Once a veteran files a VA claim for PTSD, even if the veteran has a valid diagnosis of PTSD from a qualified medical professional, the VA is still going to require that the veteran undergo a Compensation and Pension Examination (C&P exam) in order to verify the diagnosis, assess the severity of the condition, and determine if it is related to service. This is normally the case, even if a VA doctor has diagnosed the veteran with PTSD. It is important to note that the purpose of a C&P exam is not treatment, and if a veteran has been receiving treatment at a VA medical facility, the doctor conducting the exam will almost never be the same doctor who a veteran has gone to see for treatment. What this means is that even if a veteran has been seeing a VA doctor at a VA facility for many years, and that doctor has diagnosed the veteran with PTSD, the veteran will still need to report for a C&P exam with a different doctor, who may or may not reach the same conclusion.
It is important to remember that C&P examiners are examining thousands of veterans per year, and most of the examiners do not have the patience, time, or resources to try to figure out how a veteran really feels or to dig deep to figure out what the veterans symptoms really are. As such, it is important that veterans be as honest and forthright with the C&P examiner as time allows. Remember that the VA almost always gives more weight to the diagnosis of the C&P examiner than the treating doctor and if the C&P examiner does not think a veteran meets the diagnostic criteria for PTSD, or diagnoses a veteran with a different psychiatric disorder or a personality disorder, that is the opinion that the VA will consider as the most persuasive, and the PTSD claim will be denied.
Also note that psychiatric disorders can sometimes be difficult to differentiate 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 is being treated at the VA for PTSD may report to a C&P examination just to be told that he does not meet the criteria for PTSD and is, instead, suffering 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 the rating that is assigned. But, understandably, many veterans who are suffering from PTSD want the VA to recognize that they are suffering from that condition in particular, not generalized anxiety or another similar disorder.
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. All of the DSM-V criterion must be satisfied in order for a diagnosis of PTSD to be valid. If this threshold is not met, the VA will decide that the veteran does not have a valid claim for PTSD. Therefore, it is important that all symptoms be thoroughly documented, that veterans are diagnosed by qualified medical professionals, and that veterans be open and honest with their treating providers so that the VA has a true picture of the way the PTSD has impacted their lives. 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 mental disorder and that do not support a diagnosis of PTSD, and conform to the DSM-V.
At the exam
It is always a good idea for the veteran to take a witness to the examination such as a spouse, adult child, or close friend. A witness is important because it is very easy for veterans to forget important details about the exam, let alone deal with the normal stress that veterans experience when being evaluated by the VA’s C&P examiners. If possible, the veteran should take the witness into the examination room with them; however, this request is frequently denied by the VA. If the request to take a witness into the examination is denied, it is important that the veteran proceed with the exam. Failure to cooperate with a C&P examination can result in denial of the claim. At the very least, the veteran should ask for the examiner’s business card, so that the veteran can ensure that the person doing the examination was actually the one who wrote the final report.
In addition, the veteran should bring a written list of symptoms, even embarrassing symptoms, to help refresh his or her memory during the exam. What veterans sometimes feel are unimportant details could very well be the key to success in the claim. Additionally, if one of the veteran’s treating medical providers has provided a favorable opinion in the matter, it does not hurt for the veteran to give the favorable opinion to the C&P examiner for consideration.
One of the most intense symptoms of PTSD is nightmares. As awful as nightmares can be for a veteran, 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 though they may not be as frequent or intense, show the true measure of the severity of the disability. These symptoms might be better observed by loved ones, so written statements from those individuals may be helpful as well.
Recently, the VA has really begun to heavily advocate the use of Disability Benefits Questionnaires (DBQs) by the C&P examiners. The VA has said that the DBQs were created to help streamline the VA claims process, and to help complete the record if they determine that the record as a whole is incomplete or insufficient to decide a claim. According to the VA, there are more than 70 DBQs, covering the overwhelming majority of conditions for which a veteran can receive disability compensation, 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).
After the exam
After a C&P examination, it is important that the veteran and any witnesses write down their thoughts about the examination as soon as possible. Issues for a witness to write down include how long the exam is, 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 the exam was thorough, whether the veteran was able to express all of his or her thoughts about the disabilities being evaluated, whether the examiner seemed to be listening and writing down the veteran’s responses, and 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 the chances of getting the VA to correct the problem. Depending on the situation, the veteran or his or her representative may choose to send in a response to the VA challenging the C&P results. The written response may request several things, such as that the VA order a new C&P exam with a different C&P examiner or that the VA order the C&P examiner to clarify his or her opinion.
Rating increase exams
Note that if a veteran is seeking a rating increase for PTSD that has already been service connected, the VA will send him or her to an examination for additional psychological testing. Unfortunately, in many instances the VA has been quick to find during these rating increase exams that a veteran is malingering, instead of finding a justification for a rating increase. Malingering is not considered a mental illness, but is defined by the DSM-V 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 a July 2013 article by the American Psychological Association Law Society, there is disagreement among experts as to whether PTSD is over-reported in veterans because of malingering. Due to the nature of PTSD examinations and the fact that the majority of symptoms are self-reported, it is difficult to gather empirical evidence as to whether malingering is more prevalent among veterans.
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). This test was developed 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 – for instance, if a veteran scores highly on the M-FAST, additional tests may be done such as 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, with 2 sections devoted specifically to PTSD which are used to detect malingering. As discussed in the VA’s Best Practice Manual for PTSD Compensation and Pension Examinations (see below), the MMPI-2 consists of “validity scales” that are elevated when a person is exaggerating his or her symptoms. 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, but that the VA may use it anyway to save money and time. Other tests that can be used to detect malingering are the Personality Assessment Inventory (PAI) and the Trauma Symptom Inventory (TSI).
Note that it is not always the case that a VA examiner will administer multiple tests to determine if a veteran is malingering. If a veteran scores higher than a 6 on the M-FAST, the VA doctor may write in the C&P exam report that the veteran is possibly malingering without looking further into the issue. Because that one word is now a part of the veteran’s claims file, the PTSD claim will be even more difficult to win, and the veteran will most likely need to get an independent medical opinion that refutes the allegation of malingering. In fact, the Army recognized this back in 2012, when it put out a memo on policy guidance on the assessment and treatment of PTSD (Army Medical Command Policy Memo 12-035). 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 also 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 Best Practice Manual notes that several studies suggest the Vietnam veterans may have elevated scores on tests such as the MMPI-2 due to their chronic post-traumatic difficulties, and not due to any intentional exaggeration of symptoms. In fact, no test for malingering exists which can reliably tell which symptoms are being exaggerated or when the exaggeration started. Tests such as the M-FAST, MMPI-2, PAI, and TSI are the best available but can too easily result in veterans with genuine PTSD claims being labeled as malingerers.
Unfortunately, bias against the “malingering veteran” still exists among VA examiners and 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 with the VA and be prepared to submit evidence that the PTSD has gotten worse in order to back up the claim for rating increase.
Continue to Part Four to learn how PTSD is rated by the VA.
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 this manual is given internally within the VA healthcare system given the fact it has not been updated in over 10 years, but it has not been officially repealed. 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.