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Best Practice Manual for
Compensation and Pension
Prepared by:
Patricia Watson, Ph.D.
Miles McFall, Ph.D.
Northwest Network Mental Illness Research, Education, and Clinical Center
VA Puget Sound Health Care System
Caroll McBrine, M.D.
Compensation and Pension Service
Paula P. Schnurr, Ph.D.
Matthew J. Friedman, M.D., Ph.D.
Terence Keane, Ph.D.
Jessica L. Hamblen, Ph.D.
Compensation and Pension Examinations
Executive Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
CORE DOCUMENT
I. Background Information: PTSD Initial Claims Review . . . . . . . . . . . . . . 5
II. Background Information: Assessment of PTSD. . . . . . . . . . . . . . . . . . . 7
III. Recommended Guidelines for Assessing
Trauma Exposure and PTSD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
IV. Compensation and Pension PTSD disability
examination worksheets. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
A. Worksheet I: Initial Evaluation for PTSD . . . . . . . . . . . . . . . . . . . . . 23
B. Worksheet II: Review Evaluation for PTSD . . . . . . . . . . . . . . . . . . . 31
V. Suggested Report Template for Initial Exam . . . . . . . . . . . . . . . . . . . . . 37
VI. Suggested Report Template for Follow-up Exam . . . . . . . . . . . . . . . . . . 47
A. Training Letter Based on PTSD Case Review . . . . . . . . . . . . . . . . . . . . 55
B. Governing Regulation for Service Connection for PTSD
(From 38 CFR Part 3) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
C. Excerpts from Veterans Benefit Administration's Adjudication
Procedures Manual concerning the adjudication
of claims for PTSD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
D. Detailed Guideline for Global Assessment of Functioning Scale . . . . . 73
E. Global Assessment of Functioning Scale . . . . . . . . . . . . . . . . . . . . . . . . 79
F. Scoring rules for Mississippi and PTSD checklist. . . . . . . . . . . . . . . . . . 81
G. Examples of PTSD Symptom Narratives in Compensation
and Pension Examination Reports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
H. Social History Questionnaire. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
I. References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
This document provides information on Posttraumatic Stress Disorder and current recommendations regarding what is known about "best practice" procedures for assessing PTSD among veteran populations. A Veterans Benefits
Administration (VBA) review of 143 initial claims for PTSD revealed that
PTSD was diagnosed in 77% of the cases, that the exam was not adequate for
rating in at least 8%, but that inadequate exams were not routinely returned for
correction. A common problem was that the examiner did not describe how
Diagnostic and Statistical Manual for Mental Disorders-IV (DSM-IV) diagnostic criteria were met. Good exams delineated how the PTSD diagnostic criteria
were met by giving specific examples. Other noted problems were the examiner
using DSM-III rather than DSM-IV criteria, and the examiner sometimes failing to discuss whether other mental disorders that were diagnosed are due to or
part of PTSD. The VBA and Veterans Health Administration (VHA) are committed to improving these services to veterans, and improving the quality of
compensation and pension examinations for PTSD.
Included in this manual are an assessment protocol based on best practices for
assessing PTSD, and disability examination worksheets which correlate with
the protocol. Included in the protocol are guidelines on:
I. Trauma Exposure Assessment
• The objective of trauma assessment
• DSM-IV Stressor Criterion
• Sources of information used in trauma assessment
• Guidelines for interview assessment of trauma exposure
• Orienting the claimant to trauma assessment
• Documentation of trauma-related information.
• Suggested interview queries
• Orienting statement
• Administration of the Clinician-Administered PTSD Scale (CAPS) Life
• Recommended Instruments for Trauma Assessment.
II. Assessment of PTSD
• Four objectives which should be addressed:
a. Establishing the presence or absence of a diagnosis of PTSD
b. Determining the severity of PTSD symptoms
c. Establishing a logical relationship between exposure to military
stressors and current PTSD symptomatology
d. Describing how PTSD symptoms impair social and occupational
functioning and quality of life.
• DSM-IV Diagnostic Criteria for PTSD
• Diagnostic interview assessment of PTSD.
• Psychometric assessment of PTSD
III. Recommended Time Allotment for Completing Examination
• Initial PTSD compensation and pension evaluations typically require
about three hours, but complex cases may demand additional time.
• Follow-up evaluations usually require an hour to an hour and a half.
IV. Professionals Qualified to Conduct Compensation and Pension
Examinations for PTSD
The VHA encourages use of this protocol when examining veterans for compensation purposes to ensure that a detailed history is obtained from the veteran and a comprehensive evaluation is performed and documented.
Comprehensive report templates have also been included as guides when writing reports.
Also included in this manual as reference material are:
• The VBA training letter based on a PTSD case review
• The governing regulation from 38 CFR, Part 3 for Service Connection
for PTSD
• Excerpts from VBA's Adjudication Procedures manual concerning the
adjudication of claims for PTSD
• Background research on PTSD and the Global Assessment of
Functioning (GAF)
• The GAF Scale
• Scoring rules for Mississippi and PTSD checklist
• Examples of trauma history and PTSD symptom narratives
• A social history questionnaire.
It is anticipated that this document will raise the quality and standards of
PTSD Compensation and Pension (C&P) examinations. This increased quality
will require increased time and expense allotted to the evaluation process.
Under current VA standards, with local and regional variations in time mandated for exams, clinical expertise, and resources, the examiners must use their discretion in selecting the most relevant information for completing a competent,
comprehensive examination for PTSD.
The examination protocol can be accessed electronically through VA's Veterans
Health Information Systems and Technology Architecture (VISTA) computer
system – formerly the Decentralized Hospital Computer System (DHCP).
Clinicians may receive assistance in accessing this protocol from C&P clerks,
Information Resources Management (IRM) staff, chiefs of Health
Administration Services (HAS), or other staff members, depending on the facility's local organization.
PTSD Initial Claims Review
A review of 143 initial claims for PTSD under a special protocol was conducted
during the week of June 19, 2000, by three field reviewers and one member of
the Star Review Staff under the supervision of Dr. Caroll McBrine. The statistics reported are based on the 143 files formally reviewed, but an additional 77
cases were informally reviewed. The review was not statistically valid but was
sufficient to point out problem areas that call for additional training.
Examination findings
• PTSD was diagnosed in 77% (75/97 exams).
• The exam was not adequate for rating in at least 8% (8), but only 3 were
returned.
• The examiner reconciled multiple psychiatric diagnoses in all but 3 or
35% (34) where they were present."
• The examiner had the claims folder in 44% (43).
• The examiner considered and discussed documentary evidence
in 36% (35).
• The examiner identified the stressor and commented on the nexus in
68% (51/75).
• A common problem (in at least 5 exams) was that the examiner did not
describe how DSM-IV diagnostic criteria were met. All exams were
accepted by regional office (RO), but should have been returned. Good
exams delineated how the PTSD diagnostic criteria were met by giving
specific examples.
• The examiner clearly used DSM-III rather than DSM-IV criteria in
many cases.
• The examiner sometimes failed to discuss whether other mental disorders that were diagnosed are due to or part of PTSD.
II. Background Information:
Assessment of Posttraumatic Stress Disorder
PTSD is a prevalent mental disorder among veterans exposed to traumatic
stress during military service. The VA's commitment to providing thorough and
accurate assessment and care of veterans raises a need for a more standardized
approach to assessment and documentation of PTSD and resulting impairment
in psychosocial functioning. This background information reports on the current standards for PTSD assessment. Further information on the research associated with PTSD is included in Appendix E.
Assessment of PTSD
PTSD is assessed by a variety of methods, including questionnaires, interviews,
and biological tests. Chapter 2 gives a summary of the recommended instruments and format for PTSD assessment. Under optimal circumstances, assessment of PTSD and associated disorders is based on multiple sources of information, derived from clinical interview, psychometric testing, review of military
and medical records, reports from collaterals who know the veteran, and studies
of psychophysiological reactivity. A multi-method approach is especially helpful
to address concerns about either denying or overreporting symptoms.
Many clinicians find the addition of the Minnesota Multiphasic Personality
Inventory (MMPI) and Minnesota Multiphasic Personality Inventory-2 (MMPI2 helpful, particularly in very complex or difficult cases. The MMPI and MMPI2 include scales that assess overreporting; they have what are known as "validity
scales" that are elevated in people who are trying to exaggerate their symptoms.
There has been evidence to suggest that compensation-seeking veterans
endorse higher levels of psychopathology across measures and produce elevated
validity indices on the MMPI and MMPI-2 as compared to non-compensationseeking veterans (Smith & Frueh, 1996; Frueh & Kinder, 1994). Sample sizes in
these studies, however, are small, and clinicians were not correlating scores on
the MMPI with collateral sources of data suggestive of overreporting. Even in
non-compensation-seeking settings, the preponderance of evidence suggests
that people with PTSD report significantly higher subjective distress than those
without PTSD. Several studies suggest that Vietnam combat veterans and child
abuse survivors may have elevated scores as a result of chronic post traumatic
difficulties or comorbid affective symptoms, as opposed to motivated symptom
overendorsement (Elliott, 1993; Jordan, Nunley, & Cook, 1992; Smith & Frueh,
The Infrequency-Psychopathology Scale F(p), was designed by Arbisi and BenPorath (1995), for the MMPI-2 as an additional validity measure for use with
patient populations where a high rate of endorsement of psychological disturbance is expected. The scale's validity has been tested in with inpatient veterans, with results indicating that the F(p) scale may be used as an adjunct to the
F in settings characterized by relatively high base rates of psychopathology and
psychological distress. Arbisi and Ben-Porath suggest that when the F(p) scale
is elevated along with the F Scale, the clinician can more confidently attribute
the high scores to a patient's attempt to overreport psychopathology if other
validity measures are not elevated significantly. The F(p) Scale is less influenced by diagnostic group and distress/psychopathology than the F Scale in distinguishing groups with genuine psychopathology from those asked to feign psychiatric impairment (Arbisi and Ben-Porath, 1997; 1998). In patients likely to
be encountered in both clinical and forensic settings, elevations on the F(p)
Scale are much more common when malingering or exaggeration of psychopathology is expected (Rothke et. al, 2000). Hit rates (Rothke et. al. 2000)
and cutoff scores (Strong et. al., 2000) have been reported across a number of
settings (see disability examination worksheets for cutoff scores). Nonetheless,
it is critical that clinicians understand the nature of their population with regard
to frequency and type of psychopathology before interpreting the F(p) Scale.
Independent verification that patients are overreporting is needed. With this
caveat in mind, use of the MMPI and MMPI-2 may help the evaluator in determining test-taking style of the veteran (i.e., defensive, overendorsing,
underendorsing).
In using the MMPI-2 to assess for PTSD, cutoff scores for utilizing the MMPI-2
to assess validity of PTSD diagnosis have been reported in a number of studies
(Lyons, 1999; Wetter et al., 1993). In addition, MMPI-2 cutoff scores for specific PTSD scales (i.e., PK, PS) have been shown to be effective at assessing PTSD
(Lyons & Keane, 1992). (See disability examination worksheets for cutoff
scores). A Cochrane review of Effectiveness report (September, 2000) indicated that six of 21 studies reviewed (29%) reported that the mean 8-2 profile pattern significantly differentiated PTSD from non-PTSD patients. Seven (33%) of
the studies demonstrated either no significant mean two-point profile pattern
differences, or differences that were attributable to scale elevations, but not
mean code type patterns. In five of these seven studies, mean 8-2 profile patterns were produced by both the PTSD and comparison samples, although the
PTSD groups were significantly more elevated than the comparison groups. Of
seven inpatient veteran studies, all reported an 8-2 mean profile pattern,
although four of these reported non-significant differences. When five outpatient veteran studies were grouped together, 50% demonstrated the mean 8-2
profile pattern. The three POW studies were consistent in generating an averaged 1-2 profile pattern. Of the eight studies that reported many profile patterns other than the 8-2, the most frequent mean two-point profile patterns
were 1-2 (four, 19%), 4-8 (three, 14%), 4-2 (three, 14%), and 8-7 (three, 14%).
At this time, the current findings call for careful and accurate, multimodal
assessment, and a conservative approach in our ability to interpret symptom
overendorsement in the context of psychometric testing alone. Comprehensive
assessments based on multiple sources of information that yield consistent
results tend to create greater confidence in the veracity of diagnostic judgments.
Biological measures such as measures of heart rate, blood pressure, skin conductance, and EKG muscle tension have been found to yield valuable information for corroborating a PTSD diagnosis (Keane et. al, 1998). Veterans more
prone to psychophysiological response to war-zone cues tended to be more
impaired on both clinician and self-report measures of PTSD, have poorer
functioning, and endorse patterns of guilt and depression. However, it is important to keep in mind that some psychophysiological responses can be fabricated,
and almost one third of veterans with PTSD do not show a psychophysiological
response to war-zone cues. Therefore, biological data can best be framed as
corroborative of other data, rather than as a determining factor in
making a diagnosis.
Assessment of Functioning Using the GAF Scale
In 1997, the Department of Veterans Affairs mandated (VHA Directive # 97059) that a GAF score be assigned at regular intervals for veterans receiving
mental health care in the VHA system. According to this directive, the GAF
scores were to be used to define who is seriously mentally ill (SMI), and to calculate a GAF index for the SMI population in 1998.
On occasion, the GAF score has been employed by disability rating boards as
an index of a claimant's functional status as part of the process of determining
eligibility for benefits. The GAF scale was included as the fifth axis in a DSM
profile beginning as a 7-point format with the DSM-III. It was changed from a
7-point scale in DSM-III to a 0-90 point scale in DSM-III-R, and to a 0-100
point scale in DSM-IV. The current version of the GAF is based on the Global
Assessment Scale (GAS) developed by Endicott and colleagues. The GAF and
the GAS are almost identical to each other in content, with the exception of
some re-arrangement of rating descriptions and examples for the categories.
While no information on the reliability and validity of the GAF is included in
the DSM-IV, these psychometric features of the GAS were formally examined
and published by the GAS authors (Enidcott, Spitzer, Fleiss & Cohen, 1976; see
Appendix F of this manual for more details on the GAS).
GAF Rating Issues
1. GAF Reliability and Training. The existing GAF literature shows that in the
absence of systematic training with the GAF, reliability is generally poor.
Evidence suggests that without training some raters may base their ratings on
average symptom occurrence or functionality over time, while others will rate
the most recent episode or lowest level of these two components. In disorders
like PTSD, where symptom severity and functionality can fluctuate, these two
approaches will yield very different GAF scores. Therefore, training in using
the GAF with PTSD is essential.
2. GAF Accuracy and Clinician-Rater Biases. While training is important for
obtaining reliable ratings; high accuracy should be given equal consideration.
Outcome data from GAF trainings have shown that raters show a bias against
assigning low GAF scores for PTSD vignettes. For PTSD cases used as part of
organized GAF trainings, it was typically true that the GAF ratings made
before training were too high. This reflected various biases and beliefs of the
clinician raters regarding what defined a functional problem, and equally
important, their personal perspective on what qualified as a "mild," "moderate," and "serious" levels of severity. These biases affect the accuracy of the
GAF rating assigned.
3. GAF Accuracy with PTSD and Comorbidity. DSM-IV GAF symptom examples in the text do not represent PTSD symptoms directly, although they capture associate features and general level of functioning . The clinician must
decide what should be considered as either a symptom or functional problem
that is then rated for its severity (e.g., avoidance can be an individual PTSD
symptom and part of more broad social and interpersonal dysfunction).
Additionally, the presence of other comorbid diagnoses is common in cases of
chronic PTSD. To assess PTSD symptom severity in the context of comorbidity,
the clinician must somehow weigh the combined impact of all coexisting diagnoses, but without directions or examples.
4. Resolution of the GAF Scale. The GAF scale is organized into 10 decile (10point) bands that yield 100 possible points. Available GAF instructions recommend first finding the decile band that seems to best describe either the degree
of symptomatology or functional severity. Then, parenthetically, the DSM-IV
adds a note advising that the rater "use intermediate codes when appropriate (
e.g., 45, 68, 72)", but gives no guidance on exactly how to arrive at these intermediate values. Practically speaking, the larger deciles may have greater reliability because they are more clearly specified in the DSM-IV and thus easier to
select. Consequently, if GAFs are based only on decile values (30, 40, 50, 60,
etc.), then the difference between raters assigning GAFs for the same patient
could easily vary by 20 points. This could occur, for example, if one rater considered the symptoms to be Mild and the other judged them to be Moderate Severe in nature. This discussion highlights the problem of using GAF cutoff
scores that set strict thresholds for disability (e.g., 40 and higher is not disabled
/ below 40 is disabled). This is unwise and unsupported by both the inherent
resolution of the GAF scale (3 – 5 points) and the data from standardization
studies of the GAS (see Appendix F) showing that raters normally vary by as
much as +/- 5 to 8 points.
5. Assigning Separate GAFs by Condition. No published information associated
with the DSM-IV instructs users in a valid method for partitioning the GAF
score (Partial Assessmemt of Functioning [PAF]) by comorbid clinical conditions for the areas of Social and Occupational / School functioning. While the
same is also true for Psychological functioning, it might appear from reading
the descriptors in DSM-IV (i.e., mild, moderate, serious) that separate ratings
by diagnosis could be made (e.g., only for depression symptoms, only for anxi-
ety symptoms, only for substance abuse symptoms). However, the separate ratings that would result have no validated relationship to each other, and no
established process for integrating them into a value that truly considers the
combined effect of having them all concurrently. Second, if PAFs are requested
for a disability determination, it is likely that multiple conditions exist comorbidly, and having separate ratings of severity of dysfunction would fit with a
process of assigning a percentage of service connection to each particular disorder. In PTSD, depression and substance abuse frequently coexist and attempting to attribute a portion of the functional problems to depression and another
to substance use and another to PTSD, as if they were independent of each
other, is beyond the intended purpose and capability of the GAF scale. This is
an instance of incompatibility between the capabilities of the GAF scale and the
compensation review process. While the logic of separate ratings by disorder
may make sense from an adjudication perspective, it is not clinically validated,
and PAFs assigned in this manner should be seriously questioned for their
validity as evidence in the disability determination proceedings.
Some Considerations for Making GAF Ratings:
Given the GAF considerations described above, clinicians who assign GAF ratings should: a) attend available trainings, b) study available GAF materials
carefully, c) try to assign scores as accurately as possible by adhering to the definitions provided, and d) strive to become consistent in choosing their
GAF ratings.
It is important to gather through multiple means (i.e., structured interview,
social history, self-report measures), an assessment of the individual's level of
functioning across the time periods prior to, during, and subsequent to military
service. Areas of functioning to assess include: developmental, social, familial,
educational, vocational, cognitive, interpersonal, behavioral, and emotional
domains. The clinician is then responsible for assigning a GAF score, but more
importantly including sufficient narrative which supports the rationale behind the
score assigned.
At the current time, existing Disability Examination worksheets (as included in this
publication) reflect VBA's policy of sometimes requesting that the examiner partition out GAF scores for comorbid disorders. While this information may be
requested, if the clinician feels that to do so would be impossible or clinically
invalid, he or she is not required to do so, and should state specifically why he or
she feels that this is not possible.
Finally, in making ratings, clinicians should be cognizant of the presence of violence toward self and others in the veteran's history. While these events may be
episodes of aggression vs. continuous aggression or a general aggressive
demeanor, they are significant features that drop the GAF into the lower decile
ranges. If these features are present clinically, they should not be overlooked or
minimized by the clinician when making GAF ratings, even if it appears that the
veteran has higher functionality in other areas.
Trauma Exposure and PTSD
A. Trauma Exposure Assessment
A.1. Objective. Compensation and pension examinations routinely address
PTSD resulting from combat exposure. However, many other forms of militaryrelated stress are sufficient to induce PTSD and should be reviewed among veterans applying for service-connected disability benefits. Non-combat forms of
military-related trauma that are not uncommon include sexual assault or severe
harassment; non-sexual physical assault; duties involved in graves registration or
morgue assignment; accidents involving injury, death, or near death experiences; and actions associated with peace-keeping deployments that meet the
DSM-IV stressor criterion.
The objective of trauma assessment is to document whether the veteran was
exposed to a traumatic event, during military service, of sufficient magnitude to
meet the DSM-IV stressor criterion, described below.
DSM-IV Stressor Criterion
The person has been exposed to a traumatic event in which both of the
following have been present:
1. The person experienced, witnessed, or was confronted with an
event or events that involved actual or threatened death or serious
injury, or a threat to the physical integrity of self or others;
2. The person's response involved intense fear, helplessness,
or horror.
Note. Adverse psychological reactions are often associated with stressful events that
have the quality of being unpredictable and uncontrollable. Additionally, stressors
that result in bodily injury, threat to life, tragic loss of a significant other, or involvement with brutality or the grotesque heighten risk for subsequent PTSD. Exposure
to assaultive violence, particularly of a criminal nature, is more likely to induce
PTSD than are random "acts of God." It is known that severity of the stressor, in
terms of intensity, frequency, and duration, is the most important trauma characteristic associated with subsequent development of PTSD. Factors surrounding the
trauma incident, such as absence of social support for the victim, may also influence the degree to which a stressful event is experienced as psychologically traumatic and may contribute to its potential for inducing psychiatric symptoms.
