constitutes a good longitudinal psychiatric history?

a. A detailed history is essential in psychiatric disorders. It should be developed and recorded in full if the examination is an initial one, and in re-examinations it should bridge the period since the preceding examination.

b. It is sometimes insufficient to rely entirely upon the history given by the veteran. A study by a social worker should be requested, if necessary. The problem involved, and the period or area requiring clarification, should be clearly indicated

c. The examiner should not be tempted into making a spot diagnosis on impressions of the moment. Determining whether a disability is developmental or not cannot be made without a longitudinal study.

d. The examiner must have a fair estimate of the personality development, knowledge of all previous illnesses, injuries, residual conditions, other impairments, and a chronological picture of the evolution of the current psychiatric disorder; so that the present condition and disability can be viewed in its proper perspective.

13.3 What indicates the level of social and occupational functioning?

a. Of first importance in the consideration of social and occupational functioning is a chronological social and occupational history covering the period since the most recent of any previous reports.

b. Taking into account the economic conditions generally prevailing in the veteran’s community, indicators of adequate social and occupational functioning, partial or complete, include the ability to hold employment continuously; the showing of efforts to advance one’s self; satisfactory adjustment to superiors and fellow workers; conformance to social standards of the environment; the absence of eccentricities of behavior or gross errors in judgment; and freedom from the necessity of supervision.

c. On the other hand, a history of no real attempt to secure available employment, or a history of frequently interrupted employment plus evidence of defective judgment, abnormalities in behavior, emotional lability, poor community adjustment, or antisocial tendencies, are evidences of poor social and occupational functioning and should be recorded.

d. Social integration is one of the best evidences of mental health and reflects the ability to establish (together with the desire to establish) healthy and effective interpersonal relationships. Poor contact with other human beings may be an index of emotional illness.

13.4 What are disability evaluations based on?

a. Disability evaluations by raters in the VBA regional offices are based primarily on a combination of the signs and symptoms of the mental health disorder and their effects on social and occupational functioning.

b. Raters consider the extent of social impairment, but do not assign an evaluation solely on the basis of social impairment. Impaired social functioning is important for rating purposes primarily as it affects occupational functioning.

c. Unemployment because of such extrinsic factors as economic depression, dissatisfaction with work environment, or domestic difficulties is not an indication of occupational impairment.

13.5 What information should be provided to support the diagnosis?

A disability evaluation cannot be made merely on the basis of the diagnosis. The diagnosis must be supported by the history and examination findings. For adequate justification for the diagnosis, the examiner should consider the following and record all information of importance concerning them:

a. Chronological historical medical, social, occupational, and military data.

b. Clearly and fully detailed symptomatology. The examiner will usually need to include in the examination report a statement covering the following main topics:

Appearance, attitude, and behavior.

Stream of talk and mental activity.

Emotional reactions and mood tendencies.

Content of special preoccupations.

Sensorium and intellectual resources.

c. Sufficient data upon which the differential diagnosis can be made.

d. Hospital study in cases where indicated.

e. The existence of an underlying organic condition that may cause the psychiatric symptoms.

f. Resolution of any inconsistencies between findings of specialists.

g. Necessity for social work service study.

h. Indication for psychological evaluation and results of any psychological tests conducted, to be correlated with other findings.

i. Conference with other examiners in the examining unit, if needed.

j. A diagnosis must never be made solely by exclusion. In other words the absence of physical findings is not in itself sufficient to justify a psychiatric diagnosis, nor does the mere suspicion on the part of the physician that the symptoms are functional warrant a positive psychiatric diagnosis.

13.6 How should the current diagnosis be related to previous diagnoses?

In the interpretation of the veteran’s history and behavior, the examiner should be familiar with previous diagnostic interpretations. One cannot presume that the initial diagnosis, for example in the service medical records, is correct.

a. Care is required before changing a diagnosis previously established, especially on more than one occasion, by the same or different psychiatrists.

b. Whenever the history and findings of the examination do not confirm a diagnosis that has been previously made, the examiner should record the diagnosis which, in his/her opinion is justified on the basis of all the evidence, but should relate a current diagnosis to a former one, so that the rating boards may clearly understand whether:

A current diagnosis corrects an old (erroneous) one.

A current diagnosis represents a mere change in nomenclature. Include diagnosis from the old and new Diagnostic Statistical Manuals.

A current diagnosis reflects a new phase or later development of a condition formerly diagnosed differently.

