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Routine: DVBCWPT1

DVBCWPT1.m

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DVBCWPT1 ;ALB/CMM PTSD WKS TEXT - 1 ; 6 MARCH 1997

 ;;2.7;AMIE;**12**;Apr 10, 1995

 ;

 ;

TXT ;

 ;;Narrative:  Service connection for post-traumatic stress disorder (PTSD) 

 ;;requires medical evidence establishing a clear diagnosis of the 

 ;;condition, 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 

 ;;extreme traumatic stressor leading to PTSD, if he or she makes the 

 ;;diagnosis of PTSD.  It is the responsibility of the rating specialist

 ;;to confirm that the cited stressor occurred during active duty.

 ;;

 ;;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 examinations of other disorders.  Ninety minutes to two 

 ;;hours on an initial exam is normal.

 ;;

 ;;A.  Review or Medical Records:

 ;;

 ;;

 ;;

 ;;B.  Medical History (Subjective Complaints):

 ;;

 ;;    Comment on:

 ;;    1. PAST MEDICAL HISTORY:

 ;;

 ;;       a. Previous hospitalizations and outpatient care.

 ;;

 ;; 

 ;;       b. Medical and occupational history (from the time between last

 ;;          rating examination and the present) needs to be accounted 

 ;;          for, UNLESS the purpose of this examination is to ESTABLISH

 ;;          service connection, then a complete medical history 

 ;;          including description of stressors and history since 

 ;;          discharge from military service is required.

 ;;

 ;; 

 ;;       c. Review of Claims Folder is also required on initial exams 

 ;;          to establish or rule out the diagnosis.

 ;;

 ;;

 ;;

 ;;    2. PRESENT MEDICAL, OCCUPATIONAL AND SOCIAL HISTORY - over the 

 ;;       past one year.

 ;; 

 ;;       a.  Frequency, severity, and duration of psychiatric symptoms.

 ;;

 ;;

 ;;       b.  Length of remissions, to include capacity for adjustment 

 ;;           during periods of remissions.

 ;;

 ;;

 ;;       c.  Extent of social impairment and time lost from work over 

 ;;           the past 12-month period.  If employed, identify current 

 ;;           occupation and length of time at this job.  If unemployed,

 ;;           note in COMPLAINTS whether veteran contends it is due to 

 ;;           the effects of a mental disorder.  Further discuss in 

 ;;           DIAGNOSIS what factors and objective findings support or 

 ;;           rebut that contention.

 ;;

 ;;

 ;;    3. SUBJECTIVE COMPLAINTS:

 ;;

 ;;        a. Describe fully.

 ;;

 ;;

 ;;C.  Examination (Objective Findings):

 ;;

 ;;    Address each of the following and fully describe:

 ;;    1. Stressor information:  Clearly describe the stressor. 

 ;;       Particularly if the stressor is a type of personal assault, 

 ;;       including sexual assault, provide information, with examples, 

 ;;       if possible, on behavioral, cognitive, social, or affective 

 ;;       changes that the veteran links to the stressor.  Include 

 ;;       information on related somatic symptoms.  If there is a

 ;;       history of multiple stressors, assess the impact of each, to 

 ;;       the extent possible.

 ;;  

 ;;

 ;;    2. Mental status exam to confirm or establish diagnosis in 

 ;;       accordance with DSM-IV:

 ;; 

 ;; 

 ;;       a. Are all diagnostic criteria to establish a diagnosis for 

 ;;          309.81, Post Traumatic Stress Disorder, as specified in 

 ;;          DSM-IV, fully met?

 ;;

 ;;

 ;; 

 ;;       b. For initial examination to establish service connection, 

 ;;          fully discuss the criteria in steps A through F supporting 

 ;;          or ruling out the diagnosis.

 ;; 

 ;; 

 ;;       c. Describe any associated symptoms.

 ;; 

 ;; 

 ;;       d. Specify onset and duration of symptoms as acute, chronic, or

 ;;          with delayed onset.

 ;; 

 ;; 

 ;;    3. Describe in detail the linkage between the stressor and the 

 ;;       current symptoms and clinical findings.

 ;; 

 ;; 

 ;;    4. 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:

 ;;

 ;;       a. Impairment of thought process or communication.

 ;; 

 ;; 

 ;;       b. Delusions, hallucinations and their persistence.

 ;;  

 ;; 

 ;;       c. Inappropriate behavior cited with examples.

 ;; 

 ;; 

 ;;       d. Suicidal or homicidal thoughts, ideations or plans or intent.

 ;; 

 ;; 

 ;;       e. Ability to maintain minimal personal hygiene and other basic

 ;;          activities of daily living.

 ;; 

 ;; 

 ;;       f. Orientation to person, place, and time.

 ;; 

 ;; 

 ;;       g. Memory loss, or impairment (both short and long-term).

 ;; 

 ;; 

 ;;       h. Obsessive or ritualistic behavior which interferes with 

 ;;          routine activities and describe any found.

 ;; 

 ;; 

 ;;       i. Rate and flow of speech and note any irrelevant, illogical,

 ;;          or obscure speech patterns and whether constant or intermittent.

 ;; 

 ;; 

 ;;       j. 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.

 ;; 

 ;; 

 ;;       k. Depression, depressed mood or anxiety.

 ;; 

 ;; 

 ;;       l. Impaired impulse control and its effect on motivation or mood.

 ;; 

 ;; 

 ;;       m. Sleep impairment and describe extent it interferes with 

 ;;          daytime activities.

 ;; 

 ;; 

 ;;       n. Other symptoms and the extent they interfere with activities.

 ;;

 ;;

 ;;D. Diagnostic Tests:

 ;;

 ;;   1. Provide psychological testing if deemed necessary.

 ;;   2. If testing is requested, the results must be considered in 

 ;;      arriving at the diagnosis.

 ;;   3. Provide specific evaluation information required by the rating 

 ;;      board or on a BVA Remand.

 ;; 

 ;;      a. COMPETENCY:  State whether the veteran is capable of managing

 ;;         his 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 incompetence unless the veteran is, by

 ;;         reason of that disability, incapable of directing someone 

 ;;         else in handling the individual's financial affairs.)

 ;; 

 ;;      b. OTHER OPINION:  Furnish any other specific opinion requested

 ;;         by the rating board or BVA remand, furnishing 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.

 ;;

 ;;     4.  Include results of all diagnostic and clinical tests 

 ;;         conducted in the examination report.

 ;; 

 ;;