A.2. Sources of information used in trauma assessment. Multiple sources of infor-
mation should be used to assess history of exposure to traumatic stress, as well
as its nature and severity. These sources include: (a) VA Claims File, (b) DD214, (c) medical records from the VA, Department of Defense, and non-VA
health care facilities, (d) statements from others who have information about
the veteran's trauma exposure and its behavioral sequela, (e) evidence of
behavior changes that occurred shortly after the trauma incident, and (f) statements derived from interview of the claimant. The occurrence of some forms of
trauma (e.g., combat exposure) are usually substantiated by official military
records, while support for other stressors (e.g., sexual assault) may depend on
sources other than military records. (See Section VII for further information
about supporting evidence regarding traumatic stressors.)
A.3. Guidelines for interview assessment of trauma exposure. Initial examinations
conducted for purposes of establishing a diagnosis of PTSD require clinician
assessment of trauma exposure and documentation of findings. Provided below
are guidelines for (a) orienting the claimant to the interview assessment
process, (b) gathering and documenting information about the trauma, (c) eliciting information about the stressor from the claimant, and (d) assessing trauma
using structured questionnaire and interview methods.
A.3.a. Orienting the claimant to trauma assessment. For initial examinations, it is
important to explain to the claimant that it is necessary to obtain a detailed
description of one or more traumatic events related to military service, in order
to complete the examination. Further, it is helpful to alert him or her to the fact
that trauma assessment, though brief (about 15-20 minutes), may cause some
distress. The veteran should be advised that trauma assessment is a mutual and
collaborative process, and that he or she is not required to provide unnecessarily detailed answers to all questions, if it is too distressing to do so.
A.3.b. Documentation of trauma-related information. For initial examinations, a
detailed narrative description of the traumatic episode must be recorded in the
report. This description, as appropriate and feasible, should include information about: (1) the objective features of the traumatic event; (2) date and location of the stressor(s); (3) names of individuals who witnessed or were involved
in the traumatic incident; (4) individual decorations or medals received; (5) the
veteran's subjective emotional reaction and behavioral response during and
after the trauma; (6) the veteran's view of perceived consequences of the traumatic event, including abrupt changes in behavior, adjustment, and well-being;
and (7) names of health care facilities where trauma-related injuries
were treated.
A.3.c. Suggested interview queries. Assessment of one or more personally relevant traumas proceeds after sufficient rapport has developed and some cursory
details regarding the context of the trauma situation(s) have been gathered
(e.g., branch of the military served in; events leading up to the traumatic situation). Provided below are suggested questions, strategies, and tools that may
assist in trauma assessment, as appropriate to the nature and context of the veteran's stressful military experiences:
Stem or lead inquiry: The Clinician Administered PTSD Scale (CAPS) (Blake
et al., 1995) strategy for assessing the stressor criterion is recommended for the
initial inquiry about trauma exposure. This strategy involves the following orienting procedures and questions:
Orienting statement: "I'm going to be asking you about some difficult or stressful things that sometimes happen to people. Some examples of this are being in
some type of serious accident; being in a fire, a hurricane, or an earthquake; being
mugged or beaten up or attacked with a weapon; or being intensely sexually
harassed or forced to have sex when you didn't want to. I'll start by asking you to
look over a list of experiences like this and check any that apply to you. Then, if any
of them do apply to you, I'll ask you to briefly describe what happened and how
you felt at the time.
"Some of these experiences may be hard to remember or may bring back uncomfortable memories or feelings. People often find that talking about them can be
helpful, but it's up to you to decide how much you want to tell me. As we go along,
if you find yourself becoming upset, let me know and we can slow down and talk
about it. Do you have any questions before we start?"
Administration of the CAPS Life Event Checklist: The CAPS 17-item Life
Event Checklist may be administered as a preliminary means of identifying
exposure to different traumatic events. Detailed inquiry should follow positive
endorsement of traumatic events, in order to clarify objective features of the
stressor, using questions suggested below as appropriate:
Were you wounded or injured?
Did you witness others being killed, injured or wounded?
Were you exposed to bodies that had been dismembered?
About how many times were you exposed to [the traumatic event]?
During the trauma, did the perpetrator coerce (i.e., threaten, demand,
push, trick) you into doing something against your will? (sexual assault)
During the trauma, did the perpetrator threaten to injure you or kill you
if you did not comply with his or her wishes? Did you believe there
would be any other negative consequences to you if you did not comply
with the perpetrator's intentions (i.e., do what was demanded)?
(sexual assault)
Was somebody important to you killed or seriously hurt during
this situation?
What did other people notice about your emotional response?
What were the consequences or outcomes of this event?
Did you receive any help, or talk to anyone, after this event occurred?
Suggested Questions for Screening Sexual Assault Experiences:
"Have you ever had any unwanted or uncomfortable sexual experiences, either as a
child or an adult?"
The Life Events Checklist has 2 questions that offer the opportunity for the
assessor to ask follow-up questions. It is suggested that you change the listed
follow-up questions referring to sexual assault experiences to questions such as:
a) During this event, did the other person pressure you verbally or physically to do something against your will?
b) During this event, did the other person threaten to hurt or kill you if you
didn't do what he or she wanted?
c) Did you think that there would be something else that would happen if
you didn't do what he or she wanted?
Questions assessing subjective response to the stressor: Suggested inquiries for
assessing subjective reactions to trauma exposure (DSM-IV criterion A.2)
a) At the time the trauma was occurring, did you believe your life was
threatened? Did you think you could be physically injured in
b) At the time this occurred, how did you feel emotionally (fearful,
horrified, helpless)?
c) Were you stunned or in shock so that you didn't feel anything at all?
d) Did you disconnect from the situation, like feeling that things weren't
real or feeling like you were in a daze?
e) Can you recall any bodily sensations you may have had at the time?
Suggested inquiries if no events are endorsed on the
CAPS trauma exposure checklist:
If no events were identified on the CAPS trauma exposure checklist or during
other parts of the interview, consider the following additional inquiries:
a) Has there ever been a time in the military when your life was in danger
or you were seriously injured or harmed?
b) What about a time when you were threatened with death or serious
injury, even if you weren't actually injured or harmed?
c) What about witnessing something like this happen to someone else or
finding out that it happened to someone close to you?
d) What would you say are some of the most stressful experiences you had
during the military, which still upset you today?
A.3.d. Recommended Instruments for Trauma Assessment. The following instruments are useful in assessing objective features of trauma exposure. These
instruments should be administered only to claimants who represent the appropriate criterion group that the instruments were developed for. Clinicians may
use items from these instruments as prompts for interview questions, and
responses to items may provide a focus for more detailed interview inquiry.
Some instruments (e.g., the Combat Exposure Scale) provide sufficient information to make gross assessments of whether the individual was exposed to a
"high," "moderate," or "low" degree of trauma. While helpful, use of these
instruments is never sufficient, and must be accompanied by a narrative
description of unique details of the veteran's traumatic experience. Many of the
self-report measures noted in this document have means and cut-off scores that
were validated on combat veterans. Other traumatized populations (i.e., sexual
assault) may look differently on these measures.
Infantryman and other ground troop personnel
• Combat Exposure Scale (Keane et al., 1989)
Females serving in a war zone
• Women's Wartime Stressor Scale (Wolfe, Brown, Furey, & Levin, 1993)
• Trauma Questionnaire (McIntyre et al., 1999).
Persian Gulf War Veterans
• Desert Storm Trauma Exposure Questionnaire (Southwick et al., 1993)
Veterans Exposed to Sexual Assault (both male and female)
• Sexual Experiences Survey (SES, Koss & Oros, 1982).
Veterans Exposed to Sexual Harassment (both male and female)
• Sexual Experiences Questionnaire (SEQ-DOD, Fitzgerald, Gelfand, &
Drasgow, 1995). There is a version specifically asking about sexual
harassment in the military.
B. Assessment of PTSD
B.1. Objective. Assessment of PTSD for compensation and pension purposes
should address four objectives: (a) establish the presence or absence of a diagnosis of PTSD; (b) determine the severity of PTSD symptoms; (c) establish a
logical relationship between exposure to military stressors and current PTSD
symptomatology; and (d) describe how PTSD symptoms impair social and occupational functioning and quality of life. Assessment of PTSD requires inquiry
into the presence/absence of all 17 symptoms of the disorder, but consideration
should also be given to associated features articulated in DSM-IV.
Assessment of PTSD using a structured interview constitutes the recommended
minimum or "core" diagnostic procedure in compensation and pension settings.
Structured diagnostic interview assessment has the advantage of enhancing the
objectivity, standardization, and consistency of evaluations across settings
and examiners.
Routine use of psychometric tests and questionnaires for assessing PTSD and
psychopathology may not be feasible in all settings, though many practitioners
regularly use these instruments to enhance the comprehensiveness and quality
of their evaluation. The clinician's reliance on psychometric assessment is at the
discretion of clinician, and may depend on the professional background of the
examiner and availability of personnel trained in use of the relevant methods.
However, psychometric assessment is strongly suggested as a supplement to interview methods in complex examination situations. These situations may include
but are not limited to (a) claimants who are appealing a rating decision, (b)
cases where interview findings are of questionable validity, and (c) veterans
having complicated clinical pictures involving multiple and confusing comorbid
mental disorders.
Many instruments are available for assessing PTSD. Provided below is a menu
of suggested instruments to be used in compensation and pension settings,
based on their established reliability and validity, ease of administration, and
the fact that no fee is charged for their use. Selection of particular assessment
instruments will likely depend on the examiner's professional background, preferences, and allotted time to complete the assessment. The instruments suggested here are designed to assist the examiner in assessing the presence and
severity of PTSD diagnostic criteria (listed below) in a manner that is systematic, objective, and standardized.
DSM-IV Diagnostic Criteria for PTSD
A. The person has been exposed to a traumatic event .
B. The traumatic event is persistently re-experienced in one (or more)
of the following ways:
1. Recurrent and intrusive distressing recollections of the event,
including images, thoughts, or perceptions.
2. Recurrent distressing dreams of the event.
3. Acting or feeling as if the traumatic event were recurring
(includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that
occur on awakening or when intoxicated).
4. Intense psychological distress at exposure to internal or external
cues that symbolize or resemble an aspect of the
traumatic event.
5. Physiological reactivity on exposure to internal or external cues
that symbolize or resemble an aspect of the traumatic event.
C. Persistent avoidance of stimuli associated with the trauma and
numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following:
1. Efforts to avoid thoughts, feelings, or conversations associated
with the trauma.
2. Efforts to avoid activities, places, or people that arouse recolle
tions of the trauma.
3. Inability to recall an important aspect of the trauma.
4. Markedly diminished interest or participation in
significant activities.
5. Feeling of detachment or estrangement from others.
6. Restricted range of affect (e.g., unable to have loving feelings).
7. Sense of a foreshortened future (e.g., does not expect to have a
career, marriage, children, or a normal life span).
D. Persistent symptoms of increased arousal (not present before the
trauma), as indicated by two (or more) of the following:
1. Difficulty falling or staying asleep.
2. Irritability or outbursts of anger.
3. Difficulty concentrating.
4. Hypervigilance.
5. Exaggerated startle response.
E. Duration of the disturbance (symptoms in Criteria B, C, and D) is
more than 1 month.
F. The disturbance causes clinically significant distress or impairment
in social, occupational, or other important areas of functioning.
Specify if:
Acute: if duration of symptoms is less than 3 months
Chronic: if duration of symptoms is 3 months or more
With Delayed Onset: if onset of symptoms is at least 6 months after
the stressor.
B.2. Diagnostic interview assessment of PTSD. The Clinician Administered PTSD
Scale (CAPS) (Blake et al., 1995) is recommended as the interview method of
choice, for conducting compensation and pension examinations for PTSD. The
CAPS is a structured clinical interview designed to assess symptoms of PTSD
corresponding to DSM-IV criteria. The CAPS has a number of advantages over
other diagnostic interview methods for PTSD, including (a) the use of explicit
behavioral anchors as the basis for clinician ratings, (b) separate scoring of frequency and intensity dimensions for each PTSD symptom, (c) measurement of
associated clinical features, (d) assessment of the impact of PTSD symptoms on
social and occupational functioning, and (e) ratings of the validity of information obtained. The CAPS provides dichotomous information about the presence/absence of the PTSD diagnosis as well as overall severity of the disorder.
An additional advantage of the CAPS is its sound psychometric structure, with
high inter-rater agreement, very high diagnostic sensitivity and specificity, and
convergent validity with other measures of PTSD.
The CAPS requires approximately one hour to administer, though it can be customized and abbreviated by eliminating less relevant components. However,
other interview-based diagnostic instruments for PTSD are also suitable for use
in conducting compensation and pension examinations and require less time to
administer. These instruments include the PTSD Symptom Scale (Foa, Riggs,
Dancu, & Rothbaum, 1993); Structured Interview for PTSD (Davidson, Malik,
& Travers, 1997); Structured Clinical Interview for DSM-IV (First, Spitzer,
Gibbon, & Williams, 1995); Anxiety Disorders Interview—Revised (DiNardo &
Barlow, 1988); and the PTSD Interview (Watson, Juba, Manifold, Kucala, &
Anderson, 1991). Although a modest time savings may result from using these
alternative instruments, the information gleaned from them is typically not as
comprehensive and, unlike the CAPS, there may be a charge associated with
their use.
B.3. Psychometric assessment of PTSD. Psychometric assessment of PTSD provides quantitative assessment of the degree of PTSD symptom severity.
Judgments about symptom severity can be made by comparing an individual's
scores against norms established on reference samples of individuals who are
known to have or not have PTSD. Cutting scores have been established for the
psychometric measures of PTSD recommended here, based on their high sensitivity and specificity in discriminating individuals with PTSD from those without
PTSD. Data from psychometric tests never serve as a "stand alone" means for
diagnosing PTSD. Rather, the psychometric measures suggested here should be
used to supplement and substantiate findings gleaned from interview assessment and other sources of data, particularly when there is a need to reconcile
multiple diagnoses. Use of at least one of the following psychometric instruments is recommended for inclusion in disability evaluations for PTSD, on a
routine basis or in cases where testing is selectively administered:
a) Mississippi Scale for Combat-Related PTSD (Keane, Caddell, & Taylor,
1988) (for combat-exposed populations)
b) PTSD Checklist (Blanchard, Jones-Alexander, Buckley, & Forneris,
1996; Weathers, Litz, Herman, Huska, & Keane, 1993) (for individuals
exposed to both combat and non-combat forms of trauma)
A number of other psychometric instruments are acceptable alternative methods for assessing PTSD. These include, but are not limited to, the MMPI PTSD
subscales (Lyons & Keane, 1992), Impact of Event Scale—Revised (Weiss &
Marmar, 1997), Penn Inventory (Hammarberg, 1992), PTSD Stress Diagnostic
Scale (Foa, 1995), and Trauma Symptom Inventory (Briere, 1995). Additionally,
many instruments that provide comprehensive assessment of psychopathology
and personality functioning that may supplement PTSD-specific symptom
assessment (e.g., MMPI, MCMI, Personality Assessment Inventory). These
instruments are useful in quantifying severity of symptoms of other disorders
that often co-occur with PTSD and may provide information about possible
overstatement of symptoms and test-taking attitude (e.g., defensiveness).
C. Recommended Time Allotment for Completing Examination
This guideline is designed to enhance the objectivity, reliability, and overall
quality of PTSD C&P examinations. It is recognized that implementing these
recommendations may require more clinician time and institutional resources
than is currently devoted to the PTSD assessment. The time required for the
conduct of initial PTSD examinations may vary widely, depending on a number
of factors. These factors include, but are not limited to, the availability and
quantity of records to be reviewed, the existence of objective evidence of clearcut stressors, the veteran's degree of emotional distress exhibited during trauma
assessment, the amount and complexity of comorbid psychopathology, and a
number of other veteran-specific factors that may impact the pace of the assessment process.
C&P examinations for PTSD extend far beyond the scope of simply rendering a
diagnosis of PTSD, similar to that occurring in a clinical assessment situation.
Specific complexities of PTSD assessment in the compensation and pension situation include: (a) implicit examiner requirements to make complex judgments
about potential malingering in the context of an administrative evaluation with
obvious financial implications; (b) VBA requests of examiners to comprehensively diagnose all comorbid mental disorders and partition disability to different disorders in an increasingly chronic veteran population, where co-occurring
mental disorders are inextricably related to PTSD; and (c) requirements of
examiners to render an informed opinion about the effects of PTSD on social
and occupational functioning. Since examiners are not able to observe the work
performance of claimants and they typically do not have access to such observational information, a careful and often time-consuming walk-through of the his-
tories of our aging veteran claimants is required as the foundation for an opinion regarding functional disability.
Initial PTSD compensation and pension evaluations typically require up to
three hours to complete, but complex cases may demand additional time. Time
estimates for accomplishing components of the examination are as follows:
• Records review (30 minutes)
• Orientation to interview, review military history, and conduct trauma
assessment (20 minutes)
• PTSD symptom assessment and diagnosis (40 minutes)
• Mental status examination and multiaxial DSM-IV diagnoses
• Psychosocial history and assessment of change in social and occupational
functioning (30 minutes)
• Report preparation (50 minutes)
• Psychometric assessment (additional time required, if administered)
Follow-up evaluations for PTSD do not require a trauma exposure assessment,
military history, or comprehensive psychosocial history, and the records review
burden is usually less than for an initial examination. These evaluations can typically be completed in about half the time required for an initial PTSD examination. (See Examination Worksheet I [p. 23-29] and Examination Worksheet II
[p. 30-34] for a distinction between initial and follow-up examination content.)
D. Professionals Qualified to Conduct Compensation and Pension
Professionals qualified to perform PTSD examinations should have doctorallevel training in psychopathology, diagnostic methods, and clinical interview
methods. They should have a working knowledge of DSM-IV, as well as extensive clinical experience in diagnosing and treating veterans with PTSD. Ideally,
examiners should be proficient in the use of structured clinical interview schedules for assessing PTSD and other disorders, as well as psychometric methods
for assessing PTSD. Board certified psychiatrists and licensed psychologists
have the requisite professional qualifications to conduct compensation and pension examinations for PTSD. Psychiatric residents and psychology interns are
also qualified to perform these examinations, under close supervision of attending psychiatrists or psychologists.
IV. Compensation and Pension PTSD
Disability Examination Worksheets
INITIAL EVALUATION FOR
SSN:
Date of Exam:
C-number:
Place of Exam:
A. Identifying Information
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 serviceconnected 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:
a. Previous hospitalizations and outpatient care.
b. Complete medical history is required, including history since discharge
from military service.
c. 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.
a. Frequency, severity and duration of medical and psychiatric symptoms.
b. 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):
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, 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),
and level of overall functioning.
• branch of service (enlisted or drafted)
• dates of service
• dates and location of war zone duty and number of months stationed in
• 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 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 (perform-
ance 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 Bureau of Veterans' Affairs (BVA) Remand
• comment on validity of psychological test results. Arbisi and Ben-Porath
(1995) recommend that the following sequence be used when interpreting an elevated F Scale: a). rule out random responding and acquiescence by eliminating profiles with elevated VRIN (t>100) or TRIN
(t>80) scores, b). Rule our malingering or exaggeration by considering
whether the F(p) Scale is elevated, and c). if Steps a and b are negative,
then a high F Scale can be considered consistent with psychopathology.
A hit rate of 97% or greater for F(p) at a cut score of T = 100 was
found for both clinical and forensic samples, and taxometric analysis
revealed that F(p) cutting cores are stable across non-VA and VA clinical
settings and that F(p) raw scores greater than 6 could be classified as
overreported (Strong et. al., 2000). Nonetheless, it is critical that clinicians understand the nature of their population with regard to frequency
and type of psychopathology before interpreting the F(p) Scale.
Independent verification that patients are overreporting is needed.
• 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.)
H. Diagnosis:
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 and 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 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)
[Preference is for current level of functioning for C&P purposes, although rating should take into consideration all evidence of functioning, over past year or
since previous exam.]
J. 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.)
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 that 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 should be rated as competent for VA purposes in terms of being capable of managing his/her benefit payments in
his/her own best interest.
REVIEW EXAMINATION FOR POSTTRAUMATIC
STRESS DISORDER
A: Review of Medical Records.
B. Medical History since last exam:
1. Hospitalizations and outpatient care from the time between last rating
examination to the present, UNLESS the purpose of this examination is
to ESTABLISH service connection, then the complete medical history
since discharge from military service is required.
2. Frequency, severity and duration of psychiatric symptoms.
3. Length of remissions from psychiatric symptoms, to include capacity for
adjustment during periods of remissions.