A current diagnosis represents a new clinical entity not related to an earlier diagnostic entity.

c. An examination report which is the basis for a diagnostic conclusion of “No disease, following observation (or careful examination) for psychiatric disorder” should reflect the same careful consideration and thorough examination as required for the diagnosis of a psychiatric disease.

d. The examiner is frequently confronted with the absence of any present findings attributable to a disorder previously reported. If he/she is of the opinion that the subsequent course disproves the earlier diagnosis, he/she should so state. If the examiner reaches the conclusion that the formerly diagnosed condition actually existed at some earlier date but that the veteran has recovered, he/she should so state. In either case, reasons for such a conclusion must be recorded.

e. A previously recorded diagnosis, if different from the currently accepted terminology, will be parenthesized after the current diagnosis. If the current diagnosis represents an entirely different category of disorder, you will need to provide a summary of the pertinent evidence to support it.

13.7 How should developmental or congenital conditions be reported?

Distinction must be made between conditions due to disease or injury and conditions which are of developmental or congenital origin. Primary personality disorders and disorders of intelligence should be fully described and classified.

13.8 How and why should an examiner consider mental incompetency?

a. Incompetence for VA purposes is defined in section 3.353(a) of title 38, Code of Federal Regulations, as follows: “A mentally incompetent person is one who because of injury or disease lacks the mental capacity to contract or to manage his or her own affairs, including disbursement of funds without limitation.” This is a determination ultimately to be made by the VBA rater based on all evidence of record. However, the examiner’s assessment regarding incompetency is important and should be reported for two reasons:

as a factor in measuring the relative disability.

to assist in determining the propriety of payments of monetary awards directly to the veteran or to a guardian appointed by a court.

b. While an opinion of incompetency frequently follows a determination that a veteran is psychotic, this is not always true, so a distinction should be recognized between a psychosis as a mental disorder and incompetency as an existing fact.

c. A determination of incompetency will be based upon affirmative answers to these questions:

Is the individual incapable of administering his/her personal affairs?

Is there definite evidence of a more or less prolonged departure from normal behavior as compared with the social standards of the community indicated by such things as dissipation of funds, irresponsibility toward personal and financial obligations, and lack of appreciation of values?

13.9 What pertinent information is available in the claim file and medical folder?

The claim file and medical folder may be useful to show:

chronological medical, social, and occupational history (including social study, if made).

the basis for previous diagnoses.

previous ratings.

13.10 What constitutes a good psychiatric examination?

a. A review of the physical status, particularly with somatic complaints (including a brief neurological survey) is not only of value to the examiner but reassures the veteran that he/ she has had complete medical attention, even if a physical examination, including neurological examination, is already of record.

b. A detailed history as described in paragraph 13.2.

c. The examiner does two things at the same time—participates in the interview, and observes general appearance, behavior, and speech production (noting emotional, intellectual, and physiological reactions). The quality of the patient-doctor relationship established and the extent to which the veteran feels accepted and understood will markedly affect his/her feeling toward the final rating decision.

d. Knowledge of pertinent data in the claim file and medical record file and skill in interviewing and understanding the objectives are both essential to an examination.

e. The following psychiatric interview technique is offered as a suggestion only, since most examiners have their own methods of eliciting information to be used as a basis for diagnostic classification and evaluation:

1) Begin by asking the veteran to relate everything that is troubling him/her. Permit the veteran to give a full spontaneous account of the symptoms and difficulties. Ask no leading questions except in instances where it is apparent that a psychotic process is present. Record verbatim a few representative statements and all complaints.

2) After the veteran has finished an uninterrupted story, inquire what else troubles him/her.

3) Probe each symptom and how long it is present. Note the severity and whether it is persistent or intermittent. Describe its influence or effect upon total functioning, including relationship with others, work, and financial security.

4) Inquire what the veteran has done about his/her symptoms. What factors aggravate and what factors diminish the symptoms?

5) Has the veteran been thoroughly examined previously? What has he/she been told?

6) Inquire what the veteran thinks is behind the symptoms—the cause of them. Did they follow some stress? (Precipitating factors.)

7) Determine how the veteran felt about him/herself before the onset of the present trouble.

8) While the veteran is relating the story, formulate your impression concerning the following points:

(a) How much discomfort or trouble does the veteran seem to be having as a result of the symptoms?

(:) Is the emotional display consistent with the symptoms?

