ts: si Velorane Affairs Memorandum JUN 26 Deputy Under Secretary of Health for Operations and Management (10N) VHA Guidance for Mental Health Compensation & Pension (C&P) Examinations VISN Directors, VAMC Directors 1, The C&P program is one of VA's most important missions, especially in the eyes of disabled veterans and their families. A thorough, complete C&P examination is a critical component to the fair, timely award of compensation or pension to deserving veterans. | ask that each C&P examiner continue to exercise their usual, good judgment in conducting a thorough and complete examination. 2, As @ reminder, complex conditions such as Post Traumatic Stress Disorder (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 examinations of other disorders. 3. Quality indicators for the Initial PTSD exam include documentation of the following: frequency, severity and duration of the symptoms, specific stressors during service and the link to current condition, post-military stressors and desoription of the psychosocial consequences, presence of problematic alcohol or substance abuse, effects on employment functioning, impairment of thought process or communication, the diagnosis is consistent with DSM-IV and supported by the exam findings, description of multiple mental disorders and symptoms, and the veterans ability o manage VA benefits. 4. A thorough examination adheres to these quality indicators. These indicators can be accessed and reviewed at hetp://vaww.cpep.va.qov/pi/qualitystandards.aspx Please be sure you have allocated enough time to these examinations to ensure each veteran gets the thorough, thoughtful examination he or she deserves. 8. For any questions please contact the DoD Coordination Office at (202) 461-6082. ‘tla t William F. Feeley, MSW, FAGHE varoaue MAREE 2105National Center for PTSD CLINICIAN-ADMINISTERED PTSD SCALE FOR DSM-IV Name: ID#: Date: ~ Interviewer: Study: Dudley D. Blake, Frank W. Weathers, Linda M. Nagy, Danny G. Kaloupek, Dennis 8. Charney, & Terence M. Keane National Center for Posttraumatic Stress Disorder Behavioral Science Division -- Boston VA Medical Center Neurosciences Division -- West Haven VA Medical Center Revised July 1998CAPS Page 2 Criterion A, “The person has Been exposed to a Waumatic event In whi (1) the person experienced, witnessed, or was confronted with threatened death or serious injury oF throat fo the physical intority of set or others (2) tho person's response involved intense fear, 88, oF horror... Note: In ehildren, this may be | expressed instead by dosiganlzed oy agtatea wenavior both of the following were present: fit or events that Involved actual or: Frm 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 forced to have sex when you didn't want to, Fl start by asking you to look over alist of experiences like this and check any that apply to you. Then, if any of them do apply to you, Ill ask you to briofly describe what happened and how you felt at the time. ‘Some of these experiences may be hard to remember or may bring back uncomfortable memorles or feelings. People ofton 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 iecoming upset, let me know and we can slow down and talk about i. Also, if you have any questions or you don't understand something, please let me know. Do you have any questions before we start? ADMINISTER CHECKLIST, THEN REVIEW AND INQUIRE UP TO THREE EVENTS, IF MORE THAN THREE EVENTS. ENDORSED, DETERMINE WHICH THREE EVENTS TO INQUIRE (E.,, FIRST, WORST, AND MOST RECENT EVENTS; THREE WORST EVENTS; TRAUMA OF INTEREST PLUS TWO OTHER WORST EVENTS, ETC.) IF NO EVENTS ENDORSED ON CHECKLIST: (Has there ever been a time when your fife was In danger or you were ‘seriously injured or harmed?) IF.NO: (What about a time when you were threatened with death or serfous injury, even if you werentt actually injured or harmed?) IF NO: (What about witnessing something ike this happen fo someone olse or finding out that it happened 10 ‘someone close fo you?) IF NO: (What would you say are some of the most stress experienaes you havo had over your ite?) EVENT #1 What happened? (low old ware you? Who oles | Describe [ag., event type, vielim, perpetrator, aG6, was involved? How many times did this happen? | frequency): Life throat?” Serious injury?) RePinccaierea gr tte |Svcehnio? wo ves tat Sohal ragenach et ns 6 event -| Threat io physical integrity? NO YES |self__other__] an Intense fearhhelo/horror? NO YES [during after__] other Criterion A mot? NO PROBABLE YESEVENT #2 CAPS Pege3 What happened? (Wow od ware you? Who alse was involved? How many times did this happen? Ue thesat? Serious injury?) How did you respond emotionally? (Were you ory anxious or fightened? Horriled? Helpless? How sa? Were you stunned or In shock so that ‘you didi’ fee! anything at al? What was that inka? What aid other people notice about your ‘emotional response? ‘What about after tha avent - how