4. Treatments including statement on effectiveness and side
effects experienced.
5. Subjective Complaints: Describe fully.
C. Psychosocial Adjustment since the last exam
• extent of time lost from work over the past 12 month period and social
impairment. 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 indicate following diagnosis,
what factors, and objective findings support or rebut that contention.
• marital and family relationships (including quality of relationships with
spouse and children)
• problematic substance abuse
• significant medical disorders (resulting pain or disability; current medications)
• history of violence/assaultiveness
D. Mental Status Examination
• 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
E. Assessment of PTSD
• state whether the veteran currently meets the DSM-IV stressor criterion
• identify behavioral, cognitive, social, affective, or somatic symptoms veteran attributes to PTSD
• specify typical frequency and severity of symptoms
F. Psychometric Testing Results
on a BVA Remand.
• comment on validity of psychological test results
G. Diagnosis:
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.
H. Diagnostic Status
Axis V (GAF score: current)
I. Global Assessment of Functioning (GAF):
J. Competency:
Competency, for benefits purposes, has a special meaning, and refers only to
veterans' ability to manage benefit payments in their own best interests without
restriction, and not to any other subject. State whether the veteran is capable of
managing his/her or her benefit payments in the individual's own best interests
(a physical disability which prevents the veteran from attending to financial
matters in person is not a proper basis for a finding of incompetency unless the
veteran is, by reason of that disability, incapable of directing someone else in
handling the individual's financial affairs).
L. Integrated Summary and Conclusions
1. Describe changes in psychosocial functional status and quality of life since
the last exam (performance in employment or schooling, routine responsibilities of self care, family role functioning, physical health, social/interpersonal relationships, recreation/leisure pursuits).
2. Describe linkage between PTSD symptoms and aforementioned changes
3. If possible, describe extent to which disorders other than PTSD (e.g.,
4. If possible, state prognosis for improvement of psychiatric condition and
5. Comment on whether veteran should be rated as competent for VA purposes in terms of being capable of managing his/her benefit payments in
Suggested Report Template For Initial PTSD
Compensation and Pension Exam
The following template includes examples of all information listed in the Initial
Disability Examination worksheet, and is intended as an aid to organizing
information gained during the examination. Taking into account the individual
differences in patients, clinician specialty, writing style, and resources and time
available, it is recommended that the examiner utilize clinical judgment in
choosing which template options are particularly relevant to documenting a
thorough assessment and diagnosis of the veteran.
SS#:
Clinician:
1. Identifying information & Referral Question
The veteran is a __ year old, ____ (race), _____ war era veteran , living with
______ for the past _______, referred to the C&P program, _______ division for
a comprehensive evaluation for the diagnosis of PTSD. General remarks on the
2507 form request ____________________.
2. Sources of Information
The veteran was interviewed for approximately ___ hour(s) on (date) ______.
In addition, a review was made of his/her C-file / DD-214, / medical records
from VA, Department of Defense, and other health care facilities. In addition,
the veteran saw (social worker) ____________ on (date) ______ who conducted
a comprehensive psychosocial history. Additionally, the veteran saw Dr. ______
on (date) __________ who diagnosed the veteran with ____________,
_____________________________. Other sources of information include statements from collaterals or others who have information about the veteran's trauma exposure and its behavioral sequelae, evidence of behavior changes that
occurred shortly after the trauma incident, and statements derived from interview of the claimant. These will be cited where appropriate as sources of information below.
The veteran was administered a battery of psychometric tests to assess psychopathology and specific symptoms of PTSD. Instruments utilized included
the following (choose): Mississippi Scale for Combat Related PTSD, the
Combat Exposure Scale, the PCL, a modified version of the Structured Clinical
Interview for DSM-IV PTSD module, the Women's Wartime Stressor Scale, the
Desert Storm Trauma Exposure Questionnaire, the Sexual Experiences Survey,
the Childhood Trauma Questionnaire, the MMPI PTSD subscales, the Impact
of Event Scale—Revised, the Penn Inventory , the PTSD Stress Diagnostic
Scale, and the Trauma Symptom Inventory. The assessments were administered
Suggested Report Template For Initial
PTSD Compensation and Pension Exam
at the time of this interview. Results will be reported below.
1. Premilitary History and Functioning
The veteran was raised by his/her biological / adoptive / step parents until the
age of ____, at which time he/she enlisted in the (military branch) ___________.
His/her father was described as (type of work, personality):
___________________, and his/her mother as (type of work, personality)
___________________________________. He/she has (#) _________ siblings
who currently are ages _______, and living in _______________________.
He/she maintains that he/she has(type of relationship; contact)
__________________________ with parents and (type of relationship; contact )
__________________ with his/her siblings.
Prior to entering the service, the veteran completed ______ years of schooling
and earned / did not earn a high school diploma. He describes him/herself during this time as being " __________, " and his/her pre-military adjustment as
being / very good / good / average / marginal / poor. His/her performance in
school, grades, suspensions, general behavior, sports participation, dating were
____________. Legal history included: _______________________________.
He/she had ________ history of trouble as a youth which he/she described as
___________________________________. His/her college history is __________.
His/her substance usage was reported to be ___________________________ and
included the use of (types) ____________ with (no) associated problems including: _______________________. He/she had health-related problems which
included (include history of injury, including head injury) __________________.
According to the veteran's reports, his/her pre-military stressors included:
_______________________, at ages ______, resulting in (academic problems,
hospital, jail, mental symptoms, treatment, etc). ___________. Medications
taken regularly prior to military included _____________________.
Family history of psychiatric problems included: ________________________.
Overall assessment of psychosocial adjustment, progression through developmental milestones, and general level of functioning is: ____________________
_________________________________________.
2. Military History
According to military records and self-report, the veteran __________ was
enlisted / was drafted / commissioned in (branch ________ ) from _______ to
_______. He/she was stationed for (months/years) ____ in (location/s)
________________________, from (dates) _________ to ________. His/her primary duty was ____________.
In addition, other duties included ________________________________.
He/she served _________ tours in (war) __________ with the (unit)
______________ as (MOS & Duties) _________ in the areas of (location)
_______ from (dates) _________ to _________. He/she attained the rank of
_____ while in (war) ______. He/she was /honorably / dishonorably / generally /
discharged. The veteran's duty in (war) ______ could be classified as mainly
combat / combat support / support. The veteran was awarded _________
medals. The veteran reported the following general war experiences: (see:
Combat Scale): ______________.
Specific Trauma's will be discussed below in Section VIII.
3. Post-Military History
Education and Employment History:
The veteran received ______________ education following active duty, with a
__________ certificate / degree(s) achieved. His/her employment history
includes _______________ jobs from _________ to ___________. He/she is currently unemployed / employed. His/her current occupation is ____________ and
length of time at this job has been __________.
Social Functioning:
The veteran is currently Married/Divorced (onset and length of time for each,
reason for divorce): _______________________. He/she has __________ contact
(with spouse & children). His/her children are (ages) ________________.
He/she describes his/her current relationships as: _________________________.
His/her attitude towards social interactions, and how he/she feels others view
him/her appears to be: ____________________________________________.
His/her social support & hobbies include: ___________________________.
Post Military Stressors:
According to the veteran's reports, his/her post-military stressors and significant
losses have included: _______________________, at ages ______________.
Legal History:
The veteran's legal history includes the following incidents (reckless driving,
DWI, assault, etc.) ___________________ on (dates for each) ______________,
which resulted in ______________________.
Substance Abuse/Alcohol History & Treatment:
The veteran reports the following use of alcohol and drug (s): (age of onset):
_______, (types): ______________, (amounts): ___________________ (last
usage): ____________, periods of exacerbation and remission):
_________________, (related psychosocial problems (marital, occupational,)):
_________________________________________, (withdrawal problems):
_________________, (related health problems): ______________, (treatments):
___________________________.
Medical History:
The veteran's medical history includes the following significant illnesses and
injuries: _______________________________________________.
Hospitalizations: _____________________.
Current medications: _________________.
Review of Claims Folder (for initial exams) revealed: ________________.
Current disability rating is: _____________________.
Subjective Complaints:
The veteran ______ reports the following current subjective complaints:
________________ _____________. Suicidal / homicidal ideation: ____________.
During and following his/her active duty, the veteran reported the following
psychiatric symptoms (onset, frequency, severity and duration, suicide attempts)
____________________________________________________ . His/her most
troublesome / frequent / disruptive symptoms appear to be _________________.
History of Psychiatric care:
The Veteran's history of psychiatric care began on ________________, and has
included (medications, inpatient treatment, outpatient care, groups, etc).
___________________. The veteran is currently receiving (type and frequency
of treatment) ________________.
History and length of remissions, have been ___________________. His/her
capacity for adjustment during periods of remissions appeared to be
_________________________.
Social Impairment:
The extent of social impairment and work impairment (time lost, problems with
supervisors/coworkers, loss of productivity, etc.) over the past 12 month period
was ________________________. (If unemployed), The veteran does not contend / contends it is due to the effects of a mental disorder. (Further discuss in
DIAGNOSIS, if possible, what factors and objective findings support or rebut
that contention).
4. Mental Status Exam and Observations
Dress: (casual) (formal) (other: _______ )
Eye contact: (excellent) (good) (fair) (poor) (variable) (other: _________ )
Grooming: (excellent) (good) (fair) (poor) (other: _________ )
Hygiene: (excellent) (good) (fair) (poor) (other: _________ )
Posture: (excellent) (good) (fair) (poor) (variable) (impaired) (abnormal)
(other: ________ )
Appearance: (healthy) (excellent) (good) (fair) (poor) (sickly) (muscular)
(atrophied) (other: ______________ )
Psychomotor:
Gait: ________
Level of Activity: (hyperactive) (combative) (normal) (restless) (lethargic)
(fatigued) (tense) (other: ________________________ )
Manner: (cooperative) (angry) (defensive) (apathetic) (interested) (guarded) (attentive) (achievement orientated) (rigid conscience) (other: _________ )
Speech: (normal rate & rhythm)(rapid) (slow) (pressured) (hesitant) (loud)
(whispered) (slurred) (mumbled) (echolalia) (spontaneous) (irrelevant
answers) (loosening of answers) (muddled) (other: ___________________ )
Mood {pt. Report}: (dysphoric) (euthymic) (depressed) (elated) (expansive)
(anxious) (frightened) (angry) (labile) (inappropriate) (appropriate) (guilty)
(other: ___________ )
{examiner's evaluation of affect} (broad) (restricted) (depressed) (blunted)
(flat) (anxious) (mood congruent) (mood incongruent) (other: ___________ )
Thought Processes: (overabundance of ideas) (paucity of ideas) (flight of
ideas) (slow thinking) (perseverations) (goal directed answers to questions)
(loose associations to questions) (tangential) (rambling) (evasive) (blocking)
Thought Content: (obsessions) (compulsions) (phobias) (intrusive memories)
[delusions] (bizarre) (somatic) (grandeur) (persecution) (reference) ( selfaccusation) (control) (paranoid) (other): ___________ )
[hallucinations] (auditory) (visual) (olfactory) (gustatory) (tactile)
(other: ___________ ) (SUICIDAL IDEATION) (PLAN) (INTENT)
(HISTORY) [No evidence of SI]
(HOMICIDAL IDEATION) (PLAN) (INTENT) (HISTORY)
[No evidence of HI]
Orientation: person _______
place __________
date ______________
Abstract Thinking "A Rolling Stone Gathers No Moss"
(concept formation
problems) (appropriate answer) (Result: _______________________________ )
Information and Intelligence: (relative to education level: _________________ )
Concentration: SERIAL 7's: 100, 93, 86, 79, 72, 65, 58, 51, 44, 37, 30, 23, 16,
9, 2, (report number of integers): __________________ )
Remote memory (memory for childhood information) (intact) (deficits)
Recent memory: (past few months) (intact) (deficits)
(other: _____________________ )
Immediate retention: (pen, clothespin, car, dog)
Delayed recall: (pen, clothespin, car, dog)
Judgment: Social Judgment: understand outcome of behavior? (YES
NO)
Insight: (awareness of problems) (other: __________________________ )
7. Testing Results
The veteran was administered measures specifically designed to assess PTSD.
In summary, the psychometric findings are consistent with information gathered
during the diagnostic and social history interviews for the presence and level of
symptomatology. On all measures he or she scored in a manner similar to normative patient samples known to have PTSD. (Scores are suggestive of an individual with Mild / Moderate / Severe PTSD.) OR The veteran scored in a
range that is characteristic of patient samples that do not carry the diagnosis of
PTSD. The pattern among the psychometric findings supports / does not support a diagnosis of PTSD.
In summary, the psychometric findings are inconsistent with information gathered during the diagnostic and social history interviews for presence and level
of symptomatology. The level of reporting on the battery of psychometrics is
greater than / less than / more variable than interview information. The discrepancy may be due to (discuss reasons why the two sources do not agree):
_____________. Given this inconsistency, conclusions about a PTSD diagnosis
based on the psychometric findings cannot be advanced.
Mississippi: ___________ PCL: __________ Combat Exposure Scale:
_______ Women's Wartime Stressor Scale: ________ Sexual Experiences
Survey: ___________ Brief Questionnaire for Sexual Assault:
_________________ Desert Storm Trauma Exposure Questionnaire:
_____________ Childhood Trauma Questionnaire: ___________ MMPI PTSD
subscales: ________________ Impact of Event Scale—Revised: ____________
Penn Inventory: _____________ PTSD Stress Diagnostic Scale: _____________
Trauma Symptom Inventory: _________ Other:_________
5. Other Symptoms
This veteran also meets criteria for: (Diagnostic and Statistical Manual for
Mental Disorders-IV DSM-IV diagnosis, brief description of symptoms)
___________________________________________.
6. PTSD Assessment
Military Stressor(s)
(To follow from Combat Exposure Questionnaire and interview):
The veteran's military-related stressors have included injury / captivity / torture
/ witnessing atrocities / personal assault / sexual assault / other. Because there
is a history of multiple stressors, the veteran considers the most severe to have
been ___________________. The impact of each is believed to have been:
a: _______________ b: ________________ c:__________________
d: ______________. Other stressful life events during this period included (noncombat events such as death in family, etc): _________________________.
Symptoms and impairment in functioning:
(To follow from SCID/CAPS):
Behavioral, cognitive, social, or affective changes linked to the veteran's military stressor(s) have included: ______________. Related somatic symptoms
have included: ______________________________. One of his/her most bothersome symptoms seems to be ____________________.
PTSD Symptoms include:
A. The veteran has been exposed to a traumatic event in which both of the
following were present:
• The veteran experienced, witnessed, or was confronted with an event
or events that involved actual or threatened death or serious injury,
or a threat to the physical integrity of self or others
• The veteran's response involved intense fear, helplessness, or horror.
B. The traumatic event is persistently re-experienced in one or more of the
following ways:
• Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions.
• Recurrent distressing dreams of the event.
• Acting or feeling as if the traumatic event were recurring includes a
sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those which occur on awakening
or when intoxicated).
• Intense psychological distress at exposure to internal or external cues
• Physiological reactivity on exposure to internal or external cues that
symbolize or resemble an aspect of the traumatic event
C. Persistent avoidance of stimuli associated with the trauma and numbing
of general responsiveness (not present before the trauma), as indicated
by three or more of the following:
• Efforts to avoid thoughts, feelings, or conversations associated with
the trauma
• Efforts to avoid activities, places, or people that arouse recollections
of the trauma
• Inability to recall an important aspect of the trauma
• Markedly diminished interest or participation in significant activities
• Feelings of detachment or estrangement from others
• Restricted range of affect (e.g., unable to have loving feelings)
• Sense of foreshortened future (e.g., does not expect to have a career,
marriage, children, or a normal life span)
D Persistent symptoms of increased arousal (not present before the trauma), as indicated by two or more of the following:
• difficulty falling or staying asleep
• irritability or outbursts of anger
• difficulty concentrating
• hypervigilance
• exaggerated startle response
E. Duration of the disturbance (symptoms in Criteria B, C, D) is more
than 1 month
F. The disturbance causes clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
Acute: if duration is less than 3 months
Chronic: if duration is 3 months or more
With Delayed Onset: if onset of symptoms is at least 6 months
after the stressor.
7. Impression:
The overall picture is one of an individual who had made a / satisfactory / poor /
adjustment prior to entering military service to the extent that there were / no /
many / gross indications of behavior control problems, subjective unhappiness
or family dysfunction. The veteran did struggle in (date, age) _______________,
and he/she did / did not / appear to come from a deprived or abusive background or exhibit early life disturbances of conduct that would predict his/her
psychiatric and psychosocial adjustment problems as an adult. Prior to entering
the military, the veteran did / did not appear to suffer from symptoms
of PTSD / other.
In summary, this veteran meets the DSM-IV criteria for (PTSD, etc)
_________. He/she maintains that he/she has (summarize symptoms)
__________________________. In the interview, he/she exhibited (any behavioral observations noted from interview which are consistent with reported
symptoms) _________________________, and reports from collaterals / records
/ previous evaluations confirm his/her interview responses and observed behaviors. The veteran maintains that these symptoms have been present over for
(duration of time) ________. The symptoms seem to be intensified during
(anniversary dates) ________________.
Changes in functioning from pre to post military service were noted in the areas
of: affect / mental health / cognition / sleep / health / social / employment /
housing / finances / litigation / acculturation / academic. Changes in psychosocial functional status and quality of life following trauma exposure were noted
in employment or schooling / routine responsibilities of self care / family role
functioning / physical health / social/interpersonal relationships / and recreation/leisure pursuits (describe changes in all areas).
The veteran's PTSD symptoms /appear to be/do not appear to be/ related to
changes in impairment in functional status and quality of life (describe)
___________.
OPTION 1: Disorders other than PTSD (e.g., substance use disorders) are
independently responsible for impairment in psychosocial adjustment and quality of life (describe) _______________.
OPTION 2: At this time, it is not possible, to separate the effects of PTSD and
co-occurring disorders on the veteran's functioning because ___________ (e.g.,
substance use had onset after PTSD and clearly is a means of coping with
PTSD symptoms).
Pre-trauma risk factors or characteristics than may have rendered the veteran
vulnerable to developing PTSD subsequent to trauma exposure are ______.
Prognosis for improvement of psychiatric condition and impairments in functional status is ______________.
11. Other Psychiatric Symptoms:
12. Diagnoses:
Axis I:
Axis II:
Axis III:
Axis IV: health problems, death of family member, separation or divorce, exposure to combat, inadequate social support, living alone, unemployment, discord at work, inadequate housing, inadequate finances, litigation, difficulty
with acculturation, academic problems, other.
Axis V: GAF= (current level of functioning. Use descriptor phrases - link
functioning to diagnoses via behavioral / concrete anchors and descriptions)
13. Competency:
It is recommended that this veteran be rated as competent for VA purposes.
The veteran is capable of managing his/her or her benefit payments in his/her
own best interests.
VI. Suggested Report Template For Follow-up
**The following template includes examples of all information listed in the
Follow-up Disability Examination worksheet, and is intended as an aid to
organizing information gained during the examination. Taking into account the
individual differences in patients, clinician specialty, writing style, and
resources and time available, it is recommended that the examiner utilize clinical judgement in choosing which template options are particularly relevant to
documenting a thorough assessment and diagnosis of the veteran.**
The veteran is a __year old, ____ (race), _____war era veteran, living with
a follow-up evaluation for compensation and pension for PTSD.
3. History Since Last C & P Exam
The veteran received ______________ education, with a __________ certificate /
degree(s) achieved. His/her employment history includes _______________ jobs
from _________ to ___________. He/she is currently unemployed / employed.
His/her current occupation is ____________ and length of time at this job has
been __________.
Stressors:
According to the veteran's reports, his/her stressors and significant losses since
the last C & P exam have included: _______________________.
DWI, DV etc.) ___________________ on (dates for each) ______________,
The veteran reports the following use of alcohol and drug (types):
______________, (amounts): ___________________ (last usage): ____________,
periods of exacerbation and remission): _________________, (related psychosocial problems (marital, occupational,)): __________________________________,
(withdrawal problems): _________________, (related health problems):
______________, (treatments): ___________________________.
The veteran's medical history since the last C & P exam includes the following
significant illnesses and injuries: ______________________________________.
The veteran ______reports the following current subjective complaints:
________________ ____________. Suicidal / homicidal ideation: ____________.
Since his/her last C & P exam, the veteran reported the following psychiatric
symptoms (onset, frequency, severity and duration, suicide attempts)
troublesome / frequent / disruptive symptoms appear to be
_____________________. His/her history of psychiatric care has included (medications, inpatient treatment, outpatient care, groups, etc). ______________.
The veteran is currently receiving (type and frequency of treatment)
__________.
supervisors/coworkers, loss of productivity, etc.) since the last C & P examination was ________________________. (If unemployed), The veteran does not
contend / contends it is due to the effects of a mental disorder. (Further discuss
in DIAGNOSIS, if possible, what factors and objective findings support or
rebut that contention).
