"Fighting for Our Veterans-Supporting Our Troops"
Proudly Serving All Branches & All Eras Since 1999
Search Veterans' Voice Site Below
Entire web
Department of Veterans Affairs
Best Practice Manual for
Posttraumatic Stress Disorder (PTSD) Compensation and Pension Examinations
PDF File for download below:
CONTENTS
Executive Summary. .1
CORE DOCUMENT
I. Background Information: PTSD Initial Claims Review 5
II. Background Information: Assessment of PTSD. .7
III. Recommended Guidelines for Assessing
Trauma Exposure and PTSD . . . . . . . . . . . . . . .13
IV. Compensation and Pension PTSD disability
examination worksheets. . . . . . . . . . . . . . . . . . . . 23
A. Worksheet I: Initial Evaluation for PTSD . . . . . .23
B. Worksheet II: Review Evaluation for PTSD . . .31
V. Suggested Report Template for Initial Exam . . . . 37
VI. Suggested Report Template for Follow-up Exam . . 47
APPENDICES
A. Training Letter Based on PTSD Case Review . . . . 55
B. Governing Regulation for Service Connection for PTSD
(From 38 CFR Part 3) . . . . . . . . . . . . . . . . . . . . . . . . . . .65
C. Excerpts from Veterans Benefit Administration’s Adjudication
Procedures Manual concerning the adjudication
of claims for PTSD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .67
D. Detailed Guideline for Global Assessment of Functioning Scale . .73
E. Global Assessment of Functioning Scale . . . . . . . . . . . . . . . . . . 79
F. Scoring rules for Mississippi and PTSD checklist. . . . . . . . . . . . 81
G. Examples of PTSD Symptom Narratives in Compensation
and Pension Examination Reports . . . . . . . . . . . . . . . . . . . . . . .83
H. Social History Questionnaire. . . . . . . . . . . . . . . . . . . . . . . . . 109
I. References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
Compensation and Pension Examinations iii
References.................................................................................36
Copyright © National Academy of Sciences. All rights reserved.
Posttraumatic Stress Disorder: Diagnosis and Assessment
http://www.nap.edu/catalog/11674.html
What you'll find in the report:
Executive Summary
This document provides information on Posttraumatic Stress Disorder and currentrecommendations regarding what is known about “best practice” procedures for assessing PTSD among veteran populations.
A Veterans BenefitsAdministration (VBA) review of 143 initial claims for PTSD revealed that PTSD was diagnosed in 77% of the cases, that the exam was not adequate for rating in at least 8%, but that inadequate exams were not routinely returned for correction. A common problem was that the examiner did not describe how
Diagnostic and Statistical Manual for Mental Disorders-IV (DSM-IV) diagnostic criteria were met. Good exams delineated how the PTSD diagnostic criteria were met by giving specific examples. Other noted problems were the examiner using DSM-III rather than DSM-IV criteria, and the examiner sometimes failing to discuss whether other mental disorders that were diagnosed are due to or part of PTSD. The VBA and Veterans Health Administration (VHA) are committed to improving these services to veterans, and improving the quality of
compensation and pension examinations for PTSD.
Included in this manual are an assessment protocol based on best practices for assessing PTSD, and disability examination worksheets which correlate with the protocol. Included in the protocol are guidelines on:
I. Trauma Exposure Assessment
• The objective of trauma assessment
• DSM-IV Stressor Criterion
• Sources of information used in trauma assessment
• Guidelines for interview assessment of trauma exposure
• Orienting the claimant to trauma assessment
• Documentation of trauma-related information.
• Suggested interview queries
• Orienting statement
• Administration of the Clinician-Administered PTSD Scale (CAPS) Life Event Checklist
• Recommended Instruments for Trauma Assessment.
II. Assessment of PTSD
• Four objectives which should be addressed:
a. Establishing the presence or absence of a diagnosis of PTSD
b. Determining the severity of PTSD symptoms
c. Establishing a logical relationship between exposure to military
stressors and current PTSD symptomatology
d. Describing how PTSD symptoms impair social and occupational
Compensation and Pension Examinations
functioning and quality of life.
• DSM-IV Diagnostic Criteria for PTSD
• Diagnostic interview assessment of PTSD.
• Psychometric assessment of PTSD
III.Recommended Time Allotment for Completing Examination
• Initial PTSD compensation and pension evaluations typically require
about three hours, but complex cases may demand additional time.
• Follow-up evaluations usually require an hour to an hour and a half.
IV. Professionals Qualified to Conduct Compensation and Pension
Examinations for PTSD
The VHA encourages use of this protocol when examining veterans for compensation purposes to ensure that a detailed history is obtained from the veteran and a comprehensive evaluation is performed and documented.
Comprehensive report templates have also been included as guides when writing reports.
Also included in this manual as reference material are:
• The VBA training letter based on a PTSD case review
• The governing regulation from 38 CFR, Part 3 for Service Connection for PTSD
• Excerpts from VBA’s Adjudication Procedures manual concerning the adjudication of claims for PTSD
• Background research on PTSD and the Global Assessment of
Functioning (GAF)
• The GAF Scale
• Scoring rules for Mississippi and PTSD checklist
• Examples of trauma history and PTSD symptom narratives
• A social history questionnaire.
It is anticipated that this document will raise the quality and standards of PTSD Compensation and Pension (C&P) examinations. This increased quality will require increased time and expense allotted to the evaluation process.
Under current VA standards, with local and regional variations in time mandated for exams, clinical expertise, and resources, the examiners must use their discretion in selecting the most relevant information for completing a competent, comprehensive examination for PTSD.
The examination protocol can be accessed electronically through VA’s Veterans Health Information Systems and Technology Architecture (VISTA) computer system – formerly the Decentralized Hospital Computer System (DHCP).
2 Post-Traumatic Stress Disorder
Clinicians may receive assistance in accessing this protocol from C&P clerks,Information Resources Management (IRM) staff, chiefs of Health Administration Services (HAS), or other staff members, depending on the facility’s local organization.
