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A Practical Guide to Conducting VA Compensation
and Pension Exams for PTSD and Other Mental Disorders
Mark D. Worthen &Robert G. Moering
Received: 24 November 2011 /Accepted: 27 November 2011 /Published online: 16 December 2011
#Springer Science+Business Media, LLC. 2011
Abstract Despite being one of the most common forensic
mental health evaluations, no article has ever appeared in a
peer-reviewed journal describing how to conduct US
Department of Veterans Affairs (VA) mental health compen-
sation and pension examinations. This article rectifies that
paucity of information. We outline the legal framework, eth-
ical considerations, and administrative challenges inherent in
these evaluations. We provide separate guidelines for private
practice clinicians and VA staff or contractors. We pay special
attention to the multiple sources of collateral information
available for these exams and how to access relevant records.
The article alerts examiners to the possibility that they might
face resistance from VA officials if they screen for and assess
symptom exaggeration or feigning and that they could en-
counter VA-imposed restrictions on time allotted for exams.
Specific suggestions are made for different types of exams:
Initial Post-traumatic Stress Disorder (PTSD), PTSD Review,
Initial Mental Disorder, and Mental Disorder Review.
Keywords PTSD .Veterans Affairs (VA) .Compensation
and pension (C&P) examination .Disability Benefits
Questionnaire (DBQ)
In the US Department of Veterans Affairs (VA) 2010 Fiscal
Year, 60,535 veterans began to receive VA disability bene-
fits for mental disorders (Veterans Benefit Administration,
2010). The majority of those veterans received a compen-
sation and pension examination (C&P exam) at a VA facility
or a contract provider’s office.
Beginning in 2011, private providers (primarily psychol-
ogists and psychiatrists although other mental health pro-
fessionals are eligible
1
) will be able to conduct some C&P
mental disorder exams with the advent of the VA’snew
Disability Benefits Questionnaire (DBQ) system.
To date, there are no articles published in peer-reviewed
journals that describe how to conduct VA mental health-
related compensation and pension exams. Our intention is to
rectify the lack of peer-reviewed information by outlining a
recommended procedure for conducting four different types
of C&P mental disorder exams. The article also addresses
legal, ethical, and administrative concerns that arise with
these often complex forensic evaluations.
1
The Mental Disorders DBQ form states: “In order to conduct an
initial examination for mental disorders, the examiner must meet one
of the following criteria: a board-certified or board-eligible psychia-
trist; a licensed doctorate-level psychologist; a doctorate-level mental
health provider under the close supervision of a board-certified or
board-eligible psychiatrist or licensed doctorate-level psychologist; a
psychiatry resident under close supervision of a board-certified or
board-eligible psychiatrist or licensed doctorate-level psychologist; or
a clinical or counseling psychologist completing a one-year internship
or residency (for purposes of a doctorate-level degree) under close
supervision of a board-certified or board-eligible psychiatrist or li-
censed doctorate-level psychologist. In order to conduct a review
examination for mental disorders, the examiner must meet one of the
criteria from above, OR be a licensed clinical social worker (LCSW), a
nurse practitioner, a clinical nurse specialist, or a physician assistant,
under close supervision of a board-certified or board-eligible psychia-
trist or licensed doctorate-level psychologist.”(emphasis added). See:
http://www.vba.va.gov/disabilityexams.
Notice This article and the recommendations or opinions stated herein
should in no way be construed to reflect the opinions or beliefs of the
US Department of Veterans Affairs or the US government. The
opinions expressed in this article are the authors’alone.
M. D. Worthen (*)
Compensation & Pension Program, Charles George VA Medical
Center, Department of Veterans Affairs,
1100 Tunnel Road,
Asheville, NC 28805-2576, USA
e-mail: mark.worthen2@va.gov
R. G. Moering
Compensation & Pension Office, James A. Haley Veteran’s
Hospital, Department of Veterans Affairs,
Tampa, FL, USA
Psychol. Inj. and Law (2011) 4:187–216
DOI 10.1007/s12207-011-9115-2
The four types of exams covered in this article are:
&Initial Post-traumatic Stress Disorder (PTSD)
&PTSD Review
&Initial Mental Disorder
&Mental Disorder Review
Legal Framework
Like all forensic mental health evaluations, VA compensa-
tion and pension exams exist within a legal framework, i.e.,
a collection of statutes, regulations, and case law that deter-
mine the referral questions asked of examiners; outline the
procedures veterans must follow to establish a disability
claim; describe how evidence is weighed; govern who
may conduct these exams; and otherwise define the C&P
exam process. Understanding the legal landscape is impor-
tant for examiners because referral questions often directly
or indirectly reference statutes or regulations, case law can
dictate the content of an exam report and the rules of
evidence used to evaluate the adequacy of an examiner’s
documentation and rationale (Nieves-Rodriguez v. Peake,
2008), and one’s ethical code might require it.
