127 lines
6.6 KiB
Mathematica
127 lines
6.6 KiB
Mathematica
DVBCWPE5 ;BP-CIOFO/MM - REVIEW PTSD WORKSHEET TEXT ;3/27/2002
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;;2.7;AMIE;**43**;Apr 10, 1995
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TXT ;
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;;E. Assessment of PTSD
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;;
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;; 1. state whether or not the veteran meets the DSM-IV stressor criterion
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;; 2. identify behavioral, cognitive, social, affective, or somatic symptoms
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;; veteran attributes to PTSD
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;; 3. describe specific PTSD symptoms present (symptoms of trauma
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;; re-experiencing, avoidance/numbing, heightened physiological arousal,
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;; and associated features [e.g., disillusionment and demoralization])
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;; 4. specify typical frequency, and severity of symptoms
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;;TOF
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;;F. Psychometric Testing Results
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;;
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;; 1. provide psychological testing if deemed necessary.
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;; 2. provide specific evaluation information required by the rating board or
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;; on a BVA Remand.
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;; 3. comment on validity of psychological test results
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;; 4. provide scores for PTSD psychometric assessments administered
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;; 5. state whether PTSD psychometric measures are consistent or inconsistent
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;; with a diagnosis of PTSD, based on normative data and established
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;; "cutting scores" (cutting scores that are consistent with or supportive
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;; of a PTSD diagnosis are as follows: PCL - not less than 50;
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;; Mississippi Scale - not less than 107; MMPI PTSD subscale a score
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;; greater than 28; MMPI code type: 2-8 or 2-7-8)
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;; 6. state degree of severity of PTSD symptoms based on psychometric data
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;; (mild, moderate, or severe)
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;; 7. describe findings from psychological tests measuring other than
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;; PTSD (MMPI, etc.)
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;;
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;;G. Diagnosis:
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;;
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;; 1. The Diagnosis must conform to DSM-IV and be supported by the findings
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;; on the examination report.
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;; 2. If there are multiple mental disorders, delineate to the extent possible
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;; the symptoms associated with each and a discussion of relationship.
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;; 3. Evaluation is based on the effects of the signs and symptoms on
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;; occupational and social functioning.
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;;
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;;NOTE: VA is prohibited by statute, 38 U.S.C. 1110, from paying compensation
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;;for a disability that is a result of the veteran's own ALCOHOL OR DRUG ABUSE.
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;;However, when a veteran's alcohol or drug abuse disability is secondary to
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;;or is caused or aggravated by a primary service-connected disorder, the
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;;veteran may be entitled to compensation. See Allen v. Principi, 237 F.3d
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;;1368, 1381 (Fed. Cir. 2001). Therefore, it is important to determine the
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;;relationship, if any, between a service-connected disorder and a disability
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;;resulting from the veteran's alcohol or drug abuse. Unless alcohol or drug
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;;abuse is secondary to or is caused or aggravated by another mental disorder,
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;;you should separate, to the extent possible, the effects of the alcohol or
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;;drug abuse from the effects of the other mental disorder(s). If it is not
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;;possible to separate the effects in such cases, please explain why.
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;;
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;;H. Diagnostic Status
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;;
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;; Axis I disorders
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;; Axis II disorders
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;; Axis III disorders
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;; Axis IV (psychosocial and environmental problems)
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;; Axis V (GAF score - current)
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;;
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;;TOF
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;;I. Global Assessment of Functioning (GAF):
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;;
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;; NOTE: The complete multi-axial format as specified by DSM-IV may be required
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;; by BVA REMAND or specifically requested by the rating specialist. If so,
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;; include the GAF score and note whether it refers to current functioning.
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;; A BVA REMAND may also request, in addition to an overall GAF score,
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;; that a separate GAF score be provided for each mental disorder present when
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;; there are multiple Axis I or Axis II diagnoses and not all are service-
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;; connected. If separate GAF scores can be given, an explanation and
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;; discussion of the rationale is needed. If it is not possible, an explanation
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;; as to why not is needed. (See the above note pertaining to alcohol or drug
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;; abuse.)
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;;
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;;J. Competency:
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;;
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;; Competency, for benefits purposes, has a special meaning,
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;; and refers ONLY to veterans' ability to manage benefit payments in their own
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;; best interests without restriction, and not to any other subject. State
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;; whether the veteran is capable of managing his/her or her benefit payments
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;; in the individual's own best interests (a physical disability which prevents
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;; the veteran from attending to financial matters in person is not a proper
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;; basis for a finding of incompetency unless the veteran is, by reason of that
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;; disability, incapable of directing someone else in handling the individual's
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;; financial affairs).
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;;
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;;K. Other Opinion:
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;;
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;; Furnish any other specific opinion requested by the rating
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;; board or BVA remand (i.e., furnish the complete rationale and citation of
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;; medical texts or treatise supporting opinion, if medical literature review
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;; was undertaken). If the requested opinion is medically not ascertainable
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;; on exam or testing please state WHY. If the requested opinion can not be
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;; expressed without resorting to speculation or making improbable assumptions
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;; say so, and explain why. If the opinion asks "... is it at least as likely
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;; as not..", fully explain the clinical findings and rationale for the opinion.
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;;
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;;L. Integrated Summary and Conclusions
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;;
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;; 1. Describe changes in PSYCHOSOCIAL FUNCTIONAL STATUS and QUALITY of LIFE
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;; since the last exam (performance in employment or schooling, routine
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;; responsibilities of self care, family role functioning, physical health,
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;; social/interpersonal relationships, recreation/leisure pursuits)
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;; 2. Describe linkage between PTSD symptoms and aforementioned changes in
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;; impairment in functional status and quality of life.
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;; Particularly in cases where a veteran is unemployed, specific details
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;; about the effects of PTSD and its symptoms on employment are especially
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;; important.
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;;TOF
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;; 3. If possible, describe extent to which disorders other than PTSD
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;; (e.g., substance use disorders) are independently responsible for
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;; impairment in psychosocial adjustment and quality of life. If this is not
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;; possible, explain why (e.g., substance use had onset after PTSD
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;; and clearly is a means of coping with PTSD symptoms).
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;; 4. If possible, state prognosis for improvement of psychiatric condition
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;; and impairments in functional status.
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;; 5. Comment on whether veteran should be rated as competent for VA purposes
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;; in terms of being capable of managing his/her benefit payments in his/her
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;; own best interest.
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;;
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;;
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;;Signature: Date:
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;;END
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