4
The PTSD Compensation and Pension Examination

This chapter provides an overview of the Veteran’s Administration (VA’s) posttraumatic stress disorder (PTSD) compensation process and the conducting of PTSD compensation and pension (C&P) examinations. These examinations generate the information used by raters to evaluate compensation claims and, where appropriate, to determine the level of disability—a process that is described in Chapter 5. The chapter also offers the committee’s response to several elements of the charge that related to these evaluations.

COMPENSATION AND PENSION EXAMINATION OVERVIEW

A C&P examination is a very important and nearly universal step1 in the process of obtaining disability benefits from VA. Initial examination requests are typically initiated by VA after a veteran files an application2 with the Veterans Benefits Administration (VBA) and all pertinent evidence has been obtained. The application, at minimum, requires a veteran to submit evidence of a disability or disabilities and to indicate how it or they may be connected to the veteran’s military service. There are several ways

1

There are limited circumstances where a C&P exam is not necessary in order to obtain benefits from the VA. These include situations where a veteran is able to provide sufficient medical and disability documentation and evidence of a service connection to allow VBA to make its determination without the need for further evaluation.

2

VA Form 21-526, which can be submitted on paper or electronically, is used to initiate the process.



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PTSD Compensation and Military Service 4 The PTSD Compensation and Pension Examination This chapter provides an overview of the Veteran’s Administration (VA’s) posttraumatic stress disorder (PTSD) compensation process and the conducting of PTSD compensation and pension (C&P) examinations. These examinations generate the information used by raters to evaluate compensation claims and, where appropriate, to determine the level of disability—a process that is described in Chapter 5. The chapter also offers the committee’s response to several elements of the charge that related to these evaluations. COMPENSATION AND PENSION EXAMINATION OVERVIEW A C&P examination is a very important and nearly universal step1 in the process of obtaining disability benefits from VA. Initial examination requests are typically initiated by VA after a veteran files an application2 with the Veterans Benefits Administration (VBA) and all pertinent evidence has been obtained. The application, at minimum, requires a veteran to submit evidence of a disability or disabilities and to indicate how it or they may be connected to the veteran’s military service. There are several ways 1 There are limited circumstances where a C&P exam is not necessary in order to obtain benefits from the VA. These include situations where a veteran is able to provide sufficient medical and disability documentation and evidence of a service connection to allow VBA to make its determination without the need for further evaluation. 2 VA Form 21-526, which can be submitted on paper or electronically, is used to initiate the process.

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PTSD Compensation and Military Service to established service-connectedness, the most common being to prove one of the following: the “injury or disease resulting in disability was incurred coincident with service in the Armed Forces” (38 CFR §3.303); a preexisting injury or disease was aggravated by active service (38 CFR § 3.306); a presumptive service connection was established by law or VA policy (38 CFR §§3.307, 3.308, or 3.309); or the condition occurred as a result of an injury or disease that was incurred during the time of service (38 CFR §3.310). After an application is received, the VBA reviews it for completeness and is responsible—under the so-called duty to assist3—to help a claimant “who files a substantially complete application in obtaining evidence to substantiate his or her claim before making a decision on the claim” (DVA, 2006). Once all of the relevant evidence has been collected and all of the requested (and available) information has been received, depending on the conditions that have been identified a VBA Veterans Service Representative (VSR) or a Rating Veterans Service Representative (RVSR) will request that the Veterans Health Administration (VHA) set up and conduct one or more examinations. These examinations will be conducted either by staff clinicians or by contracted health professionals, depending on the facility used and the need for specialists. Examinations may also be conducted in other circumstances. These include when: it is required by regulations; it is necessary to resolve an uncertainty related to a diagnosis; there is a need to establish a nexus between an already-diagnosed condition and military service; a veteran who has a disability that has already been established as being service connected indicates that this disability has worsened or that the level of the disability rating does not accurately reflect his or her condition; or it is required as part of an adjudication to resolve a compensation-related issue. According to a procedural handbook, “VHA has a time standard of 35 3 The tasks falling under VA’s duty-to-assist responsibility are set forth in the Veterans Claims Assistance Act of 2000, Public Law 106-475.

