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Compensation and Pension (C&P) Exams for PTSD – Video

VA C&P Exams for PTSD

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Video Transcription:

Courtney: Good afternoon and welcome to Facebook Live with Chisholm Chisholm & Kilpatrick. My name is Courtney Ross and I’m joined by Christine Clemens and Nicholas Briggs. Today we’re going to be talking about compensation and pension examinations for PTSD. Before we get started, if you guys have any questions throughout the presentation, please feel free to leave them in the comment section and we will do our best to answer them as we go along. We have a lot to cover today so let’s jump right in. I want to start by talking about Compensation and Pension exams or C&P exams generally. So Christine, can you tell us what a C&P examination is and why it is so important to a veteran’s claim?

Christine: Sure. A C&P examination is a medical examination that the VA will request to assist them in determining certain aspects related to a veteran’s claim. It could be that they’re trying to determine the diagnosis or they’re trying to determine the severity or they’re trying to determine whether a condition is related to something that happened to a veteran in service.

Courtney: To get service connection for PTSD, there are three elements you really need: Current diagnosis, a medical nexus and a medical nexus to an in-service stressor. Nick, does a C&P exam usually hit on all three of those points?

Nicholas: So generally speaking, they’re not going to schedule the exam until they have some indication of two or three of the criteria for service connection. There’s at least some indication that there was an event or an injury in service, and then, there’s also probably medical evidence suggesting a possible diagnosis. Usually, when they’re requesting an examination, it’s because they’re missing that third element, the medical nexus.

Courtney: Okay. And Christine, you said that a C&P exam is a medical examination. Is it used for treating purposes?

Christine: It’s not used for treating purposes and sometimes the examiners will specify that. Sometimes, I think, people can be a little bit confused by that or misled when an examiner sitting there with them and saying, “I’m here to assess you or evaluate you, only I’m not here to treat you.” What that basically means is that, that day is kind of the end of the experience with that examiner. The veteran is not going to be coming back and going to that examiner for treatment. The examiner is not going to prescribe any medication or even suggest types of mechanisms that the veteran can employ to address the situation or their problem. So, it’s just for the purposes of, again, diagnosing, determining severity to really assist the VA Regional Office in determining, and fully developing the veteran’s claim which is part of why they order them, in determining whether they can grant service connection or assign a higher rating.

Courtney: And sometimes, a veteran may be treating with their own private doctor or a doctor at the VA Medical Center for PTSD but in addition to that treatment, they are still required to go to a C&P examination. In the case where maybe a veteran has a C&P examination and it comes back that it’s a negative nexus opinion, but then they are able to get an opinion from the doctor they’ve been treating with for the PTSD and it says the opposite that the PTSD is due to an in-service stressor, if both of those are submitted to VA, does VA give more weight to one over the other?

Nicholas: It’s not necessarily– they can’t just blanket accept the VA exam as more probative than the private medical opinion. It really comes down to not only what the opinion contains in terms of positive or negative but the evidence that they considered in rendering the opinion, the facts that they considered as it relates to the veteran’s service and then providing a detailed explanation. Ultimately, if the VA exam only checks a few boxes and doesn’t explain itself, but the private opinion does provide the detailed explanation, there’s no reason why VA shouldn’t accept the private opinion instead.

Courtney: And honestly, a private opinion is being provided by a treating doctor or a third party independent doctor. Who is it that’s conducting a C&P exam?

Nicholas: Those people are going to be VA-approved psychologists, psychiatrists, or another medical professional. Generally speaking, it’s either going to be a VA doctor themselves or somebody that VA contracts with who they approve to perform C&P examinations.

Courtney: Okay. What do VA examiners– what do they review as part of the examination or before the examination?

Christine: They are supposed to have access to the veteran’s full claims file. So, they are going to have access to any medical records that would be part of that, any VA medical records that the veteran has indicated to the Regional Office and that they hold any elements that might be in there. Statements from the veteran saying, you know, this is what happened to me, service records corroborating the events or deck logs if they are relevant. So, they should have access to the full file and in their opinion, they’re actually asked to indicate that they have reviewed the file. Whether they go page by page in the file is certainly not something that they are required to indicate nor they’re required to do that. But they are asked to at least provide some level of review so they have some context into the veteran’s situation.

