Jay Member posted July 11, 2004 11:16 -------------------------------------------------------------------------------- The claims process can be difficult for some. When you bring the illness of PTSD into the mix it can be especially difficult. The illness effects your mental ability to handle certain situations. --------------------------------------------
I. - What is PTSD II. - should I file a claim III.- whats the next step? IV.- Proof of claim V. - PTSD Treatment VI.- Treatment and claims VII.- Alcohol and drug abuse VIII.- Compensation and pension exam. IX.- Copy of C&P exams. X. - How to read C&P exam XI.- GAF and Axis XII.- Timetable for claims XIII.- Compensation table. XIV.- Appealing a disappointing claim. XV.- Summary and links. ---------------------------------------------------------
I. But what is PTSD? (POST TRAUMATIC STRESS DISORDER)
There is a short answer to this question, but people who suffer from it may be able to write novels to answer this question.
Quote: -------------------------------------------------------------------------------- When an individual who has been exposed to a traumatic event develops anxiety symptoms, re-experiencing of the event, and avoidance of stimuli related to the event lasting more than four weeks, they may be suffering from this Anxiety Disorder. --------------------------------------------------------------------------------
Truth be known, individuals may respond different to stressors, especially on the battlefield. Some show immediate reactions to trauma and some may take years to show it.
There is the story of the WWII veteran who became suddenly unable to function in life after seeing the movie "Saving Private Ryan". --------------------------------------------------------
II. I believe I have PTSD, should I file a claim?
The answer is yes, but there are some things to be aware of when filing a claim. The first thing to do is to get a service representative to help you through the process. VFW, AMVETS, DAV, and VVA are examples of service organizations that can help you through the process. They don't charge you money and are very knowledgeable about the claims process. ---------------------------------------------------------
III. Whats next?
There is 1 major thing that you need in order to get a PTSD claim approved. This is a diagnosis of Post Traumatic stress disorder from a medical professional. The diagnosis can come from a private physician or from a VA physician.
Your service officer can help you to make a decision to file the claim before receiving an official diagnosis or after receiving a diagnosis. One reason to file before receiving a diagnosis is that claims are granted from the date you file the claim. any monetary award will be paid retroactively from the date of file. I would suggest that if you truly believe you have PTSD and and are certain to receive a diagnosis of the illness, go ahead and file for PTSD.
A warning would be that it is more difficult to re-open your claim if denied. It does not matter how many people believe you have PTSD, a diagnosis from a medical professional is the only thing the VA accepts as proof of illness. Again, ask the opinion of your service representative.
When filing a claim the VA will ask for any or all medical evidence regarding you in-service health and health after leaving the military. This includes any medical treatment from private physicians, military physicians, or VA treatment centers. Your service officer will give you a form to fill out that will ask you for all the doctors you have seen. The VA will take care of requesting the information from these physicians. But, it may be important for you to have copies of these documents just in case any information is not received by the VA.
Helpful information on how to get your medical records from various physicians. remember the important reason to get a service rep. is so you would not have to do all of this work by yourself. It is simply much easier to use a service representative. www.kfvn.com/ptsd/chapter10.htm
This is the mailing address on where to send the form:
National Personnel Records Center 14 (Military Personnel Records) 9700 page Boulevard St. Louis, Mo 63132
Other evidence to support your claim would be:
Purple Heart, CIB, CAR and Valor Medals can be helpful but are certainly not needed.
These are reports of the incident that you have filed for. they can be included in unit logs as well. If you believe there may be evidence that a record of the incident exists your service officer may be able to help you locate these records. If you wish to find them here is some info on this:
Incident reports will help you provide further evidence for your claim.
Buddy letters and stressor letters
Buddy letters are highly regarded among raters. If you know of someone you served with that may have been there with you and witnessed the same thing you did, a simple note from him or her would be great. Just ask the person to include the incident as he or she remembers it in the note.
If you can't find a buddy do not spend too much money trying to find them on investigative searches. some of these sites are leaches.
Letters from family and friends, co-workers or ex co-workers describing hop the illness has affected you is also very helpful. You may even ask you psychiatrist or psychologist for a letter describing how your PTSD is affecting your ability to work and act socially. All the evidence you are gathering just strengthens your case.
A stressor letter is something you will be asked to write during the evidence gathering process. Your service representative may help you with this. the letter will, however be written by you. I know it may be painful to put down in words what happened. I may also take you a while to write it.
A stressor letter is one that gets included with you claim that explains in your own words what happened. date, times, location and unit should be included in this letter as well.
If your stressor is well known, you may want to include news reports or articles concerning the incident. all this evidence is helpful. ---------------------------------------------------------- V. Medically speaking, how should i be treated?
During the process of gathering evidence you should start or continue to be treated at a VA facility or a private physician for your PTSD. Remember, you need that diagnosis for your claim and possibly the medication to help you cope with your illness.
below is a list of medications used to treat your illness. PTSD affects everyone in different ways and there are many symptoms that affect us. Your physician may choose to provide medication to you. Make sure you are incredibly honest with your physician about your problems. don't hold back, because honesty is the best policy.
Also, medications are strong. They may affect you in ways that you might not like. You and your doctor should work together so you are receiving the best treatment for you. In the beginning it will be trial and error with medication. You are really in control of your own treatment. The honesty with your physician is important because he needs to know that you want to try to feel as good as possible with what you are experiencing. No matter what horror stories you may have hear, most physicians are really willing to work for what's best for YOU. ------------------------------------------------------- VI. What does my treatment have to do with my claim?
Your health is the basis for your rating. By now you are in the process of gathering all your evidence. You will be confident that you have proved your stressor and are now being treated for it. You have been honest with your physician and controlling your own health-care.
Now is the best time to check out the Code of Federal Regulations as it regards to PTSD.
