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1DVBCWPE7 ;BPOIFO/ESW - REVIEW PTSD WORKSHEET TEXT ; 10/1/02 5:48pm
2 ;;2.7;AMIE;**46**;Apr 10, 1995
3 ;Per VHA Directive 10-92-142, this routine should not be modified
4 ;
5TXT ;
6 ;;E. Assessment of PTSD
7 ;;
8 ;; 1. state whether or not the veteran meets the DSM-IV stressor criterion
9 ;; 2. identify behavioral, cognitive, social, affective, or somatic symptoms
10 ;; veteran attributes to PTSD
11 ;; 3. describe specific PTSD symptoms present (symptoms of trauma
12 ;; re-experiencing, avoidance/numbing, heightened physiological arousal,
13 ;; and associated features [e.g., disillusionment and demoralization])
14 ;; 4. specify typical frequency, and severity of symptoms
15 ;;TOF
16 ;;F. Psychometric Testing Results
17 ;;
18 ;; 1. provide psychological testing if deemed necessary
19 ;; 2. provide specific evaluation information required by the rating board or
20 ;; on a BVA Remand
21 ;; 3. comment on validity of psychological test results
22 ;; 4. provide scores for PTSD psychometric assessments administered
23 ;; 5. state whether PTSD psychometric measures are consistent or inconsistent
24 ;; with a diagnosis of PTSD, based on normative data and established
25 ;; "cutting scores" (cutting scores that are consistent with or supportive
26 ;; of a PTSD diagnosis are as follows: PCL - not less than 50;
27 ;; Mississippi Scale - not less than 107; MMPI PTSD subscale a score
28 ;; greater than 28; MMPI code type: 2-8 or 2-7-8)
29 ;; 6. state degree of severity of PTSD symptoms based on psychometric data
30 ;; (mild, moderate, or severe)
31 ;; 7. describe findings from psychological tests measuring other than
32 ;; PTSD (MMPI, etc.)
33 ;;
34 ;;G. Diagnosis:
35 ;;
36 ;; 1. The Diagnosis must conform to DSM-IV and be supported by the findings
37 ;; on the examination report.
38 ;; 2. If there are multiple mental disorders, delineate to the extent possible
39 ;; the symptoms associated with each and a discussion of relationship.
40 ;; 3. Evaluation is based on the effects of the signs and symptoms on
41 ;; occupational and social functioning.
42 ;;
43 ;;NOTE: VA is prohibited by statute, 38 U.S.C. 1110, from paying compensation
44 ;;for a disability that is a result of the veteran's own ALCOHOL OR DRUG ABUSE.
45 ;;However, when a veteran's alcohol or drug abuse disability is secondary to
46 ;;or is caused or aggravated by a primary service-connected disorder, the
47 ;;veteran may be entitled to compensation. See Allen v. Principi, 237 F.3d
48 ;;1368, 1381 (Fed. Cir. 2001). Therefore, it is important to determine the
49 ;;relationship, if any, between a service-connected disorder and a disability
50 ;;resulting from the veteran's alcohol or drug abuse. Unless alcohol or drug
51 ;;abuse is secondary to or is caused or aggravated by another mental disorder,
52 ;;you should separate, to the extent possible, the effects of the alcohol or
53 ;;drug abuse from the effects of the other mental disorder(s). If it is not
54 ;;possible to separate the effects in such cases, please explain why.
55 ;;
56 ;;H. Diagnostic Status
57 ;;
58 ;; Axis I disorders
59 ;; Axis II disorders
60 ;; Axis III disorders
61 ;; Axis IV (psychosocial and environmental problems)
62 ;; Axis V (GAF score - current)
63 ;;
64 ;;TOF
65 ;;I. Global Assessment of Functioning (GAF):
66 ;;
67 ;; NOTE: The complete multi-axial format as specified by DSM-IV may be required
68 ;; by BVA REMAND or specifically requested by the rating specialist. If so,
69 ;; include the GAF score and note whether it refers to current functioning.
