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Robert G. Moering, Psy.D.
Licensed Psychologist
James A. Haley VAMC
MISSION STATEMENT
The VHA: "Honor America's Veterans by
providing exceptional health care that improves
their health and well-being"
No official mission statement for C&P exams
"To provide evidence-based mental health assessments of
veterans claiming service-connected disabilities in order to
help the Veterans Benefits Administration make accurate
benefit determinations.“
Clearly, these missions are not the same
Forensic refers to professional practice by any
psychologist who applies the scientific,
technical, or specialized knowledge of
psychology to the law to assist in addressing
legal, contractual, or administrative matters.
Clinical refers to professional practice by any
psychologist who applies the scientific,
technical, or specialized knowledge of
psychology to address treatment issues.
Forensic: Evidenced Based and Multi-Method
Review of Records
Collateral Information usually obtained
Psychological testing typically administered
Usually One visit
Clinical: Self Reports
May or may not review records
May or may not obtain collateral information
Psychological testing typically not done
Multiple visits
Are C&P Exams Forensic Exams?
Are C&P exams intended to help answer legal or
clinical questions?"
C&P exams help answer legal (not clinical) Qs
Medical Opinions requested come from U.S.
statutes, regulations, and case law.
I.e., Is a veteran's stressor is related to "the
veteran’s fear of hostile military or terrorist
activity."
This question did not arise because of clinical
concerns but because of a change in the Federal
Regulations governing these exams. (1)
Forensic Guidelines
Professional Organizational Guidelines:
American Academy of Psychiatry and Law's
"Practice Guideline for the Forensic Evaluation of
Psychiatric Disability”
American Psychological Association’s “Specialty
Guidelines for Forensic Psychology,”
The Practice Guideline (2) highlights some of the
differences between clinical and forensic
evaluations
Opinions are impartial, fair, independent
Weigh all data, unbiased, avoid partisan
presentation of data
Why not use the Treatment Notes?
Providing forensic and therapeutic services
impairs objectivity
Treatment providers do not access c-file records
Treatment providers rely entirely on veteran’s
self-reported history
e.g., Veteran seen for TBI, PTSD secondary to
combat in Iraq; military personnel records and
service medical records clearly show he never
deployed from MacDill AFB
“Pt. states he killed over 600 VC as an infantryman
and was awarded a Bronze Star w/V for his
heroism.”
Reality?
Treatment Notes : Don’t Believe
Everything You Read
Veteran 100% SC
Seeking A/A
Claims wheelchair bound, Tx notes indicate same
Claims unable to transfer on his own, Tx notes
indicate same
Claims unable to move his legs, Tx notes indicate
same
C&P Examiners are not mind readers
The 2507 request is paramount to getting it
right
“Please opine if the [insert condition here] is
related to his [insert condition here].”
“PTSD due to fear of military or hostile terrorist
acts” versus “PTSD or any acquired psychiatric
disorder”
Identify specific records in c-file you want the
examiner to comment on
don’t put “see c-file” or “note is tagged with sticky note”
Specify: “Dr. X note dated 3/3/10” CPRS note dated
1/1/11”
What Did We Review?
Remand cases require the examiner to
thoroughly review the c-file and BVA Remand
Imperative to note the review of the c-file
Mental Health Exams require C-File review
Initial and Review
CPRS Records (Local and Remote)
Example: CPRS records including remote data from
Orlando and Atlanta, service medical records, military
personnel records, veteran’s lay statements, BVA
Remand, 6 volumes of c-file records, collateral
statements from XX and XX, relevant research (see
references below), psychological test results
Structured Interviews
Current research clearly shows the use of structured
interviews are significantly and statistically superior in
assessing for PTSD and other disorders versus an
unstructured or semi-structured interview. (3-9)
Clinician-Administered PTSD Scale
Developed by the VAs National Center for PTSD
Recommended in “Best Practice Manual” (2)
Easy to use - CAPS interview form, manual, and
training videos are all available at no charge:
(http://vaww.ptsd.va.gov/Assessment.asp).
Assess symptom frequency and severity
Determine how symptoms interfere with
functioning (important for rating purposes)
More reliable and valid diagnostic decisions
CAPS
Nine scoring methods, or rules
Each of the rules differs with regard to their
sensitivity, specificity, and the extent to which
they can be considered lenient or strict with
regard to the ultimate diagnostic decision.
The "F1/I2" scoring rule is the most lenient of
the nine possible scoring rules. (10)
This scoring rule gives the veteran the greatest
degree of benefit of doubt.