9440 Chronic adjustment disorder
General Rating Formula for Mental Disorders:
Total occupational and social impairment, due to 100 such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name.......................
Occupational and social impairment, with 70 deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships...........................
Occupational and social impairment with reduced 50 reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships...........
Occupational and social impairment with occasional 30 decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events)...........................................
Occupational and social impairment due to mild or 10 transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication...............
A mental condition has been formally diagnosed, but 0 symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication.....................
What your doctor writes down puts you in one of these categories. You can see by your treatment where you expect to fit in. Read the criteria for each rating and put yourself in it. You should expect, in your mind, nothing more and nothing less that where you fit in. This will help you, believe me, in the stress of waiting though the process of the claim.
A note on these ratings as it applies to your employment:
Quote: -------------------------------------------------------------------------------- If you are unable to work due to your service connected PTSD or mental disorder you will be granted 100% SC disability --------------------------------------------------------------------------------
38 CFR 4.16
There are 3 ways the VA may choose to set your 100% rating.
IU...Individual unemployability. This means you are really a 70% rating but you cannot work so they grant you 100% based on that.
IU is a tough rating for PTSD. A letter sent to rating officials in the VA states:
Quote: -------------------------------------------------------------------------------- Don’t go through the I.U. process if there is clear evidence on the examination that the veteran is unable to work because of PTSD. A 100% evaluation would be more appropriate in such cases, and a future exam can be requested when indicated. --------------------------------------------------------------------------------
The same letter gives more information to raters on a study conducted on PTSD ratings. Remember me mentioning that "Saving Private Ryan" guy. well here it is:
Reluctance to grant 100%
Many cases of PTSD were rated at 70% even when there were clear indications on the examination that the veteran had severe symptoms and had total occupational impairment because of PTSD symptoms.
Examples: One veteran had not been working for 2 years because of PTSD symptoms; one was reported as unable to work and getting progressively worse; one had not worked for 7 or 8 months since seeing “Saving Private Ryan”; one was complying with his treatment plan but was said not to be sufficiently stable (e.g., had suicidal ideation) to maintain competitive employment; one was said to have an inability to function in almost all areas; and one had impairment of reality testing, active flashbacks, depression, hopeless mood, etc.
Each of these was rated at 70% but could have been rated at 100%. GAF scores in these cases ranged from 30 to 45. (30 was the lowest GAF score given for any case in this review.) Most were eventually given I.U., but there seemed to be great reluctance to grant a schedular 100-percent evaluation even when there was ample medical evidence of severe disability due to PTSD, and a clear indication of impaired functioning sufficient for a schedular 100-percent evaluation.
The old Physician’s Guide stated in the chapter on mental disorders: “In the case of anxiety disorders, except for severe phobias, it is unusual for a person to be completely incapacitated.” However, VA’s National PTSD Center states that anxiety disorders, severe phobias, PTSD, OCD (obsessive-compulsive disorder), panic disorder (esp. with agoraphobia), and social phobia all can be debilitating, sometimes to the point of complete incapacitation. Currently, over 29,000 veterans with PTSD are rated at 100% and over 6000 with generalized anxiety disorder are rated at 100%. Therefore, it is no longer correct to say that total incapacitation for anxiety disorders is unusual.
Another rating is schedular: Schedular is the rating that says you are 100% and under the CFR. You fit into that rating criteria.
The last is Permanent and Total or P&T:
This means that rating board feels that you will not improve during your lifetime and you are permanently disabled for life in their eyes. If you haven't done so, file for SSDI if you get this rating.
--------------------------------------------------------- VII. I did drugs and drank while during the period after i left the Military. Should i tell them that?
Always be honest!.... Tell your physician that because many people did the alcohol and drug thing because they were trying to escape the pain and the symptoms they were experiencing. The Rating board knows this. Most of the time they will not hold it against you. I myself drank quite a bit because I had very disturbing episodes when trying to fall asleep. I drank alot so i could pass out. I was honest and i am rated at 100%. ---------------------------------------------------------
VIII. What is the Compensation and Pension exam or C&P exam and what should I expect out of it?
When you have submitted your evidence the VA will ask you to take a compensation and pension exam or C&P exam. This exam is not conducted by your treating physician but rather conducted by a different qualified examiner who specializes in mental disabilities.
This exam is crucial to your rating and is centralized on your health rather than all that evidence you gathered. I call the exam BAD (before, after, and during). The exam will focus on your life before the military where they ask you personal questions about your family life and childhood. The during part, which is the toughest focuses on your stressor. this will be the part where you explain what happened to you and why you believe you have PTSD. This part is very emotional at times. The after part focuses on your life outside the military. It looks into your behavior and mental well being. There are also parts of the exam where you will common Psych tests like remembering three words after 5 minutes and drawing shapes and figures to test your memory and focus. You may have already taken these type of tests when you enrolled in the Psych clinic.
The examiner does work with a pre-determined set of written questions. You will tell them the story of your life, basically. This story is probably the same story you told your regular physician. The examiner already knows from reading your medical record what you have already said about this stuff. This is why you MUST be as honest as possible in this exam. This exam is also a test on your truthfulness. The exam may run up to two hours and it is most definitely the longest C&P exam you could take in the VA system. you may be asked to retell the same things two or three times during the same exam.
--------------------------------------------------------- IX. Can i get a copy of my C&P exam?
Yes. About three to four weeks after the exam you can go to the freedom of information desk or records section of your VA clinic to get a copy of this exam. ---------------------------------------------------------- X. I got a copy of my C&P exam but don't understand alot of the phrasing.
here is an explanation of a C&P report: Name: SSN: Date of Exam: C-number Place of Exam: 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 make 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 examinations itself, and the dictation for an examination initially establishing PTSD will often require more time than for examinations of other disorders. Ninety minutes to two hours on an initial exam in normal.