2
Brief Legal History
Although providing monetary benefits for US veterans dates
back to the Revolutionary War (Ridgway, 2011), contempo-
rary veterans compensation law has its roots in 1917 amend-
ments to the War Risk Insurance Act of 1914 (Economic
Systems Inc., 2004), which provided compensation to
World War I veterans for “average impairment in earnings
capacity.”That phrase, “average impairment in earnings
capacity”is important because the 1917 laws represented a
shift from gratuity payments (awarding benefits as a “thank
you”to veterans for their service) to an indemnity model
that compensates veterans for functional impairments that
adversely affect their ability to work (Economic Systems
Inc., 2004).
Mental health professionals interested in conducting
C&P exams need to keep that distinction in mind because
a crucial issue for them to address in their exam report is the
extent of the veteran’s occupational impairment. In this
regard, C&P exams are similar to Social Security disability
evaluations in that occupational impairment is the focus
(Foote, 2008). Also, some examiners seem to mistake VA
compensation as an entitlement program, i.e., one that
awards benefits for a veteran’s service in a combat zone
when, in fact, it is an indemnity program in which the VA
provides benefits to veterans who have suffered occupation-
al impairment as a result of their psychological injury.
Currently, the statutory authority for regulations govern-
ing the VA’s compensation program comes from Title 38 of
United States Code. Regulations are primarily found in 38
Code of Federal Regulations (C.F.R.), Part 3 and Part 4. A
comprehensive review of veterans law (statutes, regulations,
and case law) is beyond the scope of this article (but see
Ridgway, 2011 in this issue). Instead, we will focus on
important differences between the legal parameters govern-
ing the adjudication of veterans’disability claims and the
legal contours of more traditional forensic mental health
evaluations.
Unique Legal Parameters
The most important difference to understand is that proceed-
ings regarding VA compensation and pension claims are
intentionally informal and nonadversarial (“Proceedings be-
fore VA are ex parte in nature …”; Procedural Due Process
and Appellate Rights, 38 C.F.R. § 3.103, 2010), and they are
“uniquely pro-claimant”(Hodge v. West,1998). Table 1
provides a comparison between the types of evaluations
with which most forensic psychologists and psychiatrists
are familiar and the VA compensation and pension
examination.
Legal Language Required
When asked to provide a medical opinion (even if the
examiner holds a non-medical degree, the opinion still is
referred to as a “medical”opinion), examiners must use
specific language, based on the legal requirements in veter-
ans compensation cases. Specifically, examiners must use
one of the following phrases when writing their opinion
(Department of Veterans Affairs, 2001):
&“Is due to”(100% assure)—the phrase “caused by or the
result of”seems to be an acceptable alternative based on
our experience (it is often the phrase suggested in exam
requests from the Veterans Benefits Administration
(VBA))
&“More likely than not”(greater than 50%)
&“At least as likely as not”(50%)
&“Not at least as likely as not”(less than 50%)—the less
cumbersome, “is less likely than not”appears to be an
acceptable alternative based on our experience
&“It is not due to”(0%)
&I cannot formulate an opinion without resorting to mere
speculation
2
American Psychological Association Ethical Standard 2.01 (f) reads,
“When assuming forensic roles, psychologists are or become reason-
ably familiar with the judicial or administrative rules governing their
roles.”(American Psychological Association, 2002).
188 Psychol. Inj. and Law (2011) 4:187–216
Thus, if an examiner concludes that a veteran suffers
from PTSD because of traumatic events he or she en-
dured during wartime, the examiner will usually opine,
“It is at least as likely as not that the veteran’sPTSD
wascausedbyortheresultof his claimed traumatic
stressors.”Note that the “at least as likely as not”phrase
encompasses the evidentiary standard of equipoise,i.e.,
if the evidence is at equipoise (50/50 chance) then
benefit of the doubt goes to the veteran (Gilbert v.
Derwinski,1990).
