Disability Examination Worksheets
Initial Evaluation for Post-Traumatic Stress Disorder
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The following health care providers can perform
initial examinations for PTSD. a board-certified or board "eligible" psychiatrist; a licensed doctorate-level psychologist; a doctorate-level mental health provider under the close supervision of a board-certified or board eligible psychiatrist or licensed doctorate-level psychologist a psychiatry resident under close supervision of a board certified or board eligible psychiatrist or licensed doctorate-level psychologist; or a clinical or counseling psychologist completing a one-year internship or residency (for purposes of a doctorate-level degree) under close supervision of a board-certified or board eligible psychiatrist or licensed doctorate-level psychologist. 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:
- Past Medical History:
- Previous hospitalizations and outpatient care.
- Complete medical history is required, including history since
discharge from military service.
- Review of Claims Folder is required on initial exams to
establish or rule out the diagnosis.
- Present Medical History - over the past one year.
- Frequency, severity and duration of medical and psychiatric
symptoms.
- 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:
Premilitary 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
- substance use and consequences of substance use
- 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,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
- 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.
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
accomplishmentsjail
- 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
- substance use and consequences of substance use
- 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 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
- Rate and flow of speech (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
F. Assessment of PTSD
- identify the primary stressor or stressors
- state whether or not the stressor meets the DSM-IV stressor criterion
- identify behavioral, cognitive, social, affective, or somatic changes 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
- state whether or not the current symptoms are linked to the identified stressor or stressors
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 - not less that 50; Mississippi Scale - not
less than 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:
- The Diagnosis must conform to DSM-IV and be supported by the
findings on the examination report.
- If there are multiple mental disorders, discuss their relationship with PTSD.
- The 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) (If you do not have Microsoft Word software installed, you may download free viewer and reader software to view the case.)
. 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.
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.)
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
than 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.
N.
Effects of PTSD on Occupational and Social Functioning
Evaluation of PTSD is based on its effects on occupational and social functioning. Select the appropriate assessment of the veteran from the choices below:
- Total occupational and social impairment due to PTSD signs and symptoms.
Provide examples and pertinent symptoms, including those already reported.
OR
- PTSD signs and symptoms result in deficiencies in most of the following areas: work, school, family relations, judgment, thinking, and mood.
Provide examples and pertinent symptoms, including those already reported for each affected area.
OR
- There is reduced reliability and productivity due to PTSD signs and symptoms.
Provide examples and pertinent symptoms, including those already reported.
OR
- There is occasional decrease in work efficiency or there are intermittent periods of inability to perform occupational tasks due to signs and symptoms, but generally satisfactory functioning (routine behavior, self-care, and conversation normal).
Provide examples and pertinent symptoms, including those already reported.
OR
- There are PTSD signs and symptoms that are transient or mild and decrease work efficiency and ability to perform occupational tasks only during periods of significant stress.
Provide examples and pertinent symptoms, including those already reported.
OR
- PTSD symptoms require continuous medication
OR
- Select all that apply:
- PTSD symptoms are not severe enough to require continuous medication.
- PTSD symptoms are not severe enough to interfere with occupational and social functioning.
Include your name; your credentials (i.e., a board certified
psychiatrist, a licensed psychologist, a psychiatry resident or a psychology
intern); and circumstances under which you performed the examination, if
applicable (i.e., under the close supervision of an attending psychiatrist or
psychologist); include name of supervising psychiatrist or psychologist.
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Reviewed/Updated Date: December 15, 2008 |
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