70 ;; A BVA REMAND may also request, in addition to an overall GAF score,
71 ;; that a separate GAF score be provided for each mental disorder present when
72 ;; there are multiple Axis I or Axis II diagnoses and not all are service-
73 ;; connected. If separate GAF scores can be given, an explanation and
74 ;; discussion of the rationale is needed. If it is not possible, an explanation
75 ;; as to why not is needed. (See the above note pertaining to alcohol or drug
76 ;; abuse.)
77 ;;
78 ;;J. CAPACITY TO MANAGE FINANCIAL AFFAIRS
79 ;;
80 ;; Mental competency, for VA benefits purposes, refers only to the ability
81 ;; of the veteran to manage VA benefit payments in his or her own best
82 ;; interest, and not to any other subject. Mental incompetency,
83 ;; for VA benefits purposes, means that the veteran, because of injury
84 ;; or disease, is not capable of managing benefit payments in his or her
85 ;; best interest. In order to assist raters in making a legal determination
86 ;; as to competency, please address the following:
87 ;; What is the impact of injury or disease on the veteran's ability
88 ;; to manage his or her financial affairs, including consideration
89 ;; of such things as knowing the amount of his or her VA benefit
90 ;; payment, knowing the amounts and types of bills owed monthly,
91 ;; and handling the payment prudently? Does the veteran handle
92 ;; the money and pay the bills himself or herself?
93 ;;
94 ;; Based on your examination, do you believe that the veteran is
95 ;; capable of managing his or her financial affairs?
96 ;; Please provide examples to support your conclusion.
97 ;;
98 ;; If you believe a Social Work Service assessment is needed before
99 ;; you can give your opinion on the veteran's ability to manage his
100 ;; or her financial affairs, please explain why.
101 ;;
102 ;;K. Other Opinion:
103 ;;
104 ;; Furnish any other specific opinion requested by the rating
105 ;; board or BVA remand (i.e., furnish the complete rationale and citation of
106 ;; medical texts or treatise supporting opinion, if medical literature review
107 ;; was undertaken). If the requested opinion is medically not ascertainable
108 ;; on exam or testing please state WHY. If the requested opinion can not be
109 ;; expressed without resorting to speculation or making improbable assumptions
110 ;; say so, and explain why. If the opinion asks "... is it at least as likely
111 ;; as not..", fully explain the clinical findings and rationale for the opinion.
112 ;;TOF
113 ;;L. Integrated Summary and Conclusions
114 ;;
115 ;; 1. Describe changes in PSYCHOSOCIAL FUNCTIONAL STATUS and QUALITY of LIFE
116 ;; since the last exam (performance in employment or schooling, routine
117 ;; responsibilities of self care, family role functioning, physical health,
118 ;; social/interpersonal relationships, recreation/leisure pursuits)
119 ;; 2. Describe linkage between PTSD symptoms and aforementioned changes in
120 ;; impairment in functional status and quality of life.
121 ;; Particularly in cases where a veteran is unemployed, specific details
122 ;; about the effects of PTSD and its symptoms on employment are especially
123 ;; important.
124 ;;
125 ;; 3. If possible, describe extent to which disorders other than PTSD
126 ;; (e.g., substance use disorders) are independently responsible for
127 ;; impairment in psychosocial adjustment and quality of life. If this is not
128 ;; possible, explain why (e.g., substance use had onset after PTSD
129 ;; and clearly is a means of coping with PTSD symptoms).
130 ;; 4. If possible, state prognosis for improvement of psychiatric condition
131 ;; and impairments in functional status.
132 ;; 5. Comment on whether veteran should be rated as competent for VA purposes
133 ;; in terms of being capable of managing his/her benefit payments in his/her
134 ;; own best interest.
135 ;;
136 ;;
137 ;;Signature: Date:
138 ;;END
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