A. Review of 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 need be accounted for, UNLESS the purpose of this examination is to ESTABLISH service connection, then 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 stressor, 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 extend 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, ideation or plans or intent. e. Ability to maintain minimal personal hygiene and other basis 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 affect 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 reported and 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 interest (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 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. 4. Include results of all diagnostic and clinical tests conducted in the examination report. E. Diagnosis: Provide: 1. The Diagnosis must conform to DSM-IV and be supported by the findings on the examination report. 2. If the diagnosis is changed, explain fully whether the new diagnosis represents a progression of the prior diagnosis or development of a new and separate condition. 3. Is there are multiple mental disorders, delineate to the extent possible the symptoms associated with each and a discussion of relationship. 4. Evaluation is based on the effects of the signs and symptoms on occupational and social functioning.
NOTE: VA is prohibited by statue 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. F. 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 over the past years, etc.
If multiple Axis I or II diagnoses exist, attempt to the extent possible to provide a GAF score for the service connected conditions alone as well as a separate overall GAF score based on all mental disorders present, and explain and discuss you rationale. (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). If it is not possible to separate the symptomatology, explain why.
DSM-IV is only for application from 11/7/96 on. Therefore, when applicable note whether the diagnosis of PTSD was supportable under DSM III-R prior to that date. The prior criteria under DSM III-R are provided as an attachment. --------------------------------------------------------- XI. What is the GAF and what does it have to do with my rating?
ah...GAF stands for Global Assessment of Function. It is incredibly nice of the VA to put a numerical value to your mental health. You receive a GAF score every time you visit your mental health professional. It is a value that represents what you are mentally like on that particular day. the higher the number the better you are on that day.
Here is a basic explanation on what the numbers actually mean:
100-91 Superior functioning in a wide range of activities. Life's problems never seem to get out of hand, is sought out by others because of his or her many positive qualities. No symptoms.
Absent or minimum symptoms (e.g. mild anxiety before an exam), good functioning in all areas, interested and involved in a wide range of activities, socially effective, generally satisfied with life, no more than everyday problems or concerns ("e.g.. an occasional argument with family members)
If symptoms are present, they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument); no more than slight impairment in social, occupational, or school functioning (e.g temporarily falling behind in schoolwork).
Some mild symptoms (e.g., depressed mood and mild insomnia) OR some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships.
Moderate symptoms (e.g.. flat affect and circumstantial speech, occasional panic attacks) OR moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers).
Serious symptoms(e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) OR any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job).
Some impairment in reality testing or communication (e.g... speech is at times illogical, obscure, or irrelevant) OR major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g depressed man avoids friends, neglects family, and is unable to work: child frequently beats up younger children. Is defiant at home, and is failing at school).
Behavior is considerably influenced by delusions or hallucinations OR serious impairment in communications or judgment (e.g., sometimes incoherent, acts grossly inappropriately, suicidal preoccupation) OR inability to function in almost all areas. (e.g. stays in bed all day; no job, home, or friends).
Some danger of hurting self or others (e.g., suicide attempts without clear expectation of death, frequency violent; manic excitement) OR occasionally fails to maintain minimal personal hygiene (e.g smears feces) OR gross impairment in communication (e.g. largely incoherent or mute.)
Persistent danger of severely hurting self or others. (e.g. recurrent violence) OR recurrent inability to maintain minimal personal hygiene OR Serious suicidal act with clear expectation of death.
What does the GAF mean to my overall rating?
Well, its subjective. some people get a GAF of 45 and receive a 100% rating and others with a GAF of 45 could end up with a 50% rating. Its really just a guide.
In the letter used earlier to raters the VA explains its position on the GAF score:
Quote: -------------------------------------------------------------------------------- Do not base a rating solely or mainly on the GAF score. The GAF score does not translate directly to the rating schedule criteria. --------------------------------------------------------------------------------
If you would like to see a general guide on how the GAF may correspond to ratings here it is:"The rule of thumb for the amounts the VA assigns for psychiatric disabilities is:
Raters may choose to ignore this, but it does give you a general idea of where you stand.
what does the Axis mean on my C&P report?
The AXIS I through AXIS V are your evaluation. The most important is AXIS I being the diagnosis, or what was found wrong, and AXIS V is the prognosis, or how it looks for future progress. Also you will find it says, "Competent for VA purposes," don't worry about that it's a good thing. It just means that you don't need to be locked up against your will, or "committed" as the doctors prefer saying.
AXIS 1: MAJOR PSYCHIATRIC ILLNESSES, INCLUDING SUBSTANCE ABUSE.
AXIS 2: PERSONALITY DISORDERS/FEATURES
AXIS 3: PHYSICAL PROBLEMS (MEDICAL DIAGNOSIS-AS OPPOSED TO A PSYCH DIAGNOSIS)
AXIS 5: GLOBAL ASSESSMENT of FUNCTIONING SCALE, expressed as: none, mild, moderate, severe and then it'll have numbers listed to represent, eye movement, or non-eye contact, tearful, fearful, and these kinds of assessments. ---------------------------------------------------------
XII. I filed the claim, received my C&P and the report. How long do I have to wait before I receive my decision?
This, as always, depends on the backlog of cases at your regional VA office. The rule of thumb ,I say, is 3-6 months after your C&P exam if and only if the rating board has all the information they need. But remember, especially with PTSD, that it may take longer to hear a reply. Always keep in contact with your service rep for any updates. --------------------------------------------------------- XIII. I received my decision and it was favorable. How much do i get?
XIV. I got denied or i did not get the rating i expected, What do I do?
IF YOU LOSE: APPEAL
If the VA Regional Office says your disability is not service-connected or if the percentage of disability is lower than what you think is fair, you have the right to appeal to the Board of Veterans' Appeals.