Courtney: And we’re going to touch on this a little bit later in the presentation but if you go to a C&P examination and your examiner doesn’t check off that they’ve reviewed the entire file and they’ve only reviewed just some medical record. It t could be one thing that you could use to challenge the exam and we’ll get into a little bit more detail with that later in the presentation. So, I want to turn a little bit now to PTSD specifically. How is PTSD typically diagnosed?

Nicholas: They have what’s called the Diagnostic and Statistical Manual of Mental Disorders or the DSM. Currently, VA applies the DSM-5 and what that does is it provides a specific list of criteria and in order for a veteran to have a diagnosis of PTSD, according to a psychologist or a psychiatrist, they need to meet certain elements of each of those individual criteria. There’s obviously a pretty extensive list but the most important thing that we need to be able to establish is the stressor, either something that the veteran directly experienced or something that they witnessed in addition to being exposed to a threat of harm to somebody else as well.

Courtney: Okay. Under the DSM-5, which is as you noted Nick, VA currently uses to diagnose PTSD, GAF scores are no longer used. Is that correct, Christine?

Christine: That is correct. So, let me qualify that a little bit. Depending on how old the case is, right? If the case goes back to August 4th, 2014, the GAF scores were used prior to that and it was certified to the board prior to that, then GAF scores may be used. It’s not the end of the story. It’s only one aspect to the story which is really the number that corresponds theoretically to how severe the symptoms or symptomatology were but that’s part of the older version of the DSM. And so, they’re not typically not used anymore as they’re not found to really be as reliable in determining the severity of the condition.

Courtney: Before a veteran goes into the examination, typically or not typically. Sometimes when they are in the waiting room they might be given what’s called a PCL-5. Nick, can you talk a little bit about what that is and why it might be part of– right before a VA examination?

Nicholas: Sure. It’s really meant to be an initial assessment of both the presence and severity of the veteran’s PTSD symptoms. Like you mentioned, it’s a short 20-question checklist where they’re basically asked to go through and respond to specific things that they’re experiencing over a certain period of time and then the examiner will use this to sort of gauge the veteran’s initial symptoms reported prior to the exam because it’s usually something that’s completed in the waiting room before the examination actually gets started.

Courtney: During the examination, often times VA will use what’s called a DBQ or Disability Benefits Questionnaire to complete the C&P examination. Christine, can you talk a little bit more about what a DBQ is and what it looks like?

Christine: Yes. The Disability Benefits Questionnaire is a form that the provider will fill out. The VA providers will typically fill out the form electronically. It has a number of questions that they’ll ask them to go through to determine with PTSD for example, if there is a stressor event, what the stressor event is, whether that qualifies. It’ll go through all of the aspects that are required in the DSM to determine at the end of the exam whether the veteran fits the criteria. The DBQs are available on the VA’s website also. Not all of them but a lot of them are. A lot of the more common ones are available on the VA’s website. And so, if a veteran wanted to have their provider complete the form and submit that as evidence, they could download it and have their provider complete the form. The form is not something that the veteran can fill out themselves and submit. It does need to be completed by a medical professional. But it is a useful tool that the VA uses when they’re making their decisions.

Courtney: And are there any problems that are somewhat common with the DBQs?

Christine: Yes. The challenge is that most people don’t– their life stories, their experiences and their medical conditions, don’t necessarily fit very well on a form. What we’re asking the VA to do or these examiners to do is to sort of complete checkboxes that sometimes don’t correspond to what the law says the VA is supposed to look at. They don’t always define levels of severity or conditions and so, we’re trying to put people in boxes when they’re really not. It’s very difficult to do that. So, the goal was to try to have consistency and that’s why the VA does use them as a tool. But just like any other tool that the VA employs, there should be some flexibility at the Regional Office in looking at them. There are also comment sections that the providers can include more information on and they can give a little bit more context to some of their answers in the checkboxes. But sometimes the examiners are going through the exams pretty quickly. They have a number of people to get through in a day and so, they’re just checking off boxes without qualifying any of the information.