did you respond emotionally?) Describe (e.g, event We, Wel, perpetrator, age, frequency) Life threat? NO YES [self other _} ‘Serious injury? NO YES [eolf__. othor__] Threst to physical integrty? NO YES {self other _} Af Intense fearthelpihoror? NO YES [during attor__] Criterion A met? NO PROBABLE YES EVENT #3 ‘What happened? (How od were you? Who alse was Involved? How many times did this happen? Life threat? Serious Injury?) How did you respond emotionally? (Ware you vary anxious or fightonod? Hornifed? Helpless? How so? Were you stunned ar in shock so thot ‘you didn feel anything at ail? What vras that ‘ike? “What aid other people notice about your emotional response? What about after the event ~ “how did you respond emotionally?) Describe (e.g, avant type, vil, perpetrator, age, frequency): Att fe treat? NO YES [self other__} Serious inlury? NO YES |solf__ other_} Threat fo physical integety? NO YES [self othor a) 4 Infonse fearMhelnthoror? NO YES [during after — Criterion A mot? NO PROBABLE YES For the rest of the interview, | want you to keep (EVENTS) in mind as I ask you some questions about how they may have affected you. Fm going to ask you about twenty-five questions altogether. Most of them have two parts, First, I'll ask if you've ever had @ particular problem, and if so, about how often in the past month (week). Then I'll ask you how ‘much distress or discomfort that problem may have caused you,CAPS Page 4 (Caan Ti mai ov Te para oy Teo Nn [oc OE Te TORT 1. (6-1) recurrent and intrusive distressing recollections ofthe event, including images, thoughts, oF perceptions. Note: In young children, repetitive play may occur in which themes or aspects of the vauma are expressed, Frequency Have you ever had unwanted memories of (EVENT)? What wore they like? (What ald you remember?) (IF NOT CLEAR} (Did thay ever ‘eau while you ware awake, or only In dreams?) EXCLUDE IF MEMORIES OCCURRED ONLY DURING DREAMS] How often have you had Tatas How much distress or discomfort dd these memories cause you? Ware you able to put them out of your mind and think about something else? (Mow hard did you have to ty?) How much did they interfere with your Ife? Paes 2, (B-2) recurrent distressing dreams of the event. Né recognizable content, these memories inthe past month (week? | None 4) Mid; minimal sates or deuotion of ectes 0 Never 2 Modorate lavoss dearly prosent but i 3 Once o tice manageable, some daruton of actes 2 Ghee a ice a week 3 Sovere, conierable cists, ctfeully 3 Several times a wook Sismissing memories, marked dupton of 4 Dalyoralmoet every day aces 4 Extrome, Incapactatng sistess, cannot Deseription/Examples dismiss mererie, unable fo cantnve iitine sclities : ae av (specity i sey In chron, there may be Fghteing dreams without Frequency Have you ever had unpleasant dreams about (EVENT)? Describe a typical dream. (What happens in them?) How often have you had these dreams in tho past month (week)? 2 Never 1 Once oF twice 2 Onca or twice a week 3 Several times a wook % Daily or almost every day Des las Tntensity How much distress or discomfort did these dreams cause you? Did thoy over wake you up? [IF YES: (What happened whon you woke up? How long aid it taka you to get back to sloop?) [LISTEN FOR REPORT OF ANXIOUS AROUSAL, YELLING, ACTING OUT THE NIGHTMARE] (Did your dreams ever affect anyone ‘else? How 0?) © None Mild, minimal distress, may not have awoken Moderato, awoke In distress but readlly roturned fo sleep Severe, considerable distress, difficulty retuming to sleep Extreme, incapacitating distress, dd not return io sleep QV (speci) 1 2 3 4CAPS (8-3) acting or feeling as if the traumatic event were recurring (Includes a sense of reliving the experienc hallicinations, and dissociative flashback episodes, including those that occur on awakening or when Intoxicated). Nate: In young chidren, traume-epectic reenactment may occur, Pages iusions, Freqianay Have you ever suddenly acted or felt a if (EVENT) were happening again? (Have you over hhad flashbacks about [EVENT]?) {IF NOT CLEAR] (Did this over occur whils you were ‘awako, or only in dreams?) (EXCLUDE IF ‘OCCURRED ONLY DURING OREAMS] Tell me ‘more about that. How often has that happened inthe past month (week)? © Never 1. Once or twice 2 Once or twice a week 3. Several times a week 4 Dally or almost every day Tatensiy How much did It soem as if (EVENT) were happening again? (Were you confused about where you actualy were or what you were doing at the fimo?) How long did it last?” What did you do while this was happening? (Did other people notice your behavior? What did they say?) 9 Norelving 1. Mild, somewhat more realistic than just thinking about event 2 Moderato, definite but transient diesociative uality, stil very aware of surroundings, daydreaming quality 2 Severe, strongly dissociative (reports images, ‘sounds, or sracis) but retained some ‘Ltn Description/Examples awareness of