Table 1 Differences between the legal parameters governing typical forensic mental health evaluations versus VA compensation and pension
examinations
Typical forensic mental health evaluations VA compensation and pension examinations
Relationship of the parties Adversarial Ex Parte
a
Standard of proof “Beyond a Reasonable Doubt,”“Clear and Convincing
Evidence,”or “Preponderance of the Evidence”
(51% probability or greater)
Equipoise—“at least as likely as not”(50% or
greater chance)
b
Level of formality Formal Informal
c
Obligation of the
government
In criminal cases, the government represents the
people and vigorously prosecutes persons accused
of crimes
The government must help a claimant develop
his or her case
d
Side favored? Neither side is favored over the other If there is doubt about a decision, benefit of the
doubt goes to the veteran
e
Right to representation Defendants in criminal cases have a right to be
represented by an attorney, even if they cannot
afford one. In civil matters, litigants have the right
to be represented, although payment can be an issue
for many lower and middle class litigants
Claimants have a right to representation by an
attorney only after a claims decision has been
made and the veteran has filed a
Notice of Disagreement.
f,g
The attorney’s fee
can be paid from a “past due”lump sum
amount, if benefits are awarded
h
Recording of evaluation
sessions
In some forensic evaluation contexts, audio or video
recordings are permissible and even encouraged
Veterans do not have a right to record their
C&P examinations
i
Responsibility to
obtain records
The attorney or forensic mental health professional
must obtain records he or she deems necessary to
conduct a thorough evaluation
The Veterans Benefit Administration is required
by law to assist veterans by
seeking to obtain all relevant government and
private records that might further the veteran’s
claim
j
Rules of evidence Federal Rules of Evidence or State Rules of Evidence The Federal Rules of Evidence do not apply to
veterans cases but “…the rules on expert
witness testimony provide useful guidance…”
k
a
Latin, “On one side only.”Done by, for, or on the application of one party alone. http://legal-dictionary.thefreedictionary.com/ex+parte
b
“… when a veteran seeks benefits and the evidence is in relative equipoise, the law dictates that veteran prevails.”Gilbert v. Derwinski, 1 Vet.
App. 49 (1990)
c
Although a case becomes progressively more formal as it moves up the chain of appeals from the VA Regional Office, to the Board of Veterans
Appeals, to the Court of Appeals for Veterans Claims, etc. See Fig. 2for a graphic describing the appeals process for veteran’s disability benefits
claims
d
“The Secretary must make reasonable effort to assist claimant in obtaining evidence necessary to substantiate the claimant’s claim for benefits
under a law administered by the secretary.”(Duty to Assist Claimants, 38 U.S.C. §5103A, 2010)
e
“When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the
Secretary shall give the benefit of the doubt to the claimant.”(Claimant Responsibility; Benefit of the Doubt, 38 U.S.C. § 5107(b), 2010)
f
Payment of fees for representation by agents and attorneys in proceedings before agencies of original jurisdiction and before the Board of
Veterans’Appeals, 38 C.F.R. § 14.636(c) (2010)
g
However, veterans can receive assistance in developing their claim from a Veterans Service Organization such as Disabled American Veterans,
Vietnam Veterans of America, or American Legion (not an exhaustive list)
h
Payment of fees for representation by agents and attorneys in proceedings before Agencies of Original Jurisdiction and before the Board of
Veterans’Appeals, 38 C.F.R. § 14.636(g)(2) (2010)
i
Vet. Aff. Op. Gen. Couns. Prec. 04-91 available at http://www4.va.gov/ogc/docs/1991/PREC_04-91.doc
j
38 U.S.C. § 5103A; See also Moore v. Shinseki, 555 F. 3 d 1369 (2009), wherein the Court held that a veteran’s military psychiatric hospitalization
records should have been obtained by the VA as part of its duty to assist and see also Golz v. Shinseki, 590 F.3 d 1317 at 1323 (2010): “[t]he legal
standard for relevance requires VA to examine the information it has related to medical records and if there exists a reasonable possibility that the
records could help the veteran substantiate his claim for benefits, the duty to assist requires VA to obtain the records”
k
Nieves-Rodriguez v. Peake (2008)
Psychol. Inj. and Law (2011) 4:187–216 189
Adjudication and Appeals Process
Laypersons, i.e., trained VA staff with the VA’s VBA, adju-
dicate compensation claims filed by veterans. If a veteran is
found to have a service-connected mental disability, he or
she is assigned a “rating.”These ratings represent the per-
centage of impairment in the Veteran’s average earnings
capacity. A Rating Schedule for mental disorders (Fig. 1)
guides the rating decision. A Veteran’s rating determines the
kind and amount of benefits he or she receives, both mon-
etary and access to other services.
