This post describes a comprehensive, evidence-based assessment (EBA) protocol for VA compensation and pension examinations (C&P exams) for combat-related posttraumatic stress disorder (PTSD). I also estimate the average amount of time required for each component of this proposed evaluation protocol. [This recommended assessment protocol is not an official VA document, and should not be construed to represent the views or opinions of the Department of Veterans Affairs or the U.S. government.]
Principles of evidence-based assessment (EBA) guided the development of this exam protocol. As defined by Hunsley & Mash (2007):
Evidence-based assessment (EBA) emphasizes the use of research and theory to inform the selection of assessment targets, the methods and measures used in the assessment, and the assessment process itself.
Compensation and pension examiners (psychologists and psychiatrists), whether they are VA employees or working under contract for a third-party company (which in turn, contracts with the VA to conduct C&P exams) should use an evidence-based assessment (EBA) protocol for PTSD exams, just as the VA has—for good reasons—led the way in promoting evidence-based psychotherapy (EBP) for PTSD.
Recommended EBA Protocol for PTSD Exams
Here are the recommended components for a thorough, evidence-based assessment (EBA) of PTSD for VA compensation and pension exams:
* A structured diagnostic interview for the assessment of mental disorders other than PTSD (e.g., SCID or SADS) – 45 minutes. Structured diagnostic interviews are more reliable (consistent across examiners) and valid (diagnostically accurate) than unstructured interviews.
* A PTSD-specific structured diagnostic interview (e.g., CAPS) – 45 minutes. In addition to its well-established reliability and validity, use of the CAPS leads to “more complete, consistent, and accurate assessments” according to research conducted specifically on C&P PTSD exams.
* Specialized assessment of combat exposure (e.g., Combat Exposure Scale) and combat stress severity (e.g., Mississippi Scale for Combat-Related Posttraumatic Stress Disorder) – 5 minutes.
* Collateral interviews (e.g., with the veteran’s spouse) – 30 minutes. Collateral interviews are recommended in the Specialty Guidelines for Forensic Psychologists, published by the American Psychological Association and the Guidelines for Forensic Evaluation of Psychiatric Disability, published by the American Academy of Psychiatry and the Law.
* Reliable and valid assessment of social and occupational functioning (e.g., Inventory of Psychosocial Functioning) – 30 minutes. Research shows that use of a reliable and valid measure of social/occupational impairment during C&P exams leads to “more complete, consistent, and accurate assessments.”
* Assessment of possible response bias – 30 minutes. Abundant evidence exists showing that veterans applying for compensation tend to over-report PTSD symptoms. In addition, some Veterans under-report symptoms and functional impairment.
* Experts recommend a multi-method approach to the assessment of dissimulation, including record review, collateral interviews, standardized psychometric tests, open-ended interview questions, structured diagnostic interviews, and use of instruments specifically designed to detect significant exaggeration/feigning.
Regarding psychological testing specifically, it is important for examiners to familiarize themselves with the symptom overreporting literature, since a good portion of such overreporting among PTSD patients is due to generalized distress, and not to significant exaggeration, feigning, or malingering.
Note that research indicates that without employing specialized methods, mental health professionals are not able to detect deception at much better than chance levels and are not able to detect malingering with any reasonable accuracy, despite being confident in their ability to do so.
If you believe you can accurately identify significant exaggeration or feigning without a systematic, multi-method assessment, even after reviewing the literature on the topic, I encourage you to ask if you might have fallen under the spell of the overconfidence bias.
* Claims file (C-file) review (VBMS) – 40 minutes. VBMS is the new computer-based claims file system developed by the Veterans Benefits Administration (VBA). All documents that VBA previously stored in paper files, have been scanned for viewing via a secure computer connection.
* Medical record review – 40 minutes
* Mental status exam – 10 minutes.
* Psychosocial history – Interview of the veteran regarding developmental history, alcohol/other drug use, legal issues, social functioning, occupational history and functioning, etc. – 30 minutes.
* Literature search and review of relevant research – 10 minutes. Keeping up with the scientific literature in one’s discipline is not only sound professional practice, the courts expect it as well:
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).
* Integration of data and case analysis – 15 minutes. Applying one’s critical thinking skills to the case.
* Writing the report – 90 minutes. Effectively communicating one’s conclusions and reasoning.
The courts have emphasized that an examiner’s reasoning contributes significantly to the probative value of his or her opinion. Therefore, one cannot underestimate the importance of composing a cogent, persuasive report
In addition, the courts have signaled that submission of interrogatories to the examiner is a distinct possibility in the future. Therefore, to the extent that you anticipate and answer questions about your exam results and the reasons for your opinion, the less likely you will have to answer such interrogatories or the better prepared you will be for such post-exam inquiries from veterans’ attorneys.
Total Time Required
The average time required for this recommended EBA protocol for VA C&P PTSD exams is 420 minutes (seven hours).
I should note that this model for VA compensation and pension PTSD exams is consistent with the recommendations of the Institute of Medicine in their study of C&P exams for PTSD:
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.
The above evidence-based assessment approach also should meet the expectations of the courts:
We believe that fulfillment of the statutory duty to assist here includes the conduct of a thorough and contemporaneous medical examination, one which takes into account the records of prior medical treatment, so that the evaluation of the claimed disability will be a fully informed one. (Green v. Derwinksi, 1 Vet. App. 121 at 125, 1991).