Manner: (cooperative) (angry) (defensive) (apathetic) (interested) (guard-
ed) (attentive) (achievement orientated) (rigid conscience)
(other: ________________ )
[delusions] (bizarre) (somatic) (grandeur) (persecution) (reference) ( selfaccusation) (control) (paranoid) (other: ___________ )
[hallucinations] (auditory) (visual) (olfactory) (gustatory) (tactile) (other:
___________ ) (SUICIDAL IDEATION) (PLAN) (INTENT)
9, 2, (report number of integers: __________________ )
Recent memory: (past few months) (intact) (deficits) (other: _____________ )
during the veteran's initial C & P examination for PTSD. On all measures
he/she scored in a manner similar to normative patient samples known to have
PTSD. (Scores are suggestive of an individual with Mild / Moderate / Severe
PTSD.) OR The veteran scored in a range that is characteristic of patient
samples that do not carry the diagnosis of PTSD. The pattern among the psychometric findings supports / does not support a diagnosis of PTSD.
In summary, the psychometric findings are inconsistent with information from
the veteran's initial C & P evaluation for PTSD. The level of reporting on the
battery of psychometrics is greater than / less than / more variable than interview information. The discrepancy may be due to (discuss reasons why the two
sources do not agree): _____________. Given this inconsistency, conclusions
about a PTSD diagnosis based on the psychometric findings cannot
be advanced.
Survey: ___________ Desert Storm Trauma Exposure Questionnaire:
Penn Inventory: _____________ PTSD Stress Diagnostic Scale:
_____________Trauma Symptom Inventory: _________ Other: _________
This veteran also meets criteria for: (DSM-IV diagnosis, brief description of
symptoms) ___________________________________________.
1. The veteran experienced, witnessed, or was confronted with an event
2. The veteran's response involved intense fear, helplessness, or horror.
The traumatic event is persistently re-experienced in one or more of the
- Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions.
- Recurrent distressing dreams of the event.
- Acting or feeling as if the traumatic event were recurring includes a
- Intense psychological distress at exposure to internal or external cues
- Physiological reactivity on exposure to internal or external cues that
Persistent avoidance of stimuli associated with the trauma and numbing
- Efforts to avoid thoughts, feelings, or conversations associated with
- Efforts to avoid activities, places, or people that arouse recollections
- Inability to recall an important aspect of the trauma
- Markedly diminished interest or participation in significant activities
- Feelings of detachment or estrangement from others
- Restricted range of affect (e.g., unable to have loving feelings)
- Sense of foreshortened future (e.g., does not expect to have a career,
Persistent symptoms of increased arousal (not present before the trauma), as indicated by two or more of the following:
- difficulty falling or staying asleep
- irritability or outbursts of anger
- difficulty concentrating
- hypervigilance
- exaggerated startle response
Duration of the disturbance (symptoms in Criteria B, C, D) is more than
F. The disturbance causes clinically significant distress or impairment in
social, occupational, or other important areas of functioning.
adjustment since his/her last C & P examination for PTSD, to the extent that
there were / no / many / gross indications of behavior control problems, subjective unhappiness or family dysfunction
In summary, this veteran meets the DSM-IV criteria for (PTSD, etc., )
Changes in functioning were noted in the areas of: affect / mental health / cognition / sleep / health / social / employment / housing / finances / litigation /
acculturation / academic. Changes in psychosocial functional status and quality
of life were noted in employment or schooling / routine responsibilities of self
care / family role functioning / physical health / social/interpersonal relationships / and recreation/leisure pursuits (describe changes in all areas).
9. Other Psychiatric Symptoms:
Axis V: GAF= (current level of functioning. Use descriptor phrases - link functioning to diagnoses via behavioral / concrete anchors and descriptions)
Appendix A:
Training Letter Based On
PTSD Case Review
Director (00/21)
All VBA Regional Offices and Centers
SUBJECT: PTSD Case Review
We recently completed a review of 143 initial claims for PTSD, with the assistance of reviewers from the field, under a special protocol. An additional 77
cases were informally reviewed.
The attached training letter addresses some of our general findings as well as
problems revealed by the review. The 10 important rating points about PTSD
emphasize major areas of concern. They are followed by more detailed information on our findings.
Additional and broader training on PTSD will be conducted in the near future.
This letter is not intended to make policy but to restate and clarify existing policy.
If you have any questions or comments about the content of this letter, or note
any errors, please contact the person listed at http://vbaw.vba.va.gov/bl/21/publicat/letters/trngltrs.htm.
Robert J. Epley, Director
Appendix A: Training Letter Based On PTSD Case Review
10 important rating points about PTSD
1. You are obligated (per 4.125) to assure that the diagnosis of PTSD
is well-supported by the findings and is based on DSM-IV diagnostic criteria. Return examination reports that do not meet this
requirement.
2. You must rate PTSD based on its overall effects on social and occupational functioning. Return examination reports that do not
describe these effects in detail.
3. A veteran does not need to have any or all of the specific examples
of signs and symptoms listed in the general rating formula for mental disorders in order for a particular evaluation level of PTSD to
be assigned.
4. Evaluate PTSD on the core requirements at each evaluation level,
i.e., the language that refers to the effects of a mental disorder on
social and occupational functioning.
5. Make sure you have made reasonable efforts to obtain all pertinent
evidence (consistent with the new duty to assist requirements),
including private medical records the veteran may have referred to,
before you make an unfavorable decision.
6. 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.
7. Do not base a rating solely or mainly on the GAF score. The GAF
score does not translate directly to the rating schedule criteria.
8. Do not ignore additional mental disorders that are diagnosed in
someone with PTSD. Ask the examiner about the relationship to
PTSD if not already addressed in the examination report.
9. Explain the reasons for all of your rating decisions.
10. You must notify the veteran in clear terms of the rating decisions
and fully inform him or her of any action necessary to further or
complete the claim for PTSD.
What were our general findings in the review?
• 127 of the 143 decisions reviewed (89%) correctly disposed of the basic
issue of service connection.
• 11% (16 decisions) contained a mistake.
- 10 decisions incorrectly established service connection.
- 6 decisions incorrectly denied service connection.
• 84% (63 decisions) correctly assigned the appropriate evaluation.
• 16% (12 decisions) assigned incorrect evaluations.
- 10 decisions underevaluated the degree of disability, particularly at
the higher levels, e.g., 70%.
- 2 decisions overevaluated the degree of disability.
• 53% of the claims were granted.
• 65% of the claims cited combat as the stressor; 10% cited sexual trauma.
• When C&P examinations were conducted, 77% diagnosed PTSD.
• Very few decisions contained any real analysis.
What are some of the evaluation problems found?
1. Difficulty understanding why a particular evaluation was assigned.
Most reviewed cases were correctly evaluated, but of those that were not, most
were underevaluated. Granted that evaluating any mental disorder is difficult,
the reason these cases were underevaluated is unclear because of the failure to
analyze evidence and explain the rating decision in the reasons and bases. As a
rule, ratings laid out the evidence and gave the conclusion, but did not address
how the rater reached the decision. The rating redesign initiative directly
addresses this issue, as well as our organizational expectations concerning
the fix.
2. Problem in applying rating schedule criteria
One reason for erroneous evaluations may be confusion about the criteria in
the general rating formula for mental disorders. The signs and symptoms
named at each level are examples of what might be seen at each level.
However, the absence of those specific findings in an individual does not
exclude a rating at any given level.
It is the described effects on social and occupational functioning at each level
of whatever signs and symptoms the veteran has that should determine the rating. In particular, the examples of signs and symptoms given do not encompass
the common diagnostic findings specific to PTSD, but apply to any mental disorder. Therefore, you must look beyond the generic signs and symptoms in the
rating schedule and look at the effects of PTSD in that individual. As with other
disabilities, there is often a difference between the findings that establish the
diagnosis of PTSD and those that indicate its level of severity.
Example: Vietnam combat veteran reported or showed:
• sleep disturbances to point of getting only 3-4 hours of sleep a night
• avoidance of most people and social events, distant and estranged
from others
• restricted range of affect
• aggressive outbursts at work indicating impaired judgment in thinking (almost threw a man off a building, drove a vehicle into something else and caused damage)
• withdrawn, decreased concentration, hypervigilance
• mood depressed and hopeless, suicidal ideation
• fatigued and irritable
• hallucinatory flashbacks
• impairment in reality testing
Some of these are examples (in the general rating formula for mental disorders) of signs and symptoms at the 70-percent evaluation level, and others are
more akin to the 100-percent level. Some of his significant problems are not in
either list of examples. Taking into account all of the findings, it is clear he is at
least severely, if not totally, impaired in both social and occupational functioning. He was given a 70% evaluation. Others might judge a 100% evaluation as
more appropriate, particularly in view of the episodes of violence.
The National PTSD Center points out to examiners in soon-to-be-released
guidelines for PTSD examiners that the presence of violence toward self and
others in the veteran's history is a significant feature that should drop the GAF
score into the lower ranges, even if functioning in other areas appears better.
This indicates the Center's belief that violence should be regarded as an indication of very serious disease.
3. 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 Center for PTSD 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.
What problem was found on notification letters?
A common problem noted in the review was the failure to provide correct and
adequate notification letters. A letter notifying a claimant about a rating should
not simply refer to an attached copy of a rating for all information, only for a
more detailed explanation of what is summarized in the notification letter itself.
(See M21-1, Part III, 11.09a and FL 00-58.)
What are the examination-related problems?
1. Availability of claims file
The examiner had the claims file for review in less than half the cases. Since
these were all initial PTSD claims, this was a significant omission. We are
addressing this issue with VHA and will also discuss it on the
satellite broadcast.
2. Inadequacy of exams
Examinations were largely adequate, but of those that were not adequate, few
were returned for correction or completion.
Example: One examiner said the veteran seemed to have some minor
PTSD symptoms—but did not name them. This was the only reference
to PTSD in the examination, and the veteran was SC and evaluated for
PTSD based on this exam. The examination should have been returned
to get more specific information.
3. Failure to apply DSM-IV criteria
In good exams, the examiner listed the DSM-IV criteria and supplied examples
of the veteran's own signs and symptoms that met those criteria. When this procedure is followed, the rater should have few reservations about the validity of
the diagnosis.
In several cases, the examiner clearly used DSM-III-R criteria, and they were
accepted as adequate for rating, contrary to regulations (38 CFR 4.125). If you
read the DSM-III-R and DSM-IV diagnostic criteria, the differences will be
obvious. The language used by the examiner will usually make it clear which
version is the basis of the diagnosis.
Example: Examiner began explanation of PTSD diagnosis by stating
that the veteran has experienced an event that is outside the range of
usual human experience and would have been markedly distressing to
almost anyone. These are DSM-III-R, but not DSM-IV, criteria and are
a clear indication that the diagnosis is not based on DSM-IV criteria.
What are some problems related to the use of GAF Scores?
1. Failure to explain how GAF score was used.
The GAF score was always reported in ratings when it was available, but how it
was used or taken into account, if it was, was rarely explained. In some cases,
however, the GAF score was the only apparent justification for the evaluation.
Example: Rating stated GAF of 60 is indicative of moderate symptoms, and therefore 30% is assigned.
The GAF scale is generally acknowledged to be an unreliable tool for assessment, although it may have value for treatment and prognostic purposes. No
rating should be based primarily or even substantially on the GAF score.
2. Timeframe of GAF score.
The GAF is simply an indicator of an examiner's assessment of overall functioning, and the period of time it represents differs with different examiners.
Common timeframes are either current level of functioning or best level of
functioning during the past year. Which is intended is not always explained in
the examination report.
While current functioning is the more useful of the two for our purposes, it is
really only of interest if the veteran has been relatively stable over the past year
or since the last examination. Remember that we are to consider all evidence of
record, including any periods of remission, to attain a comprehensive picture of
functioning. Taking this into account might lead you to an evaluation that is not
consistent with the examiner's GAF score but which is more appropriate to
rating requirements.
How should the GAF score be used?
You might want to look upon the GAF score as a finding that you could use as
a crosscheck against your own evaluation based on the reported signs and
symptoms. The GAF score, your evaluation based on the rating schedule, and
the reported signs and symptoms should theoretically all correlate with one
another. If they do not, you should carefully reexamine the evidence, and perhaps explain in the rating why your evaluation is at substantial variance with the
GAF score, when it is, perhaps, for example, because of different timeframes. If
the GAF score is not supported by other information in the examination report,
it has little or no value.
However, there is no reason to change an evaluation because a GAF score differs in the assessed level of functioning from your evaluation, because your
assessment may be based on more complete information than the examiner has.
Example: One examiner reported that the criteria that best describe
the veteran are mild impairment with occasional decrease in efficiency
due to such symptoms as depressed mood, anxiety, chronic sleep
impairment, and mild memory loss (part of the 30% criteria from the
general rating formula for mental disorders), which reflects a GAF
score of 55. In essence, he was making a rating schedule determination
and correlating the GAF to it, rather than linking the GAF score to the
clinical findings.
What are the problems in duty to assist?
In some cases where it seemed indicated, all private medical records were not
requested, the SMRs were not requested, there was no U.S. Armed Services
Center for Unit Records Research (CURR) request, pertinent service personnel records were not requested, or all VA medical records were not requested. You should not deny a claim until you are sure that all requested evidence
has been received (or the reason why it could not be obtained noted), the
claimant has been afforded the opportunity to obtain and submit evidence, and
you have sought relevant evidence from available sources.
How often was CURR used for stressor verification?
CURR stressor verification was used in 4 of the 6 cases where it was required.
CURR verified the stressor in one of these 4 cases.
How should other diagnosed mental disorders be handled?
When comorbid (co-existing) mental disorders were present, the examiner did
not always comment on their relationship to PTSD. Ratings often failed to
address co-existing disorders in any way or to ask the examiner to determine
whether they were related to or part of PTSD. Since depression, for example,
and substance abuse are both common accompaniments to PTSD and are
sometimes due to or part of PTSD, mental disorders diagnosed in addition to
PTSD cannot be ignored in ratings. If the examiner doesn't make it clear
whether they are distinct and unrelated entities, the examination should be
returned to clarify that.
A related problem is the need to reconcile varying diagnoses. Clarification is
necessary if the examination upon which you are basing a rating makes a different diagnosis from a diagnosis or diagnoses in other evidence of record. This is
required by 38 CFR 4.25(b), which states: " the rating agency shall determine
whether the new diagnosis represents progression of the prior diagnosis, correction of an error in the prior diagnosis, or development of a new and separate
condition. If it is not clear from the available records what the change of diagnosis represents, the rating agency shall return the report to the examiner for a
determination." This was not routinely done.
What are examples of erroneous grants and denials?
1. Premature grants
PTSD may occur as an acute condition that resolves after a severely stressful
experience. Therefore, it cannot always be assumed to be a chronic disease.
Example: SC at 50% granted. Had PTSD in svc. Has no current diagnosis. Veteran did not appear for exam. Reason for separation was personality disorder.
Example: SC at 10% granted. Had PTSD in service related to
Lebanon embassy bombing. Exam is inadequate—gives history of
PTSD—but it is unclear whether he now has PTSD.
2. SC grants but with failure to reconcile diagnoses
Example: SC at 10% granted in Vietnam combat veteran. Treatment
records showed PTSD. VAE showed anxiety disorder. Diagnoses
should have been reconciled.
Example: SC at 50% granted. WWII Navy veteran. Had multiple diagnoses on different exams—PTSD, substance abuse, depression, etc.—
not reconciled. Stressor not confirmed.
Example: SC at 50% granted for PTSD with major depression.
Stressors were explosion on ship and abandonment by wife. Rating
does not discuss SMRs (had a medical board) or VA examination, does
not state why PTSD is SC, and does not indicate the basis of the evaluation.
3. SC grant based on inadequate exams
Example: 2 cases where SC at 10% was granted where the diagnosis
was made only by the VHA POW exam coordinator (who is not a mental health professional). One did have an examination by a mental
health professional. While inadequate, it did not diagnose PTSD.
Example: SC at 10% granted. Record of hospitalization for depression, and VAE showed bipolar disorder and PTSD. Criteria for PTSD
were not laid out and psychological tests did not support a PTSD diagnosis. Report should have been returned for clarification and
Examples of incorrect or questionable evaluations
Underevaluations
Example: SC 30% in WWII combat veteran. Examiner said PTSD has
severe impact on functioning. Evaluation of at least 50% seems
Example: SC 70%. Vietnam combat veteran. Examiner says there is
inability to function in almost all areas. GAF 30, the lowest GAF given
in this group of reviewed cases. To consider I.U. Should have been
given 100%.
Overevaluation
Example: SC 70% in 86 year old WWII veteran with Purple Heart. GAF
62. Barely meets PTSD criteria. Has mild dementia. Grossly overevaluated because there is no indication he is severely disabled, even taking
into account his mild dementia.
Appendix B:
Governing Regulation For
Service Connection For PTSD
(From 38 CFR Part 3).
3.304 Direct service connection; wartime and peacetime.
Posttraumatic stress disorder. Service connection for posttraumatic stress
disorder requires medical evidence diagnosing the condition in accordance with 4.125(a) of this chapter; a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. If
the evidence establishes that the veteran engaged in combat with the
enemy and the claimed stressor is related to that combat, in the
absence of clear and convincing evidence to the contrary, and provided
that the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran's service, the veteran's lay testimony
alone may establish the occurrence of the claimed in-service stressor. If
the evidence establishes that the veteran was a prisoner-of-war under
the provisions of 3.1(y) of this part and the claimed stressor is related
to that prisoner-of-war experience, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is
consistent with the circumstances, conditions, or hardships of the veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. (Authority: 38 U.S.C. 1154(b))
Appendix B: Governing Regulation For Service Connection For PTSD
(from 38 CFR Part 3)
Appendix C:
Excerpts from VBA's Adjudication
Procedures Manual Concerning
the Adjudication Of Claims For
PTSD.
The issue of service connection for PTSD is the sole responsibility of the rating
specialist at the local level. Central Office opinion or guidance may be requested on complex cases.
a. Stressors.
In making a decision, exercise fair, impartial, and reasonable judgment in determining whether a specific case of PTSD is service connected. Some relevant
considerations are:
(1) PTSD does not need to have its onset during combat. For example,
vehicular or airplane crashes, large fires, flood, earthquakes, and other
disasters would evoke significant distress in most involved veterans. The
trauma may be experienced alone (rape or assault) or in the company of
groups of people (military combat).
(2) A stressor is not to be limited to just one single episode. A group of
experiences also may affect an individual, leading to a diagnosis of
PTSD. In some circumstances, for example, assignment to a grave registration unit, burn care unit, or liberation of internment camps could
have a cumulative effect of powerful, distressing experiences essential to
a diagnosis of PTSD.
(3) PTSD can be caused by events which occur before, during or after service. The relationship between stressors during military service and current problems/symptoms will govern the question of service connection.
Symptoms must have a clear relationship to the military stressor as
described in the medical reports.
(4) PTSD can occur hours, months, or years after a military stressor.
Despite this long latent period, service-connected PTSD may be recognizable by a relevant association between the stressor and the current
presentation of symptoms. This association between stressor and symptoms must be specifically addressed in the VA examination report and to
a practical extent supported by documentation.
(5) Every decision involving the issue of service connection for PTSD
alleged to have occurred as a result of combat must include a factual
determination as to whether or not the veteran was engaged in combat,
including the reasons or bases for that finding. (See Gaines v. West, 11
Vet. App. 113 (1998).)
Appendix C: Excerpts From VBA's Adjudication Procedures Manual
Concerning The Adjudication Of Claims For PTSD
b. Evidence of Stressors in Service
(1) Conclusive Evidence.
Any evidence available from the service department indicating that the veteran
served in the area in which the stressful event is alleged to have occurred and
any evidence supporting the description of the event are to be made part of the
record. Corroborating evidence of a stressor is not restricted to service records,
but may be obtained from other sources (see Doran v. Brown, 6 Vet. App. 283
(1994)). If the claimed stressor is related to combat, in the absence of information to the contrary, receipt of any of the following individual decorations will
be considered evidence of participation in a stressful episode:
Air Medal with "V" Device
Army Commendation Medal with "V" Device
Bronze Star Medal with "V" Device
Combat Action Ribbon
Combat Infantryman Badge
Combat Medical Badge
Distinguished Flying Cross
Joint Service Commendation Medal with "V" Device
Navy Commendation Medal with "V" Device
Navy Cross
Other supportive evidence includes, but is not limited to, plane crash, ship sinking, explosion, rape or assault, duty on a burn ward or in graves registration
unit. POW status which satisfies the requirements of 38 CFR 3.1(y) will also be
considered conclusive evidence of an in-service stressor.
(2) Evidence of Personal Assault.
Personal assault is an event of human design that threatens or inflicts harm.