© Does the veteran seem to be exaggerating?

(d) Is the veteran apprehensive or anxious? (Note objective signs of anxiety.)

(e) Consider the question of emotional immaturity, a pathological personality, or a disorder of intelligence. (Request psychological consultation if certain tests may be expected to contribute to an understanding of the disorder).

(f) The extent of impairment of insight and judgment.

f. The eliciting of information through the interview, plus an interpretation of the material contained in the claim file and medical record file, an evaluation of a social study (if one has been made), and an assessment of special tests, should furnish the examiner with sufficient facts to provide a comprehensive report.

13.11 What is the value of and best way to use the Social Work Service?

a. A study by the social work service examines significant experiences related to family interrelationships, education, psychosexual development, employment, military history, and the onset of medical or psychiatric problems. They are examined in terms of their effect on the veteran’s psychosocial development and functioning.

b. The social study will assist the examiner in developing an appropriate diagnosis; in evaluating the degree of social, psychological, and industrial impairment; and in assessing the veteran’s potential for improved social functioning and employment.

c. A social study can help to clarify:

The nature and sequence of events that may have affected the veteran’s life.

The physical and social situation, and especially the interpersonal relationships, past and present, that have perceptibly affected him/her.

Social and psychological situations that may have brought out abnormal functioning which has a bearing on the cause and nature of the veteran’s maladjustment.

Information about the veteran’s behavior patterns.

Response to stressful situations.

Competency .

d. Social data are particularly useful in helping the examiner solve diagnostic problems such as differentiating between a transient personality reaction to an acute or special stress and an anxiety or other type psychiatric disorder; determining the significance of addiction to alcohol or drugs; indicating the existence of delusional trends, and determining what continuity of symptoms has existed over periods during which there have been conflicting diagnoses.

e. A social study may focus on the psychogenic factors in an illness where the obvious symptoms may be the disordered function of an organ or system of the body.

f. Finally, the social study may provide additional information concerning the veteran’s readiness for treatment and potential for response to treatment.

13.12 How can psychological tests help?

The use of some of the many objective and projective psychological tests can aid the examiner materially in making a complete diagnostic evaluation. Although the test findings are not a substitute for a psychiatric examination, they can provide many corroborative facts through investigating the presence, extent, and severity of symptoms. Further insight into sources of anxiety and unconscious conflicts as well as descriptions of characteristic defense reactions to stress and frustration can be secured. Additional facts concerning the veteran’s motivation, goals, aspirations, needs, and attitudes can also be obtained.

a. Psychological tests can aid in the differential diagnosis of

psychiatric and neurological disorders and reactions

psychoses and anxiety and personality disorders

psychotic and anxiety disorders

mental retardation and schizophrenia

mental retardation and organic brain disease.

b. Various tests can be used to delineate some of the veteran’s outstanding personality traits and modes of expressions, such as:

emotional responsiveness and control

the degree and quality of ideational activity

the degree to which he/she functions within the limits of capacity without undue inner tension or stress.

c. Tests can determine the differential effects of organic brain damage and psychiatric illness upon the psychological functions, such as memory, perception, and reasoning, as well as the degree of impairment.

d. Facts concerning the potential and resources of the veteran which are useful in judging the likelihood of improvement or recovery can also be provided.

13.13 Consultations

An examination by an appropriate consultant may be required in cases where there is the possibility of an organic condition being either a cause or a result of a psychiatric disorder.

Worksheet - EATING DISORDERS (Mental Disorders)

Name: SSN:

Date of Exam: C-number:

Place of Exam

A. Review of Medical Records:

B. Medical History (Subjective Complaints):

Comment on:

1. Past Medical History:

a. Previous hospitalizations and outpatient care for parenteral nutrition or tube

feeding.

b. Medical and occupational history from the time between the last such rating

examination and the present needs to be accounted for, UNLESS the purpose

of this examination is to ESTABLISH service connection, then a complete

medical history since discharge from military service is required.

c. Periods of incapacitation (during which bedrest and treatment by a physician

are required due to the eating disorder). Describe the frequency and duration.

d. Current treatment, response, side effects.

2. Present Medical, Occupational and Social History - over the past one year.

a. History of onset of eating disorder.

b. Its course, treatment, and current status to include symptoms.

c. 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.

3. Subjective Complaints:

a. Describe fully.