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PTSD Compensation and Military Service TABLE 4-1 Most Frequently Conducted C&P Examinations Examination % Conducted Examination % Conducted General medical 19 Eye 4 Joints 12 PTSD initial 3 Audio 9 Feet 3 Spine 8 PTSD review 3 Mental disorders* 6 Skin 2 *Other than PTSD. SOURCE: CPEP (2006). calendar days, after receipt of the examination request, to complete the examinations and required tests” (VHA, 2006). A presentation in June 2006 by the Compensation and Pension Examination Program Office (CPEP) indicated that VHA performs approximately 800,000 C&P exams per year at approximately 135 examination sites (CPEP, 2006). The ten most frequently conducted examinations—which collectively make up 67 percent4 of all examinations—are listed in Table 4-1. In the 1990s, the VHA began to outsource some C&P examinations or portions thereof. At the end of 2006, QTC Management Inc. (QTC) was performing nearly all VBA-contracted examinations (QTC, 2006); during the 2005 fiscal year, the company had conducted approximately 82,000 examinations for the VA (VBA, 2006). VHA also employs contracted examiners who work both onsite and offsite. C&P examinations are designed to obtain fundamental information that will be necessary for the final adjudication of a claim, including (where appropriate) the application of the VA Schedule for Rating Disabilities (VASRD). Two sections of the Code of Federal Regulations define the purpose of these examinations: For the application of [the VASRD], accurate and fully descriptive medical examinations are required, with emphasis upon the limitation of activity imposed by the disabling condition. Over a period of many years, a veteran’s disability claim may require reratings in accordance with changes in laws, medical knowledge and his or her physical or mental condition. It is thus essential, both in the examination and in the evaluation of disability, that each disability be viewed in relation to its history (38 CFR §4.1). The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the 4 This number does not correspond to the sum of the numbers in the table because of independent rounding.

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PTSD Compensation and Military Service ordinary conditions of daily life including employment…. This imposes upon the medical examiner the responsibility of furnishing, in addition to the etiological, anatomical, pathological, laboratory and prognostic data required for ordinary medical classification, full description of the effects of disability upon the person’s ordinary activity (38 CFR §4.10). C&P examinations for PTSD consist of a review of medical history; an assessment of the traumatic exposure or exposures; evaluations of mental status and of social and occupational function; and a diagnostic examination, which may include psychological testing or a determination of a Global Assessment of Functioning (GAF) score. Family may play in to the C&P process in several different ways. The evaluation of the claimant’s functional state explicitly includes his or her relationships with others, including the spouse, children, and parents. While direct input from the family is not required, family members may participate directly in parts of the clinician’s examination. Such participation may be a useful source of additional information since claimants are not necessarily aware of the symptoms they manifest. However, as would be true for any clinical evaluation, involvement by others raises confidentiality issues and could engender conflict with the claimant. Family members and others can also submit written statements for consideration.5 PTSD evaluations may be stressful because they involve discussion of the traumatic event. A training video produced for VA clinicians therefore suggests that claimants be advised to bring a family member to the C&P examination to provide support before and after the assessment (VA Employee Education System, 2004). This support may be particularly important in circumstances where the veteran must travel long distances to get to a facility for examination. To help focus the examinations, the VBA provides the VHA with Automated Medical Information Exchange (AMIE) worksheets that set forth what an examination should cover according to the conditions being claimed. In particular, these worksheets are designed to ensure that a rating specialist receives all the information necessary to rate a claim. At the end of 2006 there were 57 AMIE worksheets available. The worksheets that were in use for initial and review PTSD examinations at the time this report was completed are reproduced in Appendix C. A newer system of computerized templates intended to improve the C&P process was recently put into place at some VA regional offices as part of the Compensation and Pension Examination Program. Instead of having to work from an AMIE text document, a clinician can pull up an equivalent examination template on a computer screen. Examiners are not required to use the AMIE worksheets, and, when 5 VA Form 21-4138—Statement in Support of Claim—is used for this purpose (http://www.vba.va.gov/pubs/forms/21-4138.pdf).