If a veteran wishes to appeal a decision made by the
VBA, he or she can file a Notice of Disagreement requesting
that the case be reviewed. If the disagreement regarding a
VBA rating is not resolved at the VBA level, then the
veteran can appeal his or her case to the Board of Veterans
Appeals, which is administratively housed within the
Department of Veterans Affairs. If a veteran disagrees with
a decision by the Board of Veterans Appeals and he or she
meets the legal requirements, then they can appeal their case
to the Court of Appeals for Veterans Claims, a US federal
court that has jurisdiction over these matters. Further
appeals can be made to the Federal Circuit Court and to
the Supreme Court of the United States (see Fig. 2).
General Considerations for All Types of Exams
Disability Benefits Questionnaire
Beginning in 2010, the VBA and the Veterans Health
Administration (VHA), which are both components of the
US Department of Veterans Affairs (VA), launched the use
of DBQs. The DBQs are designed to streamline the claims
rating process by the VBA. They are much shorter than the
previous worksheets or templates, which, in the case of
mental health-related C&P exams, were detailed outlines
for a comprehensive mental health evaluation report
(Department of Veterans Affairs, 2001).
The VA released the DBQs for mental health-related disor-
ders in 2011. There are DBQs for Initial PTSD, Review PTSD,
Other Mental Disorders (Initial and Review exams use the
GENERAL RATING FORMULA FOR MENTAL DISORDERS
(SCHEDULE OF RATINGS—MENTAL DISORDERS, 38 C.F.R. § 4.130, 2010)
Total occupational and social impairment, due to such symptoms as: gross impairment
in thought process or communication; persistent delusions or hallucinations; grossly
inappropriate behavior; persistent danger of hurting self or others; intermittent inability to
perform activities of daily living (including maintenance of minimal personal hygiene);
disorientation to time or place; memory loss for names of close relatives, own
occupation, or own name …………………..100%
Occupational and social impairment, with deficiencies in most areas, such as work,
school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal
ideation; obsessional rituals which interfere with routine activities; speech intermittently
illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability
to function independently, appropriately and effectively; impaired impulse control (such
as unprovoked irritability with periods of violence); spatial disorientation; neglect of
personal appearance and hygiene; difficulty in adapting to stressful circumstances
(including work or a worklike setting); inability to establish and maintain effective
relationships ...................................... 70%
Occupational and social impairment with reduced reliability and productivity due to such
symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech;
panic attacks more than once a week; difficulty in understanding complex commands;
impairment of short- and long-term memory (e.g., retention of only highly learned
material, forgetting to complete tasks); impaired judgment; impaired abstract thinking;
disturbances of motivation and mood; difficulty in establishing and maintaining Effective
work and social relationships ………………..50%
Occupational and social impairment with occasional decrease in work efficiency and
intermittent periods of inability to perform occupational tasks (although generally
functioning satisfactorily, with routine behavior, self-care, and conversation normal), due
to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly
or less often), chronic sleep impairment, mild memory loss (such as forgetting names,
directions, recent events) ............................ 30%
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 continuous medication .................. 10%
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 .............................. 0%
Fig. 1 General rating formula
for mental disorders (Schedule
of ratings—mental disorders,
38 C.F.R. § 4.130, 2010)
190 Psychol. Inj. and Law (2011) 4:187–216
same form), and Eating Disorders. VA employees and contrac-
tors can access the DBQs online via the Compensation and
Pension Records Interchange (CAPRI). Private clinicians will
be able to access the DBQs (for which they are authorized to
complete) via the VA website.
3
Beguiling Appeal of the DBQ’s Brevity
We recommend that examiners exercise caution about sim-
ply responding to the DBQ items without supplementing
that information with the kind of details usually found in a
comprehensive psychological or psychiatric evaluation
report. We offer this recommendation for three reasons:
1. Veterans have been known to file licensing board com-
plaints against examiners. If the examiner does not write
a detailed report, it will be hard to prove that he or she
conducted a comprehensive, competent evaluation.