Other Interview Questionnaires
Structured Clinical Interview for DSM-IV (SCID)
Cyclothymic Disorder
Agoraphobia Without History of Panic Disorder
Social Phobia / Specific Phobia
Generalized Anxiety Disorder
Somatization Disorder / Undifferentiated Somatoform
Hypochondriasis / Body Dysmorphic Disorder
Anorexia Nervosa / Bulimia Nervosa
Schedule for Affective Disorders & Schizophrenia
(SADS) (semi-structured)
MINI International Neuropsychiatric Interview
(M.I.N.I.) (semi-structured)
VA Developed Measures of Combat
Combat Exposure Scale (CES)
7 item assessing combat experiences
0-8 Light
9-16 Light to Moderate
17-24 Moderate 25-32 Moderate to Heavy
33–41 Heavy
Example Items:
Were you ever under enemy fire?
How often did you fire round at the enemy?
How often were you in danger of being injured or
killed (i.e., pined down, overrun, ambushed, near
miss, etc.)?
Mississippi Combat Stress Scale (MISS)
35 items assessing PTSD-related symptoms
Self-rating scale from 1-5
Example Items:
If something happens that reminds me of the
military, I become very distressed and upset.
Before I entered the military, I had more close
friends than I have now.
I am able to get emotionally close to others.
Unexpected noises make me jump.
I feel comfortable when I am in a crowd.
Problems with CES and MISS
Studies have shown that face-valid measures
such as the Mississippi Scales are ineffective in
distinguishing between individuals with genuine
PTSD and persons who simulate PTSD (11)
MST
Most challenging type of examination
Victims are reluctant to disclose
More often than not the assault not reported
MST cases require special care to provide the most
comprehensive examination possible.
The Basic MST Opinion Request
“Please review the veteran’s entire claims file
and medical records and provide an opinion as
to whether it is at least as likely as not that the
veteran’s records support the occurrence of a
military personal trauma/sexual assault.”
Note: Personal assaults may be classified as a nonsexual trauma (e.g., physical assault, domestic
battery, robbery, and etc) or sexual trauma (e.g.,
rape, stalking, sexual harassment).
Court’s Influence
Wood v. Derwinski (1991) - VA is not bound to accept
a veteran’s uncorroborated account of what
happened in service, regardless of whether a social
worker or psychiatrist believes her or him.
Moreau v. Brown (1996) and Dizoglio v. Brown (1996)
"credible supporting evidence" = Vet’s testimony, by
itself, can’t establish the noncombat stressor.
Doran v. Brown (1994) - "the absence of
corroboration in the service records, when there is
nothing in the available records that is inconsistent
with other evidence, does not relieve the BVA of its
obligations to assess the credibility and probative
value of the other evidence.”
Patton v. West (1999) - Special development required
for MST-related cases. Court distinguished the case
from Moreau and Cohen, which were not personal
assault cases.
At the time - Manual stated veteran’s behavioral
changes at and around the time of the alleged incident
might require interpretation by a clinician.
Courts determine there must be credible evidence to
support the veteran’s assertion that the stressful event
occurred.
Court established the development of personal
assault cases is different because part of the
development of personal assault claims
included allowing “interpretation of behavior
changes by a clinician and interpretation in
relation to a medical diagnosis.”
Clinical interpretations of a veteran’s behavior is
allowed so an opinion by a M/H professional
could be used to corroborate an in-service
stressor.
The Court also noted the importance of
discussing the credibility of all evidence,
including lay statements, when providing an
adequate statement of reasons and bases
Examiner outlined extensive reasoning why a
condition was not related to service including
references to service medical records, CPRS
records, c-file records, etc…
Remanded back because veteran’s lay statements not
discussed in rationale
According to 38 CFR 3.304(f)(4), in cases of a
noncombat personal assaults, corroborating
evidence may come from other sources besides
the veteran’s service records.
YR v. West (1998) - Highlights importance of
addressing credible corroborating evidence =
Analyzing submitted alternative sources of
evidence is very important in MST cases.
Cohen v. Brown (1997) - “[a]n opinion by a mental
health professional based on a post service
examination of the veteran cannot be used to
establish the occurrence of the stressor.”
The Federal Circuit concluded that the Federal
Regulations allows veterans claiming PTSD from
an in-service personal assault to submit
evidence other than in-service medical records
to corroborate the occurrence of a stressor, to
include medical opinion evidence.
