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1DVBCWPT1 ;ALB/CMM PTSD WKS TEXT - 1 ; 6 MARCH 1997
2 ;;2.7;AMIE;**12**;Apr 10, 1995
3 ;
4 ;
5TXT ;
6 ;;Narrative: Service connection for post-traumatic stress disorder (PTSD)
7 ;;requires medical evidence establishing a clear diagnosis of the
8 ;;condition, credible supporting evidence that the claimed in-service
9 ;;stressor actually occurred, and a link, established by medical
10 ;;evidence, between current symptomatology and the claimed in-service
11 ;;stressor. It is the responsibility of the examiner to indicate the
12 ;;extreme traumatic stressor leading to PTSD, if he or she makes the
13 ;;diagnosis of PTSD. It is the responsibility of the rating specialist
14 ;;to confirm that the cited stressor occurred during active duty.
15 ;;
16 ;;A diagnosis of PTSD cannot be adequately documented or ruled out
17 ;;without obtaining a detailed military history and reviewing the
18 ;;claims folder. This means that initial review of the folder prior to
19 ;;examination, the history and examination itself, and the dictation for
20 ;;an examination initially establishing PTSD will often require more
21 ;;time than examinations of other disorders. Ninety minutes to two
22 ;;hours on an initial exam is normal.
23 ;;
24 ;;A. Review or Medical Records:
25 ;;
26 ;;
27 ;;
28 ;;B. Medical History (Subjective Complaints):
29 ;;
30 ;; Comment on:
31 ;; 1. PAST MEDICAL HISTORY:
32 ;;
33 ;; a. Previous hospitalizations and outpatient care.
34 ;;
35 ;;
36 ;; b. Medical and occupational history (from the time between last
37 ;; rating examination and the present) needs to be accounted
38 ;; for, UNLESS the purpose of this examination is to ESTABLISH
39 ;; service connection, then a complete medical history
40 ;; including description of stressors and history since
41 ;; discharge from military service is required.
42 ;;
43 ;;
44 ;; c. Review of Claims Folder is also required on initial exams
45 ;; to establish or rule out the diagnosis.
46 ;;
47 ;;
48 ;;
49 ;; 2. PRESENT MEDICAL, OCCUPATIONAL AND SOCIAL HISTORY - over the
50 ;; past one year.
51 ;;
52 ;; a. Frequency, severity, and duration of psychiatric symptoms.
53 ;;
54 ;;
55 ;; b. Length of remissions, to include capacity for adjustment
56 ;; during periods of remissions.
57 ;;
58 ;;
59 ;; c. Extent of social impairment and time lost from work over
60 ;; the past 12-month period. If employed, identify current
61 ;; occupation and length of time at this job. If unemployed,
62 ;; note in COMPLAINTS whether veteran contends it is due to
63 ;; the effects of a mental disorder. Further discuss in
64 ;; DIAGNOSIS what factors and objective findings support or
65 ;; rebut that contention.
66 ;;
67 ;;
68 ;; 3. SUBJECTIVE COMPLAINTS:
69 ;;
70 ;; a. Describe fully.
71 ;;
72 ;;
73 ;;C. Examination (Objective Findings):
74 ;;
75 ;; Address each of the following and fully describe:
76 ;; 1. Stressor information: Clearly describe the stressor.
77 ;; Particularly if the stressor is a type of personal assault,
78 ;; including sexual assault, provide information, with examples,
79 ;; if possible, on behavioral, cognitive, social, or affective
80 ;; changes that the veteran links to the stressor. Include
81 ;; information on related somatic symptoms. If there is a
82 ;; history of multiple stressors, assess the impact of each, to
83 ;; the extent possible.
84 ;;
85 ;;
86 ;; 2. Mental status exam to confirm or establish diagnosis in
87 ;; accordance with DSM-IV:
88 ;;
89 ;;
90 ;; a. Are all diagnostic criteria to establish a diagnosis for
91 ;; 309.81, Post Traumatic Stress Disorder, as specified in
92 ;; DSM-IV, fully met?
