Although the principles for all diagnoses are similar, the diagnosis of PTSD deserves special attention, particularly when the stressor is alleged to have occurred during military service. Documentation of the diagnosis and its relationship to military service must be in sufficient detail to facilitate the adjudication of disability benefit claims as well as the formulation of treatment.
A The issue of service-connection is the sole responsibility of the rating board. The physician's responsibility is to present the clinical findings in a way that clearly demonstrates why the diagnosis of PTSD was made and, when applicable, why some other diagnosis was not made. Clinical findings which bear upon any relationship between military service and the diagnosis must be described. This diagnostic clarity should be present when the patient is found to have some diagnosis other than PTSD.
B. The diagnostic evaluation for PTSD includes review of the patient's C-file, a clinical interview and mental status exam designed to determine the presence or absence of diagnostic symptomatology, and precipitants and, when indicated, psychological testing. Recent research has validated several instruments that may aid in diagnosing PTSD but do not substitute for a clinical diagnostic interview.
C. Interviews to establish a diagnosis, particularly for compensation, may be a stressful experience for the veteran, particularly for veterans with PTSD for whom issues of trust and feelings of alienation are often prominent. The veteran may be reluctant to experience the pain of relating fearful and threatening memories (e.g., of combat). For these reasons, it is vital that the interview be conducted in a sympathetic and understanding manner, and that the examiner make thorough review of the C-file and military records to provide information the veteran may not mention or to provide clues about areas or situations the examiner may wish to explore on interview.
D. The diagnosis of PTSD must be consistent with the criteria of the psychiatric diagnostic system approved by VHA (Veterans Health Administration), currently DMS-III-R (American Psychiatric Association's Diagnostic and Statistical Manual). NOTE: All criteria required for making the diagnosis must be met in order for a diagnosis of PTSD to be acceptable.
E. Specific aspects of the differential diagnosis of PTSD from other disorders, including personality disorders, substance abuse, depression, and schizophrenia, are well described in IB 11-56, Physician's Guide for Disability Evaluation Examinations. It is possible for PTSD to co-exist with other psychiatric disorders from Axis I and Axis II (e.g., major depression, substance abuse). In some instances, the other disorder may be secondary to or associated with PTSD, while in other cases, the two disorders may be unrelated co-morbidities. The nature of the relationship of PTSD to the other disorder(s) should be clearly stated.
F. The C&P (Compensation and Pension) Evaluation Report must include the following elements:
(1) Clear and complete documentation of the diagnostic criteria that have been met to make the PTSD diagnosis. The development of symptoms since the traumatic event and the absence of these symptoms prior to the event must be noted.
(2) Clear and concretely detailed description of the stressor(s) including:
(a) A description of the event;
(b) Location in time (as best it can be recalled: year, month, season, day if possible);
(c) Geographic location (military unit, providence, town, landmarks such as river or mountain); and
(d) If possible, names of others who may have been involved in the incident.NOTE: Often there are multiple stressors.
NOTE: The foregoing detail should be provided for at least one event, and descriptions of others should be provided to convey the cumulative nature of the stressful experiences.
(3) Clear and specific demonstration of the linkage between the symptoms used to make the diagnosis and the in-service stressful event, e.g., content of intrusive recollection or re-experiencing of the in-service stressor which are similar to the actual stressors experienced. NOTE: Such recollections should be of in-service stressors rather than recollection of other stressors from before or after service.
(4) Detailed description of the manner and degree to which the symptoms affect the necessary functioning of the veteran, including the effects upon:
(a) Personal relationship with family members, friends and others in social, religious, work and recreational activities (if any);
(b) Productive activity, especially employment in obtaining and maintaining effective participation; and(c) The utilization of health services.