Menegassi v. Shinseki (2011), U.S. Court of
Appeals upheld the BVA denial of S/C for MST
Veteran DX PTSD but BVA said no evidence in C-file
The Veterans Court stated that an opinion by a MH
professional based on a post-service exam cannot
be used to establish the occurrence of a stressor.
Veteran’s lay statement is insufficient evidence
Medical opinion based on a post-service
examination is insufficient evidence
Evidence must be obtained from the veteran’s
C-file records (i.e., service medical records,
military personnel records, police reports,
witness statements, lay statements, or Court
Martial records).
So, What Does This Mean to Me?
Read the service medical records
Read the military personnel records
Read ALL CPRS records
Read all lay statements
Inform the veteran of alternate evidence
Comprehensive evaluation
Re-Read all the above
Consult with colleagues and physicians
Comment on EVERYTHING, Rational Reasoning
If I don’t have it, ask for it!
Case Example
Female veteran was claiming PTSD secondary to
physical and sexual abuse perpetrated by her
husband.
The C-file contained multiple police records and
court documents indicating she claimed selfdefense bc he was physically assaulting her
Convicted of 2nd degree murder by a jury of
her peers who rejected the self-defense claim.
SMR showed MH only after she was arrested
and on the advice of her attorney
Cont.
Service personnel records, police reports, court
records, and 15 years of prison records, there
was significant doubt regarding the veteran’s
claim of physical and sexual assault.
Parole Release request indicated a 1st trial
ended in mistrial because jury could not agree
on verdict
At 2nd trial the veteran did not have several key
witnesses (PCS, unable to locate, etc)
Requested 1st trial records = Multiple
documents supporting veteran’s claim
Case Example
Veteran said was raped while a patient at XYZ
Hospital
We verified in her records she was at XYZ
Hospital
“We have conceded she was raped because she
was where she said she was.”
“Markers”
Markers = clues within the records which show
a change in behavior, health, or other
functioning that, when combined lead an
examiner to conclude some event in the
veteran’s life around the time of the noted
changes were responsible for those changes
Example Markers
visits to a medical or counseling clinic or
dispensary without a specific diagnosis or
specific ailment
use of pregnancy tests or tests for sexuallytransmitted diseases around the time of the
incident
sudden requests that the veteran's military
occupational series or duty assignment be
changed without other justification
changes in performance and performance
evaluations
increased or decreased use of prescription
medications
increased use of over-the-counter medications
evidence of substance abuse, such as alcohol or
drugs
increased disregard for military or civilian
authority
obsessive behavior such as overeating or
undereating
increased interest in tests for HIV or sexually
transmitted diseases
unexplained economic or social behavior
changes
treatment for physical injuries around the time
of the claimed trauma, but not reported as a
result of the trauma, and/or
the breakup of a primary relationship.
Finding the Markers
Service medical records
requests for specific tests (e.g., venereal disease,
pregnancy testing, or HIV)
evidence of increased use of alcohol (e.g., referred
to or attended substance abuse counseling)
“Seen in Mental Health.”
“Seen in ER for…”
Lack of Mental Health Records
MH treatment avoided because of stigma
Look for hidden evidence
For example, a veteran complaining to a primary
care provider they were having shortness of breath,
chest pains, and sweating might be experiencing
symptoms of anxiety
known etiology (SOB 20 asthma) < marker
Unknown etiology = possible marker
Is a “Marker” a “Marker”
some conditions may have medical explanations
but psychiatric implications.
For example, a service member is seen in the
medical clinic and diagnosed with “gastritis.”
Sxs of gastritis include:
Nausea or recurrent upset stomach
abdominal pain
vomiting
indigestion
loss of appetite.
Symptoms could because gastritis or anxiety.
Is a “Marker” a “Marker”
One visit for “Gastritis” = less likely
Multiple visits for “Gastritis” = more likely
One Visit for headaches = less likely
Multiple visits for headaches = more likely
Headaches in 1975, MST in 1977 = no marker
> # of HA starting 1977 = marker
Negative “Markers” in SMR
No direct reports (e.g., raped, seen by MH)
No indirect reports (e.g., headaches)
Report of Medical History form = Negative
After giving all possible benefit of the doubt and
there is nothing to “hang your hat on” =
consider the service medical records to be
negative for signs of any “Markers”
Military Personnel Records
Military personnel records may reveal “markers
of trauma.
Enlisted Performance Report
Letters of Counseling/Reprimand
UIF
Article 15, Page 11, Office Hours, Captain’s Mast
Court Martial
Enlisted Performance Report
Military Personnel Records
Cont.