2. Section 9.01 of the American Psychological Association
(2002) Ethical Principles indicates that psychologists
should base their opinions “on information and techni-
ques sufficient to substantiate their findings.”The only
way to show that an examiner’s conclusions were indeed
formed accordingly is to document what the examiner did
and why he or she reached those conclusions.
3. The federal courts evaluate examiner’s reports based on
Rule 702 of the Federal Rules of Evidence (Nieves-
Rodriguez v. Peake,2008). Specifically, they look to
see that:
(a) The testimony is based upon sufficient facts or
data.
(b) The testimony is the product of reliable principles
and methods.
U.S. Supreme Court
U.S. Court of Appeals for
the Federal Circuit
U.S. Court of Appeals
for Veterans Claims
Veterans Benefits
Administration (VBA)
Regional Office
Veteran Files
Claim
C&P Exam
(Veterans Health
Administration)
Private Clinician
(Specified Exams Only)
Board of Veterans
Appeals
Fig. 2 The VA compensation &
pension adjudication and
appeals process
3
http://benefits.va.gov/TRANSFORMATION/disabilityexams/
Psychol. Inj. and Law (2011) 4:187–216 191
(c) The expert witness has applied the principles and
methods reliably to the facts of the case (note that
when the court refers to “testimony,”they mean the
examination report, and when they refer to an
“expert witness,”they mean the examiner).
It would be very difficult for a judge to ascertain
if an examiner based his or her conclusions (as
listed on the DBQ) “upon sufficient facts or
data”if those facts and data are not documented.
And it would be hard for a judge to determine if
an examiner “applied the principles and methods
reliably to the facts of the case”without a
thorough report.
The DBQ’s Symptom Checklist
One section of every mental health-related DBQ is a symp-
tom checklist where, for example, examiners are asked to
check off a box if a veteran has “depressed mood”or
“anxiety.”Unfortunately, the DBQ does not provide any
guidance with regard to how one determines the level of
symptom frequency, severity, or duration required to en-
dorse a given symptom. Thus, for example, if a veteran
reports that she feels “a little depressed”once or twice a
week, it is not clear if the examiner should check off the
“depressed mood”box or not.
We suggest that examiners endorse a symptom if it
causes significant functional impairment. In the example
given above, being “a little depressed”once or twice a week
would probably not cause significant functional impairment;
therefore, the “depressed mood”box should not be checked.
On the other hand, if a veteran’s depressed mood caused
them to disengage from meaningful social interactions and
to become isolated, then the box should be checked. This
functional impairment approach to DBQ symptom endorse-
ment is consistent with the overarching purpose of a C&P
exam, i.e., to determine if a veteran suffers from a service-
connected mental disability that causes him or her signifi-
cant social and occupational dysfunction.
Fields Not Present on the DBQ
DBQs do not provide designated space for reporting the
results of psychological testing, and there is no mention of
the role of validity assessment (screening for dissimulation
or response bias) on the DBQ. However, we suggest that
examiners not interpret this absence as an indication that
psychological testing and screening for dissimulation should
not be conducted. On the contrary, we highly recommend,
as we detail later in this article, that examiners screen for
dissimulation using psychological tests and other methods.
Examiners can report the results of such assessments in the
“Remarks”section of the DBQ.
Private Practice Clinicians
VA policy allows private psychiatrists and psychologists to
complete DBQ forms (and conduct evaluations) for Review
PTSD and Initial and Review Mental Disorder exams (as
well as Eating Disorder exams, although these are rare).
However, private clinicians should consider the following
points before agreeing to conduct a C&P exam for a veteran.
DBQ Form
First, the DBQ form is deceptively simple. Beware of the
temptation to tell a veteran that you can interview him or her
in a standard 50-min session and then check off the DBQ
boxes. Remember that you are providing an evaluation
report for legal purposes when you complete and sign a
DBQ. These are forensic disability evaluations, and you
should approach them as such. It is entirely possible that a
state licensing board governing the practice of any of the
mental health professions would object to the brevity im-
plied by the DBQ format—especially if a Veteran com-
plained to the Board that the report was inadequate in
some manner.
