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Routine: DVBCWPE2

DVBCWPE2.m

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  1. DVBCWPE2 ;ESW/ PTSD WKS TEXT - 2 ; 10 Oct 2000
  1. ;;2.7;AMIE;**34**;Apr 10, 1995
  1. ;
  1. ;
  1. TXT ;
  1. ;;E. Assessment of PTSD
  1. ;;
  1. ;; * state whether or not the veteran meets the DSM-IV stressor criterion
  1. ;; * identify behavioral, cognitive, social, affective, or somatic symptoms
  1. ;; veteran attributes to PTSD
  1. ;; * describe specific PTSD symptoms present (symptoms of trauma
  1. ;; re-experiencing, avoidance/numbing, heightened physiological arousal,
  1. ;; and associated features [e.g., disillusionment and demoralization])
  1. ;; * specify typical frequency, and severity of symptoms
  1. ;;TOF
  1. ;;F. Psychometric Testing Results
  1. ;;
  1. ;; * provide psychological testing if deemed necessary.
  1. ;; * provide specific evaluation information required by the rating board or
  1. ;; on a BVA Remand.
  1. ;; * comment on validity of psychological test results
  1. ;; * provide scores for PTSD psychometric assessments administered
  1. ;; * state whether PTSD psychometric measures are consistent or inconsistent
  1. ;; with a diagnosis of PTSD, based on normative data and established
  1. ;; "cutting scores" (cutting scores that are consistent with or supportive
  1. ;; of a PTSD diagnosis are as follows: PCL - not less than 50;
  1. ;; Mississippi Scale - not less than 107; MMPI PTSD subscale a score
  1. ;; greater than 28; MMPI code type: 2-8 or 2-7-8)
  1. ;; * state degree of severity of PTSD symptoms based on psychometric data
  1. ;; (mild, moderate, or severe)
  1. ;; * describe findings from psychological tests measuring other than
  1. ;; PTSD (MMPI, etc.)
  1. ;;
  1. ;;G. Diagnosis:
  1. ;;
  1. ;; 1. The Diagnosis must conform to DSM-IV and be supported by the findings
  1. ;; on the examination report.
  1. ;; 2. If there are multiple mental disorders, delineate to the extent possible
  1. ;; the symptoms associated with each and a discussion of relationship.
  1. ;; 3. Evaluation is based on the effects of the signs and symptoms on
  1. ;; occupational and social functioning.
  1. ;;
  1. ;; NOTE: VA is prohibited by statute from paying compensation for a disability
  1. ;; that is a result of the veteran's own ALCOHOL OR DRUG ABUSE, whether based
  1. ;; on direct service connection, secondary service connection, or aggravation
  1. ;; by a service-connected condition. Therefore, when alcohol or drug abuse
  1. ;; accompanies or is associated with another mental disorder, separate,
  1. ;; to the extent possible, the effects of the alcohol or drug abuse from
  1. ;; the effects of the other mental disorder(s). If it is not possible
  1. ;; to separate the effects, explain why.
  1. ;;
  1. ;;H. Diagnostic Status
  1. ;;
  1. ;; Axis I disorders
  1. ;; Axis II disorders
  1. ;; Axis III disorders
  1. ;; Axis IV (psychosocial and environmental problems)
  1. ;; Axis V (GAF score - current)
  1. ;;
  1. ;;I. Global Assessment or Functioning (GAF):
  1. ;;
  1. ;; NOTE: The complete multi-axial format as specified by DSM-IV may be required
  1. ;; by BVA REMAND or specifically requested by the rating specialist. If so,
  1. ;; include the GAF score and note whether it refers to current functioning.
  1. ;; A BVA REMAND may also request, in addition to an overall GAF score,
  1. ;; that a separate GAF score be provided for each mental disorder present when
  1. ;; there are multiple Axis I or Axis II diagnoses and not all are service-
  1. ;; connected. If separate GAF scores can be given, an explanation and
  1. ;; discussion of the rationale is needed. If it is not possible, an explanation
  1. ;; as to why not is needed. (See the above note pertaining to alcohol or drug
  1. ;; abuse, the effects of which cannot be used to assess the effects of
  1. ;; a service-connected condition.)
  1. ;;
  1. ;;J. Competency:
  1. ;;
  1. ;; Competency, for benefits purposes, has a special meaning,
  1. ;; and refers ONLY to veterans' ability to manage benefit payments in their own
  1. ;; best interests without restriction, and not to any other subject. State
  1. ;; whether the veteran is capable of managing his/her or her benefit payments
  1. ;; in the individual's own best interests (a physical disability which prevents
  1. ;; the veteran from attending to financial matters in person is not a proper
  1. ;; basis for a finding of incompetency unless the veteran is, by reason of that
  1. ;; disability, incapable of directing someone else in handling the individual's
  1. ;; financial affairs).
  1. ;;
  1. ;;K. Other Opinion:
  1. ;;
  1. ;; Furnish any other specific opinion requested by the rating
  1. ;; board or BVA remand (i.e.,furnish the complete rationale and citation of
  1. ;; medical texts or treatise supporting opinion, if medical literature review
  1. ;; was undertaken). If the requested opinion is medically not ascertainable
  1. ;; on exam or testing please state WHY. If the requested opinion can not be
  1. ;; expressed without resorting to speculation or making improbable assumptions
  1. ;; say so, and explain why. If the Opinion asks "... is it at least as likely
  1. ;; as not..", fully explain the clinical findings and rationale for the opinion.
  1. ;;
  1. ;;L. Integrated Summary and Conclusions
  1. ;;
  1. ;; 1. Describe changes in PSYCHOSOCIAL FUNCTIONAL STATUS and QUALITY of LIFE
  1. ;; since the last exam (performance in employment or schooling, routine
  1. ;; responsibilities of self care, family role functioning, physical health,
  1. ;; social/interpersonal relationships, recreation/leisure pursuits)
  1. ;; 2. Describe linkage between PTSD symptoms and aforementioned changes in
  1. ;; impairment in functional status and quality of life.
  1. ;; Particularly in cases where a veteran is unemployed, specific details
  1. ;; about the effects of PTSD and its symptoms on employment are especially
  1. ;; important.
  1. ;; 3. If possible, describe extent to which disorders other than PTSD
  1. ;; (e.g., substance use disorders) are independently responsible for
  1. ;; impairment in psychosocial adjustment and quality of life. If this is not
  1. ;; possible, explain why (e.g., substance use had onset after PTSD
  1. ;; and clearly is a means of coping with PTSD symptoms).
  1. ;;TOF
  1. ;; 4. If possible, state prognosis for improvement of psychiatric condition
  1. ;; and impairments in functional status.
  1. ;; 5. Comment on whether veteran should be rated as competent for VA purposes
  1. ;; in terms of being capable of managing his/her benefit payments in his/her
  1. ;; own best interest.
  1. ;;
  1. ;;
  1. ;;Signature: Date:
  1. ;;END