- DVBCWPE2 ;ESW/ PTSD WKS TEXT - 2 ; 10 Oct 2000
- ;;2.7;AMIE;**34**;Apr 10, 1995
- ;
- ;
- TXT ;
- ;;E. Assessment of PTSD
- ;;
- ;; * state whether or not the veteran meets the DSM-IV stressor criterion
- ;; * identify behavioral, cognitive, social, affective, or somatic symptoms
- ;; veteran attributes to PTSD
- ;; * describe specific PTSD symptoms present (symptoms of trauma
- ;; re-experiencing, avoidance/numbing, heightened physiological arousal,
- ;; and associated features [e.g., disillusionment and demoralization])
- ;; * specify typical frequency, and severity of symptoms
- ;;TOF
- ;;F. 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 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)
- ;; * state degree of severity of PTSD symptoms based on psychometric data
- ;; (mild, moderate, or severe)
- ;; * 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 from paying compensation for a disability
- ;; that is a result of the veteran's own ALCOHOL OR DRUG ABUSE, whether based
- ;; on direct service connection, secondary service connection, or aggravation
- ;; by a service-connected condition. Therefore, when alcohol or drug abuse
- ;; accompanies or is associated with another mental disorder, 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, 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 or 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.)
- ;;
- ;;J. Competency:
- ;;
- ;; Competency, for benefits purposes, has a special meaning,
- ;; and refers ONLY to veterans' ability to manage benefit payments in their own
- ;; best interests without restriction, and not to any other subject. State
- ;; whether the veteran is capable of managing his/her 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).
- ;;
- ;;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).
- ;;TOF
- ;; 4. If possible, state prognosis for improvement of psychiatric condition
- ;; and impairments in functional status.
- ;; 5. Comment on whether veteran should be rated as competent for VA purposes
- ;; in terms of being capable of managing his/her benefit payments in his/her
- ;; own best interest.
- ;;
- ;;
- ;;Signature: Date:
- ;;END
- --- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCWPE2 6620 printed Jan 18, 2025@02:54:29 Page 2
- DVBCWPE2 ;ESW/ PTSD WKS TEXT - 2 ; 10 Oct 2000
- +1 ;;2.7;AMIE;**34**;Apr 10, 1995
- +2 ;
- +3 ;
- TXT ;
- +1 ;;E. Assessment of PTSD
- +2 ;;
- +3 ;; * state whether or not the veteran meets the DSM-IV stressor criterion
- +4 ;; * identify behavioral, cognitive, social, affective, or somatic symptoms
- +5 ;; veteran attributes to PTSD
- +6 ;; * describe specific PTSD symptoms present (symptoms of trauma
- +7 ;; re-experiencing, avoidance/numbing, heightened physiological arousal,
- +8 ;; and associated features [e.g., disillusionment and demoralization])
- +9 ;; * specify typical frequency, and severity of symptoms
- +10 ;;TOF
- +11 ;;F. Psychometric Testing Results
- +12 ;;
- +13 ;; * provide psychological testing if deemed necessary.
- +14 ;; * provide specific evaluation information required by the rating board or
- +15 ;; on a BVA Remand.
- +16 ;; * comment on validity of psychological test results
- +17 ;; * provide scores for PTSD psychometric assessments administered
- +18 ;; * state whether PTSD psychometric measures are consistent or inconsistent
- +19 ;; with a diagnosis of PTSD, based on normative data and established
- +20 ;; "cutting scores" (cutting scores that are consistent with or supportive
- +21 ;; of a PTSD diagnosis are as follows: PCL - not less than 50;
- +22 ;; Mississippi Scale - not less than 107; MMPI PTSD subscale a score
- +23 ;; greater than 28; MMPI code type: 2-8 or 2-7-8)
- +24 ;; * state degree of severity of PTSD symptoms based on psychometric data
- +25 ;; (mild, moderate, or severe)
- +26 ;; * describe findings from psychological tests measuring other than
- +27 ;; PTSD (MMPI, etc.)
- +28 ;;
- +29 ;;G. Diagnosis:
- +30 ;;
- +31 ;; 1. The Diagnosis must conform to DSM-IV and be supported by the findings
- +32 ;; on the examination report.
- +33 ;; 2. If there are multiple mental disorders, delineate to the extent possible
- +34 ;; the symptoms associated with each and a discussion of relationship.
- +35 ;; 3. Evaluation is based on the effects of the signs and symptoms on
- +36 ;; occupational and social functioning.