The first step in appealing is to send the VA Regional Office a "Notice of Disagreement." This Notice is a letter saying that you "disagree" with the denial. Be sure to include in your letter the date of the VA's denial letter and be sure to list the benefits you are still seeking.
Deadline: The Notice of Disagreement must be mailed to the VA Regional Office within one year of the denial of your claim or you cannot appeal. (You still can reopen your claim if you miss this deadline but you lose an earlier "effective date" for an award of back benefits.)
If you win, one issue which you should examine carefully with your representative is whether the VA has set the correct effective date for your award. If you think an earlier effective date is appropriate, you can file a Notice of Disagreement on that issue. More help is available in IF YOU LOSE: APPEAL If the VA Regional Office says your disability is not service-connected or if the percentage of disability is lower than what you think is fair, you have the right to appeal to the Board of Veterans' Appeals.
The first step in appealing is to send the VA Regional Office a "Notice of Disagreement." This Notice is a letter saying that you "disagree" with the denial. Be sure to include in your letter the date of the VA's denial letter and be sure to list the benefits you are still seeking.
Deadline: The Notice of Disagreement must be mailed to the VA Regional Office within one year of the denial of your claim or you cannot appeal. (You still can reopen your claim if you miss this deadline but you lose an earlier "effective date" for an award of back benefits.)
If you win, one issue which you should examine carefully with your representative is whether the VA has set the correct effective date for your award. If you think an earlier effective date is appropriate, you can file a Notice of Disagreement on that issue. More help is available in www.vva.org/Benefits/vvgvaclaims.htm -----------------------------------------------------------
XV. summary.... hopefully this helps take some stress away from the process. There is always room for improvement on this page. more up to date info comes out all the time so this page will always be a work in progress.
THE PERSIAN GULF WAR: NEW FINDINGS ON TRAUMATIC EXPOSURE AND STRESS Jessica Wolfe, Ph.D.1 National Center for PTSD and Boston VAMC Tufts University School of Medicine Susan P. Proctor, D.Sc.2 Boston VAMC Boston University Schools of Medicine and Public Health
Fact Sheet: VA Programs for Veterans with Post-Traumatic Stress Related Links
VA Offers On-Line Help for "Disaster Mental Health" National Center for PTSD National Institute of Mental Health "Facts about Post-Traumatic Stress Disorder" MayoClinic.com: Post-Traumatic Stress Disorder Readjustment Counseling Services Vet Centers PTSD Alliance
VA Programs for Veterans with Post-Traumatic Stress Disorder (PTSD)
PTSD is an anxiety disorder resulting from exposure to an extreme traumatic stress involving direct or indirect threat of death, serious injury or a physical threat. The trauma may be experienced alone (rape or assault) or in the company of others (military combat). The events that can cause PTSD are called "stressors." They include natural disasters (floods, earthquakes), accidental man-made disasters (car accidents, airplane crashes, large fires) or deliberate man-made disasters (bombing, torture, death camps). Symptoms include recurrent thoughts of a traumatic event, reduced involvement in work or outside interests, hyper alertness, anxiety and irritability. The disorder apparently is more severe and longer lasting when the stress is of human design.
More than 150,000 veterans were service-connected for PTSD in 2001. Nearly 2,500 veterans in this group were not being compensated for PTSD, because they declined disability compensation to receive a VA pension, which provided more income.
VA readjustment counseling is provided through the 206 community-based Vet Centers located in all 50 states, Puerto Rico, the Virgin Islands, the District of Columbia and Guam. Vet Centers are located outside of the larger medical facilities, in easily accessible, consumer-oriented facilities highly responsive to the needs of local veterans. The Vet Center mission features a holistic mix of direct counseling and multiple community access functions: psychological counseling for veterans exposed to war trauma or who were sexually assaulted during military service, family counseling, community outreach and education, and extensive social services and referral activities designed to assist veterans improve general levels of post-military social and economic functioning.
Vet Centers are staffed by interdisciplinary teams that include psychologists, nurses and social workers. Vet Center teams also reflect representative or higher levels of ethnic and gender diversity, as well as, high levels of staff having veteran status, most having served in a combat theater of operations.
Eligibility for Vet Center services includes veterans who served in any war or in any area during a period of armed hostilities. Eligibility for sexual trauma counseling at Vet Centers is open to any veteran regardless of period of service.
In 2001, Vet Centers saw more than 126,000 veterans and had more than 900,000 visits from veterans and family members. For many veterans who would not otherwise receive VA assistance, the Vet Centers make more than 100,000 referrals a year to VA medical facilities and another 120,000 referrals annually to VA Regional Offices for disability compensation, pensions or other benefits. For the third consecutive year, 99 percent of veterans using Vet Centers reported being satisfied with services received. This is the highest level of veteran satisfaction recorded for any VA program.
VA Medical Center Programs
VA operates an internationally recognized network of more than 140 specialized programs for the treatment of PTSD through its medical centers and clinics. One notable
program consists of PTSD clinical teams that provide outpatient treatment, working closely with other VA treatment programs, including Vet Centers and the community. In 2001, more than 77,300 veterans were treated for PTSD by VA specialists.
In addition to 86 PTSD clinical teams, VA operates eight specialized inpatient units around the country, plus five brief-treatment units, 18 residential rehabilitation programs, and nine PTSD day hospitals. There also are four outpatient Women’s Stress Disorder and Treatment Teams. A special focus in the program has included underserved and minority populations, such as African Americans, Hispanics and Native Americans. A specialized PTSD inpatient treatment unit serves women veterans at the Palo Alto, Calif., VA Medical Center's Menlo Park Division.