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PTSD Compensation and Military Service they do use them, they do not have to fill out all the fields, as the fields are not necessarily all relevant to every case. Furthermore, a rater may ask an examiner to develop specific information for particular examinations, and, where appropriate, examiners have the ability to provide information not specified in an AMIE worksheet. In addition to the examination templates, VSRs are encouraged to provide the veteran’s claim folder and to tab pertinent evidence in it for the benefit of the examiner. Thus C&P examinations differ in both scope and purpose from standard clinical examinations, as their core function is to provide VBA staff with the evidentiary foundation with which a claim for a service-connected disability can be rated or denied. Among the fundamental details necessary to decide a C&P disability claim are a determination that the veteran has a disabling condition or conditions, a determination of whether each disability is service-connected, and an evaluation of the level of disability (10 percent, 20 percent, etc.) to be assigned for each service-connected disability. While C&P exams generate information that is useful in offering referrals or making medical decisions, they are not made part of a veteran’s clinical record and do not play a role in the delivery of VA clinical services. Treatment referrals may be offered as part of a separate diagnostic evaluation made in a clinical (typically, VHA) context. As the C&P Service Clinician’s Guide states: The purpose of the C&P exam is to provide very specific information in order to ensure a proper evaluation of the claimed disability rather than to provide medical treatment. A treatment examination is written for clinicians to understand, but a compensation and pension examination is written for RVSRs, lawyers, and judges to understand (DVA, 2002, p. 10). Examinations for disability compensation present special challenges for clinicians no matter what the setting. At the core of these is the potential for conflict between the clinician’s role as a patient advocate and his or her responsibility as an examiner to render an impartial evaluation of a claimant’s condition. Forensic examination requires a fundamentally different relationship with the subject than is formed in a therapeutic situation. Greenberg and Shuman (1997) identify several salient distinctions: The therapist is a care provider and usually supportive, accepting, and empathic; the forensic evaluator is an assessor and usually neutral, objective, and detached as to the forensic issues (p. 53). [A] therapist must be competent in the clinical assessment and treatment of the patient’s impairment. In contrast, a forensic evaluator must be competent in forensic evaluation procedures and psycholegal issues relevant to the case (p. 53).

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PTSD Compensation and Military Service In most instances, it is not realistic, nor is it typically the standard of care, to expect a therapist to be an investigator to validate the historical truth of what a patient discusses in therapy…. In contrast, the role of a forensic examiner is, among other things, to offer opinions regarding historical truth and the validity of the psychological aspects of … claims. The accuracy of this assessment is almost always more critical in a forensic context than it is in psychotherapy (p. 53). [T]he psychotherapeutic process is rarely adversarial…. Forensic evaluation, although not necessarily unfriendly or hostile, is nonetheless adversarial in that the forensic evaluator seeks information that both supports and refutes the [claimant’s] assertions (p. 54). Therapy is intended to aid the person being treated…. Forensic examiners strive to gather and present objective information that may ultimately aid a trier of fact … to reach a just solution … (p. 54). The VASRD process introduces additional complicating factors. Examination parameters are set by raters who are required to tailor claims to meet VASRD criteria and requirements. However, these may not represent the current state of the medical science6 and may thus compel clinicians to use tools or techniques that they consider to be substandard. Further, C&P examinations may be conducted by clinicians who have a prior or future therapeutic relationship with the claimant. In a 2004 VA instructional video on the PTSD C&P process, a senior VA medical officer indicated that this created a potential conflict of interest and might lead veterans to be less than forthcoming with clinicians providing care to them (VA ESS, 2004). C&P EXAMINATION ISSUES VA identified several issues related to the conduct of C&P exams that were of particular interest: the use of the GAF in examinations, the separation of symptoms among PTSD and comorbid disorders, the time between the stressor and the appearance of symptoms related to it, and the value of standardized testing in the conduct of examinations. These are addressed below. Use of the GAF in Compensation and Pension Examinations The charge to the committee indicated that the role of the GAF score in evaluating PTSD was an area of great interest (Szybala, 2006). It noted that some advocates have argued for an increased dependence on the GAF score 6 One example of this—the use of the GAF in C&P examinations—is discussed later in this chapter.