- +37 ;;
- +38 ;; NOTE: VA is prohibited by statute from paying compensation for a disability
- +39 ;; that is a result of the veteran's own ALCOHOL OR DRUG ABUSE, whether based
- +40 ;; on direct service connection, secondary service connection, or aggravation
- +41 ;; by a service-connected condition. Therefore, when alcohol or drug abuse
- +42 ;; accompanies or is associated with another mental disorder, separate,
- +43 ;; to the extent possible, the effects of the alcohol or drug abuse from
- +44 ;; the effects of the other mental disorder(s). If it is not possible
- +45 ;; to separate the effects, explain why.
- +46 ;;
- +47 ;;H. Diagnostic Status
- +48 ;;
- +49 ;; Axis I disorders
- +50 ;; Axis II disorders
- +51 ;; Axis III disorders
- +52 ;; Axis IV (psychosocial and environmental problems)
- +53 ;; Axis V (GAF score - current)
- +54 ;;
- +55 ;;I. Global Assessment or Functioning (GAF):
- +56 ;;
- +57 ;; NOTE: The complete multi-axial format as specified by DSM-IV may be required
- +58 ;; by BVA REMAND or specifically requested by the rating specialist. If so,
- +59 ;; include the GAF score and note whether it refers to current functioning.
- +60 ;; A BVA REMAND may also request, in addition to an overall GAF score,
- +61 ;; that a separate GAF score be provided for each mental disorder present when
- +62 ;; there are multiple Axis I or Axis II diagnoses and not all are service-
- +63 ;; connected. If separate GAF scores can be given, an explanation and
- +64 ;; discussion of the rationale is needed. If it is not possible, an explanation
- +65 ;; as to why not is needed. (See the above note pertaining to alcohol or drug
- +66 ;; abuse, the effects of which cannot be used to assess the effects of
- +67 ;; a service-connected condition.)
- +68 ;;
- +69 ;;J. Competency:
- +70 ;;
- +71 ;; Competency, for benefits purposes, has a special meaning,
- +72 ;; and refers ONLY to veterans' ability to manage benefit payments in their own
- +73 ;; best interests without restriction, and not to any other subject. State
- +74 ;; whether the veteran is capable of managing his/her or her benefit payments
- +75 ;; in the individual's own best interests (a physical disability which prevents
- +76 ;; the veteran from attending to financial matters in person is not a proper
- +77 ;; basis for a finding of incompetency unless the veteran is, by reason of that
- +78 ;; disability, incapable of directing someone else in handling the individual's
- +79 ;; financial affairs).
- +80 ;;
- +81 ;;K. Other Opinion:
- +82 ;;
- +83 ;; Furnish any other specific opinion requested by the rating
- +84 ;; board or BVA remand (i.e.,furnish the complete rationale and citation of
- +85 ;; medical texts or treatise supporting opinion, if medical literature review
- +86 ;; was undertaken). If the requested opinion is medically not ascertainable
- +87 ;; on exam or testing please state WHY. If the requested opinion can not be
- +88 ;; expressed without resorting to speculation or making improbable assumptions
- +89 ;; say so, and explain why. If the Opinion asks "... is it at least as likely
- +90 ;; as not..", fully explain the clinical findings and rationale for the opinion.
- +91 ;;
- +92 ;;L. Integrated Summary and Conclusions
- +93 ;;
- +94 ;; 1. Describe changes in PSYCHOSOCIAL FUNCTIONAL STATUS and QUALITY of LIFE
- +95 ;; since the last exam (performance in employment or schooling, routine
- +96 ;; responsibilities of self care, family role functioning, physical health,
- +97 ;; social/interpersonal relationships, recreation/leisure pursuits)
- +98 ;; 2. Describe linkage between PTSD symptoms and aforementioned changes in
- +99 ;; impairment in functional status and quality of life.
- +100 ;; Particularly in cases where a veteran is unemployed, specific details
- +101 ;; about the effects of PTSD and its symptoms on employment are especially
- +102 ;; important.
- +103 ;; 3. If possible, describe extent to which disorders other than PTSD
- +104 ;; (e.g., substance use disorders) are independently responsible for
- +105 ;; impairment in psychosocial adjustment and quality of life. If this is not
- +106 ;; possible, explain why (e.g., substance use had onset after PTSD
- +107 ;; and clearly is a means of coping with PTSD symptoms).
- +108 ;;TOF
- +109 ;; 4. If possible, state prognosis for improvement of psychiatric condition
- +110 ;; and impairments in functional status.
- +111 ;; 5. Comment on whether veteran should be rated as competent for VA purposes
- +112 ;; in terms of being capable of managing his/her benefit payments in his/her
- +113 ;; own best interest.
- +114 ;;
- +115 ;;
- +116 ;;Signature: Date:
- +117 ;;END