Drop in ratings show significant behavioral
changes consistent with a Marker
Look at overall ratings
Not as helpful as EPR
Is this “Good” a “Marker”
Perhaps not when it’s followed by…
Veteran’s Reports Vs. Records
Veteran says “argued, fought, never got along
with anyone”
Performance Records show:
“Well liked and respected by peers and supervisors,
is the go-to guy in his unit”
“She is a very pleasant, outgoing airman who works
well with her customers, peers, and supervisors.”
“Needs to improve his relationships with both
peers and supervisors”
“Has been counseled a number of times to leave
his personal life at home”
Veteran says, “I was always stressed at work and
getting into trouble for poor performance and
attitude problems.”
Records show:
“She can be trusted to handle even the most
stressful customers with tact, professionalism, and
military bearing. “
“He is the number one go-to soldier when things
need fixing”
“He used to he a reliable sailor, but now…”
Disciplinary Actions
Article 15, Court Martial, Captain’s Masts, etc.,
may be “Markers”
Prevalence rate of Article 15?
DK but common
Timing
When did the NJP occur
4 NJP before MST and 1 after = not a marker
What’s the “crime”
Charged with Rape or AWOL
“failure to maintain clean room” or “Disrespect”
Case Example:
Veteran served 4 years
First 3 years = 3 Company Grade Article 15s for
disrespecting his NCOIC.
Last year = 3 Field Grade Article 15s for
disrespecting his CO (X1) and AWOL (X2).
Existence of NJP is not a Marker given the three
disciplinary actions prior to the trauma
BUT the increase in disciplinary actions and the
reasons for the disciplinary actions indicated
the possibility of a trauma.
Other Evidence
Lay statements from family members
Letters from the veteran’s roommate
Lay statement from a spouse or child who did
not know the veteran at the time of the
personal assault is not supporting evidence of
the occurrence of a stressor but may support
the subsequent diagnosis
Letters from clergy at the time of the stressor
Letter from off-duty employment at the time
Diagnostic Benefits Questionnaires
VBA coordinates with VHA and BVA and OGC
81 DBQs
DBQs standardize VHA exam reports
Enable private physicians to provide sufficient
disability assessment information
DBQs from private physicians will preclude the
need for VA exams in many cases.
Problems with the DBQ
DBQ lacks the ability to identify either the
frequency or the severity of a symptom.
The frequency and severity of a symptom make
a significant difference in the overall impact on
a person’s functioning.
Helps examiners and raters doing reviews
Improved inter-rater reliability
Use specific behavioral anchors
Eliminate idiosyncratic threshold determinations.
Example:
Depressed Mood
Frequency:
Once or twice a month
Once or twice a week
Several times a week
Daily or almost every day
Severity:
Slight - e.g., occasionally “sad" or occasionally poor concentration
Mild - e.g., often feels somewhat "depressed," mild insomnia
Moderate - e.g., few friends, conflicts with peers, flat affect
Severe - e.g., suicidal ideations, neglects friends, skips work
Extreme - e.g., attempts suicide, stay in bed all day, incoherent
CAPS is the “Gold Standard” in assessing PTSD
Embed the CAPS into the DBQ
E.g., frequency and intensity of each symptom
Improves diagnostic reliability
Add section for Psychological Test Results
The only DBQ template that incorporates this is TBI
TBI templates are not done by psychologists
Occupational and Social Impairment
Directly correlates to mental health rating scale
C&P examiner as the “rater”
Examiner is the “face” to the C&P process
4. Occupational and social impairment
a.
Which of the following best summarizes the Veteran's level of occupational and
social impairment with regards to all mental diagnoses? (Check only one)
[ ] No mental disorder diagnosis
[ ] A mental condition has been formally diagnosed, but symptoms are not severe
enough either to interfere with occupational and social functioning or to require
continuous medication
[ ] Occupational and social impairment due to mild or transient symptoms
which decrease work efficiency and ability to perform occupational tasks only during
periods of significant stress, or; symptoms controlled by medication
[ ] Occupational and social impairment with occasional decrease in work
efficiency and intermittent periods of inability to perform occupational tasks, although
generally functioning satisfactorily, with normal routine behavior, self-care and
conversation
[ ] Occupational and social impairment with reduced reliability and productivity
[ ] Occupational and social impairment with deficiencies in most areas, such as work,
school, family relations, judgment, thinking and/or mood
[ ] Total occupational and social impairment
Etiologies: Not Fully Known
Common factors — comorbidity results from
risk factors common to both disorders (e.g.,
genetics)
Secondary mental disorder — substance use
precipitates mental disorders.