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PTSD Compensation and Military Service in evaluating PTSD and requested input on the issue. Raters may request that a clinician provide a GAF score for use in claims evaluation and the Board of Veterans’ Appeals7 may require one as part of a remand of a rating decision. In addition, VHA Directive 97-059 requires clinicians to record “at least one GAF score … reflecting the ‘current level of functioning’ for each veteran patient seen at any VHA mental health inpatient or outpatient setting” (VHA, 1997). The GAF was developed for Axis V of the Diagnostic and Statistical Manual of Mental Disorders III, Revised (DSM-III-R)8 in order to provide a general measure of symptomatic and psychosocial function. It was derived by making minor modifications to the Global Assessment Scale (GAS), which itself was developed in 1976 by Endicott and colleagues as a component of the Schedule for Affective Disorders and Schizophrenia, a structured interview designed for research studies of those disorders. Since the GAF was introduced to the DSM system through DSM-III-R, it has been carried forward to the most recent edition, DSM-IV-TR (APA, 2000). The Best Practice Manual developed by VA practitioners identified five issues concerning its use: GAF reliability and training; GAF accuracy and clinician-rater biases; resolution of the GAF scale; GAF accuracy with respect to PTSD and comorbidity; and assigning separate GAFs by condition9 (Watson et al., 2002). One of the many problems with the GAF is that because it was derived from a scale used for the study of affective disorders and schizophrenia, it is very difficult to use as a general measure of symptomatic and psychosocial function across a broad range of psychiatric conditions. The scale ranges from 1 to 100, with 100 representing superior mental health and psychosocial function and 0 representing the worst possible, and with individual anchors defined at 10-point increments. The anchors for the most severe levels (0-40) are almost universally drawn from the symptoms of mood disorder or schizophrenia, reflecting the influence of the GAS. Only in the 40-50 range are symptoms from other disorders mentioned (suicidal ideation, severe obsessional rituals, frequent shoplifting). In the 50-60 range, 7 The Board of Veterans’ Appeals—a part of the VA—is responsible for reviewing challenges to benefit claims determinations made by local VA offices and issuing decisions on appeals. Their decisions can be appealed to the U.S. Court of Veterans’ Appeals. Figure 5-2 delineates the steps in the benefits application and appeals process. 8 The DSM uses a multiaxial approach to diagnosis. Axis V is the level of functioning. 9 The last two of these issues are addressed more generally in the following section on separation of symptoms of comorbid disorders.

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PTSD Compensation and Military Service symptoms from schizophrenia reemerge, along with a reference to panic disorder to give the appearance of breadth (flat affect and circumstantial speech, occasional panic attacks). In the 60-70 range, the symptoms are those of mood disorder (depressed mood and mild insomnia). In short, the GAF anchors are conceptually relatively weak. They attempt to offer some breadth of coverage, but in fact they lack adequate reference to the broad range of psychiatric symptoms. Several studies have examined the psychometric properties of the GAF, and results indicate that reliability is a major concern. A review of the literature on nonveteran psychiatric samples concluded that the reliability of the GAF ranges from weak to exceptional (Burlingame et al., 2005). Among a sample of patients with diagnoses of depression and anxiety, for example, reliability was better for depression than for anxiety (r=0.69–0.73 versus r=0.41–0.57) (Svanborg and Asberg, 1994). Ideally, if a scale such as the GAF is to be used as a benchmark for making disability evaluations in veteran populations, it should first demonstrate good interrater and test-retest reliability across VA health-care settings and also across diagnoses that commonly present for compensation evaluation. However, data establishing these characteristics are not available. The fact that disability compensation awards for mental disorders vary markedly10 suggests, in part, that the reliability of the GAF in the VA health system is very weak. And reliability is a basic instrument property that the GAF should exhibit before one can have confidence in its use in assessing functional impairment specific to PTSD. Another weakness of the GAF is that it combines symptom levels with assessment of function and does not allow for a separation of these two areas. Furthermore, the GAF does not address some areas of functioning for which evaluation is required in order to obtain a full assessment of disability, including activities of daily living (physical restrictions), quality of life, symptom burden, and self-assessed health. Among the widely used scales designed to assess these areas11 are: Sheehan Stress Vulnerability Scale (symptom burden); the Impact of Events Scale–Revised, PTSD Checklist (PCL)-17, and Short PTSD Rating Interview (symptom levels); 10 A 2005 report on compensation by the VA Office of the Inspector General found that mental disorders had the fourth highest variability rate of the 15 body systems studied and that the difference in the proportion of PTSD cases rated at 100 percent was “a primary factor contributing to the variance in average annual compensation payments by state” (DVA, 2005). 11 PTSD: Diagnosis and Assessment (IOM, 2006) and various review articles (e.g., Connor et al., 2006) examine screening tools and diagnostic instruments in greater detail. Lerner (2006) has provided a compilation of the instruments used in studies indexed in the Published International Literature on Traumatic Stress (PILOTS) database.