Record Review
Like all forensic evaluations, you should review relevant
records (Ciccone & Jones, 2010; Bush, Connell, & Denney,
2006), ideally before evaluating the veteran. The need for
records poses a unique challenge for private clinicians be-
cause, unlike VA practitioners, they do not have access to
VA computerized medical records. In the case of VHA
employees or contractors, medical records from both the
Veteran’s post-military and military years either are avail-
able in the VHA’s computerized medical records system or
provided in paper format by the VBA prior to the Veteran’s
C&P exam appointment. In contrast, private practitioners
must obtain signed consents for release of information forms
from the veteran, send a medical records request to each VA
medical facility at which the veteran has received treatment,
and wait to receive those records before concluding the
evaluation (note that the private practitioner might also be
able to request the medical records from the Regional Office
of the Veterans Benefits Administration that is handling the
veteran’s claim).
In addition, the private practitioner will also want to
request copies of all of the information in the veteran’s
VBA Claims File (also referred to as the “C-file”). Some
information within the C-file may not be relevant to the
instant examination, but we do not recommend trying to
determine in advance what records are important, as it is
impossible to know what is contained in the C-file.
192 Psychol. Inj. and Law (2011) 4:187–216
The veteran’s C-file will often contain crucial information
such as his or her written statement requesting an increase in
benefits (which is the usual reason for a Review exam);
collateral statements from the veteran’s spouse, friends, em-
ployer, or others; a copy of the previous C&P exam report;
private medical records obtained by the VBA; the veteran’s
military personnel records; the veteran’s service treatment
records (often referred to as the service treatment records
(STRs) or service medical records (SMRs)); the veteran’s
“stressor statement”(in PTSD cases, a written description of
the stressor that led to the development of PTSD); remand
orders from the Board of Veterans Appeals; and more, as
detailed by Moering (2011,inthisissue).
Note that the VA does not require that an examiner review
the claims file in order to complete a DBQ (a C-file review is
required in Initial PTSD cases but private practitioners are not
permitted to conduct those exams). The courts have also found
that review of the C-file is not absolutely necessary in all cases
(Nieves-Rodriguez v. Peake,2008).
4
We make the above
recommendations for two reasons: (a) Professional standards
of practice suggest that record reviews are an essential com-
ponent of a psychiatric disability evaluation (American
Academy of Psychiatry and Law, 2008), and (b) it is in the
veteran’s best interest that all available information be
reviewed by the examiner.
Payment
Third is the matter of payment. Private practitioners should
have a payment agreement for the veteran to sign, an estab-
lished rate for forensic evaluations, and a pre-determined
policy regarding the timing of payments, e.g., whether a
retainer fee is expected or one bills the client after the report
is complete (which is usually not a wise practice since you
might have to release your report even if you have not been
paid).
Note that the Department of Veterans Affairs does not
pay for these exams. You must collect payment from the
veteran, unless you are performing the evaluation pro bono.
Time Allotted for Exam
Fourth is the amount of time the private practitioner will
want to allow for the evaluation. We recommend at least 3h
for all aspects of the exam (review of records, psychological
testing, meeting with the veteran, writing the report). Some
practitioners routinely plan on spending six or more hours
for forensic disability evaluations.
Veteran’s Right to Exam Results
Fifth, the private practitioner should understand that veter-
ans have a right to their C&P exam results, including a copy
of your evaluation report and the DBQ. This is particularly
true since the veteran is paying for the evaluation.
Send the DBQ to the VBA
The purpose of completing the DBQ is to provide the
information to the VBA for assistance in making a rating
decision. Therefore, one should ask the veteran to sign a
release of information form allowing the private practitioner
to send the DBQ to the VBA Regional Office handling the
veteran’s claim. The veteran should know which office is
handling his claim or one can find the mailing address via an
Internet search. Fax numbers for each Regional Office are
available on the VA website.
5
Do Not Complete DBQs for Patients
Seventh, we strongly recommend not completing a DBQ for
a veteran the private practitioner is seeing for psychotherapy
or psychiatric treatment as it will create the awkward posi-
tion of a dual role relationship with the patient, viz., psy-
chologist or doctor and independent evaluator (Greenberg &
Shuman, 1997; Strasburger, Gutheil, & Brodsky, 1997;
Greenberg & Shuman, 2007). The VA also discourages its
treating providers from completing DBQs.
6
Time Allotted for Exam
VA facilities and contractors vary significantly in the
amount of time they allot for mental health-related C&P
exams. Some VA facilities expect an Initial PTSD exam to
be conducted, records reviewed, and report written in 1 h.
