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1DVBCWPD7 ;BPOIFO/ESW - PTSD WORKSHEET TEXT ; 10/1/02 5:46pm
2 ;;2.7;AMIE;**46**;Apr 10, 1995
3 ;Per VHA Directive 10-92-142, this routine should not be modified
4 ;
5TXT ;
6 ;;
7 ;;F. Assessment of PTSD
8 ;;
9 ;; * state whether or not the veteran meets the DSM-IV stressor criterion
10 ;; * identify behavioral, cognitive, social, affective, or somatic change
11 ;; veteran attributes to stress exposure
12 ;; * describe specific PTSD symptoms present (symptoms of trauma
13 ;; re-experiencing, avoidance/numbing, heightened physiological arousal,
14 ;; and associated features [e.g., disillusionment and demoralization])
15 ;; * specify onset, duration, typical frequency, and severity of symptoms
16 ;;
17 ;;G. Psychometric Testing Results
18 ;;
19 ;; * provide psychological testing if deemed necessary.
20 ;; * provide specific evaluation information required by the rating board or
21 ;; on a BVA Remand.
22 ;; * comment on validity of psychological test results
23 ;; * provide scores for PTSD psychometric assessments administered
24 ;; * state whether PTSD psychometric measures are consistent or inconsistent
25 ;; with a diagnosis of PTSD, based on normative data and established
26 ;; "cutting scores" (cutting scores that are consistent with or supportive
27 ;; of a PTSD diagnosis are as follows: PCL - not less than 50;
28 ;; Mississippi Scale - not less than 107; MMPI PTSD subscale a score
29 ;; greater than 28; MMPI code type: 2-8 or 2-7-8)
30 ;; * state degree of severity of PTSD symptoms based on psychometric data
31 ;; (mild, moderate, or severe)
32 ;; * describe findings from psychological tests measuring other than
33 ;; PTSD (MMPI, etc.)
34 ;;
35 ;;H. Diagnosis:
36 ;;
37 ;; 1. The Diagnosis must conform to DSM-IV and be supported by the findings
38 ;; on the examination report.
39 ;; 2. If there are multiple mental disorders, delineate to the extent possible
40 ;; the symptoms associated with each and a discussion of relationship.
41 ;; 3. Evaluation is based on the effects of the signs and symptoms on
42 ;; occupational and social functioning.
43 ;;
44 ;;NOTE: VA is prohibited by statute, 38 U.S.C. 1110, from paying compensation
45 ;;for a disability that is a result of the veteran's own ALCOHOL OR DRUG ABUSE.
46 ;;However, when a veteran's alcohol or drug abuse disability is secondary to
47 ;;or is caused or aggravated by a primary service-connected disorder, the
48 ;;veteran may be entitled to compensation. See Allen v. Principi, 237 F.3d
49 ;;1368, 1381 (Fed. Cir. 2001). Therefore, it is important to determine the
50 ;;relationship, if any, between a service-connected disorder and a disability
51 ;;resulting from the veteran's alcohol or drug abuse. Unless alcohol or drug
52 ;;abuse is secondary to or is caused or aggravated by another mental disorder,
53 ;;you should separate, to the extent possible, the effects of the alcohol or
54 ;;drug abuse from the effects of the other mental disorder(s). If it is not
55 ;;possible to separate the effects in such cases, please explain why.
56 ;;
57 ;;I. Diagnostic Status
58 ;;
59 ;; Axis I disorders
60 ;; Axis II disorders
61 ;; Axis III disorders
62 ;; Axis IV (psychosocial and environmental problems)
63 ;; Axis V (GAF score - current)
64 ;;
65 ;;J. 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 ;;K. 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 ;;L. Other Opinion:
103 ;;
104 ;; Furnish any other specific opinion requested by the rating
105 ;; board or BVA remand (furnish the complete rationale and citation of medical
106 ;; texts or treatise supporting opinion, if medical literature review was
107 ;; 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 ;;
113 ;;M. Integrated Summary and Conclusions
114 ;;
115 ;; - Describe changes in PSYCHOSOCIAL FUNCTIONAL STATUS and QUALITY of LIFE
116 ;; following trauma exposure (performance in employment or schooling,
117 ;; routine responsibilities of self care, family role functioning, physical
118 ;; health, social/interpersonal relationships, recreation/leisure pursuits)
119 ;; - 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
122 ;; details about the effects of PTSD and its symptoms on employment
123 ;; are especially important.
124 ;; - If possible, describe extent to which disorders other than PTSD
125 ;; (e.g., substance use disorders) are independently responsible for
126 ;; impairment in psychosocial adjustment and quality of life. If this is
127 ;; not possible, explain why (e.g., substance use had onset after PTSD
128 ;; and clearly is a means of coping with PTSD symptoms).
129 ;; - If possible, describe pre-trauma risk factors or characteristics that
130 ;; may have rendered the veteran vulnerable to developing PTSD subsequent
131 ;; to trauma exposure.
132 ;; - If possible, state prognosis for improvement of psychiatric condition
133 ;; and impairments in functional status.
134 ;; - Comment on whether veteran should be rated as competent for VA purposes
135 ;; in terms of being capable of managing his/her benefit payments in
136 ;; his/her own best interest.
137 ;;
138 ;;
139 ;;Signature: Date:
140 ;;END
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