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PTSD Compensation and Military Service Clinician-Administered PTSD Scale (symptoms and diagnosis); SF-36 and its shorter versions (function across several domains); and WHODAS12 6-, 12-, or 36-item versions (assessment of function). PTSD: Diagnosis and Assessment (IOM, 2006) and various review articles (e.g., Connor et al., 2006) examine screening tools and diagnostic instruments in greater detail. Lerner (2006) has provided a compilation of the instruments used in studies indexed in the PILOTS database. The committee concludes that the GAF score has limited usefulness in the assessment of the level of disability for PTSD compensation. The score is only marginally applicable to PTSD because of its emphasis on the symptoms of mood disorder and schizophrenia and its limited range of symptom content. The social and functional domains of the score provide some information, but if these are the sole domains of interest, better measures of them exist. Importantly, the GAF has not to date been shown to have good psychometric properties (i.e., good reliability) within the VA system and, particularly, within samples of veterans suffering from PTSD. Summary Observations and Recommendations The committee is aware that the GAF is widely used within the VBA and VHA systems and that it may not be possible to quickly implement changes regarding it without disrupting the delivery of PTSD services. It thus recommends that—in the short term—VA seek to make certain that its mental health professionals are well informed about the uses and limitations of the GAF. This includes, at minimum, system-wide training aimed to ensure that GAF scoring is conducted in a consistent and uniform manner and periodic, mandatory retraining to minimize drift and variation in scoring over time and between facilities. In the longer term, the committee recommends that VA identify and implement an appropriate replacement for the GAF in disability ratings of PTSD: one or more measures that focus on the symptoms of PTSD used to define the disorder and on the other domains of disability assessment. As noted above, there are several scales that have useful properties and should be considered. The committee does not believe it is appropriate to offer any recommendations regarding which measure or measures should be adopted instead of or, potentially, in addition to the GAF. The scientific literature offers no firm guidance on this topic and it is beyond the scope of this com- 12 The World Health Organization Disability Assessment Schedule, information on which is available at http://www.who.int/icidh/whodas/index.html.

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PTSD Compensation and Military Service mittee to perform the detailed evaluation needed. Any recommendations should be based on a careful consideration of reliability and validity data gathered from VA’s applicant and beneficiary populations. The committee recommends that VA facilitate the evaluation of alternatives and formulation of recommendations. Separation of Symptoms of Comorbid Disorders The VA requested that the committee address whether there is a scientific basis for separating out symptoms of PTSD from those of another existing mental disorder and, if so, how this is done and how reliable such a separation is. The VA stated that clinicians conducting C&P exams have indicated that it can be difficult and speculative to try to separate the symptoms of PTSD from those of others disorders, such as major depression. Separating symptoms of comorbid disorders is required under the Schedule for Rating Disabilities (38 CFR Part 4). According to the schedule, a combined rating is to be assigned when more than one service-connected disability is diagnosed. Disabilities should “be arranged in the exact order of their severity, beginning with the greatest disability,” and the combined rating is determined according to a specified protocol (§4.25).13 The clinician’s role is to provide the information used by the rater to make these assignments, and this information may include the partitioning of an overall GAF score into disorder-specific scores. The details about partitioning the GAF score may be requested by a rater or required under a Board of Veterans’ Appeals remand of a rating decision. As discussed in Chapter 3 and in PTSD: Diagnosis and Assessment (IOM, 2006), PTSD is subject to high rates of psychiatric comorbidity, with some studies finding that more than 80 percent of people who have been diagnosed with PTSD also have a major depressive or other psychiatric disorder (Black et al., 2004; Kessler et al., 1995). Common comorbid conditions include a range of mood, dissociative, anxiety, substance-related, and personality disorders (APA, 2004). Making psychiatric diagnoses can be difficult because certain types of symptoms—particularly those involving depression and anxiety—are very common and are even on a continuum with normality. It is the clinician’s responsibility to distinguish between the presence of symptoms and the presence of a discrete disorder and to properly account for the fact that some symptoms overlap across disorders, such as when mood and anxiety symptoms co-occur in PTSD and depression. When diagnostic criteria were first developed within the DSM system, 13 The topic of combined ratings is also discussed in A 21st Century System for Evaluating Veterans for Disability Benefits (IOM, 2007).