surroundings 4 Extrome, complete dissociation (fashback), | F = no awareness of surroundings, may be 7 Unreaponsive, possible amnesia for the aes episode (blackout) sev i QV (specity) 4. (B-4) intense paychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event Frequency nal Fa Have you ever gotten emotionally upset when | How much distress or discomfort did something reminded you of EVENT}? (Has | (REMINDERS) cause you? How long did it last? |" —— nyining ever tiggered had feelings rolated to | How much did it interfere with your life? rote IEVENTI?) What kinds of reminders made you fs ‘upset? How offen in the past month (weekj? | None. 1. Ml, minimal distress or disruption of activities 0 Never 2 Moderate, distress clearly present but sl | Bastmenth 1 Once oF twice Tranageable, some disruption of activites =p 2 Once or twice a week 3. Severe, considerable distress, marked anti 3. Several times a week slsruption of activities 1 4 Dally or almost every day 4 Exreme, incapacitating distress, unable to | continue activities en Description/éxamples QV (specity) | Lune *fraumatic event CAPS Pages 8.(B-8) physiological reactivity on exposure to Internal or external cues that symbolize or resemble an aspect of the (Old your body ever react in some way when ‘something reminded you of [EVENT)?) Can you give me some examples? (Did your heart race Cr did your breathing change? What about ‘swoating or feeling really tense or shaky?) What kinds of reminders triggered these reactions? How often in the past month (week)? 0 Never 1 Onoe or toe 2 Once or twice a week 3 Saveral times a wook 4 Daily or almost every day Deseription/Examples Fagoney Tafansity ag Have you evar had any physical reactions How strong were (PHYSICAL REACTIONS)? — |i when something remindod you of (EVENT)? _| How long did they last? (Did they last even after | ‘you were out of the situation?) No physical reactivity Mid, minimal reactivity Moderate, physieal reactivity clearly present, fay be sustained if exposure continues Severe, markod physical reactivity, sustained throughout expasure Extreme, dramatic physical reactivity, sustained arousal even after exposure has ended QV (specity) Fosponsiveness (not present before i Giiterion C. Persistent avoidance of slimull associated wih the frauma and numbing of genoral ie trauma), as Indicated by three (or more) of the following 6. (C-1) efforis to avoid thoughts, feolings, or conversations assoctatod with the trauma trying to avoid talking with other people about ie fy stat) How often Inthe past manth (week)? Never 4 Once or twice 2 Onoe or twice @ week 3 Sovoral times a weok 4 Dally or almost ovary day Description/Examples Frequanay Tatensite BE Have you over tried to avoid thoughts or How much offort did you make to avoid = feolings about (EVENT)? (Wifial kinds of thoughts | (THOUGHTSIFEELINGSIGONVERSATIONS)? | F=—-— or feelings aid you try fo avold?) What about | (What kinds of things old you do? What about | y 2 drinking or using medication or streol drugs?) [CONSIDER ALL ATTEMPTS AT AVOIDANCE, INCLUDING DISTRACTION, SUPPRESSION, AND USE OF ALCOHOLIDRUGS} How much did that Intorfore with your lite? © None. 1 Mild, minimal etfort, ttle or no alsrupton of activities 2 Moderate, some effort, avoidance definitely ‘resort, come disruption of activites 3 Severe, considerable affor, marked avoidance, marked cisruption of activities, or Involvement in certain activiies as avoidant stretegy 4 Extreme, drastic attempts at avoidance, lnable to continue actives, or excessive Involvement in certain activiies as avoidant strategy QV (specity)CAPS Page? 7.(C-2) efforts to avoid activities, places, or people that arouse recollections of the trauma Fraqurency Have you evor tried to avoid cartain activities, places, or people that reminded you of (EVENT)? (What kinds of things di you avoid? Winy is that?) How often in the past month (week)? Never Once or twice Once or twice a week Several times a week Daily or almost every dey Deseriotion/Examples ‘intensity How much effort did you make to avoid (ACTIVITIESIPLACESIPEOPLE)? (What did you {0 instead?) How much did that interfere with your life? 0 None 4 Mild, minimal effort, litle or no disruption of activities 2 Moderate, some effort, avoidance definitely present, some disruption of activities 3 Severe, considerable effort, marked avoidance, marked disruption of activites or involvement in certain activities as avoidant strategy 4 Extreme, drastic attempts at avoidance, ‘unable to continue actitias, or excessive involvement in certain activites 8s avoidant strategy QV (specify) 8. (C-2) inabilly to recall an important aspect of the trauma ‘Frequency Have you had difficulty remembering some important parts of (EVENT)? Toll me more about that. (Do you fel you should be able to remember these things? Why do you think you can't?) In the past month (aveek), how much of the important parts of (EVENT) have you had difficulty remembering? (What parts do you stil remember?) 