Best Practice Manual for Posttraumatic Stress …

1 Department of Veterans AffairsBest Practice Manual for Posttraumatic Stress Disorder (PTSD)Compensation and Pension ExaminationsPrepared by:Patricia Watson, Center for PTSDM iles McFall, Network Mental Illness Research, Education, and Clinical CenterVA Puget Sound Health Care SystemCaroll McBrine, and Pension ServiceVeterans Benefits AdministrationPaula P. Schnurr, J. Friedman, , Keane, L. Hamblen, Center for PTSDPost-Traumatic Stress DisorderiiCONTENTSE xecutive Summary.. 1 CORE DOCUMENTI. Background Information: PTSD Initial Claims Review .. 5II. Background Information: Assessment of PTSD.. 7 III. Recommended Guidelines for Assessing Trauma Exposure and PTSD .. 13IV. Compensation and Pension PTSD disability examination worksheets .. 23A. Worksheet I: Initial Evaluation for PTSD.

2 23B. Worksheet II: Review Evaluation for PTSD .. 31V. Suggested Report Template for Initial Exam .. 37VI. Suggested Report Template for Follow-up Exam .. 47 APPENDICESA. Training Letter Based on PTSD Case Review .. 55B. Governing Regulation for Service Connection for PTSD (From 38 CFR Part 3) .. 65C. Excerpts from Veterans Benefit Administration s AdjudicationProcedures Manual concerning the adjudication of claims for PTSD.. 67D. Detailed Guideline for Global Assessment of Functioning Scale .. 73E. Global Assessment of Functioning Scale .. 79F. Scoring rules for Mississippi and PTSD checklist .. 81G. Examples of PTSD Symptom Narratives in Compensationand Pension Examination Reports .. 83H. Social History Questionnaire .. 109I. References .. 115 Compensation and Pension ExaminationsiiiTable of ContentsPost-Traumatic Stress DisorderivExecutive SummaryThis document provides information on Posttraumatic Stress Disorder and cur-rent recommendations regarding what is known about best Practice proce-dures for assessing PTSD among veteran populations.

3 A Veterans BenefitsAdministration (VBA) review of 143 initial claims for PTSD revealed thatPTSD was diagnosed in 77% of the cases, that the exam was not adequate forrating in at least 8%, but that inadequate exams were not routinely returned forcorrection. A common problem was that the examiner did not describe howDiagnostic and Statistical Manual for Mental Disorders-IV (DSM-IV) diagnos-tic criteria were met. Good exams delineated how the PTSD diagnostic criteriawere met by giving specific examples. Other noted problems were the examinerusing DSM-III rather than DSM-IV criteria, and the examiner sometimes fail-ing to discuss whether other mental disorders that were diagnosed are due to orpart of PTSD. The VBA and Veterans Health Administration (VHA) are com-mitted to improving these services to veterans, and improving the quality ofcompensation and pension examinations for in this Manual are an assessment protocol based on best practices forassessing PTSD, and disability examination worksheets which correlate withthe protocol.

4 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) LifeEvent Checklist 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 PTSDb. Determining the severity of PTSD symptomsc. Establishing a logical relationship between exposure to militarystressors and current PTSD symptomatologyd. Describing how PTSD symptoms impair social and occupationalCompensation and Pension Examinations1 Executive Summaryfunctioning and quality of life.

5 DSM-IV Diagnostic Criteria for PTSD Diagnostic interview assessment of PTSD. Psychometric assessment of PTSDIII. Recommended Time Allotment for Completing Examination Initial PTSD compensation and pension evaluations typically requireabout 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 PensionExaminations for PTSDThe VHA encourages use of this protocol when examining veterans for com-pensation purposes to ensure that a detailed history is obtained from the veter-an and a comprehensive evaluation is performed and documented. Comprehensive report templates have also been included as guides when writ-ing 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 Connectionfor PTSD Excerpts from VBA s Adjudication Procedures Manual concerning theadjudication of claims for PTSD Background research on PTSD and the Global Assessment ofFunctioning (GAF) The GAF Scale Scoring rules for Mississippi and PTSD checklist Examples of trauma history and PTSD symptom narratives A social history is anticipated that this document will raise the quality and standards ofPTSD Compensation and Pension (C&P) examinations.