Courtney; Yes, I think that’s a really good point and one thing to keep in mind is, you know, Nick mentioned before about how VA might weigh a private treating doctor’s opinion versus a VA C&P examinations. If a veteran goes to C&P examination for PTSD and it’s just the DBQ that’s filled out with little information in the comment box or a little rationale to support the opinions and the veteran’s ability to get a more detailed opinion from a treating doctor, then that’s a case where VA should, in theory, weigh the treating doctor’s opinion and find it move probative than just the DBQ.

Courtney: Nick, something else that might be administered during the examination is something called the CAPS-5. Can you talk a little bit about what that is?

Nicholas: Sure. It’s a bit different from the questionnaire that we mentioned earlier, the PCL-5. Again, that’s meant to just be an initial assessment of the veteran’s symptoms and it can provide a provisional diagnosis of PTSD but the CAPS-5 test is basically the diagnostic tool that VA uses to determine whether or not a veteran suffers from PTSD. It’s usually provided in a structured 30-minute interview and it comes down to them asking questions that are intended to gauge what the veteran’s PTSD symptoms are, the duration and onset of those symptoms, how they affect the veteran in terms of occupational and social impairment, and other areas of their life including work, family, things like that.

Courtney: I just want to pause really quick to see if we have any questions. And we do. Sherwin wants to know, “Do you have to have been in treatment for PTSD before you can file a what I assume is a claim?”

Nicholas: No. At the end of the day, you don’t necessarily need to. One of the more common situations that we tend to see are people who sort of got out of the service or deeply affected by something and just sort of worked for the rest of their life, did their best to cope with the symptoms that they didn’t even necessarily know that they were experiencing, and then they might have something come up in their life that reawakens previous feelings or they retire and realize that they’re focusing so much on the things that happened to them in service. Ultimately, you can still seek a service connection for PTSD if you think you have the condition because you’re not a doctor at the end of the day, and you need to make sure that somebody assesses the symptoms that you are experiencing.

Christine: And where there is enough information on the file, the VA does have a duty to assist and part of that duty to assist is where there is information that suggests a veteran has a condition that might be related to service but the medical evidence is insufficient to grant is they should be scheduling these examinations to fulfill that duty to assist.

Nicholas: And there are also specific situations where they’ll just concede the stressor automatically based on certain things in the veteran’s service records such as a veteran who reported a military sexual trauma or somebody who engaged in combat. Those are generally going to be triggers for VA to schedule an exam to determine whether or not you do have PTSD based off of those stressors.

Courtney: Okay, great. So that question is actually a good segue into the next thing I want to touch on which is if a veteran goes to a C&P examination for what they think is PTSD and the end result is that the examiner diagnoses them with a psychiatric condition but it’s not PTSD, what happens from there?

Christine: So, if the examiner diagnoses them with a condition that’s not PTSD, but the condition is related to their service, the condition can be service-connected, and the VA when they’re adjudicating the claim is supposed to take that and the law’s pretty clear in this area that they’re supposed to take that diagnosis linked to service and they should grant on that basis. So, you could still get service connection for the other condition. Probably more problematic is if the condition is not related to service. If that’s the case, there are a number of ways to potentially fight the examination itself to obtain additional evidence regarding the diagnosis and regarding the relation to service.

Courtney: Nick, what are some common reasons why you might get an unfavorable examination after attending a C&P exam?

Nicholas: One of the most common things is that they just misapply the law. They forget that it’s meant to be an at least as likely as not standard. Meaning, that they’re requiring a direct causal relationship or direct medical evidence of continued symptoms over the years when it really is just, you know, — and everything else is that at least a 50-50 chance that whatever condition they experience now is related to service. Another common thing that we tend to see is the suggestion on the part of the VA examiner that the veteran is malingering, meaning that they’re exaggerating some of their symptoms or over-reporting certain things. At the end of the day, the best way that you can combat that specific finding is with both lay evidence from your self as well as people who know you so that they can document exactly which symptoms you experience and how they do affect you on a day to day basis.