0 None leat memory {Pow Sspects ol rfnombered es tan 10%) 2 Some aspects not remembered {approx 20- 30%) 2 any aspects not remnmered (oro 9 cox) 4 tos ral aspects not remembered (more than €0%) Deseription/Examples Ta How much difficulty did you have recalling important parts of (EVENT)? (Wore you abio fo recall more If you tried?) 8 None 4 Mild, minimal difficulty 2 Moderate, somo dificuty, could recall with cffort 3 Severe, considerable difieuity, even with cffort 4 Extreme, completaly unable to recall important aspects of event QV (specity)CAPS Pages 8. (C-4) markedly diminished interest or participation in significant activities Fraquang Have you been less interested in activities that you used to enjoy? (What kinds of tings hove You fost interast in? Are tharo'soma tinge you Gont do at all anymore? Why is that?) (EXCLUDE IF NO OPPORTUNITY, FF PHYSICALLY UNABLE, OR IF DEVELOPMENTALLY APPROPRIATE CHANGE IN PREFERRED ACTIVITIES] In the past month (ivo0k), how meny activities have you been less iniorested in? (What kinds of things do you tif enjoy doing?) When did you first start to eel that way? (After the [EVENT!2) © None 1. Fow actuities (loss than 10%) 2 Some activities (approx 20-30%) 3 Many activities (approx 50-60%) 4 Most or all activiles (more than 80%) Deseription/Examates intensily How strong was your oss of Interest? (Would you enjoy [ACTIVITIES] once you got started?) 0 No loss of interest 1. Mild, slight loss of interest, probably wouls enjoy afier starting activites 2 Moderate, definite loss of interest, but stl has | some enjoyment of activities 2. Severe, marked loss of interos in actives 4 Extrema, complete loss of interest, no longer Participates in any activities QV (specify) Traumacrelated? 1 defnte 2 probable 3 unikely Current Ltetime 10. (C-5) fooling of detachment or estrangement from others Fei Have you folt distant or cut off from other people? What was that like? How much of the time in the past month (ivook) have you felt that way? When did you first start to feo! that way? (After the [EVENTT?) None of the time Very title of the time (less than 10%) ‘Somo of tha time (approx 20-30%) ‘Much of the time (approx 50-60%) Most or all ofthe time (more than 80%) siption/éxemples Tatar How strong were your feelings of boing distant ‘or cut off rom others? (iho do you fee! closest {07 How many poople do you fool comfortable falking with about persoral things?) 0 No feelings of detachment or estrangomont 4. Mil, may fee! “out of synch’ with others 2 Moderate, feetings of detachment clearly present, but stil feels some interpersonal connection 3. Severe, marked feelings of detachment or ‘estrangement from most people, may feel ‘lose fo only one or two people 4 Extreme, feels completely detached or estranged from others, not close with anyone QV (specify) Trauma-rolated? 1 defisite 2 probable 3 unikely Current Lifetime11, (C-6) rosticted range of affect (0. CAPS » unable to have loving feelings) Page® Fraquenay been times when you felt ‘emotionally numb or had trouble experienci feolings ike love or happiness? What was that like? (What feelings aid you have trouble ‘oxperioncing?) How much of the time in the past ‘month (woek) have you felt that way? When dic you first start having trouble experiencing (EMOTIONS)? (Attor the (EVENT?) 0 None of the ime 4 Very litle of tha timo (less than 10%) 2 Some of the time (approx 20-30%) 3. Much ofthe time (approx 60-60%) 4 Most or all ofthe time (more than 80%) Descrintion/éxamples Tnfensify How much trouble did you have experiencing (EMOTIONS)? (What kinds of footings were you stil able to experience?) {INCLUDE OBSERVATIONS OF RANGE OF AFFECT DURING INTERVIEW. No reduction of emotional experisnoe 4 Mild, slight reduction of emotional experience 2 Moderate, defnite reduction of emotional experience, but stil able 10 experience most ‘mations 3 Severe, marked reduction of experience of at least two primary emotions (eg, love, happiness) 4 Extteme, completely lacking emotional experience QV (specity) Trauma-related? 1 efnte 2 provable 9 uniily Curent Lifetime Have there been times when you felt there is no need to plan for the future, that somehow your future will be cut short? Wy is that? [RULE OUT REALISTIC RISKS SUCH AS LIFE- THREATENING MEDICAL CONDITIONS| How ‘much of the time in the past month (waok) have ‘you felt that way? When did you first start to foal that way? (Aftor tho (EVENT]?) None of the time Very litle ofthe time (less than 10%) Soma of the time (approx 20-20%) Much of the time (approx 50-60%) Most or all ofthe time (more than 80%) tor How strong was this fooling that your future bbe cut short? (How long do you think you will live? How convinesd are you that you wil dle prematurely?) 