C. Examination (Objective Findings):

Address each of the following and fully describe:

1. Mental status exam to confirm or establish diagnosis in accordance with DSM-IV.

2. Additionally, please provide this specific information: a. Current weight.

b. Expected minimum weight based on age, height, and body build.

c. Obtain weight history.

3. Additionally, to allow evaluation by the rating specialist, describe and fully explain the

existence, frequency, and extent of the following signs and symptoms and relate how

they interfere with employment:

a. Binge eating.

b. Self-induced vomiting or other measure to prevent weight gain when weight is

already below expected minimum normal weight.

D. Diagnostic Tests (including psychological testing if deemed necessary):

1. Provide specific evaluation information required by the rating board or on a BVA

Remand. Diagnostic Tests (See the examination request remarks for specifics.):

a. Competency: State whether the veteran is capable of managing his or her

benefit payments in the individual's own best interests (a physical disability

which prevents the veteran from attending to financial matters in person is not a

proper basis for a finding of incompetency unless the veteran is, by reason of

that disability, incapable of directing someone else in handling the individual's

financial affairs).

b. Other Opinion: Furnish any other specific opinion requested by the

rating board or BVA Remand furnishing 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.

2. Include results of all diagnostic and clinical tests conducted in the examination report.

E. Diagnosis:

Signature: Date:

Worksheet - MENTAL DISORDERS (except PTSD and Eating Disorders)

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A: Review of Medical Records:

B. Medical History (Subjective Complaints):

Comment on:

1. Past Medical History:

a. Previous hospitalizations and outpatient care.

b. Medical and occupational history from the time between last rating examination and 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. Present Medical, Occupational, and Social History - over the past one year.

a. Frequency, severity and duration of psychiatric symptoms.

b. Length of remissions, to include capacity for adjustment during periods of

remissions.

c. 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.

d. Treatments including statement on effectiveness and side effects experienced.

3. Subjective Complaints:

a. Describe fully.

C. Examination (Objective Findings):

Address each of the following and fully describe:

1. Mental status exam to confirm or establish diagnosis in accordance with DSM-IV.

2. Additionally, to allow evaluation by the rating specialist, 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:

a. Impairment of thought process or communication.

b. Delusions, hallucinations and their persistence.

c. Inappropriate behavior cited with examples.

d. Suicidal or homicidal thoughts, ideations or plans or intent.

e. Ability to maintain minimal personal hygiene and other basic activities of daily

living.

f. Orientation to person, place and time.

g. Memory loss or impairment (both short and/or long term).

h. Obsessive or ritualistic behavior which interferes with routine activities

(describe with examples).

i. Rate and flow of speech and note irrelevant, illogical, or obscure speech

patterns and whether constant or intermittent.

j. 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.

k. Depression, depressed mood or anxiety.

l. Impaired impulse control and its effect on motivation or mood.

m. Sleep impairment and describe extent it interferes with daytime activities.

n. Other symptoms and the extent to which they interfere with activities.

D. Diagnostic Tests:

1. Provide psychological testing if deemed necessary.

2. If testing is requested, the results must be reported and considered in arriving at the

diagnosis.

3. Provide any specific evaluation information required by the rating board or on

BVA Remand (in claims folder).

a. 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.

b. Other Opinion: Furnish any other specific opinion requested by the

rating board or BVA Remand furnishing 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 indicate 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.

4. Include results of all diagnostic and clinical tests conducted in the examination report.

E. Diagnosis:

Provide:

1. The Diagnosis must conform to DSM-IV and be supported by the findings on the

examination report.

2. If the diagnosis is changed, explain fully whether the new diagnosis represents a

progression of the prior diagnosis or development of a new and separate condition.

3. If there are multiple mental disorders, delineate to the extent possible the symptoms

associated with each and a discussion of relationship.

4. 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.

F. 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.)

Signature: Date:

[lu12]

http://www.warms.vba.va.gov/admin21/guide/...iciansguide.doc

Chapter 13 - MENTAL DISORDERS

://www.warms.vba.va.gov/admin21/guide/...iciansguide.doc

Chapter 14 - POST-TRAUMATIC STRESS DISORDER (PTSD)

14.1 What is PTSD?

Free_Spirit_etc (FSE)

Thank you, you just make my day as for about this mental issues. and information you have posted. Now and again I feel more comfortable in regards to my 1998 MDD, Dysthymia and the 2000 PTSD Dx's.

MGB,

LU12