The Veterans Millennium Health Care and Benefits Act (Public Law 106-117) provided support for new specialized PTSD and Substance Use Disorder treatment programs. The law also re-established the Under Secretary of Health's Special Committee on PTSD. The committee is to assess VA's capacity to diagnose and treat PTSD and to provide guidance on VA's education, research and benefits activities with regard to PTSD.
National PTSD Center
In 1989, VA established the National Center for Post-Traumatic Stress Disorder, with a mandate to promote research into the causes and diagnosis of the disorder, to train health care and related personnel in diagnosis and treatment, and to serve as an information resource for professionals across the United States and, eventually, around the world. The center consists of seven divisions with distinct, but complementary responsibilities: Behavioral Science, Women’s Health Sciences, Clinical Neurosciences, Education, Evaluation, Pacific Islands Ethnocultural and Executive and Resource Center Divisions.
The Center is committed to approaching PTSD through a focus on research, education and consultation. These three threads weave the Center’s work together in a
way that brings science into practice and ensures that clinical concerns guide scientific priorities. The National Center has come to be viewed as a world leader in PTSD research. Current research at the Center includes large-scale clinical trials, as well as studies on the epidemiology, diagnosis, psychobiology and treatment of PTSD.
Among its many educational programs the center provides regular satellite broadcasts and publishes two newsletters, which highlight the latest developments in research and clinical practices for PTSD. The National Center also offers a monthly 5-day clinical training program free of charge to VA staff, and maintains a nationally recognized Web site (http://www.ncptsd.org) with information about trauma and PTSD. The Web site includes a bibliographic database of more than 21,000 articles. Finally, the National Center provides consultation to clinicians, scientists and policy makers concerning treatment, research and education regarding PTSD.
[This message has been edited by Gale (edited January 27, 2004).]
Gale Administrator posted February 06, 2004 15:46 -------------------------------------------------------------------------------- http://www.ptsdsupport.net/combat.html General Guide on Combat PTSD!
THE ETIOLOGY OF COMBAT-RELATED POST-TRAUMATIC STRESS DISORDERS By Jim Goodwin, Psy.D.
"My marriage is falling apart. We just don't talk any more. Hell, I guess we've never really talked about anything, ever. I spend most of my time at home alone in the basement. She's upstairs and I'm downstairs. Sure we'll talk about the groceries and who will get gas for the car, but that's about it. She's tried to tell me she cares for me, but I get real uncomfortable talking about things like that, and I get up and leave. Sometimes I get real angry over the smallest thing. I used to hit her when this would happen, the kids aren't sure what to do either when I get angry, but lately I just punch out a hole in the wall, or leave and go for a long drive. Sometimes I spend more time on the road just driving aimlessly than I do at home.
"I really don't have any friends and I'm pretty particular about who I want as a friend. The world is pretty much dog eat dog, and no one seems to care much for anyone else. As far as I'm concerned, I'm really not a part of this messed up society. What I'd really like to do is have a home in the mountains, somewhere far away from everyone. Sometimes I get so angry with the way things are being run, I think about placing a few blocks of C-4 (military explosive) under some of the sons-of-bitches. A couple of times a year, I get into fights at bars. I usually pick the biggest guy. I don't know why. I usually get creamed. There are times when I drive real crazily, screaming and yelling at other drivers.
"I usually feel depressed. I've felt this way for years. There have been times I've been so depressed that I won't even leave the basement. I'll usually start drinking pretty heavily around these times. I've also thought about committing suicide when I've been depressed. I've got an old .38 that I snuck back from Nam. A couple of times I've sat with it loaded, once I even had the barrel in my mouth and the hammer pulled back. I couldn't do it. I see Smitty back in Nam with his brains smeared all over the bunker. Hell, I fought too hard then to make it back to the World [U.S.]: I can't waste it now. How come I survived and he didn't? There has to be some reason.
"Sometimes, my head starts to replay some of my experiences in Nam. Regardless of what I'd like to think about, it comes creeping in. It's so hard to push back out again. It's old friends, their faces, the ambush, the screams, their faces [tears]…You know, every time I hear a chopper [helicopter] or see a clear unobstructed green tree line, a chill goes down my back; I remember. When I go hiking now, I avoid green areas. I usually stay above timber line. When I walk down the street, I get real uncomfortable with people behind me that I can't see. When I sit, I always try to find a chair with something big and solid directly behind me. I feel most comfortable in the corner of a room, with walls on both sides of me. Loud noises irritate me and sudden movement or noise will make me jump.
"Night is hardest for me. I go to sleep long after my wife has gone to bed. It seems like hours before I finally drop off. I think of so many of my Nam experiences at night. Sometimes my wife awakens me with a wild look in her eye. I'm all sweaty and tense. Sometimes I grab for her neck before I realize where I am. Sometimes I remember the dream; sometimes it's Nam, other times it's just people after me, and I can't run any more.
"I don't know, this has been going on for so long; it seems to be getting gradually worse. My wife is talking about leaving. I guess it's no big deal. But I'm lonely. I really don't have anyone else. Why am I the only one like this? What the hell is wrong with me?"
If this is you, as it was for me, please read how "Shell Shock" became Post-Traumatic Stress Disorder or PTSD. If you have these above reactions and carry any of the combat metals like CIB, Purple Heart, Bronze Star with (V-device) Device or higher; You should read the following information. There is also some very good information for the Older Vet on this page!
Included within this page is a general overview of types of treatments and medications used to treat PTSD. NOT all treatments are best for me nor would they be right for you, but the answer (In General) is that PTSD will NEVER go away they can only treat it and educate you of its effects so we can handle it better.
If you are having difficulties with your Combat PTSD please contact the nearest VA Vet center, or go to the following Veterans Web Site.
