What is a VA PTSD C&P Exam?
Once a veteran files a VA claim for PTSD the VA will make the veteran undergo a Compensation and Pension Examination (C&P exam). VA will verify the diagnosis. It does so even if the veteran already has a diagnosis of PTSD from a qualified medical professional. The C&P exam also determines if the PTSD is related to service and assesses the severity of the condition. This is normally the case, even if a treating VA doctor has diagnosed the veteran with PTSD.
What is the Purpose of a VA C&P exam?
The purpose of a C&P exam is not treatment but an exam for VA disability purposes. If a veteran has been receiving treatment at a VA medical facility, the doctor conducting the exam will not be his treating doctor. So is not enough to see a VA doctor for many years and that doctor diagnose the veteran with PTSD. The veteran still must report for a C&P exam with a different doctor, who may not reach the same conclusion.
How do C&P examiners approach the PTSD C&P exam?
C&P examiners review thousands of veterans per year. Most of the examiners do not have the patience, time, or resources to really dig into a veteran’s case. They don’t have time to deeply probe either how a veteran really feels or what the veteran’s symptoms are. As such, it is important that veterans be as honest and forthright with the C&P examiner as time allows. VA will almost always give more weight to the diagnosis of the C&P examiner than the treating doctor. If the C&P examiner does not think a veteran meets the diagnostic criteria for PTSD VA will deny the case. Sometimes the C&P examiner diagnoses a veteran with a different psychiatric disorder. In this case, VA will deny the PTSD case. The C&P examiner’s opinion is what VA usually considers as the most persuasive.
How will VA diagnose me if I have more than one psychiatric disorder?
Psychiatric disorders can sometimes be difficult to tell apart as many disorders have overlapping symptoms. For instance, a veteran who suffers from PTSD will often suffer from symptoms of anxiety and depression. Sometimes a veteran, who VA treats for PTSD, may have a C&P examiner state he doesn’t have PTSD. The examiner may, instead, say the veteran suffers from an anxiety disorder. However, mental disorders are evaluated under the same rating formula under 38 C.F.R. s. 4.130. So, in some practical ways the actual diagnosis matters less than what VA assigns for a rating. But, understandably, many veterans who are suffering from PTSD want the VA to recognize that they have PTSD. that they are suffering from that condition in particular, not generalized anxiety or another similar disorder.
What tests does VA use to determine whether I have PTSD?
The VA uses the criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) to evaluate whether there is a valid diagnosis of PTSD. The PTSD diagnosis must satisfy all of the DSM-V criterion to validly diagnose PTSD. If the veteran’s PTSD does not meet the diagnosis, the VA will deny the PTSD claim. Therefore, it is important that the veteran thoroughly document all symptoms. The veteran needs to be open and honest with her treating providers. This will give VA a true picture of the way the PTSD has impacted her life.
What do I do at a C&P exam?
It is always a good idea for the veteran to take a witness to the examination. This person can be as a spouse, adult child, or close friend. A witness is important for a couple of reasons. First, it is y easy for a veteran to not fully understand how PTSD affects him. The witness will be able to discuss how the veteran interacts with others, which is a crucial part of PTSD. Second, veterans tend to forget important details about the exam. Third, this person can help the veteran deal with the stress that veterans experience during VA’s C&P exams.
If possible, the veteran should take the witness into the examination room with them. Unfortunately, the examiner frequently denies this request. Even if the witness cannot go with the veteran, it is important the veteran proceed with the exam. Failure to cooperate with a C&P examination can result in denial of the claim.
Why you should write down your symptoms before the C&P exam?
In addition, the veteran should bring a written list of symptoms, even embarrassing symptoms, to refresh his memory. Remember, this exam is the chance to show how PTSD affects your life day to day. What veterans sometimes feel are unimportant details could be the key to the claim. The examiner needs to know all the details. If the veteran’s treating medical providers has provided a favorable opinion in the matter the veteran should bring it too. This will further help the examiner see the totality of the veteran’s symptoms.
What symptoms of PTSD should I bring up at my C&P exam?
One of the most intense symptoms of PTSD is nightmares. As awful as nightmares can be, they only fall under the 30 percent rating on the VA’s rating formula. Therefore, it is important to consider other symptoms like anger and difficulty dealing with authority. These symptoms, even if they aren’t as frequent or intense, show the true measure of the severity of the disability. Loved ones usually are better at observing these, so written statements from those individuals may be helpful as well.
Recently, the VA has insisted that C&P examiners use Disability Benefits Questionnaires (DBQs). The VA created DBQs to streamline the VA claims process. VA states that they help ensure that the record is complete to decide a claim. According to the VA, there are more than 70 DBQs, covering the majority of disabilities, including PTSD. (Note: The DBQ for service connection for PTSD is not available to the public, but you can view the Review PTSD DBQ here in order to get a general idea of what a DBQ entails).
When exam is over, the veteran should ask for the examiner’s business card. After the exam the veteran will want to order a copy of the exam report. The veteran should check that the person doing the examination was the one who wrote the final report.
What do I do at a VA PTSD Increase Rating C&P exam?
Once VA admits that your PTSD is service connected then the focus turns to the correct rating. VA ratings vary drastically from 0% to 100%. Frequently, PTSD can tear the veteran’s relationships—with all people in their lives—apart. This can lead to the veteran being unable to work. It can also lead the veteran to being socially isolated. As important as it is to get service-connected, it is more important to make sure VA gets the rating right.