Examples of this are rape, physical assault, domestic battering, robbery, mugging, and stalking. If the military record contains no documentation that a personal assault occurred, alternative evidence might still establish an in-service
stressful incident. Behavior changes that occurred at the time of the incident
may indicate the occurrence of an in-service stressor. Examples of behavior
changes that might indicate a stressor include (but are not limited to):
• Visits to a medical or counseling clinic or dispensary without a specific
diagnosis or specific ailment;
• Sudden requests that the veteran's military occupational series or duty
assignment be changed without other justification;
• Lay statements indicating increased use or abuse of leave without an
apparent reason such as family obligations or family illness;
• Changes in performance and performance evaluations;
• Lay statements describing episodes of depression, panic attacks, or anxiety but no identifiable reasons for the episodes;
• Increased or decreased use of prescription medications;
• Increased use of over-the-counter medications;
• Evidence of substance abuse such as alcohol or drugs;
• Increased disregard for military or civilian authority;
• Obsessive behavior such as overeating or undereating;
• Pregnancy tests around the time of the incident;
• Increased interest in tests for HIV or sexually transmitted diseases;
• Unexplained economic or social behavior changes;
• Treatment for physical injuries around the time of the claimed trauma
but not reported as a result of the trauma; and
• Breakup of a primary relationship.
In personal assault claims, secondary evidence may need interpretation by a clinician, especially if it involves behavior changes. Evidence that documents such
behavior changes may require interpretation in relationship to the medical
diagnosis by a VA neuropsychiatric physician.
(3) Credible Supporting Evidence.
A combat veteran's lay testimony alone may establish an in-service stressor for
purposes of service connecting PTSD (Cohen v. Brown, 94-661 (U.S. Ct. Vet.
App. March 7, 1997)). However, a noncombat veteran's testimony alone does
not qualify as "credible supporting evidence" of the occurrence of an inservice
stressor as required by 38 CFR 3.304(f). After-the-fact psychiatric analyses
which infer a traumatic event are likewise insufficient in this regard (Moreau v.
Brown, 9 Vet. App. 389 (1996)).
d. Incomplete Examinations and/or Reconciliation of Diagnosis.
If an examination is received with the diagnosis of PTSD which does not contain the above essentials of diagnosis, return the examination as incomplete for
rating purposes, note the deficiencies, and request reexamination.
(1) Examples of an unacceptable diagnosis include not only insufficient symptomatology, but failure to identify or to adequately describe the stressor, or failure to consider prior reports demonstrating a mental disorder which could not
support a diagnosis of PTSD. Conflicting diagnoses of record must be acknowledged and reconciled.
(2) Exercise caution to assure that situational disturbances containing adjust-
ment reaction of adult life which subside when the situational disturbance no
longer exists, or is withdrawn, and the reactions of those without neurosis who
have "dropped out" and have become alienated are not built into a
diagnosis of PTSD.
e. Link Between In-service Stressor and Diagnosis.
Relevant specific information concerning what happened must be described
along with as much detailed information as the veteran can provide to the
examiner regarding time of the event (year, month, day), geographical location
(corps, province, town or other landmark feature such as a river or mountain),
and the names of others who may have been involved in the incident. The
examining psychiatrist or psychologist should comment on the presence or
absence of other traumatic events and their relevance to the current symptoms.
Service connection for PTSD will not be established either on the basis of a
diagnosis of PTSD unsupported by the type of history and description or where
the examination and supporting material fail to indicate a link between current
symptoms and an in-service stressful event(s).
f. Review of Evidence
(1) If a VA medical examination fails to establish a diagnosis of PTSD, the
claim will be immediately denied on that basis. If no determination regarding
the existence of a stressor has been made, a discussion of the alleged stressor
need not be included in the rating decision.
(2) If the claimant has failed to provide a minimal description of the stressor
(i.e., no indication of the time or place of a stressful event), the claim may be
denied on that basis. The rating should specify the previous request
for information.
Excerpts from VBA's Adjudication Procedures Manual concerning
the development of PTSD claims based on personal assault
5.14 POST TRAUMATIC STRESS DISORDER (PTSD)
PTSD Claims Based on Personal Assault
(2) Because assault is an extremely personal and sensitive issue, many incidents
of personal assault are not officially reported, and victims of this type of in-service trauma may find it difficult to produce evidence to support the occurrence
of the stressor. Therefore, alternative evidence must be sought.
(4) (a) Service records not normally requested may be needed to develop this
type of claim. Responses to the development letter attachment shown in Exhibit
B.11 may identify additional information sources. These include:
A rape crisis center or center for domestic abuse,
A counseling facility,
A health clinic,
Family members or roommates,
A faculty member,
Civilian police reports,
Medical reports from civilian physicians or caregivers,
A chaplain or clergy, or
Fellow service persons.
(b) Any reports from the military police, shore patrol, provost marshal's office,
or other military law enforcement.
Appendix D:
Detailed Guildeline For the GAF
Use of the GAF score (DSM-IV Axis V) as a clinical outcome measure has
gained increased prominence in both private and public mental health settings.
In the late 1990's, the Department of Veterans Affairs mandated that a GAF
score be assigned at regular intervals for veterans receiving care in the system.
Disability boards have at times also employed the GAF as an index of a
claimant's functional status as part of the process of determining eligibility for
benefits. The GAF is appealing as a rating of functioning because it is:
widely available
intuitive in its intended goal
ostensibly time-efficient, and
a scaled value linked to symptoms or functioning
The appeal of GAF is also understandable in the context of Compensation and
Pension determinations because it is viewed as a quick and easy measure to
assign and one that is easily understood by a wide range of people without
advanced education or special training. Existing literature on the development
of the GAF indicates that it was to serve as a global summary estimation of the
veteran's functioning excluding medical problems. The DSM-IV states: " Axis
V is for reporting the clinician's judgment of the individual's overall level of
functioning...The reporting of overall functioning on Axis V is done using the
Global Assessment of Functioning (GAF) Scale. The GAF Scale is to be rated
with respect only to psychological, social, and occupational functioning. Do not
include impairment in functioning due to physical (or environmental)
limitations. (p. 30).
The actual GAF rating is the lowest level of either symptom severity or functioning, and this is based on the clinician's opinion, formed from the available
clinical data and history. As the fifth axis in the DSM profile, it represents the
severity of Axis I (Clinical Disorders) and Axis II (Personality Disorders) or
Axis IV (Psychosocial and Environmental Factors). The GAF Scale, ranging
from 0 - 100, and descriptors of levels of symptoms and functioning for each 10point, decile band (e.g., 81-90, 91-100) are listed in the DSM-IV (p. 32),
although "0", which equals insufficient information, is not an allowed option for
rating veterans according to VHA Directive # 97-059. Very little instruction is
included in the DSM-IV for how to assign ratings using the scale, and herein
lies one of the fundamental problem with assigning GAFs in PTSD cases. As a
score based primarily on the rater's impressions and synthesis of data, solid reliability and validity ultimately determines how useful the GAF scores ultimately
can be. Without clear definitions of symptom severity and functional severity
—- as they relate to PTSD, and without more detailed instructions for using the
GAF scale itself, the clinician is left to decide what to rate and how to do it
using personal standards. If the main goal of assigning a GAF score was simply
Appendix D: Detailed Guideline For the GAF
for the individual clinician to have a global rating that they would use personally, then applying their individual interpretation of the scale definitions and the
rating process would have limited impact outside of their practice or caseload.
However, in the context of Compensation and Pension determinations, consistency and accuracy in ratings needs to be based on a set of standards that are
common to all who determine the GAF score and to those who subsequently
interpret them when determining benefits.
the DSM-IV, these psychometric features of the Global Assessment Scale
(GAS) were formally examined and published by the GAS authors (Enidcott,
Spitzer, Fleiss & Cohen,1976). The GAF and the GAS are almost identical to
each other in content, with the exception of some re-arrangement of rating
descriptions and examples for the categories. Across five GAS standardization
studies reported, the intraclass correlation of the GAS ranged from .61 -.91 with
a standard error of measurement of between 5 and 8 points, meaning that the
actual GAF score would normally be expected to fall within a +/- 5 to 8 point
range around the score. Given the similarities of the GAS and the GAF, the
GAS psychometric properties may be true for the GAF as well. Regarding
validity, GAS ratings, as measures of overall severity, examined at admission
and 6-months later showed more sensitivity to change than single symptoms
measures. Correlations of GAS ratings and independent measures of Symptom
Criteria were the highest for items representing psychosis and overt behavioral
disorganization and low for affect and anxiety-related criteria.
1. GAF Reliability.
Reliability is necessary for GAF scores to be meaningful in the C&P determination process. Reliability in this context is consistency in assigning GAF ratings.
If an individual clinician had high reliability with him or herself, they would
apply similar standards to the rating process for all GAFs they assigned, and
their GAF ratings would be the same or very similar if they rated the same
patients again with the same information. For high inter-rater reliability (agreement between raters), different clinicians would arrive at the same or very similar GAF scores if they rated the same patient, presumably because they used
the same definitions and applied the same standards to the rating process (vs.
simple chance agreement). To achieve consistency, rating scales must use clear
definitions for what is to be rated and then specify clear procedures for assigning ratings. This removes or minimizes the need for the rater to make judgments based on their individual perspective. The existing literature shows that
in the absence of systematic training with the GAF, reliability is generally poor.
Wide variability in GAF ratings is a logical result if each clinician must arrive at
their own understanding of what to rate and how to rate it. To deal with this
issue, some clinical settings attempt to improve reliability by conducting
Consensus Review Groups to reach agreement on assigned GAFs. In the
process, local groups of clinicians can increase inter-rater reliability as a result
of the group discussion that shapes raters agreement with each other. While
this "local standard approach" calibrates the set of raters to each other and
results in higher consistency, the GAFs from this setting may not agree with
GAFs assigned by other settings for the same patient. Evidence suggests that
differences among groups of raters may result in part because clinicians may
use different perspectives when they rate symptom severity vs. functional
impairment. Also, some raters may average symptom occurrence or functionality over time, while others rate the most recent episode or lowest level of these
two components. In disorders like PTSD where symptom severity and functionality can vary, these two approaches will potentially yield very different
GAF scores.
2. GAF Accuracy.
Reliability is understandably a main focus because unreliable ratings clearly
limit the validity of the GAF. However, complete reliability does not necessarily
equal validity; as would be true when all raters agree on a GAF value, but it is
the wrong value (i.e., 50 is the consensus GAF, but in reality it should be 30).
This might happen when groups of clinicians work toward consensus in their
setting, and in the process impose their viewpoints on how to interpret what a
GAF score at a given level should be. For example, after years working as a clinician with PTSD veterans, those veterans who have severe symptoms, resulting
in multiple personal problems and poor occupational histories, may unintentionally become the norm. By comparison, a veteran who is working steadily,
for instance as a long-distance truck driver, may stand out in a positive way as
someone who functions in spite of his/her symptoms. In contrast to the symptomatic and unemployed veteran, he is generally functioning better. If this same
veteran presented clinically with an episode of increased depression, active suicidal preoccupation, increased irritability, and had initiated a beating of someone who cut him off on the road while he was driving, his GAF scale score for
current functioning would place him in the 11-20 band that characterizes someone who is in Some Danger of Hurting Self or Others. In deciding between the
two possibilities, symptoms or functioning, symptoms in this case are worse, and
the GAF score is based on which of the two is worse. If during the process of
reviewing the case information, the clinician applies an "averaging" type of reasoning in the form of: "...well, this was only one episode, and he is working
most of the time, and things could be worse (or other veterans are worse off
than this), and he shouldn't be labeled because of this one incident", then a
higher and inaccurate GAF (one that represents a better functional rating) is at
risk of being chosen
3. GAF Accuracy and PTSD.
A number of challenges to creating accurate GAFs face the clinician who is
tasked with assigning scores for PTSD patients. First, the GAF AXIS V examples for symptoms contained in the DSM-IV do not represent PTSD directly.
Also, in cases of chronic PTSD, comorbidity with other diagnoses is common,
including substance abuse, major depression, features of other anxiety disorders
like panic and OCD, and personality disorders. To assess symptom severity in
the context of comorbidity, the clinician must somehow weigh the combined
impact of all conditions, but without directions or examples. Second, general
descriptors like Mild, Moderate, Serious, etc., that characterize the various 10point decile bands are open to interpretation and will likely be based on the
clinician's own standards. Third, the clinician must decide what qualifies as a
symptom or functional problem to rate. Some symptoms can also be considered
functional problems (e.g., PTSD Hypervigilance and Avoidance of people and
places). Fourth, making GAF ratings for the 50 - 100 range (moderate symptoms to superior functioning) is less complicated than for the 1- 50 range
because the higher ranges reflect low symptomatology
4. Resolution of the GAF Scale.
The GAF scale is organized into ten decile (10-point) bands. The DSM-IV adds
a note suggesting that the rater "use intermediate codes when appropriate, e.g.,
45, 68, 72)", but gives only general guidance on exactly how to arrive at these
intermediate values. In supplementary GAF material, Dr. Michael First (1995) ,
the editor of text and criteria for the DSM-IV, suggested using a process where
the GAF rater first identifies a decile band that best fits the patient, then
decides if the level of symptoms or functioning was nearer to the top of the
bandwidth, nearer the middle or nearer the bottom. Depending on this decision
by the rater, either a 7, 5 or 2 would be selected to refine and select the final
GAF (for example: 47, 45 or 42 within the 41 - 50 decile band). Using this procedure, the finest resolution under the best circumstances is about 3-points, and
more practically —- 5 or 10 points because ratings tend to cluster at the middles
and ends on the scale (e.g., 45, 50, 55, 60, 65). The difference between raters
assigning GAFs for the same patient could vary by 20 points if for example one
rater considered the symptoms mild and the other thought they were toward
the moderate - severe end of the decile. Thus, using cutoffs that set strict
thresholds is unwise and unsupported by both the inherent resolution of the
GAF scale and the data showing that raters typically use larger rating intervals.
5. Assigning Separate GAFs by Condition.
Various parts of the foregoing discussion bear on this issue. For a number of
reasons, creating the equivalents of PAFs should not be done, although reports
from the field indicate that clinicians are being asked to assign PAFs using the
GAF scale. First, by name alone, it is clear that the GAF was designed to be a
"Global" index of functioning; one that represents in a single value the veteran's functional status. No published information in the DSM-IV instructs users
in a valid method for partitioning the GAF by each comorbid clinical condition,
using either separate sets of symptoms for each diagnoses or Social and
Occupational / School functioning (although supplementary material suggests
that a separate GAF might be created for all symptoms and another for general
social/occupational functioning ). While it might appear from the descriptors in
DSM-IV (i.e., mild, moderate, serious) that separate ratings by diagnosis could
be made (e.g., only for depression symptoms, only for anxiety symptoms, only
for substance abuse symptoms), the separate ratings that would result have no
validated relationship to each other, and no established means for integrating
them into a value that considers the combined effect of having them
all concurrently.
Second, if "PAFs" are requested for a disability determination, it is likely that
multiple conditions exist comorbidly, and having separate ratings of severity of
dysfunction would fit with a process of assigning a percentage of service connection to each particular disorder. In PTSD, depression and substance use frequently coexist and veterans have long-standing problems in occupational,
interpersonal, social, familial and psychological domains. Attempting to attribute a portion of the functional problems to depression and another to substance
use and another to PTSD, as if they were independent of each other, is beyond
the capability of the GAF scale. This is an instance of incompatibility between
the capabilities of the GAF scale and the compensation review process. While
the logic of separate ratings by disorder may make sense from an adjudication
perspective, it is not clinically validated, and "PAFs" assigned in this manner
should be seriously questioned for their validity as evidence in the disability
determination proceedings.
Some Considerations for Making GAF Ratings
carefully, c) try to assign scores as accurately as possible by adhering to the definitions provided, and d) strive to become consistent with themselves in choosing their GAF ratings.
Outcome data from GAF trainings have shown that raters can have a bias
against assigning low GAF scores for PTSD vignettes. This bias, conscious or
not, means that all decile bands do not have an equal chance of being selected,
and that some will be chosen more than others independently of the case information. For the GAF to be meaningful, it must accurately reflect the Current
Severity of the veteran's symptoms or functioning. For PTSD cases used as part
of organized GAF training, it was typically true that the GAF ratings made
raters regarding what defined a functional problem, and equally important, the
rater's personal perspective on what qualified as a Mild, Moderate, and Serious
level of severity. Using the exact same case information, one rater's standard
for Mild Severity might be another rater's standard for Moderate Severity.
In clinical PTSD contexts, and for those veterans filing valid claims for disability
from PTSD attributed to military experiences, symptoms are usually chronic
and their overall level of functioning is often poor. GAFs for the majority of
these cases will be 50 and under. While many claimants will easily receive a
PTSD diagnosis because they meet multiple criteria under DSM-IV Sections B,
C, and D, the process of rating PTSD symptom-severity using available information for the GAF scale is difficult. Examples given in the DSM-IV for seri-
ous symptoms (41-50 decile band) include: suicidal ideation, severe obsessional
situations, and frequent shoplifting. In PTSD contexts, suicidal ideation is often
persistent and chronic, and combined with many other symptoms. Regarding
these other symptoms, PTSD clinicians would likely agree that regular dissociative flashbacks and high hyperarousal with hit-the-deck startle response is more
serious than frequent shoplifting or obsessional rituals. Yet, this is a personal
judgment without corroboration in the DSM-IV to serve as a calibration point.
Creating ratings of functional impairment using the DSM-IV examples is easier
because they represent the impact of symptoms in domains that are common
across all diagnoses including PTSD. Applying the DSM-IV examples of social
and occupational problems to PTSD patients can be done more easily than for
the symptom severity levels.
In making ratings, clinicians should be cognizant of the presence of Violence
Toward Self and Others in the veteran's history. The decile band 11-20 (Some
Danger of Hurting Self or Others) gives as examples: a) suicide attempts without clear expectation of death; and b) frequently violent; while the decile band
1-10 ( Persistent Danger of Severely Hurting Self or Others ) lists: a) recurrent
violence, and b) serious suicidal act with clear expectation of death. Incidents
while driving in traffic are frequently reported as the impetus for aggression
towards others, and at times the beating of other drivers; while participating in
physical fights is reported as a means of managing anxiety, releasing tension
and counteracting depressed mood. In either case, the veteran or others could
be hurt. While these events may be episodes of aggression vs. continuous
aggression, they are significant features that drop the GAF into the lower decile
ranges if they are current when the veteran is assessed. If these features are
present clinically, they should not be overlooked or minimized by the clinician
when making GAF ratings.
APPENDIX E: Global Assessment of Functioning
(GAF) Scale
Consider psychological social, and occupational functioning on a hypothetical
continuum of mental health-illness. Do not include impairment in functioning
due to physical (or environmental) limitations.
Code (Note: Use intermediate codes when appropriate, e.g., 45, 68, 72.)
100 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 minimal 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 communication 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; frequently 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 persistent inability to maintain minimal personal hygiene OR serious suicidal act with
clear expectation of death.
Inadequate information.
Appendix E: Global Assessment of Functioning (GAF) Scale
The rating of overall psychological functioning on a scale of 0-100 was operationalized by Luborsky in the Health-Sickness Rating Scale (Luborsky L:
"Clinicians' Judgments of Mental Health." Archives of General Psychiatry 7:407417, 1962). Spitzer and colleagues developed a revision of the Health-Sickness
Rating Scale called the Global Assessment Scale (GAS) (Endicott J, Spitzer
RL. Fleiss JL, Cohen J: "The Global Assessment Scale: A Procedure for
Measuring Overall Severity of Psychiatric Disturbance." Archives of General
Psychiatry 33:766-771, 1976). A modified version of the GAS was included in
DSM-III-R as the Global Assessment of Functioning (GAF) Scale.
APPENDIX F:
Scoring Rules for Mississippi
and PCL-22
Mississippi Scale for Combat-Related PTSD (M-PTSD)
The M-PTSD was originally developed to assess the domain of DSM-III PTSD
symptoms and various associated features in combat-exposed Vietnam veterans
(Keane et al., 1988), and was subsequently revised to conform to DSM-III-R
criteria. The M-PTSD is a 35-item Likert-scaled questionnaire providing a continuous measure of PTSD symptom severity. Internal consistency for the scale
was reported to be .94 (Keane et al., 1988), and the test-retest reliability coefficient is .97 (Keane et al., 1988). Factor analytic studies of the M-PTSD have
yielded dimensions of intrusive re-experiencing/numbing-avoidance, anger/lability, social alienation, and sleep problems, which correspond to DSM-III-R
symptomatic criteria for PTSD (Keane et al, McFall, Smith, Mackay, & Tarver,
1990). Preliminary validation studies using the M-PTSD demonstrated excellent
agreement (Kappa = .75) between PTSD diagnoses made by the M-PTSD and
the Structured Clinical Interview for DSM-III-R among Vietnam veteran psychiatric patients (Kulka et al., 1988). Sensitivity of the M-PTSD in identifying
validated PTSD cases is 93%, and specificity is 88% for various non-PTSD
comparison groups (Keane et al., 1988; McFall et al., 1990).