I have been asked many times about veterans or friends that lost someone during the Vietnam war, I have found the following site very helpful. This is a site that list those personnel that lost their lives and is listed or searched by date or name. If you would like to look up someone please visit The Virtual Wall
Refer to pharmaceutical manufacturer’s literature for full prescribing information
SEROTONIN SELECTIVE REUPTAKE INHIBITORS (SSRIs) GENERIC BRAND NAME ADULT STARTING DOSE MAX EXCEPTION SAFETY MARGIN TOLERABILITY EFFICACY SIMPLICITY Citalopram Celexa 20 mg 60 mg Reduce dose for the elderly & those with renal or hepatic failure No serious systemic toxicity even after substantial overdose.
Drug interactions may include tricyclic antidepressants, carbamazepine & warfarin. Nausea, insomnia, sedation, headache, fatigue dizziness, sexual dysfunction anorexia, weight loss, sweating, GI distress, tremor, restlessness, agitation, anxiety. Response rate = 2 - 4 wks AM daily dosing. Can be started at an effective dose immediately.
Fluoxetine Prozac 20 mg 80 mg
Paroxetine Paxil 20 mg 50 mg
Sertraline Zoloft 50 mg 200 mg
First Line Antidepressant Medication
Drugs of this class differ substantially in safety, tolerability and simplicity when used in patients on other medications. Can work in TCA (tricyclic antidepressant) nonresponders. Useful in several anxiety disorders. Taper gradually when discontinuing these medications.
SEROTONIN and NOREPHINEPHRINE REUPTAKE INHIBITORS GENERIC BRAND NAME ADULT STARTING DOSE MAX EXCEPTION SAFETY MARGIN TOLERABILITY EFFICACY SIMPLICITY Venlafaxine IR Effexor IR 75 mg 375 mg Reduce dose for the elderly & those with renal or hepatic failure No serious systemic toxicity.
Downtaper slowly to prevent clinically significant withdrawal syndrome.
Few drug interactions. Take with food. Comparable to SSRIs at low dose.
Nausea, dry mouth, insomnia, anxiety, somnolence, head-ache, dizziness, asthenia, abnormal ejaculation, sweating. Response rate = 2 - 4 wks (4 - 7 days at ~300 mg/day) BID or TID dosing with IR. Daily dosing with XR. Can be started at an effective dose (75 mg) immediately.
Venlafaxine XR Effexor XR 75 mg 375 mg Dual action drug that predominantly acts like a Serotonin Selective Reuptake inhibitor at low doses and adds the effect of an Norepinephrine Selective Reuptake Inhibitor at high doses.
Possible efficacy in cases not responsive to TCAs or SSRIs. Taper dose prior to discontinuation.
DOPAMINE and NOREPINEPHRINE REUPTAKE INHIBITORS GENERIC BRAND NAME ADULT STARTING DOSE MAX EXCEPTION SAFETY MARGIN TOLERABILITY EFFICACY SIMPLICITY Bupropion - IR Wellbutrin - IR 200 mg 450 mg Reduce dose for the elderly & those with renal or hepatic failure Seizure risk at doses higher than max or with other drugs that increase seizure risk.
Drug/drug interactions uncommon. Rarely causes sexual dysfunction. Response rate = 2 - 4 wks BID or TID dosing. Increase dose gradually to decrease risk of seizures. Requires dose titration. Bupropion - SR Wellbutrin - SR 150 mg 400 mg Least likely antidepressant to result in a patient becoming manic. Do not use if there is a history of seizure disorder, head trauma, bulimia or anorexia. Can work in TCA non-responders.
NOREPINEPHRINE SELECTIVE REUPTAKE INHIBITORS GENERIC BRAND NAME ADULT STARTING DOSE MAX EXCEPTION SAFETY MARGIN TOLERABILITY EFFICACY SIMPLICITY Desipramine * Norpramin * 75 - 200 mg 300 mg Reduce dose for the elderly & those with renal or hepatic failure Serious toxicity can result from OD.
Reserve Maprotiline as a second-line agent due to risk of seizures at therapeutic & nontherapeutic doses. Generally Good. Response rate = 2 - 4 wks
50-150 ng/mL Can be given QD. Can start effective dose immediately.
Refer to pharmaceutical manufacturer’s literature for full prescribing information
SEROTONIN (5-H2A) RECEPTOR ANTAGONIST and WEAK SEROTONIN REUPTAKE INHIBITORS GENERIC BRAND NAME ADULT STARTING DOSE MAX EXCEPTION SAFETY MARGIN TOLERABILITY EFFICACY SIMPLICITY Nefazodone * Serzone * 200 mg 600 mg Reduce dose for the elderly & those with renal or hepatic failure No serious systemic toxicity from OD. Can interact with agents that decrease arousal, impair cognitive performance and interact with adrenergic agents that regulate blood pressure. Somnolence, dizziness, fatigue, dry mouth, nausea, headache, constipation, impaired vision. Unlikely to cause sexual dysfunction. Response rate = 2 - 4 wks BID dosing. Requires dose titration. Trazodone Desyrel 150 mg 600 mg Corrects sleep disturbance and reduces anxiety in about one week.
* Caution - Nefazodone Specific- Monitor for signs & symptoms of liver dysfunction; consider LFT monitoring. Do not take with triazolam, alprazolam, pimozide, astemizole, cisapride & terfenadine due to increased plasma levels. If on Digoxin, monitor levels.
MIXED REUPTAKE and NEURORECEPTOR ANTAGONISTS GENERIC BRAND NAME ADULT STARTING DOSE MAX EXCEPTION SAFETY MARGIN TOLERABILITY EFFICACY SIMPLICITY Amitriptyline * Elavil, Endep * 50 - 100 mg 300 mg Reduce dose for those with renal or hepatic failure Serious toxicity can result from OD.