Secondary substance use — 'self-medication
hypothesis'
Bidirectional — presence of either a mental
disorder or SUD can contribute to the
development of the other in a mutually
reinforcing manner over time. (31)
The presence of two or more disorders, is
common
possibly more common than a single diagnosis.
The Epidemiological Catchment Area study
(lifetime) - ≈ 60 percent of those with at least
one disorder qualified for two or more
diagnoses,
National Comorbidity Survey Replication – ≈45%
In the NCS-R (lifetime) - ≈14% qualified for three
or more diagnoses
NCS-R - ≈ 23% qualified for at least three.
Multiple studies have linked the use of alcohol
to PTSD (2X as likely)
Problem: ↑ alcohol = harder to cope
Alcohol use and intoxication ↑ some PTSD
symptoms
Emotional numbing, detached, irritability, anger,
depression, being on guard, sleep disturbance
Comorbidity Opinions
Separating symptoms:
Some symptoms overlap, some don’t
If all (almost all) the symptoms overlap, is there a
2nd Dx?
Etiology of symptoms:
What came first – the symptom or the trauma?
Exacerbated symptoms?
Alcohol/drug abuse before the trauma?
“Dual diagnosis" most commonly refers to the
combination of "severe mental illness" (SMI)
and a substance-use disorder (SUD).
ETOH/drug = adversely influence affective
stability, cognition, and behavior
Mental disorders place individuals at risk for
substance abuse and dependence.
Comorbidity = complicate clinical management
and is associated with poorer outcomes.
According to Regier et al. (1990)
Anxiety disorders – overall 15% SUD rate
GAD (21%), PTSD (18%), Social Phobia (17%)
Mood disorders — Individuals with mood
disorders have a lifetime SUD rate of 32 percent
Schizophrenia — 47% have had an SUD over
their lifetime (30)
DSM-IV specifically indicates “(m)alingering
should be ruled out in those situations in which
financial remuneration, benefit eligibility, and
forensic determinations play a role (pg. 467).
abundant research literature demonstrating
that compensation-seeking veterans exhibit
high rates of symptom exaggeration
Calhoun, Earnst, Tucker, Kirby, & Beckham, 2000; Dalton,
Tom, Rosenblum, Garte, & Aubuchon, 1989; DeViva &
Bloem, 2003; Freeman, Powell, & Kimbrell, 2008; Frueh,
Gold, & de Arellano, 1997; Frueh, et al., 2003; Smith &
Frueh, 1996; Sparr & Pankratz, 1983
Various reasons why a veteran might overreport symptoms.
The severity of their illness.
Generalized distress
Socio-political considerations
"Vietnam veterans ... experienced unique pressures and
traumas while in a war zone ... and were caught in a
period of social transition and stress upon return from
the war."
Vietnam vets just now 'learning' to respond to
years of dormant thoughts and feelings
Compensation-seeking status - "really make their
case”
Psychological Testing?
In general, psychological tests are as accurate
as medical tests (Meyer, et al., 2001). (27)
“Clinicians who rely exclusively on interviews
are prone to incomplete understandings"
(Meyer, et al., 2001, p. 128).
Psych tests (e.g., MMPI-2 & SIRS) = proven to
possess highly accurate classification rates
Actuarial judgment outperforms clinical
judgment (Dawes, Faust, & Meehl, 1989). (29)
Cont.
MMPI-2 or PAI
Miller Forensic Assessment of Symptoms Test
(M-FAST)
Structured Interview of Reported Symptoms
(SIRS/SIRS-2)
Morel Emotional Numbing Test for PTSD (MENT)
Structured Inventory of Malingered
Symptomatology (SIMS)
Test of Memory Malingering (TOMM)
MMPI-2
Most widely used measure
Franklin, et al. (2002) conducted research on
MMPI-2 scores of veterans undergoing a C&P
exam. Their results suggested
"…a majority of veterans with elevated F
scale scores are not intentionally
overreporting their symptoms, but likely are
achieving high elevations due to extreme
distress" (32)
Graham (2006) describes "attempts to fake bad
or malinger." (33)
Validity scales have been found to be reliable
indicators of exaggeration or feigning when
evaluating combat veterans with PTSD (Tolin, et
al., 2010). (36)
Combat veterans tend to elevate validity scales
even when they have genuine PTSD (Franklin, et
al., 2002)
But, there is a limit to the elevation (Resnick,
West, & Payne, 2008). (35)
MENT
Only measure specifically developed and
normed on veteran seeking VA compensation
for PTSD. (37)
SLEEPY
SERIOUS
Cont.