0 No sense of 2 foreshoriened future 1. Mil, slight sense of a foreshortened future Moderate, sense of a foreshortened futuro defintely present, but no specific prediction about longevity Severe, marked senso of a foreshortened future, may make epeciic precition about longevity Extreme, overwhelming sonse of a foreshortened future, completely convinced of premature dest QV (specity) Trauma-related? 1 defrite 2probeble 9 untkoly Current __—_ Lifetime 12.(€-7) sense ofa foreshrsnd futur (og, des nt expat o havea ever, malaga, chien, or 8 nora fe span) Frequency Tofensity orn,CAPS Page 10 Criterion D- “ (or mora) of tha following: Porsistent symptoms of increased arousal [nol present Bolore the Waunia), Be indleated by two, 13. (D-1) alffiuly falling or staying asleep Frequency 78 you had any problems falling or staying asleep? How offen in the past month (wok)? When did yeu first start having problems sleeping? (After the /EVENT}?) 0 Never 1 Once or tice 2 Once or tice a week 3. Several times a week 4 Dally or almost every day Sloop onset problems? YN Midesleep awakening? Yu Early am. awakening? YN ‘Total # hrs eleop/night Desired # hrs sleepnight Tafensik How much of a problem did you have with your sleap? (How long did it take you fo fail asloap? How oiten did you wako up in the night? Did you offen wake up earlier than you wanted to? ‘How ‘many (otal hours did you sleep each night?) 0 No sleep probiems 1. Mild slightly longor latency, or minimal aifficulty staying asleep (up to 30 minutes loss of sleep) 2 Moderate, definite sieep disturbance, clearly longer iatency, or clear difficulty staying aslaep (30-00 minutes loss of sleep) 3 Severe, much longer latency, of marked iffculty staying asleep (80 min to 3 hrs [oss ‘of sieen) 4 Extreme, very iong latency, or profound 3 hrs loss of sleep) QV (specify) Trauma-related? 1 definite 2 probable 3 unlksly Have there been timos whan you felt especially irritable or showed strong feelings of anger? Can you give me some examples? How offen in the past month (week)? When did you first start feeling that way? (After the [EVENT]?) Never Once or twice Once or twice a week ‘Soveral times a week Dally or almost every day ription/Examples Current Lifetime 14, (0-2) italy or outbursts of anger Frequency Tafensiby How strong was your anger? (How ald you show i?) (IF REPORTS SUPPRESSION} (How hard was if for you fo keep from showing your anger?) How long did it take you to calm down? Did your anger cause you any problems? © No initabilty or anger 11 Mi, minimal initablity, may raise voice when angry Moderate, definite iritabilty or attempts to suppress anger, but can recover quickly Severe, marked imitabiily or marked attempts to suppress anger, may become verbally or physically aggressive when angry 4 Extreme, pervasive anger or drastic attempts, to suppross anger, may have episodes of physical violence QV (specity) Trauma-related? 1 dofnite 2 probatio 3 untkoyy Current Lifetime16. (0-3) difficulty concentrating CAPS Page 11 Frequaney Have you found it difficult to concentrate on What you were doing or on things going on fround you? What was that like? How much of the time in the past month (weok)? Whon did you first start Raving trouble concentrating? (tter tho (EVENT?) None of the time Very litle ofthe time (less than 10%) ‘Some of the time (approx 20-30%) ‘Much ofthe time (approx 50-6034) Most or all ofthe time (more than 80%) ription/Examples Tntensitg How difficult was it for you to concentrate? INCLUDE OBSERVATIONS OF CONCENTRATION AND ATTENTION IN INTERVIEW] How much di that interfere with your lite? 0 No ciffutty with concentration 4 Mild, only slight effort needed to concentrate, lite or no eisruption of activities 2 Moderate, definite loss of concentration but auld concentrate with effort, some disruption of activities 3 Severa, marked loss of concontration even with efor, marked disruption of activilles 4 Extreme, complete inabilly to concentrate, Unable to engage in activites QV (specity) Trauma-related? 1 definite 2probstie 3 unikely Curent Lifetime 16. (D-4) hypervigilanca Have you been especially alert or watchful, ‘even when thero was no real need to be? (Have {you felt as f You were constanty on guard?) Why is that? How much of the time in the past month (week)? When did you frst start acting that way? (After the [EVENT]?) © None of the time 1 Very Tite of the time (less than 10%) 2 Some ef the time (approx 20-30%} 3 Much of the time (approx 50-60%) 4 Most or all of the lime (more than 80%) Deserintion/Examples Tatensiy How hard did you try to be watchful of things going on around you? {INCLUDE OBSERVATIONS OF HYPERVIGILANCE IN INTERVIEW) Did your (HYPERVIGILANCE) cause you any problems? 0 No hypervigiiance 11 Mi, trinimal hypervigianee, sight heightening of awarenoss 2 Moderato, hyperviglance clearly present, watchful in public (ag., chooses safe place to fit in.a restaurant or movie theater) 3 Severe, marked hypervialiance, very alert, scans environment for danger, exaggerated ‘concern fer safety of selffamilyzhome 4 Extoma, excessive hyperviglance, etforts to enoure safety consume significant time and energy and may involve extensive safety/checking behaviors, marked watchfulness during interview QV (specity) Trauma-related? 