Slow system clearance. Can cause multiple drug/drug interactions. Sedation, increased anticholinergic effects, orthostatic hypotension, cardiac conduction disturbances, arrhythmia & wt gain, dizziness, sexual dysfunction. Response rate = 2 - 4 wks
200-350 ng/mL Can be given QD. Monitor serum level after one week of treatment.
Imipramine * Tofranil * 75 mg 300 mg
Doxepin * Sinequan * 75 mg 300 mg
These antidepressants are not recommended for use in the elderly.
CAUTION: In rare cases initiating or titrating routine antidepressant medication can precipitate a manic episode in some individuals.
CAUTION: if patient is currently receiving an MAOI consult/refer to a behavioral health physician for medication prescribing.
NOTE: Antidepressant Medication Information current as of February 2002. May become outdated.
MEDICATIONS THAT CAN CAUSE DEPRESSION QUALITY of EVIDENCE STRENGTH of RECOMMENDATION DRUG / DRUG CLASS I B Amphetamine withdrawal, Anabolic Steroids, Digitalis, Glucocorticoids I C Cocaine withdrawal II-1 C Reserpine II-2 A Gonadotropin-releasing agonists, Pimozide II-2 B Propanolol (Beta Blockers) II-2 C ACE Inhibitors, Antihyperlipidemics, Benzodiazepines, Cimetidine, Ranitidine, Clonidine, Cycloserine, Interferons, Levodopa, Methyldopa, Metoclopramide, Oral Contraceptives, Topiramate, Verapamil, (Calcium Channel Blockers) Although there is little published information on alternative medicines causing depression, consideration should also be given to herbal, nutritional, vitamins and body building supplements, particularly when consumed in large doses.
-------------------- HONOR OUR VETERANS WITH BETTER CARE AND BENEFITS Posts: 3482 | Registered: Jul 2005
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Great to have this forum. This is my first post here. I am nervous about my upcoming C&P exam at the V.A. I have it at the end of the month. Why am I so nervous if all I have to do is tell my story? Help!
I'm glad you came over from the MSN forum. You will find answers much more quickly here.
It's natural to be nervous about any kind of exam. When a doctor is asking about your feelings and what is going on inside your mind it is even more stressful. It's not like you can point to something concrete or show him a picture. You are trying to explain how you feel mentally and emotionally. He doesn't have a point of reference like he would if he had known you for years.
It's easy to say "relax." Unfortunately my saying that won't do you any good. Let's try something a little better...
About 35% of returning vets are experiencing some form of PTSD. What you are going through, no matter how personal, is not uncommon. The things that are stressing you may be unique to you, but they are very similar to what thousands of men and women are experiencing. What you say to the doc will be some of the same things he or she has heard before. You aren't going to shock him.
Furthermore, the doc will know that the same event can and does have a different effect on different people. PTSD is an individualized problem. There is no "right" response to a traumatic event.
If you have any letters from friends, your employer, your pastor or anyone else who has seen the changes that you have gone through, bring copies with you. Have it put into your file. Also bring along any medical records from private doctors that you have since your return.
Now for a big question. Do you feel that you can discuss the events you experienced with the doctor? Does going over them cause you so much distress that you can't finish? It will help you to be able to talk to someone. Does the mere thought of discussing them make you walk away from the topic?
These questions may make you uncomfortable. If they do, I apologize. By the same token, they could easily be what is making you nervous.
Feel free to e-mail me if you would like to discuss things more privately. I will be working 12 hour shifts tomorrow and Wednesday, but I do check my e-mail before and after work. (11 a.m. to 11 p.m. shift). I will be glad to help any way I can.
Ken Baker EMT/NJ NJ Employer Support of the Guard and Reserve Committee member firstname.lastname@example.org
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It will help you to make a list of things your PTSD has affected since your return home from the war (such as difficulty in sleeping, drinking alcohol to escape or self-medicate, marital difficulties, trouble in keeping jobs or having poor job performance, etc.) If you've had other forms of counseling (from church or other agencies), you can bring that documentation along as well.
These links have additional information on PTSD that the VA uses in assessing and awarding ratings for PTSD:
I just went thru my 2nd C&P exam for PTSD, take your bottles of meds with you so they can write them down, if you forget them they won't look them up on the computer they are lazy, do not dress in your sunday best dress like you normally do, you are not there to show them how you look on your best day, you are there to explainwhat your days are normally like, isolation, friends or lack of friends, family relationships, be truthful with them, if your family doesn't want you around tell them why, they are not mind readers. Do not exaggerate your symptoms most of them can tell the story tellers.. just be your self, PTSD is bad enough without having to make it up as you go along. I usually end up being totally sleepless the night before a C&P, stress is normal, you are not going thru anything unusual. welcome to our world. Mike
Posts: 1381 | From: South Carolina | Registered: Jul 2005
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Initial Evaluation for Post-Traumatic Stress Disorder (PTSD)
# 0910 Worksheet Name: SSN: Date of Exam: C-number: Place of Exam:
The following health care providers can perform initial examinations for PTSD. a board certified psychiatrist; a licensed psychologist; a psychiatry resident under close supervision of an attending psychiatrist or psychologist; or a psychology intern under close supervision of an attending psychiatrist or psychologist.
A. Identifying Information:
* age * ethnic background * era of military service * reason for referral (original exam to establish PTSD diagnosis and related psychosocial impairment; re-evaluation of status of existing service-connected PTSD condition)
B. Sources of Information:
* records reviewed (C-file, DD-214, medical records, other documentation) * review of social-industrial survey completed by social worker * statements from collaterals * administration of psychometric tests and questionnaires (identify here)
C. Review of Medical Records:
1. Past Medical History:
1. Previous hospitalizations and outpatient care. 2. Complete medical history is required, including history since discharge from military service. 3. Review of Claims Folder is required on initial exams to establish or rule out the diagnosis.