Mean M-PTSD scores among Vietnam veterans have been reported to be 104
among help-seeking patients from a Vet Center and 130 among VA medical
center psychiatric patients with PTSD (Keane et al., 1988; McFall et al., 1990).
The optimal cutting score for accurately classifying individuals with or without
PTSD has varied from study to study, but has ranged between 100 and 107
(Keane et al., 1988; McFall et al., 1990; Watson, 1990)
PTSD Checklist (PCL)
The PCL (Weathers et al., 1993) is a 17-item self-report scale for assessing
PTSD symptoms over a variable span of time (one week or one month), appropriate to the context of administration. A version of the PCL is available for
assessment of veterans exposed to military traumas (PCL-M) as well as patients
exposed to nonmilitary forms of stress (PCLC). The PCL scales are useful as
continuous measures of PTSD symptom distress, but can also aid in making a
categorical diagnosis of PTSD by summing items across the three DSM-IV
symptom clusters of the disorder. Test-retest reliability is .96, and internal consistency is very high (alpha=.93). Convergent validity is supported by high correlations with the Mississippi scale for PTSD (.93), Impact of Event Scale (.90),
MMPI PTSD subscale (.77), and the Combat Exposure Scale (.46). The Kappa
coefficient for the PCL is reported to be .64. Cross validation studies, on independent samples of Persian Gulf theater veterans, substantiates the aforementioned psychometric properties of the PCL. The PCL can be conveniently
administered and scored, and would be appropriate for use as a PTSD
Appendix F: Scoring Rules For Mississippi and PCL-22
screening instrument.
Mean PCL scores are 63.6 (SD=14.1) for Vietnam veterans with PTSD, and
34.4 (SD=14.1) for non-PTSD subjects. A PCL cutting score of 50 provides the
optimal diagnostic sensitivity (.82) and specificity (.83).
APPENDIX G: Examples of PTSD Symptom
Narratives In Compensation and
Pension Examination Reports
CASE I: PTSD DIAGNOSIS
Example of Trauma History
Mr. Jones served in the USMC from August 1966 to August 1969. He volunteered for duty in Vietnam at the age of 18, serving a total of 13 months in that
country. He primarily served in the XXXX area from February 1967 through
March 1968. His MOS was that of an Amtrak driver, though he actually spent
ten months of his duty in a combined action unit with Vietnamese militia. This
primarily involved his living in a village with Vietnamese citizens, where he
worked in intelligence and also trained and fought with villagers against the
Viet Cong.
This individual was exposed to heavy combat for at least ten months of his tour
of duty in the combined action unit, engaging the enemy at least twice per week
in fire fights, with the exception of December 1967 when he was exposed to
daily fire from the enemy. He was involved in a number of combatant roles,
including participation in well over 50 combat patrols and ambush operations.
In addition, he occasionally participated in river boat patrols where he was fired
upon. There was frequent exposure to mines and booby traps, recurrent sniper
fire, mortar and rocket attacks and frequent ambushing of his unit by enemy
soldiers. He maintains that his village was surrounded by the enemy on at least
30 separate occasions, creating much apprehension that his outfit would be
overrun and destroyed. Although his unit primarily fought the Viet Cong, they
also engaged NVA soldiers in fire fights. During his tour, Mr. Jones maintains
that he was nearly always in danger of being injured or killed, with many near
misses. In addition, he witnessed the killing and wounding of American and
enemy soldiers on at least 50 separate occasions. Of the 14 Marines in his unit,
nine were killed and five were seriously injured. Mr. Jones received four
wounds during one particularly severe attack by the enemy, including a gunshot
wound to his right bicep, resulting in permanent nerve damage.
This individual is able to describe in considerable detail a number of specific
combat traumas he endured. The most severe battle occurred on January 2,
1968, during the Tet Offensive. At that time, Mr. Jones unit was ambushed and
destroyed by the villagers with whom they had been living and working for several months. At 1 a.m., his unit was attacked and pinned down in dwellings
where they were surrounded by the enemy. Mr. Jones witnessed the slaughter
of his own men, but somehow, miraculously, escaped to safety after having been
wounded four separate times. He was prepared to kill himself with a hand
grenade rather than be captured while he attempted to escape through the
Appendix G: Examples of PTSD Symptom Narratives In
Compensation and Pension Examination Reports
bush. He was finally rescued by American forces, being found unconscious in
the brush with a hand grenade from which the pin had been pulled clenched to
his chest. He recalls another incident when a truck of Army personnel struck a
mine and blew up. He was involved for two days in policing the area by picking
up various body parts of severely dismembered soldiers. Yet another tragedy
occurred when Mr. Jones witnessed his best friend fall to his death from a rope
suspended from a helicopter which had suddenly come under fire while
engaged in a construction project. Mr. Jones believes that the circumstances
contributing to this unfortunate outcome were largely his "fault."
The veteran claims that his only disciplinary infraction during the military was a
"write-up" for having long hair. He maintains that he was nearly abstinent from
abuse of substances while in the Service, except for the use of rice wine while in
Vietnam. He was discharged honorably with the rank of E-5. Mr. Jones
received the Purple Heart for wounds sustained in action and the Navy
Commendation Medal with a Combat V for meritorious action while trying to
save others during the January 2 assault.
Diagnostic Formulation:
Example of Description of PTSD Symptoms
The veteran meets the DSM-IV criteria for Post Traumatic Stress Disorder,
chronic, severe. He maintains that he has intrusive, distressing recollections of
the aforementioned traumatic experiences on a daily basis. He is awakened
from his sleep at least once per week by nightmarish dreams of being overrun
and of picking up the bodies of dead soldiers. Although he is oddly attracted to
reminders of his wartime experience (displaying his medals at home, watching
combat movies), he maintains at the same time that he experiences intense psychological distress when exposed to events that resemble or remind him of his
Vietnam experiences. Indeed, he became quite upset during the interview while
recounting his combat experiences.
He makes rather extreme efforts to avoid intrusive and painful recollections, to
the extent that he gambles compulsively to generate a sense of excitement as
well as distract him from inner preoccupation. There is no amnesia for his traumatic events; on the contrary, he remembers nearly every detail quite vividly.
There has been a notable and chronic loss of interest in activities and generalized anhedonia since his return from Vietnam, as he has given up most enjoyable pursuits with the exception of working over 60 hours per week, visiting his
girlfriend, and gambling. Although formerly quite estranged socially, he appears
to be re-establishing meaningful connections with family members and his girlfriend. He endorses the symptom of emotional numbing, maintaining that he is
generally emotionally under-reactive and somewhat callous, finding it particularly difficult to express tender and loving feelings toward others. Perhaps most
noteworthy, this individual seems to have a sense of a fore-shortened future,
feeling as though he "died over there and (is) just a shell." He seems to be
remarkably shortsighted, making few plans for his future other than having
vague hopes for marriage to his girlfriend.
There appears to be some modest sleep disturbance, as he awakens briefly once
or twice per night. Generally, he claims he is not particularly irritable or angry,
having gotten in only six fights since his service days, the last one being over two
years ago. However, he maintains that he has intense anger towards the
Vietnamese, fearing loss of control of aggressive impulses toward them. He
reveals that in 1980 he made a misguided attempt to ram his car into a
Vietnamese restaurant. The veteran endorses other symptoms of arousal that
seem related to his combat experiences — he is very hypervigilant, easily startled, and physiologically aroused by combat related stimulation such as helicopters. Once of his most bothersome symptoms seem to be guilt about having survived Vietnam while other soldiers died, as well as about acts of brutality
towards enemy soldiers and self-perceived failures to rescue friends killed by
the enemy.
The patient maintains that many of these symptoms have been present since he
was 19, and have been present over 90% of the time during the last five years.
They seem to be intensified during the month of January each year, the
anniversary of the date when his unit was overrun. Other points of heightened
symptom severity occurred in the mid-1970's when he was depressed and suicidal, and during 1980 when Vietnamese refugees began traveling to the U.S.
Although he recognizes the irrational quality of his current hatred towards
Vietnamese people, he is quite disdainful of them and fears that he may attack
them if provoked.
This patient also meets the criteria for major depression, recurrent, of moderate severity. In particular, he has periods of despondent mood accompanied by
anhedonia, a 20-pound weight loss, sleep disturbance, psychomotor retardation,
and notable loss of energy and fatigue. He has been self-condemning, feeling
quite worthless and inadequate. It appears his current episode of depression
has been most severe since about January 1987, to the extent that he lost 20
pounds, withdrew for days at a time on his couch, and, again, ruminated about
killing himself with exhaust fumes. There have been approximately 30 such
episodes since he was 25, though the current episode is evidently the
most severe.
The veteran also meets the criteria for Obsessive Compulsive Disorder, in particular, compulsive gambling. However, it is our opinion that his compulsive
gambling is closely linked with his PTSD symptoms, in that they represent
deliberate attempts to ward off intrusive memories of a painful nature.
The veteran appears to suffer primarily from symptoms of PTSD, with Major
Depression and Compulsive Disorders secondary. It appears that PTSD symptoms of intrusive re-experiencing are most predominant, whereas numbing and
avoidant defensive symptoms are present to a lesser degree. Distressing degrees
of guilt as well as symptoms of autonomic arousal are also quite noteworthy.
With respect to the latter, it should be mentioned that Mr. Jones participated in
a research investigation where assessments of his physiological reactivity to
combat films were made. He demonstrated observable increases in heart rate
and blood pressure, as well as heightened epinephrine response to combat
films. Although data from this procedure are in no way a conclusive means of
diagnosing PTSD, there is research support demonstrating that such response
patterns distinguish veterans with PTSD from non-PTSD psychiatric patients.
CASE II: PTSD Diagnosis
Military History: Example of Trauma History
The veteran, Mr. Smith, enlisted in the Marine Corps, serving from 1965-1977
as an infantry officer. He obtained the rank of First Lieutenant while serving in
Vietnam, and was ultimately discharged as a Captain under honorable conditions. Mr. Smith eagerly volunteered for duty in Vietnam, serving 12 months
aboard an aircraft carrier off the coast of Vietnam (June 1969 to June 1970),
and another eight months as an infantry officer in Vietnam from September
1970 to April 1971. He was 23 years of age when he was sent to Vietnam.
As a platoon commander, Mr. Smith reports he was exposed to "heavy combat," staging over 100 patrols and ambushes, and having frequent contact with
the enemy throughout the duration of his duty. He reports that his unit was surrounded by the enemy on two occasions, and that approximately 25% of the
men in his unit were either killed in action or wounded. Though he did not
directly fire rounds at the enemy, he was in charge of directing attacks against
the enemy in his role as a field commander. He maintains that there were at
least 50 occasions in which he was in danger of being injured or killed, either
from scattered, harassing sniper fire or from more direct confrontations with
the enemy. He maintains that he was not directly involved in killing any of the
enemy himself, though he directed fire at the enemy, which did kill and wound
the enemy. Mr. Smith was wounded on one occasion when a mortar round hit
near him, throwing shrapnel into his arms, chest, and legs, and contributing to a
permanent condition of tinnitus, which annoys him considerably. Mr. Smith
reports at least one episode of hand-to-hand confrontation with the enemy,
when he was exploring a tunnel in the dark and came upon four NVA officers
whom he dragged from the tunnel with considerable risk to his own life. The
veteran is particularly guilty about one occasion where he led his men into an
area that was heavily booby-trapped, resulting in the death of one man and the
serious wounding of another four men. The veteran becomes very despondent
and tearful when describing this event even today, condemning himself for having failed to prevent this outcome, despite the facts of the case, which do not
suggest any negligent conduct on his part. The veteran earned a Bronze Star for
valor by exposing himself while wounded to "intense hostile fire and directing
the activities of his men." He also obtained the Purple Heart, the Cross of
Gallantry, and the Combat Action Ribbon. Throughout his tour in Vietnam, the
veteran maintains that he was somewhat overzealous, being enthusiastic about
his Vietnam duty and often taking excessive risks by exposing himself to needless danger while assuming responsibilities that he admits would have been better left to other men in his platoon. In addition to combat exposure, the veteran
maintains that he witnessed the torture and mutilation of enemy soldiers.
While in Vietnam, Mr. Smith maintains that he was nearly totally abstinent
from alcohol, and did not use illicit drugs. His military career came to an abrupt
end when he was charged with attempted murder for obtaining a pistol he
planned on using to shoot a superior officer who assigned him to a duty station
against his liking. He was hospitalized involuntarily at the Bethesda Naval
Hospital from January to May 1977 following this incident, and was terminated
from the military shortly thereafter to his great disappointment. Apparently,
this was a very uncharacteristic behavior for Mr. Smith, who maintains that he
otherwise had a spotless military record with no infractions for
conduct problems.
Diagnostic Formulation: Description of PTSD Symptoms
The veteran meets the criteria for Post Traumatic Stress Disorder, chronic,
severe. He maintains that he has intrusive, unpleasant thoughts regarding his
experiences in Vietnam, which occur several times per day on a nearly daily
basis. Moreover, his sleep is chronically disturbed, as he awakens nearly every
night with troubling dreams and nightmares about the incident in which he is
carrying to safety men who had been wounded in a heavily booby-trapped area
where he had to lead them. The veteran is easily reminded of his Vietnam experiences by environmental stimulation, which provides him occasion to ruminate
about troubling events (his chronic tinnitus resulting from a mortar explosion
near his head is a constant reminder of the war). He maintains that alcohol is
one of the few means he has to block preoccupation with intrusive imagery as
well as to permit him freedom from troubling and disrupted sleep. The veteran
has had less frequent, though quite disturbing, flashback phenomena, the most
recent incident being the one where he was wandering around the neighborhood armed and wearing combat fatigues. There is a marked evidence of emotional numbing and constriction to ward off powerful feelings, which have been
observed to easily overwhelm him. Despite these efforts, the veteran admits his
involvement in repeated dangerous stunts to give him "an adrenaline high" that
attempts to replicate the excitement and thrill of combat. (For example, the veteran still frequently hunts rattlesnakes in the wilderness without any weapon
and wearing only tennis shoes, catching the snakes by hand.) Consistent with a
diagnosis of PTSD, the veteran has a long history of fractured and disrupted
relationships that have left him feeling quite alienated and unable to tolerate
intimacy. One of his most severe symptoms seems to be guilt, particularly about
having not done enough to save his men from being wounded/killed during the
aforementioned incident. Moreover, he is preoccupied with having survived
Vietnam at all, having expected to die, and feeling as though better men than
he were killed. Startle response is evident, with the veteran being jumpy and
easily aroused by sounds resembling the environment in Vietnam. He is
markedly hypervigilant, needing to keep his back to walls and finding it intolerable to allow others to position themselves where he cannot see them. During
our observation of him, he rather ritualistically sat in a corner near an open
window day after day without changing his position in the group rooms.
Psychophysiological assessment conducted in our facility revealed that Mr.
Smith showed marked elevations in blood pressure and heart rate while viewing
Vietnam combat films, further documenting his autonomic arousability.
The weight of the clinical evidence points to a marked change in functioning for
this individual, from his premilitary to postmilitary adjustment. That is, prior to
entering the military and prior to his Vietnam combat experience, this individual appeared to be performing at an exceptional level of adjustment in most
spheres of psychosocial functioning. However, since his discharge from the military in 1977, his course has been marked by steady deterioration in which he is
clearly achieving beneath his potential, and has a history checkered with disrupted occupational functioning, impaired interpersonal relations, subjective
unhappiness, and somewhat compulsive involvement in dangerous stunts that
reflect poor judgment and court disaster.
Case III: PTSD Diagnosis with
Sexual Harassment/Sexual Assault
Example of Pre- Military and Military History
Ms. Jones is a 40 year old, African American woman who served in the Army
from 1980 to 1984. Ms. Jones described a fairly chaotic childhood occurring
prior to her military service. She was the youngest of five siblings and her older
two sisters report being physically and sexually abused by their alcoholic father.
Ms. Jones does not recall specifics of her own sexual abuse by her father, but
states that she "believes" she was sexually molested by him. Her parents reportedly separated when Ms. Jones was 10 years old and she has had no contact
with her father since. Despite her early difficulties at home, Ms. Jones graduated from high school and reported fairly normal relationships with her peers.
She did report feeling that she "did not quite fit in with others." In retrospect,
she attributes this to her struggle over her sexual orientation. Ms. Jones experimented with alcohol in high school but denied any alcohol and/or substance
abuse history. She enlisted in the Army after completing high school in order to
"make a new life for herself and eventually go to college."
Initially, during her service, Ms. Jones adjusted well to the military and very
much enjoyed her service. Although she was unable to be open about her sexual
orientation, she was able to develop a number of friendships and reported feel-
ing mostly "at ease" for the first time in her life. She received positive evaluations from her superior officers and considered whether she would remain in
the Army to pursue a military career. However, in 1983, Ms. Jones reported
that a group of male servicemen began to sexually harass her. They frequently
made sexual comments as she walked by, grabbed her buttocks on several occasions, and asked her whether she had ever "had a real man." Ms. Jones felt
uncomfortable and unsafe around these men and avoided walking alone as a
result. Despite her efforts at avoiding contact with the servicemen, Ms. Jones
reported that she found herself cornered by one of the men (a higher ranking
officer). The officer had been drinking, as was apparent due to the smell of his
breath. Ms. Jones attempted to leave the room but the officer was blocking the
door. He threatened Ms. Jones, stating that she "would need to sleep with him
or else he would make sure everyone knew she was gay." He also told her there
was no use trying to leave since his friends would be waiting for her outside.
Ms. Jones feared for her life and was terrified that the other men would also
rape her. In addition, she feared being discharged from the military. She reported feelings of terror and helplessness at the time of the assault. Immediately
following the assault, Ms. Jones returned to her room, feeling numb.
After this assault, the sexual harassment by the other servicemen appeared to
escalate. Ms. Jones feared that the officer had told them about the assault and
her sexual orientation. She felt unable to tolerate the harassment and reacted
tearfully on each occasion. Her response, unfortunately, only provoked further
harassment. She became increasingly distressed and isolated from others, living
in constant fear of being assaulted and harassed. Ms. Jones did not report her
assault or harassment to higher authorities because she feared retaliation from
her harassers. Rather than remaining in the service and suffer further harassment, Ms. Jones decided to leave the military in 1984 and was
honorably discharged.
Description of PTSD Symptoms
Ms. Jones meets the criteria for PTSD, chronic, severe. She has intrusive, distressing recollections of the assault and harassment daily, which she described
as "very disturbing." She also reported having repetitive nightmares approximately two to three times per week in which she is being teased, harassed, and
surrounded by 5 servicemen. She awakes from her nightmare short of breath
and has significant difficulty returning to sleep. In addition, Ms. Jones reported
that, several times a week, certain triggers, such as television programs on the
military or recruitment advertisements for the military, cause her to have flashbacks of her assault. She also reported having "daydreams" daily, during which
she is suddenly taken back to her memory of being harassed. She described that
when she comes out of the "dream", she sometimes forgets where she is and
will often ask others what they were saying. This was observed several times
during the interview. In addition, upon cues associated with her assault and
harassment, Ms. Jones frequently becomes nauseous and at times tearful. In
addition, she exhibits muscle tension, shortness of breath, and psychomotor agitation. These physiological indictors were evident throughout the interview
when Ms. Jones was describing the assault and harassment as well as her daily
recollections of each.
Ms. Jones also exhibits persistent avoidance of trauma-related cues and numbing. Ms. Jones exerts effort daily to avoid thoughts of her adult sexual assault.
Despite her considerable distress, she has not discussed this assault and harassment with anyone, including her sisters. Her avoidance was also apparent in the
interview. In particular, Ms. Jones seemed quite uncomfortable from the onset
of the interview. She had difficulty maintaining eye contact and frequently
offered short answers to questions. She also became tearful when asked about
her trauma history and acknowledged her discomfort in discussing these events.
Her attempts at avoidance also take the form of complete isolation from others,
with the exclusion of her two sisters. She avoids being alone with men and has
quit jobs when she has had a male supervisor who she feels she "cannot trust."
Ms. Jones also reported a notable decrease in her interest in pleasurable activities since her return from the service. For example, she used to enjoy frequenting sporting events and concerts, but feels uncomfortable doing so due to the
large number of people present. She stated that she feels uncomfortable anywhere in which a large number of men congregate. Ms. Jones also cannot
remember important aspects of the traumatic incident. For example, she is
unclear as to the date of the sexual assault, although she recalls specific details
about what she was wearing and details regarding the location of the assault
and the smell of her assailant. Ms. Jones also exhibits significant detachment
from others. Although as a child Ms. Jones felt she "did not fit in," she had
established a number of strong peer relationships while in the military.
However, after her assault, she became increasingly isolative and detached. She
cut off ties with her peers and has not been in contact with any of them for
years. Ms. Jones does have some continued contact with her sisters but "has no
friends." In addition, Ms. Jones feels incapable of experiencing normal emotions. She reported feeling numb "everyday," and cannot remember when she
last felt happiness and love.
