PTSD Compensation and Military Service (2007) / Chapter Skim
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4 The PTSD Compensation and Pension Examination
4 The PTSD Compensation and Pension Examination
Pages 85-112
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From page 85... ...
COMPENSATION AND PENSION EXAMINATION OVERVIEW A C&P examination is a very important and nearly universal step1 in the process of obtaining disability benefits from VA. Initial examination requests are typically initiated by VA after a veteran files an application2 with the Veterans Benefits Administration (VBA)
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information has been received, depending on the conditions that have been identified a VBA Veterans Service Representative (VSR) or a Rating Veterans Service Representative (RVSR)
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. A presentation in June 2006 by the Compensation and Pension Examination Program Office (CPEP)
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. C&P examinations for PTSD consist of a review of medical history; an assessment of the traumatic exposure or exposures; evaluations of mental status and of social and occupational function; and a diagnostic examination, which may include psychological testing or a determination of a Global Assessment of Functioning (GAF)
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From page 89... ...
context. As the C&P Service Clinician's Guide states: The purpose of the C&P exam is to provide very specific information in order to ensure a proper evaluation of the claimed disability rather than to provide medical treatment.
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These are addressed below. Use of the GAF in Compensation and Pension Examinations The charge to the committee indicated that the role of the GAF score in evaluating PTSD was an area of great interest (Szybala, 2006)
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. The GAF was developed for Axis V of the Diagnostic and Statistical Manual of Mental Disorders III, Revised (DSM-III-R)
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-17, and Short PTSD Rating Interview (symptom levels) ; 10 A 2005 report on compensation by the VA Office of the Inspector General found that mental disorders had the fourth highest variability rate of the 15 body systems studied and that the difference in the proportion of PTSD cases rated at 100 percent was "a primary factor contributing to the variance in average annual compensation payments by state" (DVA, 2005)
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The committee concludes that the GAF score has limited usefulness in the assessment of the level of disability for PTSD compensation. The score is only marginally applicable to PTSD because of its emphasis on the symptoms of mood disorder and schizophrenia and its limited range of symptom content.
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It is the clinician's responsibility to distinguish between the presence of symptoms and the presence of a discrete disorder and to properly account for the fact that some symptoms overlap across disorders, such as when mood and anxiety symptoms co-occur in PTSD and depression. When diagnostic criteria were first developed within the DSM system, 13 Thetopic of combined ratings is also discussed in A st Century System for Evaluating Veterans for Disability Benefits (IOM, 2007)
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. Although clinicians conducting C&P examinations have described having difficulty in dealing with comorbid mental disorders such as PTSD and depression, a review of the current DSM diagnostic criteria indicates that only a few symptoms of these two disorders overlap.
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. Summary Observations The committee's review of the literature found no scientific guidance addressing the separation of symptoms of comorbid mental disorders for the purpose of identifying their relative contributions to a subject's condition.
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The second includes PTSD scales that are derived from self-report tests developed for other purposes. The third type involves the use of reliability or validity scales from standardized tests to estimate the respondent's response set toward test–taking, that is, evaluating such things as whether the subject is giving socially desirable answers, minimizing or exaggerating symptomatology, or malingering.
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. PTSD Scales Derived from Other Standardized Tests In addition to tests that measure PTSD symptoms per se, investigators have derived PTSD scales from extant standardized tests.
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However, the same caveat exists about these scales as was true for the other tests measuring PTSD symptoms: they should not be used to make a PTSD diagnosis in a clinical assessment situation. Tests That Evaluate Malingering The DSM-IV defines malingering as "the intentional production of false or grossly exaggerated physical or psychological symptoms motivated by external incentives .
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From page 100... ...
By comparing the response set or validity scale scores of the group simulating the disorder with those of the comparison group, researchers attempt to infer malingering. But simulation designs fall short of real-life forensic-assessment situations in several ways that severely limit external validity or generalizability (Guriel and Fremouw, 2003; Rogers and Cruise, 1998)
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From page 101... ...
However, the MMPI and MMPI-2 are self-report measures, and they are "objective" tests only in the sense that they are not projective tests. Clearly, their validity scales can be useful in providing some information about response set, but scores on these scales cannot provide definitive objective information on whether a respondent is malingering.
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From page 102... ...
When such veterans present with PTSD symptoms for treatment or compensation evaluation long after their military service, what appears to be "delayed-onset" PTSD may actually be a delayed diagnosis of a disorder that has been present for a substantial period of time. Some individuals exposed to potentially traumatic events, including war-zone stressors, develop subthreshold PTSD -- that is, they meet some of the B, C, and D criteria for PTSD (see Table 3-1)
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From page 103... ...
And substance abuse can represent attempts at self-medication, which may lead some to delay seeking care or compensation until much later than the actual trauma occurred. However, it should be recognized that seeking care or compensation for PTSD years after an inciting event does not necessarily mean that the disorder was of delayed onset per se.
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From page 104... ...
In addition, of the five patients with delayed-onset PTSD, four of them had not been diagnosed with acute stress disorder in the first month after the accident (although in general they did have higher symptom levels at one month than those who never had PTSD during the period of follow-up)
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From page 105... ...
• There is no scientific guidance addressing the separation of symptoms of comorbid mental disorders for the purpose of identifying their relative contributions to a subject's condition. • The scientific literature supports the existence of a form of PTSD that manifests long after the occurrence of the stressor upon which the
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From page 106... ...
• A national standardized training program should be developed for VA and VA-contracted clinicians who conduct compensation and pension psychiatric evaluations. This training program should emphasize diagnostic criteria for PTSD and comorbid conditions with overlapping symptoms, as set forth in the DSM.
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1998. Self report and physician-rated health in combat veterans with posttraumatic stress disorder.
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1993. The modified PTSD symptom scale: a brief self-report measure of posttraumatic stress disorder.
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2005. Mitigating effect of Department of Veterans Affairs disability benefits for post-traumatic stress disorder on low income.
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2001. Combat trauma: trauma with highest risk of delayed onset and unresolved posttraumatic stress disorder symptoms, unemploy ment, and abuse among men.
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1995. Longitudinal assessment of post traumatic stress disorder and depression after exposure to traumatic death.
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2006. DSM-IV diagnosed posttraumatic stress disorder in women veterans with and without military sexual trauma.
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