2. Present Medical History - over the past one year.
1. Frequency, severity and duration of medical and psychiatric symptoms. 2. Length of remissions, to include capacity for adjustment during periods of remissions.
D. Examination (Objective Findings):
Address each of the following and fully describe:
History (Subjective Complaints): Comment on:
Premilitary History (refer to social-industrial survey if completed)
* describe family structure and environment where raised (identify constellation of family members and quality of relationships) * quality of peer relationships and social adjustment (e.g., activities, achievements, athletic and/or extracurricular involvement, sexual involvements, etc.) * education obtained and performance in school · employment * legal infractions * delinquency or behavior conduct disturbances * substance use patterns * significant medical problems and treatments obtained * family psychiatric history * exposure to traumatic stressors (see CAPS trauma assessment checklist) * summary assessment of psychosocial adjustment and progression through developmental milestones (performance in employment or schooling, routine responsibilities of self-care, family role functioning, physical health, social/interpersonal relationships, recreation/leisure pursuits).
* branch of service (enlisted or drafted) * dates of service * dates and location of war zone duty and number of months stationed in war zone * Military Occupational Specialty (describe nature and duration of job(s) in war zone * highest rank obtained during service (rank at discharge if different) * type of discharge from military * describe routine combat stressors veterans was exposed to (refer to Combat Scale) * combat wounds sustained (describe) * clearly describe specific stressor event(s) veteran considered particularly traumatic. Clearly describe the stressor. Particularly if the stressor is a type of personal assault, including sexual assault, provide information, with examples, if possible. * indicate overall level of traumatic stress exposure (high, moderate, low) based on frequency and severity of incident exposure (refer to trauma assessment scale scores described in Appendix B). * citations or medals received * disciplinary infractions or other adjustment problems during military
NOTE: Service connection for post-traumatic stress disorder (PTSD) requires medical evidence establishing a diagnosis of the condition that conforms to the diagnostic criteria of DSM-IV, 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 traumatic stressor leading to PTSD, if he or she makes the diagnosis of PTSD. Crucial in this description are specific details of the stressor, with names, dates, and places linked to the stressor, so that the rating specialist can 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 for examinations of other disorders. Ninety minutes to two hours on an initial exam is normal.
Post-Military Trauma History (refer to social-industrial survey if completed)
* describe post-military traumatic events (see CAPS trauma assessment checklist) * describe psychosocial consequences of post-military trauma exposure(s) (treatment received, disruption to work, adverse health consequences)
Post-Military Psychosocial Adjustment (refer to social-industrial survey if completed) · legal history (DWIs, arrests, time spent in jail)
* educational accomplishment * employment history (describe periods of employment and reasons) * marital and family relationships (including quality of relationships with children) * degree and quality of social relationships * activities and leisure pursuits * problematic substance abuse (lifetime and current) * significant medical disorders (resulting pain or disability; current medications) * treatment history for significant medical conditions, including hospitalizations * history of inpatient and/or outpatient psychiatric care (dates and conditions treated) * history of assaultiveness * history of suicide attempts * summary statement of current psychosocial functional status (performance in employment or schooling, routine responsibilities of self care, family role functioning, physical health, social/interpersonal relationships, recreation/leisure pursuits)
E. Mental Status Examination
Conduct a brief mental status examination aimed at screening for DSM-IV mental disorders. 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:
* Impairment of thought process or communication. * Delusions, hallucinations and their persistence. * Eye Contact, interaction in session, and inappropriate behavior cited with examples. * Suicidal or homicidal thoughts, ideations or plans or intent. * Ability to maintain minimal personal hygiene and other basic activities of daily living. * Orientation to person, place and time. * Memory loss, or impairment (both short and long-term). * Obsessive or ritualistic behavior which interferes with routine activities and describe any found. * Rate and flow of speech and note any irrelevant, illogical, or obscure speech patterns and whether constant or intermittent. * 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. * Depression, depressed mood or anxiety. * Impaired impulse control and its effect on motivation or mood. * Sleep impairment and describe extent it interferes with daytime activities. * Other disorders or symptoms and the extent they interfere with activities, particularly:
* mood disorders (especially major depression and dysthymia) * substance use disorders (especially alcohol use disorders) * anxiety disorders (especially panic disorder, obsessive-compulsive disorder, generalized anxiety disorder) * somatoform disorders * personality disorders (especially antisocial personality disorder and borderline personality disorder)
Specify onset and duration of symptoms as acute, chronic, or with delayed onset.
F. Assessment of PTSD
* state whether or not the veteran meets the DSM-IV stressor criterion * identify behavioral, cognitive, social, affective, or somatic change 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
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 * 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 > 50; Mississippi Scale > 107; MMPI PTSD subscale a score > 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 problems other than PTSD (MMPI, etc.)
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, 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 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.)
DSM-IV is only for application from 11/7/96 on. Therefore, when applicable note whether the diagnosis of PTSD was supportable under DSM-III-R prior to that date. The prior criteria under DSM-III-R are provided as an attachment.
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 the money and pay the bills himself or herself?
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 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. 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) * 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 than 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 veteran is capable of managing his or her financial affairs.
Include your name; your credentials (i.e., a board certified psychiatrist, a licensed psychologist, a psychiatry resident or a psychology intern); and circumstances under which you performed the examination, if applicable (i.e., under the close supervision of an attending psychiatrist or psychologist); include name of supervising psychiatrist or psychologist.
Signature of Supervising psychiatrist or psychologist
-------------------- Robert Michael Roerich, M.D. Vice President National Gulf War Resource Center Posts: 964 | From: Steubenville, Ohio USA | Registered: Aug 2005
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