How Much Time Should VA Allocate for PTSD C&P Exams?

Questions to Ask When Determining Time Allocation for C&P Exams for PTSD

Introduction

VA administrators must make difficult decisions regarding resource allocation. They must balance a need for high quality services with demands for productivity and timeliness. For background, see my previous post about VA Comp and Pen psychologists who must complete six C&P PTSD exams per day.

Painting - TimeVA management and others interested in this issue–time allocation for PTSD compensation and pension examinations–might want to consider answering the following questions to help inform your decision-making process and thoughts on this issue. The goal is to strike an appropriate balance between productivity expectations and a desire to provide veterans with a high quality (reliable and valid) PTSD C&P exam.

I wrote these questions in part because many VA administrators who determine time allotments for mental health C&P exams are not psychologists or psychiatrists, or, if they are, they often have little or no experience conducting these forensic evaluations of psychiatric disability, and are not familiar with the relevant empirical and professional literature.

(As always, the advice I offer here represents my personal thoughts only, and should not be construed as representing the views or opinions of the U. S. Department of Veterans Affairs.) 

Questions

VA Guidance

Should mental health C&P examiners follow the recommendations of the VA Best Practice Manual for PTSD exams?

Should mental health C&P examiners follow the recommendations of the C&P Clinicians’ Guide?

Evidence-Based Assessment (EBA)

VA has embraced Evidence-Based Treatment (EBT) for PTSD and other mental disorders.

Should principles of Evidence-Based Assessment (EBA)1 guide the development of a C&P exam protocol for PTSD and other mental disorders?

Structured Diagnostic Interviews

For Initial and Review PTSD exams, should examiners use a PTSD-specific structured diagnostic interview such as the CAPS, particularly given that the VA’s National Center for PTSD considers it to be the “gold standard” in PTSD assessment and recent VA-sponsored research on the use of the CAPS during C&P exams showed that its use leads to more accurate results?2

If so, should the results be reported in the Remarks section of the DBQ? How much time should be allowed to write up that information?

Or, despite the research evidence, should the examiner simply ask the Veteran questions about PTSD symptoms in an unstructured, free-form manner to save time, even though the results will not be as accurate?

Given that, in general, structured diagnostic interviews are more reliable (consistent across examiners) and valid (diagnostically accurate) than unstructured interviews,3 should C&P examiners use them to assess for possible mental disorders other than PTSD during all mental health C&P exams?

If so, should the results be reported in the Remarks section of the DBQ? How much time should be allowed to write up that information?

Specialized Assessment of Combat Exposure and Stress

Should examiners use specialized assessment of combat exposure (e.g., Combat Exposure Scale) during Initial PTSD exams?U.S. soldier in Korean War

If so, should the results be reported in the Remarks section of the DBQ? How much time should be allowed to write up the results?

Should examiners use specialized assessment of combat stress severity (e.g., Mississippi Scale for Combat-Related Posttraumatic Stress Disorder) during Initial PTSD exams?

If so, should the results be reported in the Remarks section of the DBQ? How much time should be allowed to write up the results?

“Psychometric assessment of PTSD provides quantitative assessment of degree of PTSD symptom severity.  Judgments about symptom severity can be made by comparing an individual’s scores against norms established on reference samples of individuals who are known to have or not have PTSD. Cutting scores have been established for the psychometric measures of PTSD recommended here, based on their high sensitivity and specificity in discriminating individuals with PTSD from those without PTSD.” – C&P Clinicians’ Guide

Collateral Interviews

If a Veteran asks the examiner to please interview his or her spouse or other family member, should the examiner refuse to do so?

Or should the examiner conduct such a collateral interview? How much time should the examiner give the spouse or family member to discuss their loved one’s symptoms and related problems?

If collateral interviews are permitted, should the results be reported in the Remarks section of the DBQ? How much time should be allowed to write up that information?

Assessment of Social & Occupational Functioning

Should examiners use empirically-validated measures of social and occupational functioning?4 If so, should the results be reported in the Remarks section of the DBQ? How much time should be allowed to write up that information?

