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DVBCWPF6 ;ALB/RLC - INITIAL EVAL PTSD WORKSHEET TEXT ; 05/18/2006 11:00am

 ;;2.7;AMIE;**183**;Apr 10, 1995;Build 8

 ;

TXT ;

 ;;

 ;;F.  Assessment of PTSD

 ;;

 ;;    - identify the primary stressor or stressors

 ;;    - state whether or not the veteran meets the DSM-IV stressor criterion

 ;;    - identify behavioral, cognitive, social, affective, or somatic change(s)

 ;;      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

 ;;TOF

 ;;    - 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.)

 ;;

 ;;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, discuss the relationship with

 ;;        PTSD.

 ;;    3.  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).  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

 ;;TOF

 ;;    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 form 11/7/96 on.  Therefore, when

 ;;    applicable note whether the diagnosis for PTSD was supportable under

 ;;    DSM-III-R prior to that date.

 ;;

 ;;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

 ;;       his or her money and pay the bills?

 ;;

 ;;       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 cannot 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)

 ;;TOF

 ;;    - 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 the veteran is capable of managing his/her

 ;;      benefit payments in his/her own best interest.