Minimizing
WW-II and Korea veterans have history of
minimizing psychiatric symptoms.
Often deny problems
Culture of the generation
“greatest generation”
Active Duty military
Depends on reason for evaluation
All records including remote data should be
reviewed.
Ability to see consistencies and inconsistencies
Military personnel records versus treatment
notes
Aviation Operation Specialist ≠ Door Gunner
Processes flight clearances, check accuracy of flight
plans, coordinates flight plans
DD Form 214 versus reality
Southwest Asia Service Medal ≠ Combat
Case Example
6/2011 veteran has TDRL eval
Veteran wants to reenlist in USMC
Denied all psychiatric symptoms
Denied reenlistment
2/2012 veteran has C&P evaluation
Endorses every symptom associated with PTSD
Denied remission of symptoms since 2005
Awarded 100% S/C
Was he misleading the Navy psychiatrist or VA
psychologist?
Case Example
Veteran tells VA psychologist:
“perfect childhood”
No behavioral issues
Denied substance use pre-military
Raped while on leave
Service medical records
Significant childhood behavioral issues (arrested
multiple times)
Abused marijuana pre-military
history of physical abuse
Psychiatric/psychological eval = rape fabricated to
keep out of trouble
Diagnosed Antisocial Personality Disorder
Military personnel records
2 Article 15s pre “trauma”
Multiple Page 11 entries pre “trauma”
Was UA for 17 days, when picked up by MP claimed he
was robbed and raped
No disciplinary actions in the 6 months between
“trauma” and discharge
Post Military
Incarcerated 4X for armed robbery and assaults in
Ohio (17 years total)
Incarcerated 2X in Florida for Aggravated Battery with
deadly Weapon (4 years total)
Heavy alcohol, marijuana, cocaine, heroin
Means for Assessing
Quality of Life Inventory (QOLI) - measures life
satisfaction in 16 different areas
reliability and validity are very good and wellestablished
World Health Organization Disability
Assessment Schedule – II (WHODAS-II).
Not updated in 10 years
scoring of the WHODAS-II requires the use of a
statistical scoring package such as SPSS
Coming Soon
Inventory of Psychosocial Functioning (IPF)
Being developed by the VA's National Center for
PTSD
Developed with the help of veterans, who
suggested much of the item content
Normative sample is composed of veterans
Measures psychosocial functioning across six
domains: marital or other romantic
relationships, family, work, friendships and
socializing, parenting, education, and self-care.
Functional Assessment Inventory (FAI).
Advantages:
available at no cost on internet
content is more specific to the question of
employability than any other instrument.
Disadvantages
No veteran normative samples
Predictive validity of the instrument with regard to
VBA rating decisions is not known.
Green v. Derwinksi, 1 Vet. App. 121 at 125,
1991)
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.
The courts have emphasized that an examiner’s
reasoning contributes significantly to the probative
value of his or her opinion. Therefore, taking time
to write a cogent, persuasive Rationale section is
vitally important.
Nieves-Rodriguez v. Peake, 22 Vet. App. 295 at 306
(2008). “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.”
In Gambill v. Shinseki 576 F. 3d 1307 at 1311
(2009) the courts have signaled that submission
of interrogatories is a distinct possibility.
The more detailed the rationale, the less likely
you will have to answer such interrogatories or
the better prepared you will be for such postexam inquiries.
In general, medical opinions that
(a) do not indicate whether the psychologists or
psychiatrist actually examined the veteran
(b) do not provide the extent of any examination
or
(c) do not provide any supporting clinical data
will be deemed inadequate (Claiborne v.
Nicholson, 2005).
Most important part of an opinion = the
reasoning.
“[A] medical examination report must contain not
only clear conclusions with supporting data, but
also a reasoned medical explanation connecting
the two (Nieves-Rodriguez v. Peake, 2008a).”
“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.”
“[A] conclusion that fails to provide sufficient
detail for the Board to make a fully informed
evaluation” is inadequate.
An opinion “must support its conclusion with an
analysis that the Board can consider and weigh
against contrary opinions.”
Typical opinion request:
________is caused by or a result of______________
________is most likely caused by or a result of ________
________is at least as likely as not (50/50 probability) caused by or
a result of ________
________is less likely as not (less than 50/50 probability) caused by
or a result of:_______
________is not caused by or a result of _________
________I cannot resolve this issue without resorting to mere
speculation.
DBQ opinion options:
[ ] The claimed condition was at least as likely as
not (50 percent or greater probability) incurred
in or caused by the claimed in-service injury,
event, or illness.