1 definite 2 probabie 3 untkoly Current Lifetime17. (0-8) exaggerated startle response CAPS Page 12 Frequency Have you had any strong startle reactions? ‘When did that happen? (What Kinds of things ‘made you startle?) How often in the past month (week)? When did you first have reactions? (Aer tho {EVENT}?) © Never 1 Once or twice 2 Once or twice a week 3 Sovoral times a week 4 Dally or almost every day ‘nfensity How strong wore these startle reactions? (How strong ware they compared fo how most people ‘would respond?) How long did they last? 0 No starte reaction 4 Mid, minimal reaction 2 Moderate, definite startle reaction, fools “jumpy 3 Severe, marked startle reaction, sustained ‘arousal following intial roaction 4 Exireme, excessive stale raaction, overt QV (specity) Trauma-related? 1 defrte 2 probate utetime 3 untkaly current 18. onset of symptoms [Grterion E-Duration of the disturbance (symptoms in Grtora 6, ©, and D)is more than Tmonth. — (PTSD SYMPTOMS) lasted altogether? [LIFETIME] How tong did these (PTSD SYMPTOMS) last altogether? Duration more than 1 month?| Total # months duraton| Acute (< 3 months) or chranie| . & 3 months)?|".- acute chronic TE SOA REREY CLEARY When dd you ist sta Raving Total months delay onset (PTSD SYMPTOMS) you've told me about? (How fong after | ek {ho taume di hoy eta? Mere than ix mono?) ih Slared onest feo meni)? SNE. YES 49. duration of symptoms [CURRENT] How long have these “Gurtant acute. chronic ‘other important areas of functioning. Giferion F. The dltarBanee eauses Svea significant aawess or impalrhont ih socal, ooaupaHonal or 20, subjective distress {CURRENT] Overall, how much have you been bothered by these (PTSD SYMPTOMS) you've told me about? (CONSIDER DISTRESS. REPORTED ON EARLIER ITEMS] [LIFETIME] Overall, how much wore you bothered by these (PTSD SYMPTOMS) you've told me about? (CONSIDER DISTRESS. REPORTED ON EARLIER ITEMS] None Mild, minimal distress Moderate, cisiress clearly present but si manageable Severe, considerable distress incapacitating distress24, Impairment in social funetloning CAPS Page 13 TGURRENT] Have these (PTSD SYMPTOMS) affected your rolationshias with other people? How so? [CONSIDER IMPAIRMENT IN SOCIAL. FUNCTIONING REPORTED ON EARLIER ITEMS] [LIFETIME] Did these (PTSD SYMPTOMS) affect Yyour social life? How 30? {CONSIDER IMPAIRMENT IN SOCIAL FUNCTIONING REPORTED ON EARLIER ITEMS] To adverse Impact Mild impact, minimal impairment in soci functioning Moderate impact, definite impairment, but any aspects of sonia functioning stil intact Severo impact, marked impairment, few ‘agpacts of social functioning sill Intact Extreme impact, litle or no social functioning 22. Impairment in accupational or other important area of functioning PREMORBID FUNCTIONING IS UNCLEAR, | 4 INQUIRE ABOUT WORK EXPERIENCES BEFORE THE TRAUMA, FOR CHILD/ADOLESCENT TRAUMAS, ASSESS PRE-TRAUMA SCHOOL PERFORMANCE AND POSSISLE PRESENCE OF SEHAVIOR PROBLEMS) IF NO: Have these (PTSD SYMPTOMS) affected any other Important part of your life? [AS APPROPRIATE, SUGGEST EXAMPLES SUCH AS PARENTING, HOUSEWORK, SCHOOLWORK, VOLUNTEER WORK, ETC] How 50? [LIFETIME ~ IF NOT ALREADY CLEAR] Were you working then? IF YES: Did these (PTSD SYMPTOMS) affect your work or your ability to work? How so? {CONSIDER REPORTED WORK HISTORY, INCLUDING NUMBER AND DURATION OF' JOBS, AS WELL AS THE QUALITY OF WORK RELATIONSHIPS. If PREMORBID FUNCTIONING IS UNCLEAR, INQUIRE ABOUT WORK EXPERIENCES BEFORE THE TRAUMA, FOR CHILDIADOLESCENT TRAUMAS, ASSESS PRE-TRAUMA SCHOOL, PERFORMANCE AND POSSIBLE PRESENCE (OF BEHAVIOR PROBLEMS} IF NO: Did these (PTSD SYMPTOMS) affect any other Important part of your life? [AS APPROPRIATE, SUGGEST EXAMPLES SUCH ‘AS PARENTING, HOUSEWORK, SCHOOLWORK, VOLUNTEER WORK, ETC] How so? Extreme impact, litle or no occupationalfother Important functioning TCORRENT =F NOT ALREADY CLEAR] Are you [0 No adverse impact FE working now? 11 Mid impact, minimal impairment in ‘| ‘occupational/ther Important functioning pace IFYES: Hava those (PTSD SYMPTOMS) 2 Moderate impact, definite impairment, but affected your work oF your ability to work? many aspects of occupational/other important | pastianh How s0? [CONSIDER REPORTED WORK {urctioning stil intact HISTORY, INCLUDING NUMBER AND. 3 Sovere Impact, marked impalrment, few ae DURATION OF JOBS, AS WELL AS THE aspects of occupationalother important QUALITY OF WORK RELATIONSHIPS. IF functioning stil intactCAPS Pago 14 [Giobai Ratings = = z =] 23. global validity ESTIMATE THE OVERALL VALIDITY OF RESPONSES. ‘0 Excelent, no reason to suspect Invalid CONSIDER FACTORS SUCH AS COMPLIANCE WITH THE responses INTERVIEW, MENTAL STATUS (&.G., PROBLEMS WITH 4 Good, factors present that may sdversely