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PTSD Compensation and Military Service the system was designed to avoid multiple diagnoses and instead foster the identification of the one or two disorders that were most prominent. This approach was implicitly, and often explicitly, hierarchical, and intentionally prevented the diagnosis of some disorders as comorbid. If a patient had prominent symptoms of schizophrenia, for example, but also had some symptoms of mood disorder, only one diagnosis would be made. This changed with DSM-III, as it recognized that some conditions were likely to be comorbid with other conditions. In such cases, clinicians were encouraged to make both diagnoses. When PTSD was introduced as a “new” diagnosis in DSM-III (actually not new, since it was in DSM-I as gross stress reaction), it was one of the diagnoses recognized as likely to be comorbid with other disorders, particularly depression. DSM-III explicitly stated that if depressive disorder occurs in conjunction with PTSD, multiple diagnoses should be made. This recommendation was carried forward in all subsequent editions of DSM and is present in the most recent, DSM-IV-TR (APA, 2000). Therefore, the current American nosological system explicitly recognizes that PTSD may be comorbid with other conditions and indicates that when this occurs, two or more diagnoses should be made. This is completely consistent with the VA disability system. There is a scientific—that is, empirically studied—basis for defining PTSD and depression (or other conditions that may be comorbid with PTSD) as discrete disorders. Evidence for this basis can be found, for instance, in Volume IV of the DSM-IV Sourcebook (Widiger et al., 1998), which reports much of the supporting data for the reliability and validity of the various diagnostic categories in DSM-IV. The diagnosis of lifetime PTSD, for example, has a kappa coefficient of 0.85, indicating good reliability (Kilpatrick et al., 1998). Although clinicians conducting C&P examinations have described having difficulty in dealing with comorbid mental disorders such as PTSD and depression, a review of the current DSM diagnostic criteria indicates that only a few symptoms of these two disorders overlap. In particular, the three symptoms listed in Table 4-2 below are similar but not identical in PTSD and major depression, and they are generally different within the context of the other symptoms of the disorder. In general, the criteria for major depression set a higher threshold than the similar criteria for PTSD. The difficulty for clinicians lies in the additional step that the C&P process may require them to take: attribute some portion of the common symptoms of the disorders to one diagnosis and some to another, and—in particular—to assign specific GAF scores to each. The difficulty arises from the fact that clinicians don’t parse symptoms, they parse diagnoses—and there is no precedence for parsing symptoms. The Best Practice Manual

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PTSD Compensation and Military Service the onset of symptoms (each of which—intrusion, avoidance, and arousal—may have its own trajectory); the meeting of all criteria for a diagnosis of PTSD; the seeking of care; and the obtaining of a diagnosis are complex, and while they are related, they present distinct clinical and research obstacles. Determining whether an apparent case of delayed-onset PTSD is actually delayed poses challenges in both clinical and research settings. The difficulty can be attributed to several factors. Foremost, it is rare that a careful longitudinal assessment has been conducted, with data collection beginning soon after exposure to a stressor and continuing long enough to establish (1) the developmental trajectory of PTSD symptoms, (2) the documentation of diagnostic criteria, and (3) the full diagnostic assessment itself. Such information is needed to determine with some degree of confidence how long after exposure symptoms occurred, which and when individual diagnostic criteria manifested, and when and under which version of the DSM all diagnostic criteria for the PTSD diagnosis were met. Additionally, there exists a subpopulation of veterans with PTSD who do not seek mental health treatment services or compensation from the Department of Veterans Affairs at the time of the onset of the disease. When such veterans present with PTSD symptoms for treatment or compensation evaluation long after their military service, what appears to be “delayed-onset” PTSD may actually be a delayed diagnosis of a disorder that has been present for a substantial period of time. Some individuals exposed to potentially traumatic events, including war-zone stressors, develop subthreshold PTSD—that is, they meet some of the B, C, and D criteria for PTSD (see Table 3-1) but not all, or they fall one or two symptoms short of meeting full diagnostic criteria. Such individuals may not have a history of full PTSD, but with slight increases in symptomatology these cases can cross the diagnostic threshold to become full PTSD. Thus, what appears to be a new, delayed-onset case may actually be someone who for years has experienced symptoms just short of the benchmark criteria required for PTSD diagnosis and who becomes a case due to a small increase in symptomatology. There are numerous risk and protective factors that influence how exposure to war-zone and other traumatic stressors leads to the development of PTSD and thus play a role in the timing of PTSD onset. Protective factors, such as high IQ, intact cortical functioning, and strong social support networks, may originally act to suppress or mitigate PTSD symptoms but then later erode with advancing age, reducing their protective value against PTSD. Or some people with chronic PTSD and related loss of function may