[ ] The claimed condition was less likely than not
(less than 50 percent probability) incurred in or
caused by the claimed in-service injury, event,
or illness.
Nice but not compliant with Nieves-Rodriguez v.
Peake, (2008)
Based on my professional opinion as a board
certified psychiatrist
Based on a review of all the records and my clinical
evaluation
Based on current research the veteran’s XXX is not
secondary to his service connected YYY
Results of testing does not support the diagnosis
The above opinion is based on review of the c-file
records, clinical interview, treatment records,
psychological testing, and DSM-IV
Rationale should fully explain the underlying
reason(s) supporting the opinion
Specific research studies should be referenced
Clear and concise without the use of jargon
If the rationale is weak, send it back for
clarification and supporting evidence
It’s up to the examiner to communicate
Its up to the rater to request clarification
This Opinion
Based on a review of the veteran’s files, my
clinical interview, DSM-IV criteria, and my
experience as a board certified psychiatrist, it is
my opinion that this veteran’s PTSD is a result of
his military service.
OR
Or This Opinion
Although the veteran was diagnosed with PTSD by a treating
mental health provider, the VA medical records do not support the
diagnosis. The assessment of PTSD was made through the use of
an unstructured interview with the veteran. Current research (see
multiple references below) indicates that the use of a structured
interview (e.g., CAPS) is significantly and statistically superior in
assessing for PTSD versus an unstructured interview. The use of a
measure like the CAPS, which is the "gold standard" in assessing
PTSD, significantly improves the ability of an examiner to
accurately diagnose PTSD. The CAPS has demonstrated reliability
and validity (Weathers, Keane, & Davidson, 2001). It is important
to assess for not only the presence of a symptom, but it is just as
important to assess for the frequency and severity of a symptom.
It is possible to have the existence of a PTSD-related symptom, but
the symptom may not meet DSM-IV diagnostic criteria for
persistence and severity to warrant the diagnosis of PTSD. The
results of the CAPS (as well as clinical interview and psychological
testing) did not support the diagnosis of PTSD.
Cont.
Speroff, T., Sinnott, P., Marx, B. P., Owen, R., Jackson, J. C., Greevy, R., Murdoch, M., Sayer, N., Shane, A ., Schnurr, P.A.
(2011). Cluster randomized controlled trial on standardized disability assessment for service-connected posttraumatic
stress disorder. Research abstract retrieved from http://www.hsrd.research.va.gov/meetings/2011/abstractdisplay.cfm?RecordID=301
Weathers, F. W., Keane, T. M., & Davidson, J. R. (2001). Clinician-Administered PTSD Scale: A review of the first ten
years of research. Depression and Anxiety, 13(3), 132-156.
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), 255-255-264.
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.
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.
Erbes, C., Dikel, T., Eberly, R., Page, W., & Engdahl, B. (2006). A comparative study of posttraumatic stress disorder
assessment under standard conditions and in the field. International Journal of Methods in Psychiatric Research, 15(2),
57-63.
Department of Veterans Affairs (2002). Best practice manual for posttraumatic stress disorder (PTSD) compensation
and pension examinations. Washington, D.C.: Author. Available at:
http://www.avapl.org/pub/PTSD%20Manual%20final%206.pdf
Worthen, M. D. & Moering, R. G. (2011). A practical guide to conducting VA compensation and pension exams for PTSD
and other mental disorders. Psychological Injury and Law, 4(3-4), 187-216.
Moering, R.G. (2011) Military service records: Searching for the truth. Psychological Injury and Law, 4(3-4), 217-234.
Opinion Example
The veteran’s Substance Use Disorder (alcohol dependence) is
likely a result of the service connected PTSD. Multiple studies
(see references below) have linked the use of alcohol to PTSD.
Veterans who screened positive for PTSD or depression were
two times more likely to report alcohol misuse relative to
Veterans who did not screen positive for these disorders.
The association between PTSD and alcohol abuse emphasized
the clinical and public health importance of this relationship.
The available evidence does support the causal nature of this
relationship. Frequency and severity of PTSD symptoms“
were positively correlated with coping-motivated drinking ...
and with alcohol use to forget. The re-experiencing and
hyper-arousal PTSD symptom dimensions showed the
strongest and most consistent correlations with the alcohol
use indices" (Stewart et. al. 2004).
(Cont. next slide)
This opinion is also based on the veteran’s lay statement
and review of multiple treatment records, there has been
consistency related to the veteran’s substance abuse.