CONCENTRATION, COMPREHENSION OF ITEMS, affect valiily DISSOCIATION), AND EVIDENCE OF EFFORTS TO 2 Fair, factors present that definitly reduce EXAGGERATE OR MINIMIZE SYMPTOMS. valicity 2 Poor, Substantially reduced validity 4 Invalid responses, severely impalred mental slatus or possible deliberate “faking bac" or “aking good 24, global severity ESTIMATE THE OVERALL SEVERITY OF PTSD SYMPTOMS. CONSIDER DEGREE OF SUBJECTIVE DISTRESS, DEGREE OF FUNCTIONAL IMPAIRMENT, OBSERVATIONS OF BEHAVIORS IN INTERVIEW, AND JUDGMENT REGARDING REPORTING STYLE. No cineally signifcant symptoms, no distress ‘and no functional impairment | ‘Mil, minimal distress or functional impalement Moderate, definite distrase or functional impairment but functions satisfactorily with effort Severe, considerable distress or functional Impairment, Imited functioning evan with ‘effort Extreme, marked distress or marked ne. Impairment in two or more major areas of | functioning 25, global improvement RATE TOTAL OVERALL IMPROVEMENT PRESENT SINCE [0 Asynptomate THE INTIAL RATING. IF NO EARLIER RATING, ASK HOW [1 Considerabé impovement THE SYMPTOMS ENDORSED HAVE CHANGED'OVER THE | 2 Moderate iproverent PAST 8 MONTHS. RATE THE DEGREE OF CHANGE, | 2 Slight impovemont WHETHER OR NOT, IN YOUR JUDGMENT, IT IS DUE TO 4 No improvement TREATMENT, 5 Insufficient informationCAPS Page 15 (current FISo Symptoms: Criterion A met (traumatic avert)? ___# rterion & sx (1)? ___# nterion © sx (2 3)? _# Gaileion D sx (2 2)? Criterion E met (duration > 1 month)? Criterion F mot (sistrass/impairment)? GURRENT PTSD (Criteria A-F mot)? IF CURRENT PTSO CRITERIA ARE MET, SKIP TO ASSOCIATED FEATURES, No YES NO Yes No YES No YES NO YES NO YES NO YES IF CURRENT CRITERIA ARE NOT MET, ASSESS FOR LIFETIME PTSO. IDENTIFY A PERIOD OF AT LEAST A MONTH SINCE THE TRAUMATIC EVENT IN WHICH SYMPTOMS WERE WORSE, Since the (EVENT), has there been a time when these (PTSD SYMPTOMS) were a lot worse than they have been in the past month? When was that? How long did it last? (At loast a month?) \F MULTIPLE PERIODS IN THE PAST: When were you bothered ‘tho most by those (PTSD SYMPTOMS)? IF AT LEAST ONE PERIOD, INQUIRE [TEMS 1-17, CHANGING FREQUENCY PROMPTS TO REFER TO WORST PERIOD: During that time, did you (EXPERIENCE SYMPTOM)? How often? (Lifetime PTSD Symptoms, Criterion A met (traumatic event)? ___# Criterion 8 ax (2 1)? _# Gitaron © ax (2 3)? __—# Criterion D sx & 2)? Criterion & mat (duration > 1 month)? Criterion F met (aistressfimpairment)? LIFETIME PTSD (Cniteria A-F me)? No ves No ves NO YES NO YES No YES NO YES No YESCAPS Page 18 (Associated Features 26, guit over acts of commission or omission =) Fraueney Have you felt guilty about anything you did or didn't do during (EVENT)? Tell me more about that. (Wfiat do you fee! quity about?) How much of the timo have you fell that way In the past month (week)? © None of the tine 1 Very of the time (ess than 10%) 2 Some ofthe me (approx 20-30%) 3 Much of the time (approx 80-60%) 4 Most o al ofthe tne (mare then 8034) Tatenatiy How strong wore thoso feelings of guilt? How much diettess or discomfort did they cause? 0 No feelings of quit 1 Mild slight featings of guit 2 Moderate, guit feelings definitely present, some distrass but stil manageable 3 Severo, marked feelings of gull, considerable distress 4 Extreme, pervasive feelings of gut, sol ‘condemnation regerding behavior, incapacitating distress Have you felt guilty about surviving (EVENT) ‘when others did not? Toll me more about that. (What de you feel guity about?) How much of the time have you felt that way in the past month (week)? None of the time Very ite ofthe time (oss than 10%) Some ofthe time (sporox 20-20%) Much ofthe time (approx 60-80%) Most or ail of the time (more than 80%) NA Deseription/Examples QV (spocity) 27, survivor guilt (APPLICABLE ONLY IF MULTIPLE VICTIMS] Fr Tnfensity How strong wore those feelings of guilt? How ‘much distress or discomfort did thay cause? No footings of guit Mild, sight feelings of guilt Moderate, cuit feelings definitly present, Some distress but stil manageable Sovere, marked feelings of guil, considerable distros Extreme, pervasive feetings of gul condemnation regarding survival, incapacitating distress QV (specity) sett.28. a reduction in awarenass of his or her surroundings (2.0. ing in a daze" Have there been times when you felt out of {ouch with things going on around you, like you were in a daze? What was that ike? [DISTINGUISH FROM FLASHBACK EPISODES) How often has that happened in the past month (week)? [IF NOT CLEAR] (Was it due fo an liness or the effects of drugs or alcohol?) When ‘niente How strong was this feeling of being out of touch or ina daze? (Were you confused about whore you actually were or wat you were doing at the time?) How long di it fast? What did you do while this was Rappening? (Did other people notice your behavior? What aid they say?) Deseription/exempl Trauma-related? 