Courtney: Christine, do you have any additional reasons that you see commonly in terms of why the exam comes back as unfavorable?

Christine: Sure. Sometimes the examiner will say that the stressor was not sufficient, doesn’t meet the criteria for PTSD, or the veteran may not meet all of the other elements that are required specifically for a diagnosis of PTSD because there are a number that they have to go through in order to meet that full diagnosis under DSM-5. Another thing we sometimes see is that the VA will recognize that they have diagnosed a person with PTSD but they will say that the diagnosis is related to stressors that aren’t related to service but maybe post-service stressors.

Courtney: And then, what are some things you can do in those situations that those are reasons the exam comes back as unfavorable.

Christine: So, kind of the best thing to do would be if the veteran has a doctor, a psychiatrist, or a psychologist who could write an opinion who would help clarify, you know, they could certainly get an expert opinion to help clarify the diagnosis, to help clarify that maybe those post-service stressors only really are a problem because of the underlying condition which is in fact related to service. That sometimes makes it more difficult for someone to deal with the stresses of life. So these are typically– that’s kind of the big things. The other thing is they can get statements from people observing. They could certainly try to argue with the exam, that there were some deficiencies with the exam itself. Those are some of the major ways that we often see so that people can challenge the exams.

Courtney: We do have Facebook Live that was done before on challenging the C&P examinations. So for a little bit more detail,  you could check that out on CCK’s website.  Nick, do you have anything else to add in terms of challenging C&P examinations?

Nicholas: I mean just that oftentimes you’re not going to know entirely what’s in the exam until you actually request a copy. VA is obligated to provide you with one but aside from which portions of the exams they quote on the rating decisions or whatever it may be that’s denying it, you don’t necessarily know what the contents of the exam are until you request a copy. And then from there, you can sort of figure out what you specifically need to rebut and then how to go about doing it.

Courtney: And you can request a copy from your local Regional Office by writing or calling them. If you are represented and your representative has access to your VA file online, they might possibly be able to pull a copy for you. So, let’s briefly talk about how VA rates PTSD once the condition is service-connected. Again, we’ve done a Facebook Live before on how to rate psychiatric conditions. So for more details, we’re going to touch on it briefly but for additional details, you can check that out on our website as well. But just generally speaking, how does VA typically rate PTSD?

Christine: PTSD is rated in 0, 10, 30, 50, 70, and 100 percent ratings. Each level, there are symptoms that are noted in the Code of Federal Regulations in the Disability Rating Schedule. Those symptoms are examples, they’re not an exhaustive list. They go through, sort of, in increasing severity. If someone, for example, has deficiencies in most areas of their life in education, deficiencies in an occupational setting, and in social settings, then there are symptoms that typically would correspond to that such as impaired impulse control, potentially suicidal ideation. They might have issues with hygiene, difficulties getting along with co-workers. So those symptoms are listed at each of the levels that would correspond to, for example– 70% for the symptoms that I just mentioned. If they don’t have symptoms that are maybe that severe, then they might correspond to the symptoms that are listed in the other rating criteria. The VA is sort of trying to do the best guess based on what the medical evidence suggests, what the lay evidence suggests about the types of impairments that they have. But again, those lists are not exhaustive and the VA is trying to do a best match when they are assigning the ratings. They don’t always get the ratings right and that’s something that if somebody is not happy with the rating that they were assigned, that is something that they could also seek VA to review.

Courtney: So, for a veteran to get a 70% rating, they don’t have to have every single criterion that’s listed in that rating.

Christine: They don’t have to have all the criteria listed in that.

Courtney: Okay, great.  So, I want to talk a little bit about tips for attending a C&P examination for PTSD and what are some important things that veterans should keep in mind if they are going to an examination. Nick, do you want to talk a little bit about some?