Assessing for Under- or Over-reporting

Even though evidence exists showing that some Veterans applying for compensation benefits over-report PTSD symptoms,5 should examiners omit measures of response bias from their evaluation protocol? How about assessing for under-reporting (minimizing), which also happens with some frequency?

If measures of response bias are permitted, should the results be reported in the Remarks section of the DBQ? How much time should be allowed to write up that information?

Record Review

How much time should be allowed for review of the claims file (VBMS)?

If the claims file contains extensive medical records should they be reviewed in their entirety? How much time should be allowed?

If the claims file contains military personnel records, should the examiner review them?

Sgt. Peter Cimpoes receives Silver Star

Sgt. Peter Cimpoes receives Silver Star (2013)

Should the examiner take the time to learn how to read military personnel records and understand them?6 Should he or she consult if they are not sure? How much time should be allowed to review military personnel records?

For Review exams, should previous exam reports be reviewed? If so, how much time should be allowed?

Should medical records from private providers be reviewed? If so, how much time should be allowed?

Should the examiner read VBA Decision Letters? If so, how much time should be allowed?

Should the examiner read Board of Veterans Appeals Remand Orders? If the above reviews are permitted or expected, how much time should be allotted?

Should examiners review a Veteran’s VA electronic medical record for his or her local VAMC in CPRS? If so, how much time should be allowed?

Should the examiner also check for medical records from other VAMC’s accessible via VistaWeb and Remote Access? If so, should the examiner check for relevant medical records for as long as the Veteran has received VA medical care or only go back for a certain length of time?

Within VistaWeb or Remote Access, should the examiner review Progress Notes? Admission & Discharge Summaries? Pharmacy records? The Veteran’s Problem List?

If a VA treating clinician (e.g., primary care physician, social worker, psychiatrist, psychologist) has diagnosed a Veteran with a mental disorder, should the examiner determine the basis of the clinician’s diagnosis or simply assume that the diagnosis must be 100% accurate regardless of the evaluation procedures used?

To what extent should an examiner document the records reviewed? If documentation is recommended, how much time should be allowed?

Overall, how much time should be allocated for the review of the Veteran’s VA medical records via CPRS and, if applicable, VistaWeb or Remote Access?

Particularly for OEF/OIF Veterans, should the Veteran review DoD medical records in VistaWeb under Progress Notes? Consults (DoD Remote Data Only)? Problem List? Pharmacy? Outpatient Encounters? Expanded ADT? Discharge Summaries? Health Summaries? Histories and Questionnaires?

Although each of the above VistaWeb sections can contain pertinent information, perhaps it would be deemed too time-consuming to check all of them. If so, which ones should be omitted?

If mental health treatment is referenced in DoD electronic or paper medical records but the detailed progress notes are not included in either the C-file or VistaWeb or Remote Access or Virtual VA, should the examiner request that VBA try to obtain those records?

  • Detailed Behavioral Health records are usually kept separate from other medical records by the Army, Navy, and Air Force and are almost never sent to VBA when VBA requests a Veteran’s service medical records. [This recently changed, but only for examiners who have access to the new Joint Legacy Viewer (JVL).]

Mental Status Exam

Should the examiner conduct a mental status exam? If so, how much time should be allowed to write up that information?

Psychosocial History

Should the examiner conduct a cursory, brief, moderately detailed, or detailed developmental history? Employment history? Military service history? Substance use/abuse history? Legal history?

To what extent should the examiner ascertain the nature, frequency, and severity of social and occupational impairment when interviewing the Veteran for these social history sections?

To the extent each area is recommended, how much time should be allowed to document this information on the DBQ?

Comorbid Mental Disorders

If the referral question(s) from VBA or the Veteran’s presenting problem(s) or the Veteran’s history involve disorders or questions regarding etiology or questions regarding comorbidity, should the examiner conduct research into the scientific literature regarding those issues?7 If so, how much time should be allowed for such research?