When a veteran seeks a PTSD rating increase, the VA will send her to another C&P exam. This exam will include additional psychological testing. Too frequently, VA finds the veteran is malingering, instead of finding evidence for a rating increase. Malingering is not a mental illness. The DSM-V defines it as “the intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives such as avoiding military duty, avoiding work, obtaining financial compensation, evading criminal prosecution, or obtaining drugs.” According to the American Psychological Association Law Society, experts disagree as to whether veterans overreport PTSD because of malingering.
What psy tests to VA PTSD C&P examiners use?
There are a few different tests that a VA doctor may use to attempt to uncover malingering. One of these tests is the M-FAST (Miller-Forensic Assessment of Symptoms). The developers of this test looked to provide clinicians with a reliable screening tool for malingered mental illness. The test consists of a 25 item screening interview over seven scales, or categories. The categories are: reported vs. observed symptoms, extreme symptomatology, rare combinations, unusual hallucinations, unusual symptom course, negative image, and suggestibility. A score higher than 6 indicates possible malingering. The M-FAST can be used alone, but it is also meant to be used as part of a larger assessment. If a veteran scores high on the M-FAST, additional tests may be done like the MMPI-2 (Minnesota Multiphasic Personality Inventory-2).
The MMPI-2 comes with its own set of issues. It is a long, involved personality and psychopathy test. It has two sections devoted specifically to PTSD to detect malingering. As discussed in the VA’s Best Practice Manual for PTSD Compensation and Pension Examinations, the MMPI-2 consists of “validity scales.” When a person is exaggerating his symptoms these scales are elevated. There is also a revised version of the test, the MMPI-2RF, which doesn’t include PTSD specific sections. Many clinicians are concerned that this shorter test has not been proven effective. They are further concerned that VA may use it anyway to save money and time. Other tests used to detect malingering are the Personality Assessment Inventory (PAI) and the Trauma Symptom Inventory (TSI).
Do VA Examiners Always do Multiple Psy Tests?
VA examiner do not always administer multiple tests to determine if a veteran is malingering. If a veteran scores M-FAST score of 6 or higher, the VA doctor may report the veteran is possibly malingering. Because that one word is now a part of the veteran’s claims file, the PTSD claim will be even more difficult to win. The veteran will likely need an independent medical opinion that refutes the allegation of malingering.
The Army recognized this back in 2012. It issued policy guidance on the assessment and treatment of PTSD. The memo stressed that “the diagnosis of malingering should not be made unless there is substantial and definitive evidence from collateral or objective sources that there are false or grossly exaggerated symptoms that are consciously produced for external incentives.” The memo noted that there is “considerable evidence” that malingering is rare among veterans and that malingering is unlikely to be a factor in the vast majority of disability determinations. Even the VA concedes that Vietnam veterans may have elevated scores on tests due to their chronic post-traumatic difficulties. In fact, no test for malingering exists which can reliably tell which symptoms are being exaggerated. Tests like the M-FAST, MMPI-2, PAI, and TSI are the best available. That said, the tests’ findings can easily result in labeling veterans with genuine PTSD as malingers.
Does being labeled a malingerer hurt my PTSD case?
Unfortunately, bias against the “malingering veteran” still exists among VA examiners. This bias can hurt those whose PTSD has legitimately gotten worse. Therefore, it is just as important to use the tips in this section during any subsequent PTSD exams. You must be prepared to submit evidence that the PTSD has gotten worse to back up the increased rating claim.
NOTE: In the early 2000s, the VA published a Best Practice Manual for PTSD Compensation and Pension Examinations. This manual gives very technical, detailed instructions for clinicians administering C&P exams for PTSD, including the tests used for malingering, such as the MMPI-2. It is unclear how much weight VA C&P examiners give this manual since it has not been updated in over 10 years. Be that as it may, VA has not officially repealed it. Also note that because the manual pre-dates the publication of the DSM-V, its analysis revolves around the diagnostic criteria of the DSM-IV, including the Global Assessment of Functioning (GAF) scale.
What should I do After the VA C&P exam
After a C&P examination, the veteran and any witnesses should write down their thoughts about the examination asap. Issues for a witness to write down include:
- how long the exam was
- whether the examiner would let you come back and give your testimony
- any changes in the veteran’s mood before and after the exam, and
- any other observations about the facility.
Issues for the veteran to write down include whether:
- exam was thorough
- did the veteran get to express all of his thoughts about the disabilities being evaluated
- the examiner seemed to be listening and writing down the veteran’s responses,
- whether the examiner expressed a negative opinion to the veteran about the strength of his or her claim.
The more specific the veteran and the witnesses are regarding any deficiencies with the C&P exams the better. Should VA deny the claim the veteran can show the inadequacies of the exam. The veteran or his representative may choose to send in a response to the VA challenging the C&P results. The challenge may demand VA order a new exam with a different examiner. Alternately, the challenge could request that VA get the examiner to clarify his opinion.
What do I do if I disagree with the C&P results?
You should choose an appeal path under the AMA system. But you need to evaluate the C&P exam too. In order for the C&P examination to be adequate, it must:
- sufficiently describe the symptomatology
- identify and adequately describe the stressor
- acknowledge and reconcile prior reports that demonstrate a diagnosis of PTSD and
- show why these reports are not probative.
Continue to Part Four to learn how PTSD is rated by the VA.