93 ;;
94 ;;
95 ;;
96 ;; b. For initial examination to establish service connection,
97 ;; fully discuss the criteria in steps A through F supporting
98 ;; or ruling out the diagnosis.
99 ;;
100 ;;
101 ;; c. Describe any associated symptoms.
102 ;;
103 ;;
104 ;; d. Specify onset and duration of symptoms as acute, chronic, or
105 ;; with delayed onset.
106 ;;
107 ;;
108 ;; 3. Describe in detail the linkage between the stressor and the
109 ;; current symptoms and clinical findings.
110 ;;
111 ;;
112 ;; 4. Describe and fully explain the existence, frequency, and extent
113 ;; of the following signs and symptoms, or any others present, and
114 ;; relate how they interfere with employment and social functioning:
115 ;;
116 ;; a. Impairment of thought process or communication.
117 ;;
118 ;;
119 ;; b. Delusions, hallucinations and their persistence.
120 ;;
121 ;;
122 ;; c. Inappropriate behavior cited with examples.
123 ;;
124 ;;
125 ;; d. Suicidal or homicidal thoughts, ideations or plans or intent.
126 ;;
127 ;;
128 ;; e. Ability to maintain minimal personal hygiene and other basic
129 ;; activities of daily living.
130 ;;
131 ;;
132 ;; f. Orientation to person, place, and time.
133 ;;
134 ;;
135 ;; g. Memory loss, or impairment (both short and long-term).
136 ;;
137 ;;
138 ;; h. Obsessive or ritualistic behavior which interferes with
139 ;; routine activities and describe any found.
140 ;;
141 ;;
142 ;; i. Rate and flow of speech and note any irrelevant, illogical,
143 ;; or obscure speech patterns and whether constant or intermittent.
144 ;;
145 ;;
146 ;; j. Panic attacks noting the severity, duration, frequency, and
147 ;; effect on independent functioning and whether clinically
148 ;; observed or good evidence of prior clinical or equivalent
149 ;; observation is shown.
150 ;;
151 ;;
152 ;; k. Depression, depressed mood or anxiety.
153 ;;
154 ;;
155 ;; l. Impaired impulse control and its effect on motivation or mood.
156 ;;
157 ;;
158 ;; m. Sleep impairment and describe extent it interferes with
159 ;; daytime activities.
160 ;;
161 ;;
162 ;; n. Other symptoms and the extent they interfere with activities.
163 ;;
164 ;;
165 ;;D. Diagnostic Tests:
166 ;;
167 ;; 1. Provide psychological testing if deemed necessary.
168 ;; 2. If testing is requested, the results must be considered in
169 ;; arriving at the diagnosis.
170 ;; 3. Provide specific evaluation information required by the rating
171 ;; board or on a BVA Remand.
172 ;;
173 ;; a. COMPETENCY: State whether the veteran is capable of managing
174 ;; his or her benefit payments in the individual's own best
175 ;; interests. (A physical disability which prevents the veteran
176 ;; from attending to financial matters in person is not a proper
177 ;; basis for a finding of incompetence unless the veteran is, by
178 ;; reason of that disability, incapable of directing someone
179 ;; else in handling the individual's financial affairs.)
180 ;;
181 ;; b. OTHER OPINION: Furnish any other specific opinion requested
182 ;; by the rating board or BVA remand, furnishing the complete
183 ;; rationale and citation of medical texts or treatise supporting
184 ;; opinion, if medical literature review was undertaken. If the
185 ;; requested opinion is medically not ascertainable on exam or
186 ;; testing, please state why. If the requested opinion cannot be
187 ;; expressed without resorting to speculation or making
188 ;; improbable assumptions, say so and explain why. If the
189 ;; opinion asks " ... is it at least as likely as not ... ",
190 ;; fully explain the clinical findings and rationale for the
191 ;; opinion.
192 ;;
193 ;; 4. Include results of all diagnostic and clinical tests
194 ;; conducted in the examination report.
195 ;;
196 ;;
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