Nicholas: The most important one, obviously, is attending the examination. They’re scheduling them for a reason and if a veteran fails to report and can’t provide good cause for not showing up, they can basically deny your claim without looking into further evidence. But once you’re there, there are certain steps you can take to make sure that they’re addressing your concerns fairly. One, be as honest as possible. We mentioned malingering earlier but don’t under-report your systems but don’t over-report them either. Just make sure to carefully explain what you’re experiencing and how it affects you. Often times you don’t need to go alone. You can always bring somebody with you if you like and it can sometimes be helpful to bring additional information with you if you don’t necessarily feel comfortable interviewing with somebody that you don’t know. It can be helpful to provide a statement detailing how you feel in your own words.

Courtney: Do you have anything additional, Christine?

Christine: Yes. I think something that sometimes surprises people is that the examiner might not be– they’re observing the person from the very beginning. Not just when the person walks into the room and sits down with them. But they might be observing their interactions with people in the waiting room or with staff. So, again, that being honest is pretty important and they might use something that didn’t happen within the interview but something that they have observed in their report.  I think the other thing is that it can be useful to ask the examiner’s name and after the examination, the veteran can request a copy of the individual’s credentials and that might useful if they need to challenge the exam at some point. And the other thing is sometimes people wonder if they should bring anything with them. Some of the exams are longer than others. So, they might want to bring food, water with them. But sometimes people like to take notes before an exam to make sure that they feel comfortable if they have issues with memory, they might want to write something done so they remembered to tell the examiner what is was that they wanted to know. Sometimes they might bring photographs or want to bring medical records. The examiners won’t always take the information that someone brings with them that day. A lot of times people when they give the examiner information that is already part of their file which the examiner, as I discussed earlier, should have access to. So, if the information is not in the file and the examiner does not accept it, the veteran should make sure that the VA gets it so that it can be considered as part of their claim. There really is no rule. Some of the examiners will take the information. Some of them won’t take the information. You know, my advice is always if it makes someone feel better or more comfortable to have the information with them, they should bring it.

Courtney: I think those are all really excellent point and good tips to keep in mind. Do we have any additional questions?  We don’t, okay. So, do you guys have any final thoughts before we wrap our today’s presentation?

Nicholas: Just kind of generally speaking both toward tips and to challenging a negative VA exam. It’s important to keep in mind that these are meant to be thorough. They’re supposed to be reviewing your entire record. They’re supposed to be asking you the necessary questions. So, if there’s ever a time at which you feel that they haven’t necessarily addressed your concerns or if you feel the examination wasn’t long enough and it wasn’t thorough enough, that’s something to communicate to VA, either in a letter or through some other means in addition to figuring out who the exam was conducted by and what their credentials were.

Christine: I think the thing that I would say is that if someone feels that they do have  a bad exam, that they can fight it but it’s not the end of the road. A lot of times we will see an exam early on in the claims process and there might be another exam or two before the claim does get favorably decided. So, a bad exam isn’t just, you know, don’t quit, don’t give up just because you have a bad experience or one bad exam.

Courtney: Okay, great. We have one last question from Megan. She says, “My husband had a C&P for a major depressive disorder and PTSD. Will they be rated separately or combined?

Nicholas: The mental health disabilities, for the most part, are rated based on a general formula. So as Christine mentioned earlier, there’s a 0,10, 30, 50, 70 or 100, and for the most part, regardless of what your psychiatric disability is, they’re all going to rate them on that same schedule. So, if the examiner ultimately only opines one diagnosis or opines both diagnoses, they’ll assign a single rating that reflects all of the symptoms that are attributable to each of the conditions they’re diagnosed with.

Courtney: And Megan, the Facebook Live I mentioned before that was recently done on Rating Mental Disorders, might really be helpful for you. It goes into a lot of detail about how the different psychiatric disorders are rated under the same criteria. All right, well that is all we have for you today. Thank you for joining us on Facebook Live with Chisholm Chisholm & Kilpatrick.