If relevant studies are found, should they be documented (cited) in the exam report?

Critical Thinking & Effective Communication

Should the examiner spend some time exercising his or her critical thinking skills toward integrating all the relevant information in the case?

Toward analyzing the data in order to formulate a cogent response to referral questions? If so, how much time should be allowed for data integration and critical analysis?

How much time should the examiner spend writing an Opinion statement and a Rationale?

Or, since the DBQ Medical Opinion template is rarely requested, should the examiner give a formal Opinion statement and Rationale only if the DBQ Medical Opinion template is specifically requested by VBA?

Even though the courts expect examiners to provide clear, cogent reasoning for their opinions?8

Federal Rules of EvidenceSeal of the Court of Appeals for Veterans Claims

Should the examiner pay any heed to the Court of Appeals for Veterans Claims reference to Federal Rules of Evidence 702 with regard to the probative value of an examiner’s opinion and rationale?9

Peer Review

Should the examiner consider asking a colleague to peer review some of his or her exam reports?

Differential Effects of Multiple Conditions

If a Veteran suffers from more than one mental disorder, should the examiner offer an opinion regarding the relationship between the disorders, e.g., whether or not a depressive disorder is secondary to PTSD? If so, how much time should be allowed to write such an opinion and rationale?

Specialty Guidelines for Forensic Psychologists

Should psychologist examiners be familiar with the Specialty Guidelines for Forensic Psychologists and generally seek to follow those Guidelines as long as they do not conflict with VA policy? For example:

2.05 Knowledge of the Scientific Foundation for Opinions and Testimony

Forensic practitioners seek to provide opinions and testimony that are sufficiently based upon adequate scientific foundation, and reliable and valid principles and methods that have been applied appropriately to the facts of the case.

9.02 Use of Multiple Sources of Information

Forensic practitioners ordinarily avoid relying solely on one source of data, and corroborate important data whenever feasible (American Educational Research Association, American Psychological Association, & National Council on Measurement in Education, in press). When relying upon data that have not been corroborated, forensic practitioners seek to make known the uncorroborated status of the data, any associated strengths and limitations, and the reasons for relying upon the data.

10.01 Focus on Legally Relevant Factors

Forensic examiners seek to assist the trier of fact to understand evidence or determine a fact in issue, and they provide information that is most relevant to the psycholegal issue. In reports and testimony forensic practitioners typically provide information about examinees’ functional abilities, capacities, knowledge, and beliefs, and address their opinions and recommendations to the identified psycholegal issues.

10.06 Documentation and Compilation of Data Considered

Forensic practitioners are encouraged to recognize the importance of documenting all data they consider with enough detail and quality to allow for reasonable judicial scrutiny and adequate discovery by all parties.

11.03 Disclosing Sources of Information and Bases of Opinions

Forensic practitioners are encouraged to disclose all sources of information obtained in the course of their professional services, and to identify the source of each piece of information that was considered and relied upon in formulating a particular conclusion, opinion or other professional product. Consistent with relevant law and rules of evidence, when providing professional reports and other sworn statements or testimony, forensic practitioners strive to offer a complete statement of all relevant opinions that they formed within the scope of their work on the case, the basis and reasoning underlying the opinions, the salient data or other information that was considered in forming the opinions, and an indication of any additional evidence that may be used in support of the opinions to be offered.

American Academy of Psychiatry and the Law Evaluation Guidelines

Should psychiatrist and psychologist examiners be familiar with the American Academy of Psychiatry and the Law Guidelines for Forensic Evaluation of Psychiatric Disability and generally seek to follow those Guidelines as long as they do not conflict with VA policy? For example:

“… psychological and neuropsychological tests can be valuable sources of information when conducted in conjunction with the psychiatric interview, examination of records, and review of information from collateral sources.”

“[The psychiatrist should review] evaluations performed by other mental health experts as well as those from other nonpsychiatric physicians can help determine the consistency of an individual’s reports and allow comparison of diagnostic formulations. Evaluations that include psychological and neuropsychological testing can be helpful in establishing the validity of self-reports, clinical symptom patterns, and personality features of the individual.”