There were no indications in the veteran’s service
medical records or military personnel records to suggest
any difficulties related to the use of alcohol until 1970
when he returned from Vietnam and had a DUI. Multiple
medical records dating back to the 1970s clearly indicate
ongoing alcohol abuse issues and multiple treatment
program failures. Consistently (since 1970s) the veteran
has indicated no substance abuse prior to military service
or service in Vietnam. Given the substance abuse
occurred after the traumatic stressor, it is likely a means
for coping with symptoms associated with PTSD.
Opinions and Rationales
Driessen, M., Schulte, S., Luedecke, C., Schaefer, I., Sutmann, F.,
Ohlmeier, M., et al. (2008). Trauma and PTSD in patients with alcohol,
drug, or dual dependence: a multi-center study. Alcoholism, Clinical
And Experimental Research, 32(3), 481-488.
Jakupcak, M., Tull, M., McDermott, M., Kaysen, D., Hunt, S., &
Simpson, T. (2010). PTSD symptom clusters in relationship to alcohol
misuse among Iraq and Afghanistan war veterans seeking postdeployment VA health care. Addictive Behaviors, 35(9), 840-843.
Simons, J., Gaher, R., Jacobs, G., Meyer, D., & Johnson-Jimenez, E.
(2005). Associations between alcohol use and PTSD symptoms among
American Red Cross disaster relief workers responding to the
9/11/2001 attacks. The American Journal Of Drug And Alcohol Abuse,
31(2), 285-304.
Stewart, S., Mitchell, T., Wright, K., & Loba, P. (2004). The relations of
PTSD symptoms to alcohol use and coping drinking in volunteers who
responded to the Swissair Flight 111 airline disaster. Journal Of
Anxiety Disorders, 18(1), 51-68
C&P Opinion vs Treatment Opinion
Whose opinion has more probative value?
Only one mental health professional has diagnosed the veteran with
PTSD. This professional did not administer a structured interview (e.g.,
CAPS); did not administer any objective testing (e.g., MMPI-2); did not
review the veteran's claims file; did not follow the American Academy
of Psychiatry and Law's "Practice Guideline for the Forensic Evaluation
of Psychiatric Disability"; did not follow the American Psychological
Association’s “Specialty Guidelines for Forensic Psychology,” and did
not follow the VA's "Best Practice Manual for Posttraumatic Stress
Disorder (PTSD) Compensation and Pension Examinations" in reaching
his diagnostic conclusions.
The current C&P assessment approach is based on scientific evidence
for its reliability and validity, e.g., use of the CAPS during C&P exams
leads to "more complete, consistent, and accurate assessments" than
unstructured interviews (Speroff, et al., 2011) and is consistent with
the above published literature regarding conduct of these exams.
C&P Opinion vs Treatment Opinion
What did the Treating psychologist say?
“Writer perused the record, and discovered that
veteran has twice been administered the MMPI-2,
which technically could be ruled as invalid. Veteran's
reading level and reading comprehension levels were
apparently not assessed prior to administration of
those tests. Completion of the MMPI-2 typically
requires at least an 8th to 10th grade education level,
and the normative population tends to be somewhat
better educated (e.g. 1-4 years of college, on the
average)than that of much of the veteran population.”
What happened?
Remand back to C&P for another examination given the
“new and material evidence”
The Reality
MMPI-2 Readability: The University of Minnesota Press (publisher)says
the MMPI-2 requires a 5th grade reading level using the Lexile average or
a 4.6 grade level using Flesch-Kincaid.
Schinka and Borum (1993) indicated the MMPI-2 had overall reading
levels at the 5th grade or lower” but also indicated a 6th grade level is a
better
Butcher (1991) found that the MMPI-2 reading level was at the 5th or
6th grade level.
Shipley Institute of Living Scale is an intellectual functioning screener and
does not assess reading comprehension as indicated by the treating
provider. There are no research studies linking reading comprehension to
the Shipley.
Treating provider says the veteran didn’t have reading ability but he
graduated from high school, was a helicopter mechanic in the army, and
worked as a master electrician for 20 years.
C&P examiners administered MENT, M-FAST, and SIRS-2. All showed
significant exaggeration
Treating provider never did a structured interview (CAPS)
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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), 255-255-264.
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
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Segal, D. L., & Coolidge, F. L. (2007). Structured and semistructured interviews for differential diagnosis: Issues
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Erbes, C., Dikel, T., Eberly, R., Page, W., & Engdahl, B. (2006). A comparative study of posttraumatic stress
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Psychiatric Research, 15(2), 57-63.
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