6 This increased qualitywill require increased time and expense allotted to the evaluation current VA standards, with local and regional variations in time mandat-ed for exams, clinical expertise, and resources, the examiners must use their dis-cretion in selecting the most relevant information for completing a competent,comprehensive examination for PTSD. The examination protocol can be accessed electronically through VA s VeteransHealth Information Systems and Technology Architecture (VISTA) computersystem formerly the Decentralized Hospital Computer System (DHCP).Post-Traumatic Stress Disorder2 Executive SummaryClinicians may receive assistance in accessing this protocol from C&P clerks,Information Resources Management (IRM) staff, chiefs of HealthAdministration Services (HAS), or other staff members, depending on the facil-ity s local and Pension Examinations3 Executive SummaryPost-Traumatic Stress Information: PTSD Initial Claims ReviewA review of 143 initial claims for PTSD under a special protocol was conductedduring the week of June 19, 2000, by three field reviewers and one member ofthe Star Review Staff under the supervision of Dr.

7 Caroll McBrine. The statis-tics reported are based on the 143 files formally reviewed, but an additional 77cases were informally reviewed. The review was not statistically valid but wassufficient 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 werereturned. The examiner reconciled multiple psychiatric diagnoses in all but 3 or35% (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 in68% (51/75). A common problem (in at least 5 exams) was that the examiner did notdescribe how DSM-IV diagnostic criteria were met.

8 All exams wereaccepted by regional office (RO), but should have been returned. Goodexams delineated how the PTSD diagnostic criteria were met by givingspecific examples. The examiner clearly used DSM-III rather than DSM-IV criteria inmany cases. The examiner sometimes failed to discuss whether other mental disor-ders that were diagnosed are due to or part of and Pension Examinations5I. Background Information: PTSD Initial Claims ReviewPost-Traumatic Stress Disorder6II. Background Information:Assessment of Posttraumatic Stress DisorderPTSD is a prevalent mental disorder among veterans exposed to traumaticstress during military service. The VA s commitment to providing thorough andaccurate assessment and care of veterans raises a need for a more standardizedapproach to assessment and documentation of PTSD and resulting impairmentin psychosocial functioning.

9 This background information reports on the cur-rent standards for PTSD assessment. Further information on the research asso-ciated with PTSD is included in Appendix of PTSDPTSD is assessed by a variety of methods, including questionnaires, interviews,and biological tests. Chapter 2 gives a summary of the recommended instru-ments and format for PTSD assessment. Under optimal circumstances, assess-ment of PTSD and associated disorders is based on multiple sources of infor-mation, derived from clinical interview, psychometric testing, review of militaryand medical records, reports from collaterals who know the veteran, and studiesof psychophysiological reactivity. A multi-method approach is especially helpfulto address concerns about either denying or overreporting clinicians find the addition of the Minnesota Multiphasic PersonalityInventory (MMPI) and Minnesota Multiphasic Personality Inventory-2 (MMPI-2 helpful, particularly in very complex or difficult cases.)

10 The MMPI and MMPI-2 include scales that assess overreporting; they have what are known as validityscales that are elevated in people who are trying to exaggerate their has been evidence to suggest that compensation-seeking veteransendorse higher levels of psychopathology across measures and produce elevatedvalidity indices on the MMPI and MMPI-2 as compared to non-compensation-seeking veterans (Smith & Frueh, 1996; Frueh & Kinder, 1994). Sample sizes inthese studies, however, are small, and clinicians were not correlating scores onthe MMPI with collateral sources of data suggestive of overreporting. Even innon-compensation-seeking settings, the preponderance of evidence suggeststhat people with PTSD report significantly higher subjective distress than thosewithout PTSD. Several studies suggest that Vietnam combat veterans and childabuse survivors may have elevated scores as a result of chronic post traumaticdifficulties or comorbid affective symptoms, as opposed to motivated symptomoverendorsement (Elliott, 1993; Jordan, Nunley, & Cook, 1992; Smith & Frueh,1996).