“Collateral information is an essential component of a comprehensive disability evaluation. Objective evidence of a psychiatric disorder and actual impairment is necessary to reach a conclusion that a psychiatric impairment is present.”

Institute of Medicine Recommendations

Should administrators take seriously the recommendations of the Institute of Medicine in their study of C&P exams for PTSD? For example:PTSD_Compensation_and_Military_Service

“Many of the problems and issues identified by the committee in previous chapters can be addressed by consistently allocating and applying the time and resources needed for a thorough PTSD C&P clinical examination. This measure will facilitate:

  • more comprehensive and consistent assessment of veteran reports of exposure to trauma;
  • more complete assessment of the presence and impact of comorbid conditions;
  • the conduct of standardized psychological testing where appropriate;
  • more accurate assessment of the social and vocational impacts of identified disabilities;
  • evaluation of any suspected malingering or dissembling using multiple strategies including standardized tests, if appropriate, and clinical face-to-face assessment;
  • more detailed documentation of the claimant’s condition to inform the rater’s decision (and thus potentially lead to better and more consistent decisions); and
  • an informed, case-specific determination of whether reexamination is appropriate and, if so, when.”

 

 

Footnotes
1. Hunsley, J., & Mash, E. J. (2007). Evidence-based assessment. Annual Review of Clinical Psychology, 329-51.

2. Speroff, T., Sinnott, P., Marx, B. P., Owen, R., Jackson,  J. C., Greevy, R., Sayer, N., Murdoch,  M., Shane, A. C., Smith, J., Alvarez, J., Nwosu, S. K., Keane, T., Weathers, F., Schnurr, P. A., Friedman, M. J. (2012). Impact of evidence-based standardized assessment on the disability clinical interview for diagnosis of service-connected PTSD: A cluster-randomized trial. Journal of Traumatic Stress, 25(6), 607-615. doi:10.1002/jts.21759

3. Kashner, T. M., Rush, A. J., Surís, A., Biggs, M. M., Gajewski, V. L., Hooker, D. J., Shoaf, T., & Altshuler, K. Z. (2003). Impact of structured clinical interviews on physicians’ practices in community mental health settings. Psychiatric Services, 54(5), 712-718.

Miller, P. R., Dasher, R., Collins, R., Griffiths, P., & Brown, F. (2001). Inpatient diagnostic assessments: 1. accuracy of structured vs. unstructured interviews. Psychiatry Research, 105(3), 255-264. 

Miller, P. R. (2001). Inpatient diagnostic assessments: 2. Interrater reliability and outcomes of structured vs. unstructured interviews. Psychiatry Research, 105(3), 265–271. doi:10.1016/S0165-1781(01)00318-3

Rogers, R. (2001). Handbook of Diagnostic and Structured Interviewing. New York, NY: Guilford Press.

Rogers, R. (2003). Standardizing DSM-IV Diagnoses: The Clinical Applications of Structured Interviews. Journal of Personality Assessment, 81(3), 220-225.

Segal, D. L., & Coolidge, F. L. (2007). Structured and semistructured interviews for differential diagnosis: Issues and applications. In M. Hersen, S. M. Turner, D. C. Beidel, M. Hersen, S. M. Turner, D. C. Beidel (Eds.) , Adult psychopathology and diagnosis (5th ed.) (pp. 78-100). Hoboken, NJ US: John Wiley & Sons Inc.

Shear MK; Greeno C; Kang J; Ludewig D; Frank E; Swartz HA; Hanekamp, M. (2000). Diagnosis of nonpsychotic patients in community clinics. The American Journal Of Psychiatry, 157(4), 581-587.

Sheehan, D. V., LeCrubier, Y., Sheehan, K. H., Amorim, P., Janavs, J., Weiler, E., . . . Dunbar, G. C. (1998). The Mini-International Neuropsychiatric Interview (M.I.N.I.): The development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. Journal of Clinical Psychiatry, 59(Suppl 20), 22–33.