Ms. Jones also reported severe symptoms of increased arousal attributable to
her traumatic experiences. She has significant difficulty falling asleep on a daily
basis and experiences mid-sleep awakenings several times a week, usually due
to the occurrence of a nightmare (described above). She has difficulty returning
to sleep and receives an average of only 3-4 hours of sleep a night. Ms. Jones
also reported frequent irritability and some outbursts of anger that typically
occur on the job. These outbursts have resulted in Ms. Jones being fired and/or
disciplined on a number of occasions. In addition, Ms. Jones exhibits and
reported significant concentration difficulties. Her inability to remain focused
was evident throughout the interview, especially during discussions of traumarelated material. Ms. Jones stated that her difficulty concentrating is a "daily
thing" that has resulted in problems at work. Finally, Ms. Jones reported that
she pays excessive attention to "where she is and where others are at all times."
She says she is most vigilant when on public transportation, at work with men,
or in a crowded place (which she tries to avoid).
In addition to the symptoms described above, Ms. Jones reported that she is
depressed. She cries uncontrollably at times and has limited interest in any
activities. She feels a sense of hopelessness and worthlessness and experiences
chronic suicidal ideation. In addition, after dismissal from her last job two
months ago, she reported that she has lost ten pounds. She also described having limited energy for anything and extreme difficulty getting herself motivated
to leave the house.
Overall, it is clear that Ms. Jones has demonstrated a significant change in functioning as a result of the harassment and assault she experienced in the military.
She is currently presenting with severe impairments in both social and occupational functioning, evidenced by her social isolation and difficulty maintaining
employment. Although it is likely that her trust in others (in particular, men)
was also significantly impacted by her childhood trauma and chaotic home environment, she had no previous disciplinary problems in school or the service and
had established strong relationships with her peers prior to the events described
above. Ms. Jones had also proven to be a hard and reliable worker while in the
Army and received positive reviews by her supervising officers. Her symptoms
of PTSD and depression were also not present prior to the military assault and
harassment and the symptoms began immediately following the reported incidents. In addition, her re-experiencing symptoms are central to the military
assault and harassment, rather than her possible childhood abuse. The timing
and content of the symptoms clearly suggest that they are related
CASE IV: PTSD Diagnosis
Example of Entire Report
Mr. Xxxxx is a 72-year-old, married, Caucasian male.
PREMILITARY HISTORY
Mr. Xxxxx's premilitary adjustment was average to good. He was born in
Massachusetts. He was the youngest of 18 children. He lived with his parents
and siblings, though his older siblings gradually married and moved out of the
home. Mr. Xxxxx stated that his family was poor, but they always had food and
clothing. His father was a brick worker, and his mother stayed at home to care
for the children. Mr. Xxxxx stated that he was close with his parents and siblings. In terms of discipline, he stated that at times he was spanked, but that he
would also be punished by having privileges taken away or being given a chore.
Mr. Xxxxx stated that he enjoyed school and interacted well with other children.
He achieved grades at approximately a C level. His conduct was good, and he
denied repeating grades or any learning difficulties. He played baseball, hockey,
and basketball with neighborhood friends, but was not part of a school team.
Mr. Xxxxx reported very limited use of alcohol and no use of drugs prior to theservice ("a few sips of alcohol with my parents," "I drank a beer after high
school graduation").
Mr. Xxxxx was drafted into the Army on October 30, 1944, when he was 18
years old. He was initially sent to Germany in March of 1945, by way of France,
but spent most of his time in Austria. Mr. Xxxxx was trained as a rifleman, but
served in combat as both a rifleman and scout as part of the 44th infantry division. He attained the rank of Corporal. He was honorably discharged in August
of 1946.
Mr. Xxxxx's duty in World War II would be classified as mainly combat. His
report on the combat scale indicated that he had moderate to heavy exposure
to combat.
Mr. Xxxxx experienced numerous combat experiences, too many of which to
described in this report. Two particularly traumatic events occurred during his
service that continue to distress him.
1) Mr. Xxxxx was sworn in and went through infantry training with a friend. He
then served in World War II in the same unit with this friend. Mr. Xxxxx stated
that in one particular combat situation his friend jumped on top of an activated
German grenade and saved the lives of Mr. Xxxxx and those soldiers around
him. Mr. Xxxxx described experiencing tremendous fright, knowing that if his
friend did not do that, they all would have died. Shortly after, he also experienced significant guilt because of his friend's death. He described, "I wanted to
jump in the line of fire so I could be with him (in heaven)."
2) Mr. Xxxxx reported that two weeks prior to the event described above, he
reported that he was riding in a truck with several other soldiers. A grenade fell
out of one of the soldier's pockets ("I can still hear the click and hissing"). He
stated that he and the other men jumped from the truck. Mr. Xxxxx stated that
he was very scared for his life. Two men were killed during this incident.
In addition to these stressors mentioned above, Mr. Xxxxx stated that he was
also troubled by seeing numerous dead and wounded American soldiers, as well
as German civilians, including women, children, and the elderly. Mr. Xxxxx's
score on the Combat Exposure Scale of 32 was indicative of moderate to heavy
combat exposure, suggesting that Mr. Xxxxx probably was exposed to a whole
series of difficult combat experiences typical of that level of exposure.
POST-MILITARY HISTORY AND CURRENT FUNCTIONING
Mr. Xxxxx returned home to Massachusetts following his service. He described
that during the first winter he returned, he carried a gun and "took lots of walks
to do some thinking." Mr. Xxxxx stated, "I wanted so much to forget everything, but it is impossible to forget the bad things."
Mr. Xxxxx reported that he tried to return to his old job as an apprentice in a
shipyard. However, he stated that his job was no longer available, and he
instead worked as a machinist. Mr. Xxxxx stated that he liked his job, and often
worked overtime. He described, "I plunged myself into it, and worked (overtime) to be a good worker, but it also had the bonus of getting my mind off (the
war)." Difficulties with sleeping and frequent nightmares were particularly distressing and affected his work. His nightmares would escalate prior to important meetings at work and made him feel "jittery."
Mr. Xxxxx reported that his symptoms of PTSD were clearly present immediately when he returned from the war. However, because he was able to distract
himself with his work, he was able to function fairly successfully. Mr. Xxxxx's
symptoms later exacerbated when he retired in 1988 and had "more time to
think." He was therefore less able to control his symptoms. Although retired,
he initially continued to do consulting until 1993. During this time, he reported
that he did a fair amount of traveling. He stated that long plane trips gave him
time to think about World War II, and his symptoms of PTSD worsened. When
Mr. Xxxxx stopped this consulting, he reported that his symptoms became even
worse. He stated that whereas previously he could distract himself from his
memories through work, he no longer was able to use this coping mechanism.
His ability to work and distract himself is still of concern.
At the outset of the assessment he stated, "I would like to be evaluated in the
VA to see if I'm capable of working physically. I feel I can, but I'm not sure if I
can do it mentally because I can't sleep or get (the war) off my mind. The
biggest thing I've lost is not working since I retired."
Mr. Xxxxx's retirement and associated increase in PTSD symptomatology have
also caused difficulty with his family relationships. Mr. Xxxxx met his current
wife in 1948 and married her in 1950. They had one son who was born in 1954.
Mr. Xxxxx described being easily frustrated and irritable with his wife and son.
He stated, "I realize I am wrong afterwards, but I can't help acting like I do."
Mr. Xxxxx reported that he also has one or two close friendships. He stated that
he never told his friends about the war and grew distant from them because he
was "afraid they would think I was an awful person." Finally, Mr. Xxxxx stated
that his symptoms of PTSD also affected him during his personal time, both
before and after his retirement. Specifically, during his personal time, he did
not have his work to distract himself and he would be very distressed by intrusive thoughts of the war.
Mr. Xxxxx denied use of alcohol more than occasionally, and never used drugs.
Mr. Xxxxx was assessed for possible presence of posttraumatic stress disorder
(PTSD) by clinical interview, psychometric testing, and mental
status examination.
Mental Status and Behavior/affect during the assessment:
Mr. Xxxxx was alert and oriented X3. He was dressed casually, and sometimes
came to sessions unshaven. Mr. Xxxxx's speech was somewhat pressured, but of
normal tone. He was very talkative, though he responded to redirection. Mr.
Xxxxx's thought process was logical and goal directed, though frequently he
would tell lengthy stories about his experiences in the war that were marked by
circumlocution. He denied ever experiencing hallucinations or delusions. Mr.
Xxxxx's stated moods were anxious and depressed, and his affect was consistent
with this report. When talking about things that made him upset or anxious,
Mr. Xxxxx would frequently shake his hands and was observed to be distressed.
Likewise, when he was discussing his past traumatic experiences, Mr. Xxxxx
would often cry. Mr. Xxxxx endorsed having passive thoughts of suicidal
ideation ("I just like to go to sleep and have it over"). He denied current
suicidal intent or plan.
The interview data are consistent with a DSM-IV diagnosis of PTSD. Mr. Xxxxx
currently meets the following PTSD diagnostic criteria:
(A) Exposure to a recognizable stressor as noted above by combat history and
traumatic events (see above).
(B) Re-experiencing of the trauma:
Mr. Xxxxx reported having daily unwanted memories of his traumatic experiences in World War II. He stated that he tries to keep busy to eliminate these
thoughts, although this is more difficult to do when he is driving or flying. He
described that the thoughts, "go with me wherever I go."
Mr. Xxxxx stated that 1-2 times per week he has nightmares related to World
War II. In particular, he reported having a recurrent nightmare during which 30
troops line up and he marches them to the front. He described, "I'm always the
only survivor, and I'm tired and frightened. All the men are the same height
and hair as my buddy who was killed. Sometimes I wake up and I can't
breathe." The dream sequence then repeats, and he goes back to march 30
more troops in clean uniforms into battle. Mr. Xxxxx stated that this sequence
can recur 15 times in a night. He stated that when he wakes from his nightmares, it takes him approximately 2 hours to fall back to sleep.
Mr. Xxxxx reported that approximately 1-2 times per month he will experience
flashbacks. He stated that they occurred more frequently when he first returned
from the war. He described, "I would re-live it. I would yell and scream for
everybody to hit the dirt." More recently, he stated that two weeks ago, he was
outside in his yard and heard noises in the bushes and believed someone was
sneaking around. He described, "I knew where I was, but for a moment there
was the fear that came back. I hear a shot and feel like I'm back as a scout and
can't see my guys because I wandered off too far."
Mr. Xxxxx stated that several times a week he will become emotionally upset
when reminded of the war. This was observed in the interview, during which
Mr. Xxxxx cried easily when discussing his memories. He stated, "I never know
what's going to trigger it." Mr. Xxxxx reported that he will also have a physiological response to reminders. He stated that his heart will race and he will feel
like he cannot breathe. At times, this escalates to the level of a panic attack.
(C) Persistent avoidance of stimuli associated with the trauma or numbing of
general responsiveness (not present before the trauma):
Mr. Xxxxx stated that he avoids having thoughts and feelings related to his
experiences in the war. He will go to great lengths to avoid thinking about the
war. For example, he stated that he will try to watch television to distract himself, although this is not always effective. He described, "When I have an avalanche of thinking, unless you chase me with a gun, nothing helps." Mr. Xxxxx
further stated that he avoids watching war movies, as well as going to cemeteries or on nearby roads, because they remind him of death. Moreover, he indicated that at times it is difficult for him to go to the VA ("something grips at
me"), although this does not stop him from attending his appointments.
Mr. Xxxxx reported that there are portions of time during his experiences that
he cannot remember. In particular, he stated that he is unable to remember the
10 days after his friend died, even with considerable effort. Alternatively, he
described, "I clearly remember my buddy dying and the few hours after-that's
the part I wish I couldn't remember."
(D) Persistent symptoms of increased arousal (not present before the trauma):
Mr. Xxxxx stated that he has nightly difficulties with sleeping. Mr. Xxxxx
described that part of his difficulty with sleeping is related to nightmares and
being fearful to go to sleep. He will also lay awake with memories. He reported
that it takes him approximately 45 minutes to an hour to fall asleep. He also
will have mid-sleep and early morning awakenings. Mr. Xxxxx currently sleeps
about 6 hours per night, though he would like to sleep for 8 hours.
Mr. Xxxxx reported difficulties with irritability, and that he will at times
become verbally abusive towards his wife and daughter. Mr. Xxxxx stated that
his symptoms of irritability increased after he retired. He described, "There was
a big difference when I retired and I found myself thinking about the war."
Mr. Xxxxx described difficulties with concentration much of the time. He stated, "My memories of the war sneak in and it affects everything that I think and
do." He reported that his difficulties with concentration also increased after he
retired and "had more time to think about the war."
Mr. Xxxxx stated that he is always on alert. He reported that he will check his
home for safety multiple times. He described, "I'm always on alert for things to
happen so I'm ready." He stated that he is particularly on alert when cars drop
off money at a bank or store, and that he has a fear that someone will shoot
him in the head while driving. Mr. Xxxxx stated that he also is startled easily
and often feels "jumpy."
Depressive Symptoms:
Mr. Xxxxx reported a number of symptoms of depression. He endorsed feelings
of depressed mood and loss of interest in doing activities that he would normally enjoy. Mr. Xxxxx reported that his energy and appetite are poor ("I don't
enjoy food like I used to"). He reported symptoms of guilt, difficulty concentrating, and difficulties sleeping. As mentioned previously, he indicated that at
times he has thoughts of wishing he were dead, though denied any current plan
to attempt suicide.
It was further evaluated whether these depressive symptoms might be part of a
Bipolar Disorder. Mr. Xxxxx denied any manic symptoms consistent with this
diagnosis. However, his medical records indicate that current and past treatment providers have felt that Mr. Xxxxx has exhibited manic/hypomanic symptoms at times. Therefore, a diagnosis of Bipolar I or II should be further evaluated longitudinally. It has been our impression that Mr. Xxxxx exhibits hypomanic-like symptoms that may actually be a manifestation of prominent anxiety,
as well as a tendency to express himself in a dramatic and emotional fashion.
Current Medications:
Mr. Xxxxx is currently taking Imipramine (25 mg/three times per day)
and Lorazepam.
Psychological Treatment History:
Mr. Xxxxx has an extended treatment history with the Brockton VA. He stated
that he was seeing Ms Y., MSW, from 1994 to 1999 for both individual therapy
and a World War II group medications simultaneously, and associated
side effects.
Psychometric Testing:
Mr. Xxxxx completed a MMPI-2. Validity scales of the MMPI suggest that the
scales should be interpreted with caution. The profile is indicative of a person
who's abilities to cope with stressors are low. It also is suggestive of a person
who is experiencing emotional pain, and has difficulty controlling emotions and
behaviors. There is a tendency to admit psychological problems, to be self-critical, and to believe that they have insufficient skills to handle problems.
The interpretive code type that conforms to the high-point scales in the profile
was 8-7. This configuration is a variation of the modal 2-8/8-2 profile of other
combat veterans with chronic PTSD who are evaluated at the Boston DVAMC.
Individuals who obtain this code type on the MMPI-2 are described as frequently worrying, irritable, nervous, agitated, and socially withdrawn. The profile is also suggestive of a person who tends to be guilty and depressed. These
individuals have a tendency to feel inferior, be self-critical, and overreact to
minor problems. Mr. Xxxxx's profile was also elevated on scales 6, 3, and 2. This
is suggestive of a person who is depressed and has a number of somatic complaints. Further, such individuals may be overly sensitive and concerned that
they have not been treated fairly in life.
Mr. Xxxxx scored a 40 on the special PTSD subscale of the MMPI. Patients
who have scored 28 and above on this scale have been diagnosed as having
PTSD in 82% of the cases examined.
Mr. Xxxxx also completed the Multidimensional Personality Questionnaire. His
profile on this measure was suggestive of a person who has few experiences of
joy and excitement, and is seldom really happy. The person likes to be alone,
and can be distant with others, often preferring to work things out on his/her
own. Such individual are nervous, feel vulnerable and sensitive, and are prone
to worrying and irritability. Guilt and distress occur at a high frequency even
with everyday life conditions. Such individual also have a tendency to react catastrophically to minor mishaps and daily hassles. They may feel mistreated or
that others wish to do him/her harm. Finally, such individuals may become
readily absorbed in vivid and compelling recollections and imaginings.
Mr. Xxxxx obtained a score of 140 on the Mississippi Scale for Combat-Related
PTSD. This score exceeds the cut-off of 107, and is consistent with a diagnosis
of PTSD.
Mr. Xxxxx's score of 44 on the Beck Depression Inventory was indicative of
severe levels of depression. His scores of 34 on the Beck Anxiety Inventory also
indicated that he has severe levels of anxiety.
during the diagnostic and social history interviews for presence and level of
symptomatology. The pattern among the psychometric findings supports a diagnosis of PTSD.
Psychophysiological Assessment:
Mr. Xxxxx was evaluated for his appropriateness to have a psychophysiological
assessment. This assessment measures the veteran's cognitive, behavioral, and
physiological response to combat scenes as compared to non-combat (control)
scenes. The assessment was not deemed necessary at this time because Mr.
Xxxxx's diagnosis of PTSD is clear.
SUMMARY AND RECOMMENDATIONS
In summary, Mr. Xxxxx functioned fairly well prior to the military. However,
related to his experiencing several life threatening events during his service, his
functioning declined following the military. Mr. Xxxxx met criteria for PTSD
immediately when he returned from World War II. His primary coping strategy
was to immerse himself in his work as a means of distracting himself from his
memories of the war. Consequently, his functioning was still in the range of fair
to good following the military. However, when Mr. Xxxxx retired, his primary
coping strategy was no longer available. He had more time to think about his
past, and his symptoms correspondingly increased. Currently, Mr. Xxxxx is quite
symptomatic and is very distressed. This, in turn, has caused discord within his
family, and has particularly affected his relationships with his son and wife.
The following recommendations are made:
1) Mr. Xxxxx has been receiving treatment from the VA for a number of years.
It is recommended that Mr. Xxxxx seek treatment there for continuity in his
care. We have reviewed their treatment plan and it appears to be the best
course of action at this time.
2) Mr. Xxxxx reported fair to good functioning for 50 years while working. It is
our recommendation that it is extremely important for him to remain active,
whether that is in a work environment, in a volunteer position, and/or being
active in clubs or other organizations.
3) Diagnostically, there is a question whether or not there is a bipolar process.
Data from this evaluation could not support that diagnosis. Though he exhibits
hypomanic-like symptoms, it was our impression that these may actually be
manifestations of significant anxiety and a tendency towards expressing himself
in an exaggerated manner. However, a trial on a mood stabilizer would be valuable to evaluate the effects of this type of medication on his mood.
DSM-IV PROFILE
Axis I
Axis IV
Axis V
309.89 PTSD
296.33 Major Depression, recurrent, moderate
R/O Bipolar Disorder I and II
Hypertension (by self report)
Global Assessment of Functioning
Current GAF: 42
Highest GAF past year: 42
CASE V: PTSD Diagnosis
REPORT OF PSYCHOLOGICAL ASSESSMENT
Xxxxx Xxxxxx is a 59 year-old, remarried, non-service connected, white male
referred by Dr. Y. of the V.A. for psychological assessment. Please refer to earlier report for additional background information. The following is a partial
evaluation of Mr. Xxxxxx's psychological status.
Patient enlisted in the Army during June of 1954. He served approximately 21
months in Germany as a tank driver. He attained the rank of corporal (Sp-3)
while in Germany. He was honorably discharged during June of 1957 as an Sp3.
The patient's unit was in Germany and Hungary as the Cold War began to
intensify. During this time period American troops in Europe were still referred
to as the Army of Occupation. Mr. Xxxxxx stated that his company was the only
heavy armored American unit in Europe at the time, and that they were on
alert for all but one of the months he was stationed there. He was a witness to
the Berlin Wall going up, and was fired upon by Russian forces during the
Hungarian Revolution. Upon return from Germany the patient was stationed at
Fort Carson Colorado where he was assigned to infantry training, a job for
which he felt completely unprepared as a tank crewman. The patient's duty in
Europe would be classified as mainly "combat ready". His report on combat
scales indicate that he had light to moderate exposure to combat. Patient
reports that none of the men in his unit were killed or wounded while he was
stationed in Europe, but that a number of people died while he was stateside,
as detailed below. Patient received severe wounds during a training accident
and spent several weeks in the hospital.
Military events which patient considered particularly traumatic included:
1) The continual tension of being on alert in Europe for 20 months.
2) Witnessing a French tank explode when a crewman dropped a cannon
shell which detonated.
3) Being fired upon by Russian and East German troops while under
orders not to return fire.
4) Accidentally driving his tank off of a pontoon bridge into the water during the winter. The tank immediately filled with freezing water and gasoline. The patient had frost-bite, and most likely would have died if not
for an officer who quickly moved him to the tank's exhaust to warm him.
5) While driving a tank upon which two squads of troops rode, the patient
drove off the road and the tank track caught a piece of concertina wire
which whipped across the tank's top wounding many of the soldiers,
including one who lost both legs. The patient takes sole responsibility for
this event, even though no disciplinary charges were brought against
Fort Carson Colorado:
6) Witnessing a training accident where a recruit dropped a grenade and it
detonated in a crowd, killing everyone present. This occurred during a
class the patient was responsible for teaching.
7) While setting up an obstacle course with TNT charges, the patient and
the company demolitions expert were blown out of a hole when the TNT
was accidentally detonated from a remote control board. The patient
had noticed that the wires they were to use for detonation were "live",
and he told this to the sergeant who felt no charge when he touched
them, and proceeded to wire the TNT. The patient observed people near
the control board and thought someone was brushing against the switch,
he turned to tell the sergeant this just as the TNT detonated. The sergeant was killed instantly and the patient awoke in the hospital.
Patient was assessed for possible presence of posttraumatic stress disorder
(PTSD) by clinical interview, and psychometric testing.
Interview: Interview data are consistent with a DSM-III-R diagnosis of PTSD.
PTSD diagnostic criteria which the patient meets include:
A) exposure to a recognizable stressor as noted above by military history
and traumatic events (see above).
B) re-experiencing of the trauma (need 1): The patient experiences intrusive and distressing recollections of military events on average twice per
week. Intensity is moderate and he reports that he can suppress memories with effort, and that he is very practiced at this. Over the course of
the evaluation intrusions have increased in frequency and intensity even
though actual discussion of the events has been limited due to the availability of a past Compensation Exam Report. Intense psychological distress at exposure to events that symbolize or resemble an aspect of the
traumatic events occurs once or twice per week, and is extremely upsetting to the patient. His inability to control his reactivity to these cues
seems to result in an intensity of reaction that is dramatically increased
from that he reports to uncued intrusions. The patient reports two
severe dissociative episodes related to being blown up with the sergeant.
These have both occurred since 1985, but none recently. Mr. Xxxxxx
reports that he will wake from a military trauma related nightmare once
or twice per week, and that on these occasions his distress is such that he
cannot return to sleep for the rest of the night.
C) persistent avoidance of stimuli associated with the trauma or numbing of
general responsiveness (not present before the trauma) (need 3): The
patient reports that he makes daily efforts to avoid thoughts or feelings
associated with his trauma. His avoidance is severe and requires considerable effort on his part. He distracts himself as much as possible, drank
heavily in the past, worked long hours prior to being disabled, and
attempts to suppress thoughts. The patient makes dramatic efforts to
avoid activities or situations that arouse recollections of the traumas.
Externally cued memories are very upsetting to him and he avoids
parades, music concerts, his Vietnam veteran neighbor, his brother who
wants to talk about the military generally, obituaries in the newspaper,
military-related movies, films containing violence generally, guns, 4th of
July celebrations, other veterans, and news programs related to the military. As an example of his avoidance the patient described attending a
coming home party for his nephew who participated in Operation Desert
Storm. When guests asked about the war the patient felt unable to
remain in the house and he left with no explanation. He has not spoken
to his sister since that time, and she does not know why he left the party.
Since leaving the military, the patient shows markedly diminished interest in significant activities, including hunting, music concerts, social
events generally, fishing and camping. The patient reports feelings of
detachment or estrangement from others since the early 1970's when he
stopped drinking alcohol. Feelings of detachment and estrangement are
severe and almost constant. The patient feels he will not be trusted by
others generally, and feels unable to talk to his mother, his siblings, and
sometimes not even his wife. Mr. Xxxxxx expressed marked emotional
numbing which has been his usual state for many years. Often he feels
unable to love anyone. The patient describes a strong sense of foreshortened future. He stated he felt this way all the time, and that he could die
"any day now". He made clear that he was not speaking of suicidal
thoughts, but that his future will be cut short at some point. The patient
stated that he has felt this way since the mid 1970s.
D) persistent symptoms of increased arousal (not present before the trauma) (need 2): The patient describes nightly problems with sleep onset,
mid, and early awakenings. His sleep loss is profound, and he frequently
fears falling asleep. Mr. Xxxxxx states that this has been the case since
his discharge from the Army. The patient reports chronic irritability and
outbursts of anger on a daily basis. His anger is severe, including verbal
or physical aggression. He states that when angered he is prepared for a
physical confrontation and has no regard for his own physical safety, in
spite of the fact that he has severe physical limitations. The patient
reports daily concentration difficulties dating to the 1970s when he
would occasionally drive his truck to the wrong stop on his route necessitating unloading his tractor trailer from front to back, the reverse of
what one would usually do. He also remarked when asked this question
that he had that day driven to the wrong part of town on his way to the
hospital, and could not remember where he was supposed to be going.
The patient displays severe symptoms of hypervigilence and feels this way all of
the time. He keeps a knife by his bedside, and states he has "ever since the
service" (37 years). He describes himself as "paranoid" stating he trusts no one,
will not ever live on the first floor of any building due to easy access through
windows, can't stand to have anyone behind him while walking on the street, or
in an elevator; will avoid large crowds because he cannot observe everyone. In
restaurants he sits with his back to a wall and "watches everyone like a hawk",
and if he cannot get a "safe" seat he will leave the restaurant. He states that he
and his wife no longer go to the movie theater together because he insists upon
sitting in the last row in the back, which she does not like. Several times per
week the patient will hear a noise in his apartment during the night and he will
search each room while carrying the knife from his bedside. Mr. Xxxxxx reports
a severe startle response once or twice per month including sustained arousal
following the initial reaction. Physiologic reactivity upon exposure to trauma
related cues occurs once or twice per week and consist of tachycardia, sweating,
difficulty catching his breath, and visible trembling.
Mental status:
The patient is a 57 year-old man who appears his stated age. He was casually
and neatly dressed and walked with the aid of a cane. His mood and affect were
congruent, anxious and dysphoric. There was no evidence of a thought disorder.
When discussing traumatic events he expressed a great deal of sadness, guilt,
and shame. There was no evidence of suicidal or homicidal thoughts. Although
abstraction abilities were not formally tested the patient's thought processes
were concrete and goal directed. Memory and concentration problems were not
evident within session, but there was some noticeable forgetfulness between
sessions. The patient stated that he suffered a head and back injury in 1985, and
that he has been unemployed since that time. He reports that neuropsychological testing revealed some deficits, including reading difficulties (grade level 3 to
4) and poor concentration. The present writer has not reviewed these records.
Given the patient's reading problems only relatively brief psychometric instruments with a direct bearing upon a PTSD diagnosis were administered to him
by reading the items and response choices.
Patient scored a 36 on the special PTSD subscale of the MMPI. Vietnam combat veteran patients who have scored 30 and above on this scale have been
diagnosed as having PTSD in 82% of the cases examined.
Patient scored 149 on the Mississippi Scale for Combat-Related PTSD. This
score exceeds the 107 cutoff used with Vietnam combat veterans, and is consistent with a diagnosis of PTSD.
Patient presents with symptoms consistent with a diagnosis of PTSD (DSM-IV
Axis I 309.89 Posttraumatic stress disorder). Additionally, he reports some
symptoms of depression, and a history of alcohol abuse which clearly was an
attempt to self-medicate symptoms of PTSD.
CASE VI: PTSD Diagnosis
The patient reports that within six months of being discharged from the Army,
he started to feel depressed, and could not remember a time from the time that
he was discharged until present where he actually felt joy in his life. It was
within one year of his military injury that he began to experience significant
nightmares three to four times per week, of people in uniform chasing him with
guns and his not being able to run away or escape them. The nightmares
became so intense that he would wake up in the middle of the night with his
hands around his wife's throat or thrash in the bed and hit her or kick her while
asleep. When he awoke the next morning, he had no recollection of this.
Subsequently, his wife divorced him, though he has had other female bed partners who have been the recipient of similar such violence while he is asleep.
These nightmares persist to the present time.
He also experienced recurrent and intrusive distressing recollections of the
event including images and perceptions, 20-30 times per week, which he rated
as "severe" in interfering with functioning. He would frequently become overwhelmed while in crowds, fearing eminent danger. The patient reports, "I don't
like crowds. I don't think that anyone in particular is trying to harm me, but it
feels that people are following me and trying to do something to me. I just have
to run and escape those situations." Currently, he avoids all crowds, and ultimately all situations that make him feel suspicious and paranoid. He also
reports excessive startle when people come up behind him, and when he is
awakened by surprise.
Beginning about thirty years ago, the patient has experienced dissociative periods, about 1-2 per month, when he did not know where he was. The last period
occurred about one month prior to his last admission. During these times, he
could be walking on the street or driving in his care and the next thing that he
would remember would be 15-20 minutes later, when he may be sitting on the
ground, may be at home, or may be in a strange place. He does not know what
has happened during this time lapse.
The patient feels chronically anxious and has felt so the majority of his adult
life, with an impending sense of doom, especially when he leaves familiar envi-
ronment. He also has an inability to recall many aspects of being shot, and has
feelings of detachment and estrangement from others. He has had throughout
his adult life, a foreshortened sense of future, that he would die at a much
younger age.
CASE VII: PTSD Diagnosis
Veteran's positive symptoms of PTSD since Vietnam include:
1. Persistently re-experiencing the traumatic event in:
• Intrusive thoughts: "especially on rainy cloudy days and when I'm walking at night."
• Nightmares of Vietnam: "roommates rigged up an alarm system that
keeps me from leaving the room, because I was sleep walking when I
first got here."
• Recent flashbacks
• Intense psychological distress with symbolic events
2. Persistent avoidance of associated stimuli, including:
• Trying to avoid thoughts or feelings associated with the trauma. While he
is a Domiciliary Resident, he finds that "it's hard to avoid activities or
situations that arouse recollections of the trauma." For instance, he
"sees guys walking around with fatigues, etc."
• Psychogenic amnesia
• Diminished interest in significant activities
• Restricted range of affect: "unable to have loving feelings," "don't trust
easily," tends to wonder, "why are you being so nice to me, what do you
want to do? I try not to but I can't help it."
• Avoidance about thought of the future: "afraid to look into the future, I
don't even go there."
3. Persistent symptoms of increased arousal manifested in:
• A sleep disorder: "difficulty falling and staying asleep." "When night
comes, I automatically wake up."
• Distractibility: "things easily distract me."
• Irritability or outbursts of anger.
• Impaired concentration
• Physiologic reactivity upon exposure to events that symbolize the
trauma: "heart races."
• The veteran also experiences depressive symptoms and "survivor guilt."
CASE VIII: PTSD Diagnosis
The veteran reported that he is moderately to severely depressed. He denied
suicidal/homicidal ideation. He said he becomes extremely angry and frustrated
at times. The veteran reported that he has distressing dreams and nightmares
now about once a week that he remembers, although he wakes up more frequently in the night in cold sweats though unaware of a nightmare. He reported
that he has recurrent intrusive recollections of his experiences in Vietnam, not
only of the rocket attacks but also of other things that happened, and he said
that he feels guilty that he came back when so many of his friends didn't given
that his life is so unproductive. The veteran reported psychological distress
and reactivity on exposure to cues, events, and reminders of his experiences in
Vietnam. He also reported efforts to avoid thoughts, feelings, activities, and
conversations that arouse recollections of his experiences. He keeps to himself,
doesn't like to be around people, stays away from anything on television that
might arouse memories. He has become particularly isolative. He describes a
recent event in which he went to a Christmas tree lighting ceremony where
there were fireworks. This caused feelings of distress, fear, tension, and anxiety
and he had to leave the event. He described edginess and hypervigilance, and
an exaggerated startle response. He gave various examples of this, including
recently being in a friend's body shop when somebody dropped a metal bar. He
said the noise scared him to the point that "he was going to have a heart
attack." The veteran also reported a loss of interest, feelings of detachment,
and not feeling close to anyone, restricted affect, a sense of fore-shortened
future, sleep disturbances described earlier, irritability, and
Results of psychological testing revealed a score on the Mississippi Scale which
fell in the high and significant range. It should be noted that this is exactly the
same score that he reported when he was evaluated two years ago. His CES was
in the moderate range and a few points lower than it was previously reported in
his interview of two years ago. The validity scales on the MMPI-II are moderately elevated but still considered to be interpretable for the purposes of this
interview. It is particularly noted that these scores on the validity scales are not
as elevated as is often seen in veterans being evaluated for compensation for
PTSD. The PK Scale on the MMPI-II is in the significant range. The clinical
scales are suggestive of the presence of difficulty concentrating, depression,
apathy, feeling isolated and distant from others, sleep disturbances, and interpersonal isolation and withdrawal. Thinking may be confused and there may be
feelings of guilt and a sense of personal inadequacy.
In summary, The veteran was interviewed and evaluated to rule in / rule out
PTSD associated with a specific stressor event. The veteran did report this as
his primary stressor event. He also presented with symptoms of PTSD which he
directly related to that event. The veteran does have a history of drug use and
dependence but this does not negate the presence of PTSD. Also many of the
symptoms of PTSD overlap with depression and the clinical notes throughout
his C-file indicate the presence of depression. These are entirely consistent with
each other. While his last C & P evaluation did not attribute these symptoms to
PTSD, based on this interview, the review of the records as noted in this report,
and the consistency of reports noted throughout the records from at least 19xxpresent, and his very early complaint of "nerve problems" in 19xx, it is considered most likely that the veteran is suffering from PTSD and an associated
major depression and that this is long-term and chronic.
CASE IX: NO PTSD Diagnosis
Secondary to his exposure to the traumas cited above, the veteran reports occasional distressing recollections, especially when he is exposed to war-related
movies and the current Bosnian crisis. He reports waking up in a cold sweat
occasionally and yelling "watch out," according to his wife. He denies memory
of his dreams. He reported no incidents of flashbacks. He was quite tearful in
discussing the possibilities that he shot an enemy officer during the last stay in
the field.
In terms of persistent avoidance and numbing symptoms, the veteran described
not wanting to converse about Vietnam, not being able to watch war movies,
and an inability to continue hunting activities.
In terms of persistent symptoms of arousal, the veteran described his sleep as
"pretty good, " although he stated that he wakes up 2-3 nights a week in a "cold
sweat." He described no problems with his temper control, and no difficulty
concentrating. He described no hyper-vigilant symptoms, but did describe an
exaggerated startle response, onset since his return from Vietnam.
The veteran's responses to psychometric testing appear to be valid. Such individuals are usually described as relatively free of stress, yet willing to admit to
minor faults and problems. Such individuals are frequently focused most strongly on the wide variety of physical ailments from which they suffer. It is frequently found that such individuals exhibit somatic problems in response to stress. In
terms of emotional distress, such individuals are usually described as very tense
and anxious, as well as depressed and alienated from others, and have relatively
poor interpersonal relationships as a result. Although the focus of somatic complaints is consistent with the veteran's presentation, the finding of poor relationships, depression, and unhappiness is inconsistent with his demeanor during
the interview as well as his verbal report. The veteran's completion of the CES
yielded a sore suggestive of moderate to heavy combat exposure, which is not
consistent with his reported duties in the military. His completion of the
Mississippi scale yielded a score below the cutoff suggestive of possible PTSD.
His completion of the Keane PTSD Scale also did not reach the level suggestive
of possible PTSD. These results are not consistent with the diagnosis of combat-related PTSD.
C-file, background, behavioral observations, and test results are not suggestive
of a diagnosis of PTSD. The veteran did not report symptoms of a severity suggestive of this disorder, nor did test results suggest possible PTSD. He did not
report clear recurrent and intrusive recollections of the traumatic event. He
reported dreams that were sufficiently distressing to awaken him, but he has no
memory of these dreams. Given his recent [traumatic events], it is conceivable
that his dreams are related to these experiences as well as perhaps Vietnam.
Finally, the veteran's current distress appears to be largely an attempt to adjust
to his status as unemployed/retired, since 1998, to which he has responded with
symptoms of anxiety, not reaching the level of intensity, frequency, or duration
indicative of a clinical disorder.
Appendix H: Social History Questionnaire *
I. Identifying Information:
Name: __________________________________ Date: _____________________
Address:_________________________________ DOB: ____________________
SS#: ____________________________________
Race: ___________________________________
Who are you currently living with?______________
For how long?________________
What is your relationship? ❏ parent ❏ child ❏ spouse ❏ friend ❏ relative
Who were you raised by? Biological / adoptive / foster / step parents
/other_____
Until what age? ____,
Age at enlistment / draft /commission into the military____________
How would you describe your caretakers (type of work, personality):
(mother, father, other) ________________________________________________
Check any that you feel you experienced during childhood:
❏ Physical abuse / Assault
❏ Sexual abuse / Assault / Molestation
❏ Emotional abuse
❏ Neglect
❏ Witness of Domestic Abuse
❏ Severe stressor
❏ Unwanted sexual advance
❏ Motor Vehicle Accident
❏ Death of family member or close friend
❏ Natural Disaster
❏ Community violence
How many siblings do you have (indicate if step, adoptive)_________________
What are their names and current ages __________________________________
Appendix H: Social History Questionnaire
What type of relationship / contact do you currently have with your parents______________________________________________________________
What type of relationship/ contact do you currently have with your
siblings______________________________________________________________
Prior to entering the service, how many years of schooling did you complete?________
Did you earn a high school diploma? ____________________________________
Years of College_______________Degrees? _______________________________
How would you describe yourself during the time prior to entry into the
military_ ____________________________________________________________
How would you describe your pre-military adjustment:
❏ very good ❏ good ❏ average ❏ marginal ❏ poor.
*This Social History Questionnaire may be included in re-exams, for the purpose of expediting completion of the social and industrial survey.
How would you describe:
School / grades: ❏ very good
❏ good
❏ average
❏ marginal
❏ poor.
Discipline (suspensions from school, police intervention, etc) _______________
General behavior / attitude_____________________________________________
Sports_______________________________________________________________
Social (friends, dating, hobbies) ________________________________________
Did you have any history of trouble as a youth? ___________________________
If so, please describe __________________________________________________
Substance usage prior to military _______________________________________
Any associated problems: ______________________________________________
Pre-military health-related problems (history of hospitalization, significant illness, injury, including head injury) ______________________________________
What were pre-military stressors:________________________________________
at what ages ______,
Did stressors result in academic problems, hospital, jail, mental symptoms,
treatment, etc) _______________________________________________________
Medications taken regularly prior to military: _____________________________
Psychiatric history prior to military:______________________________________
Family history of psychiatric problems: __________________________________
Military branch of service:
❏ Army ❏ Air Force ❏ Navy ❏ Marines ❏ Coast Guard o National Guard
Dates of Service: from _______ to _______.
Duty Stations and dates: _______________________________________________
Primary duty _________________________________________________________
Other duties _________________________________________________________
Combat tours _________________________ Combat unit______________
Location ____________________________________________________________
Dates _________to _________.
Rank attained while in combat__________________________.
Type of discharge:
❏ honorable ❏ dishonorable ❏ general ❏ other than honorable
Medals awarded ______________________________________________________
Post-Military History
Education history following active duty___________________________________
Certificate(s) / degree(s) achieved. ______________________________________
Number of jobs held since active duty____________________________________
Type of jobs__________________________________________________________
Longest time employed at one job: ______________________________________
Any problems in jobs (conflict, resulting in firing, etc.) _____________________
Are you currently: ❏ unemployed ❏ employed.
Current occupation ___________________________________________________
Post-military stressors and significant losses: (i.e., academic / occupational /
financial / health / marital problems, separation/divorce, hospital, jail, emotional/mental symptoms, hospitalization, treatment, etc.) _______________________
Do you have any legal incidents (i.e., reckless driving, DWI, theft, assault, etc.)
Dates for each: _______________________________________________________
What were the results: (i.e., incarceration, payroll, etc.) ____________________
Please describe your use of alcohol and drug (s) since military duty: __________
Age of onset:_______,
Types of substances: ___________________________________________________
Last usage:____________,
Related psychosocial problems (marital, occupational): _____________________
Withdrawal problems: _________________________________________________
Related health problems: ______________________________________________
Diagnoses received related to substance use: ______________________________
Treatment related to substance use: _____________________________________
Significant illnesses and injuries: _______________________________________
Hospitalizations:______________________________________________________
Current medications: __________________________________________________
Current disability rating : ______________________________________________
Current subjective mental/emotional complaints: __________________________
Current psychiatric treatment: __________________________________________
Number of inpatient hospitalizations for mental /emotional /substance use complaints: ______________________________________________________________
The extent of time lost from work over the past 12 month period_____________
Do you feel that time lost from work is due to your mental / emotional complaints? _____________________________________________________________
Marital/Relationship History:
Current Marital Status: ❏ Married ❏ Divorced ❏ Separated
Previous marriages: (onset and length of time for each, reason for divorce): ___
Children's ages _______________________________________________________
How would you describe your current significant relationship with partner: ____
How would you describe your current relationship with children:_____________
What is your current attitude towards social interactions in general: __________
How do you feel others in your life view you: _____________________________
___________________________________________________________________.
Social support & hobbies: _____________________________________________.
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