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PTSD Compensation and Military Service seek compensation later in life, as their capacity for resiliency diminishes. The often-seen consequences and comorbidities of PTSD, such as substance abuse, depression, panic, and somatic symptoms, may heighten PTSD-related loss of function as they manifest and make a person more likely to seek help as time goes on. And substance abuse can represent attempts at self-medication, which may lead some to delay seeking care or compensation until much later than the actual trauma occurred. However, it should be recognized that seeking care or compensation for PTSD years after an inciting event does not necessarily mean that the disorder was of delayed onset per se. A delay in symptom-related loss of function or in an individual’s focus on and attention to symptoms and functional loss may simply be the result of various contextual life changes that occur over time. It is also the case that risk factors, such as exposure to a new traumatic stressor or vicarious exposure to stressors via extensive media coverage of new wars, can increase over time. Just as in the case of a decrease in protective factors, an increase in risk factors might be expected to produce cases of PTSD that were apparently of delayed onset but that would be more correctly viewed as subthreshold cases that were exacerbated by events that occurred long after exposure to war-zone stressors. A study of temporal trends, PTSD, and depression among combat injured soldiers (Grieger et al., 2006) found that, among a group of soldiers from the Iraq war followed for one year postinjury, the signs and symptoms of PTSD waxed and waned over that year—present at some times and not at others. Approximately 40 percent of those diagnosed with PTSD in the first seven months after serious combat injury—having been screened at one, four, and seven months—did not have the diagnosis until seven months after combat injury (Grieger et al., 2006). There are also many documented cases of even longer delays in PTSD onset. Among Israeli veterans of the 1982 Lebanon War who were followed for 20 years after the war, approximately 5 percent of those who had a combat stress reaction but no PTSD in the first three years postcombat met PTSD criteria at the 20-year follow-up. Even more striking, of those who had neither a combat stress reaction nor a diagnosis of PTSD at 1, 2, or 3 years postcombat, approximately 9 percent had PTSD 20 years postcombat (Solomon and Mikulincer, 2006). While delayed-onset PTSD was not observed in some studies of war veterans (Bremner et al., 1996; Kluznik et al., 1986), the results of other studies do support the existence of delayed-onset (onset six months or more after the traumatic event) PTSD and suggest that delayed onset may be more likely in cases caused by combat trauma than in cases caused by other traumatic exposures (Gray et al., 2004). About 22 percent of men studied in the National Comorbidity Study who had combat-related PTSD had delayed-onset PTSD (Prigerson et al., 2001). Those with PTSD related to combat trauma were about 4.5 times more likely to have a delayed type

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PTSD Compensation and Military Service of PTSD than were men with PTSD related to other types of trauma. A study of Vietnam veterans using data from the National Vietnam Veterans Readjustment Study and the Hawaii Vietnam Veterans Project (Schnurr et al., 2003) found 40 percent of the PTSD cases were delayed onset with symptoms occurring 2 or more years after entering Vietnam. Delayed-onset PTSD has also been reported among noncombat trauma-exposed populations (North et al., 2002, 2004; North, 2001). In a two-year study of 103 motor-vehicle-accident survivors, 25 had PTSD at two years (Bryant and Harvey, 2002). Of those 25, 5 of them, or 20 percent, had not met the criteria for PTSD at six months and thus had delayed–onset PTSD. In addition, of the five patients with delayed-onset PTSD, four of them had not been diagnosed with acute stress disorder in the first month after the accident (although in general they did have higher symptom levels at one month than those who never had PTSD during the period of follow-up). Roughly half (47 percent) of the PTSD cases seen in a cohort of injury admissions to the trauma service of a hospital were delayed-onset cases, where PTSD was observed at 12 months but not at 3 months (Carty et al., 2006). One study of delayed-onset PTSD after motor-vehicle accidents reported that 20 percent of the cases of the PTSD diagnosed during one year of follow-up after the accident were delayed-onset cases (Ehlers et al., 1998). Other studies of motor-vehicle-accident cohorts have reported from 8 percent (Koren et al., 2001) to 50 percent (Mayou, 1997) of the cases of PTSD being delayed onset—having been detected at four to five years after the accident but not at one year. In a long-term follow-up study of a ship disaster (Yule et al., 2000), 10 percent of PTSD cases had delayed onset of PTSD. Delayed-onset PTSD is consistently observed, albeit in a fraction of the overall PTSD cases, and data indicate that delayed-onset PTSD is perhaps more common among those exposed to war-related trauma than among those exposed to other kinds of trauma. Some cases of delayed-onset PTSD are symptomatic individuals who do not meet all the criteria of PTSD. It has been reported that subsyndromal cases often fail to meet the avoidance criteria of PTSD (McMillen et al., 2000; Dirkwagner et al., 2001; Carty et al., 2006). A number of factors have been found to be associated with the delayed onset of PTSD in previously undiagnosed individuals, including the occurrence of negative life events, decline in self-esteem, ethnicity, and negative health changes. These factors have been shown to exacerbate symptoms in those with existing PTSD as well (Port et al., 2002; Adams and Boscarino, 2006; Holloway et al., 1984; Ruzich et al., 2005). Late life brings additional challenges to the assessment, diagnosis, and trajectory of war-related PTSD (Davison et al., 2006; Owens et al., 2005). Cognitive decline, life losses, medical illness, increased feelings of powerlessness, and the psychological changes related to decreased autonomy and

