ptsd Va C & P Service Clinicians Guide

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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: