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1DVBCWPF2 ;ALB/RLC - INITIAL EVAL PTSD WORKSHEET TEXT ; 05/18/2006 11:00am
2 ;;2.7;AMIE;**87**;Apr 10, 1995;Build 6
3 ;Per VHA Directive 10-92-142, this routine should not be modified
4 ;
5TXT ;
6 ;;
7 ;;F. Assessment of PTSD
8 ;;
9 ;; - identify the primary stressor or stressors
10 ;; - state whether or not the veteran meets the DSM-IV stressor criterion
11 ;; - identify behavioral, cognitive, social, affective, or somatic change(s)
12 ;; veteran attributes to stress exposure
13 ;; - describe specific PTSD symptoms present (symptoms of trauma
14 ;; re-experiencing, avoidance/numbing, heightened physiological arousal,
15 ;; and associated features [e.g., disillusionment and demoralization])
16 ;; - specify onset, duration, typical frequency, and severity of symptoms
17 ;; - state whether or not the current symptoms are linked to the identified
18 ;; stressor or stressors
19 ;;
20 ;;G. Psychometric Testing Results
21 ;;
22 ;; - provide psychological testing if deemed necessary.
23 ;; - provide specific evaluation information required by the rating board or
24 ;; on a BVA Remand.
25 ;; - comment on validity of psychological test results
26 ;; - provide scores for PTSD psychometric assessments administered
27 ;;TOF
28 ;; - state whether PTSD psychometric measures are consistent or inconsistent
29 ;; with a diagnosis of PTSD, based on normative data and established
30 ;; "cutting scores" (cutting scores that are consistent with or supportive
31 ;; of a PTSD diagnosis are as follows: PCL - not less than 50;
32 ;; Mississippi Scale - not less than 107; MMPI PTSD subscale a score
33 ;; greater than 28; MMPI code type: 2-8 or 2-7-8)
34 ;; - state degree of severity of PTSD symptoms based on psychometric data
35 ;; (mild, moderate, or severe)
36 ;; - describe findings from psychological tests measuring other than
37 ;; PTSD (MMPI, etc.)
38 ;;
39 ;;H. Diagnosis:
40 ;;
41 ;; 1. The Diagnosis must conform to DSM-IV and be supported by the findings
42 ;; on the examination report.
43 ;; 2. If there are multiple mental disorders, discuss the relationship with
44 ;; PTSD.
45 ;; 3. The evaluation is based on the effects of the signs and symptoms on
46 ;; occupational and social functioning.
47 ;;
48 ;; NOTE: VA is prohibited by statute, 38 U.S.C. 1110, from paying compensation
49 ;; for a disability that is a result of the veteran's own ALCOHOL OR DRUG ABUSE.
50 ;; However, when a veteran's alcohol or drug abuse disability is secondary to
51 ;; or is caused or aggravated by a primary service-connected disorder, the
52 ;; veteran may be entitled to compensation. See Allen v. Principi, 237 F.3d
53 ;; 1368, 1381 (Fed. Cir. 2001). Therefore, it is important to determine the
54 ;; relationship, if any, between a service-connected disorder and a disability
55 ;; resulting from the veteran's alcohol or drug abuse. Unless alcohol or drug
56 ;; abuse is secondary to or is caused or aggravated by another mental disorder,
57 ;; you should separate, to the extent possible, the effects of the alcohol or
58 ;; drug abuse from the effects of the other mental disorder(s). If it is not
59 ;; possible to separate the effects in such cases, please explain why.
60 ;;
61 ;;I. Diagnostic Status
62 ;;
63 ;; - Axis I disorders
64 ;; - Axis II disorders
65 ;; - Axis III disorders
66 ;; - Axis IV (psychosocial and environmental problems)
67 ;; - Axis V (GAF score - current)
68 ;;
69 ;;J. Global Assessment of Functioning (GAF):
70 ;;
71 ;; NOTE: The complete multi-axial format as specified by DSM-IV may be required
72 ;; by BVA REMAND or specifically requested by the rating specialist. If so,
73 ;; include the GAF score and note whether it refers to current functioning.
74 ;; A BVA REMAND may also request, in addition to an overall GAF score,
75 ;; that a separate GAF score be provided for each mental disorder present when
76 ;; there are multiple Axis I or Axis II diagnoses and not all are service-
77 ;; connected. If separate GAF scores can be given, an explanation and
78 ;;TOF
79 ;; discussion of the rationale is needed. If it is not possible, an
80 ;; explanation as to why not is needed. (See the above note pertaining to
81 ;; alcohol or drug abuse.)
82 ;;
83 ;; DSM-IV is only for application form 11/7/96 on. Therefore, when
84 ;; applicable note whether the diagnosis for PTSD was supportable under
85 ;; DSM-III-R prior to that date.
86 ;;
87 ;;K. Capacity to Manage Financial Affairs
88 ;;
89 ;; Mental competency, for VA benefits purposes, refers only to the ability
90 ;; of the veteran to manage VA benefit payments in his or her own best
91 ;; interest, and not to any other subject. Mental incompetency,
92 ;; for VA benefits purposes, means that the veteran, because of injury
93 ;; or disease, is not capable of managing benefit payments in his or her
94 ;; best interest. In order to assist raters in making a legal determination
95 ;; as to competency, please address the following:
96 ;;
97 ;; What is the impact of injury or disease on the veteran's ability
98 ;; to manage his or her financial affairs, including consideration
99 ;; of such things as knowing the amount of his or her VA benefit
100 ;; payment, knowing the amounts and types of bills owed monthly,
101 ;; and handling the payment prudently? Does the veteran handle
102 ;; his or her money and pay the bills?
103 ;;
104 ;; Based on your examination, do you believe that the veteran is
105 ;; capable of managing his or her financial affairs?
106 ;; Please provide examples to support your conclusion.
107 ;;
108 ;; If you believe a Social Work Service assessment is needed before
109 ;; you can give your opinion on the veteran's ability to manage his
110 ;; or her financial affairs, please explain why.
111 ;;
112 ;;L. Other Opinion:
113 ;;
114 ;; Furnish any other specific opinion requested by the rating
115 ;; board or BVA remand (furnish the complete rationale and citation of medical
116 ;; texts or treatise supporting opinion, if medical literature review was
117 ;; undertaken). If the requested opinion is medically not ascertainable
118 ;; on exam or testing please state why. If the requested opinion cannot be
119 ;; expressed without resorting to speculation or making improbable assumptions
120 ;; say so, and explain why. If the opinion asks "...is it at least as likely
121 ;; as not..", fully explain the clinical findings and rationale for the
122 ;; opinion.
123 ;;
124 ;;M. Integrated Summary and Conclusions
125 ;;
126 ;; - Describe changes in psychosocial functional status and quality of life
127 ;; following trauma exposure (performance in employment or schooling,
128 ;; routine responsibilities of self care, family role functioning, physical
129 ;; health, social/interpersonal relationships, recreation/leisure pursuits)
130 ;;TOF
131 ;; - Describe linkage between PTSD symptoms and aforementioned changes in
132 ;; impairment in functional status and quality of life.
133 ;; Particularly in cases where a veteran is unemployed, specific
134 ;; details about the effects of PTSD and its symptoms on employment
135 ;; are especially important.
136 ;; - If possible, describe extent to which disorders other than PTSD
137 ;; (e.g., substance use disorders) are independently responsible for
138 ;; impairment in psychosocial adjustment and quality of life. If this is
139 ;; not possible, explain why (e.g., substance use had onset after PTSD
140 ;; and clearly is a means of coping with PTSD symptoms).
141 ;;
142 ;; - If possible, describe pre-trauma risk factors or characteristics that
143 ;; may have rendered the veteran vulnerable to developing PTSD subsequent
144 ;; to trauma exposure.
145 ;; - If possible, state prognosis for improvement of psychiatric condition
146 ;; and impairments in functional status.
147 ;; - Comment on whether the veteran is capable of managing his/her
148 ;; benefit payments in his/her own best interest.
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