1 dofints 2.prbable 3 unikely Current Lifetime did you first start festing that way? (Afer the | 0 No redustion in awareness weveNT??) 1 Mid, aight reduction in awareness 2. Moderato, dette but transient reduction in 0 Never awareness, may fepat feeling “spaoy" 4 Ones or tien 3 Severe, marked reduction im awareness, may 2 Onoe or tise a week persist for several hours 4 Saveral tmes a week 4 Extreme, complete lose of awareness of : 4 Dailyor almost every day Surroundings, may be unresponsive, possible | Lins amnesia forthe episode flackout) : Description/Exemples nee Qv (specity) pee seri Trauma-related? 1 defile 2 probobie 3 untkoly Current Lifetime 28. dereatzation Fraguanay Tatensiiy ae Have there been times when things going en | How strong was (OEREALIZATION)? How long | around you seemed unroal of vary strange and | did itlast? What did you do while this was oe linfamitiar? NO} (What about dmes when. | happening? (Did athe people noice your (sae ooplo you know suddenly seemed untamitar?) | behav? What dd they say?) What wae that ike? How often has that happened in the past month (waeh)? {NOT |0 No derealization ae CLEAR] (Was it due fo an iliness or the effects of | 1 Mild, slight derealization Pasimmath rage or alcohol?) When aid you fist start 2 Moderate, definite but transient dereatzation |p. {oling that way? (After the [EVENTI?) 3 Severe, considerable derealzation, markos contsion about what fa real, may persist for | f= Several hours 0 Never 4 Extreme, profound derealization, dramatic aS 4 Once or twice loss of sense of really or farliarty 2 Once of tice a week 3 Several times © week QV (specity) stn 4 Dally or almost every day F80, depersonatization CAPS Page 18 Frequency Have there been times when you felt as if you were outside of your body, watching yourself as if you were another person? (IF NO} (What ‘boul times when your Body felt strange or unfamiliar to you, a8 i i had changed in some way?) What was that like? How often has that hhapponed in the past month (week)? (]F NOT CLEAR] (Was it duo fo an ithoss or the effects of drugs 0” alcohol?) When did you frst start oling that way? (After the [EVENT]2) Never ‘Once oF woe ‘Once oF twice a week ral times a week Daily or almost every day Deseription/Examplos Tntensity, How strong was (DEPERSONALIZATION)? How {ong did it last? What did you do while this was happening? (Did other poople notice your behavior? Whit ald thoy say?) No depersonalization Mild, sight depersonetization Moderato, definite but transient depersonalization Severe, considerable depersonalization, marked sense of detachment from self, may persist for several hours 4 Extreme, profound depersonaiization, 100) or TRIN (280) 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, itis critical that clini- cians 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 inconsis- tent 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 > 1075 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, eic.) H. Diagnosis: L NM ‘The Diagnosis must conform to DSM-IV and be supported by the Compensation and Pension PTSD Disability Examination Worksheetsfindings on the examination report. 2. If there are multiple mental disorders, delineate to the extent possi- ble 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 compensa- tion 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 F3d 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 veter- an’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 IIT disorders Axis IV (psychosocial and environmental problems) Axis V (GAF score - current) [Preference is for current level of functioning for C&P purposes, although rat- ing 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 ration- ale 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.) IV. Compensation and Pension PTSD Disability Examination Worksheets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 bene- fit 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 man- aging 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 request- ed 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 ration- ale for the opinion. M. Integrated Summary and Conclusions * Describe changes in psychosocial functional status and quality of life fol- Jowing trauma exposure (performance in employment or schooling, rou- tine 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. * Ifpossible, 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, IV. Compensation and Pension PTSD Disability Examination Worksheetsexplain why (¢.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. * Ifpossible, state prognosis for improvement of psychiatric condition and impairments in functional status. + Comment on whether veteran should be rated as competent for VA pur- poses in terms of being capable of managing his/her benefit payments in his/her own best interest. IV. Compensation and Pension PTSD Disability Examination Worksheets