Suppiger, A., In-Albon, T., Hendriksen, S., Hermann, E., Margraf, J., & Schneider, S. (2009). Acceptance of structured diagnostic interviews for mental disorders in clinical practice and research settings. Behavior Therapy, 40(3), 272-279.

4. Rodriguez, P., Holowka, D., & Marx, B. (2012). Assessment of posttraumatic stress disorder-related functional impairment: a review. Journal Of Rehabilitation Research And Development, 49(5), 649-665.

5.Calhoun, P., Earnst, K., Tucker, D., Kirby, A., & Beckham, J. (2000). Feigning combat-related posttraumatic stress disorder on the personality assessment inventory. Journal Of Personality Assessment, 75(2), 338-350

Dalton, J. E., Tom, A., Rosenblum, M. L., Garte, S. H., & Aubuchon, I. N. (1989). Faking on the Mississippi Scale for Combat-Related Posttraumatic Stress Disorder. Psychological Assessment: A Journal of Consulting and Clinical Psychology, 1(1), 56-57.

Freeman, T., Powell, M., & Kimbrell, T. (2008). Measuring symptom exaggeration in Veterans with chronic posttraumatic stress disorder. Psychiatry Research, 158(3), 374-380.

Frueh, B., Elhai, J., Gold, P., Monnier, J., Magruder, K., Keane, T. & Arana, G. (2003). Disability compensation seeking among Veterans evaluated for posttraumatic stress disorder. Psychiatric Services, 54(1), 84–91.

Frueh, B. C., Gold, P. B., & de Arellano, M. A. (1997). Symptom overreporting in combat Veterans evaluated for PTSD: Differentiation on the basis of compensation seeking status. Journal of Personality Assessment, 68, 369–384

Geraerts, E., Kozaric-Kovacic, D., Merckelbach, H., Peraica, T., Jelicic, M., & Candel, I. (2009). Detecting deception of war-related posttraumatic stress disorder. Journal of Forensic Psychiatry & Psychology, 20(2), 278-285

Gerardi, R. J., Blanchard, E. B., & Kolb, L. C. (1989). Ability of Vietnam Veterans to dissimulate a psychophysiological assessment for post-traumatic stress disorder. Behavior Therapy, 20(2), 229-243

McCaffrey, R. J., & Bellamy-Campbell, R. (1989). Psychometric detection of fabricated symptoms of combat-related post-traumatic stress disorder: A systematic replication. Journal of Clinical Psychology, 45(1), 76-79

Orme, D. R. (2012). Diagnosing PTSD: Lessons from neuropsychology. Military Psychology, 24(4), 397-413.

Smith, D. W., & Frueh, B. C. (1996). Compensation seeking, comorbidity, and apparent symptom exaggeration of PTSD symptoms among Vietnam combat Veterans. Psychological Assessment, 8, 3–6

Sparr, L. & Pankratz, L. D. (1983). Factitious posttraumatic stress disorder. The American Journal of Psychiatry, 40(8), 1016–1019.

6. Moering, R. G. (2011). Military service records: Searching for the truth. Psychological Injury and Law, 4(3-4), 217-234. doi:10.1007/s12207-011-9114-3

7. The examiner may also have an obligation to conduct research in the medical literature depending on the evidence in the record at the time of examination.” – Jones v. Shinseki, 23 Vet. App. 382 at 391 (2010)

8. “That the medical expert is suitably qualified and sufficiently informed are threshold considerations; most of the probative value of a medical opinion comes from its reasoning. Neither a VA medical examination report nor a private medical opinion is entitled to any weight in a service connection or rating context if it contains only data and conclusions. … It is the factually accurate, fully articulated, sound reasoning for the conclusion … that contributes probative value to a medical opinion.” – Nieves-Rodriguez v. Peake, 22 Vet. App. 295 at 306 (2008)

9. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 at 304 (2008)