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PTSD Compensation and Military Service decreased feelings of control and efficacy have all been reported as possible explanations for the increases in PTSD symptoms observed with aging. However, little empirical research addresses these issues directly. Issues related to the variation in the battlefield environment (such as the nature of threats and trauma types experienced) across different war cohorts (World War II, Korea, Vietnam, and Operation Enduring Freedom/Operation Iraqi Freedom) compound the difficulty of assessing any changes in rates of PTSD in the aging veteran. Summary Observations Based on its review, the committee concludes that the scientific literature supports the existence of a form of PTSD that manifests long after the occurrence of the stressor upon which the diagnosis is based. In addition, clinical experience indicates that some persons who are exposed to traumatic events may develop PTSD that is not recognized for an extended period of time and that others may develop some symptoms of PTSD that do not cross the diagnostic threshold to become incident cases of full PTSD until long after exposure to the stressor. The scientific literature does not identify any differences material to the consideration of compensation between these delayed-onset or delayed-identification cases and those chronic PTSD cases where there is a shorter time interval between the stressor and the onset of symptoms. The committee did not address the issue of whether there may be differences relevant to treatment decisions. FINDINGS, CONCLUSIONS, AND RECOMMENDATIONS On the basis of the review of the papers, reports, and other information presented in this chapter, the committee has reached the following findings, conclusions, and recommendations, and identified the following research needs. Findings and Conclusions The GAF score has limited usefulness in the assessment of the level of disability for PTSD compensation. The score is only marginally applicable to PTSD because of its emphasis on the symptoms of mood disorder and schizophrenia and its limited range of symptom content. There is no scientific guidance addressing the separation of symptoms of comorbid mental disorders for the purpose of identifying their relative contributions to a subject’s condition. The scientific literature supports the existence of a form of PTSD that manifests long after the occurrence of the stressor upon which the

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PTSD Compensation and Military Service diagnosis is based. In addition, clinical experience indicates that some persons who are exposed to traumatic events may develop PTSD that is not recognized for an extended period of time and that others may develop some symptoms of PTSD that do not cross the diagnostic threshold to become incident cases of full PTSD until long after exposure to the stressor. The scientific literature does not identify any differences material to the consideration of compensation between these delayed-onset or delayed-identification cases and those chronic PTSD cases where there is a shorter time interval between the stressor and the onset of symptoms. Recommendations In the short term, VA should ensure that its mental-health professionals are well informed about the uses and limitations of the GAF, that it make certain—to the extent possible—that these professionals are trained to implement the GAF in a consistent and uniform manner, and that it provide periodic, mandatory retraining to minimize drift and variation in scoring over time and across facilities. In the longer term, VA should identify and implement an appropriate replacement for the GAF: one or more measures that focus on the symptoms of PTSD used to define the disorder and on the other domains of disability assessment. The research needed to accomplish this effort should be facilitated. A national standardized training program should be developed for VA and VA-contracted clinicians who conduct compensation and pension psychiatric evaluations. This training program should emphasize diagnostic criteria for PTSD and comorbid conditions with overlapping symptoms, as set forth in the DSM. Psychological testing may be a useful adjunct to the PTSD compensation and pension examination, but the committee recommends that the decision of whether to test and of which tests are appropriate should be left to the discretion of the clinician—the person who is best able to evaluate the individual circumstances of the case. REFERENCES Adams RE, Boscarino JA. 2006. Predictors of PTSD and delayed PTSD after disaster: the impact of exposure and psychosocial resources. Journal of Nervous and Mental Disorders 194:485–493. APA (American Psychiatric Association). 1994. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). Washington, DC: APA. APA. 2000. Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR, Fourth Edition (Text Revisions). Washington, DC: APA.

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