Others allow 2, 3, or 4 h. The VA is under tremendous
pressure from veterans groups and Congress to speed up
the time required to process a veteran’s claim for service-
connected disability benefits and to work through a backlog
4
But note that the Court also wrote: “This is not to say that particular
medical information contained in a claims file might not have signif-
icance to the process of formulating a medically valid and well-
reasoned opinion. As with any expert opinion, the factual premises of
a medical opinion are certainly subject to examination. Many times
those facts can be found in the information contained in the claims file.
Critical pieces of information from a claimant’s medical history can
lend credence to the opinion of the medical expert who considers them
and detract from the medical opinions of experts who do not.”(Nieves-
Rodriguez v. Peake, 22 Vet. App. 295 at 306, 2008).
5
http://benefits.va.gov/TRANSFORMATION/disabilityexams/
fax_numbers.asp
6
VHA Directive 2010-045 states, “For mental health-related DBQs that
are made available for providers not functioning as C&P examiners and
to maintain the integrity of the patient–provider relationship, it is recom-
mended that a Veteran’s treating provider not complete the DBQ.”(italics
in original). Available at: http://www.va.gov/vhapublications/
ViewPublication.asp?pub_ID02298.
Psychol. Inj. and Law (2011) 4:187–216 193
of claims. Unfortunately, this pressure has led some VA
facilities to demand that examiners complete exams so
quickly that quality is bound to suffer. This is not simply
our opinion. An independent, widely respected organiza-
tion, the Institute of Medicine came to a similar conclusion
and recommended that the VA allow examiners in PTSD
cases sufficient time to consistently conduct thorough, ac-
curate evaluations (IOM (Institute of Medicine) and NRC
(National Research Council), 2007). The courts also insist
on an adequate exam, as expressed in Green v. Derwinksi
(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 treat-
ment, so that the evaluation of the claimed disability
will be a fully informed one (Green v. Derwinksi,
1991).
The time allowed to conduct a C&P exam is an ethical
issue for many examiners. For psychologists, we highly rec-
ommend reviewing Standard 9.01, Bases for Assessments, of
the Ethical Principles and Code of Conduct (American
Psychological Association, 2002). If the psychologist has
concerns about being able to comply with the requirements
of that Standard because of time constraints, he or she might
want to make their concerns about the time restriction known,
in writing, to their supervisor and save documentation of this
communication (see Standard 1.03, American Psychological
Association, 2002).
Examiners might also want to advocate within their VA
facility for more time for exams. If a disgruntled veteran
files a complaint with an examiner’s licensing board be-
cause of an allegedly inadequate report, the examiner will
be in a better position to defend him or herself if they can
document their adherence to ethical principles of their pro-
fession and their advocacy for more time to be allotted for
mental health-related C&P exams.
Forensic Nature of the Exam
Although it is probably clear to most readers, we should
emphasize that C&P exams are forensic mental health eval-
uations. The term “forensic”does not mean “crime-related”
or “what you see on CSI.”Rather, the origin of the term
comes from the Latin, forēnsis, meaning “public, of a fo-
rum.”Definitions of “forensic”include:
Relating to or dealing with the application of scientific
knowledge to legal problems. <forensic medicine>
<forensic science> <forensic pathologist> <forensic
experts> (http://www.merriam-webster.com/dictionary/
forensic)
Relating to the use of science or technology in the
investigation and establishment of facts or evidence in
a court of law (http://www.answers.com/topic/forensic)
Forensic Psychiatry is defined as: “a medical subspecial-
ty that includes research and clinical practice in the many
areas in which psychiatry is applied to legal issues”
(American Academy of Psychiatry and Law at http://www.
aapl.org/org.htm).
Forensic Psychology is defined as: “the application of the
science and profession of psychology to questions and
issues relating to law and the legal system”(American
Board of Forensic Psychology at http://www.abfp.com).
In order to determine if VA disability evaluations are
forensic in nature, one need only ask: “Are C&P exams
intended to help answer legal or clinical questions?”
Clearly the answer is that VA disability evaluations are
conducted to help answer legal, not clinical, questions. As
discussed earlier in this article, the questions one is asked for
a C&P exam come specifically from US statutes, regula-
tions, and case law. For example, beginning in July of 2010,
C&P examiners have been asked in PTSD exams if a vet-
eran’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.
7
Given that C&P examinations are clearly forensic mental
health evaluations, clinicians who conduct these exams will
probably want to familiarize themselves with basic princi-
ples of forensic psychology or forensic psychiatry. See
“Appendix”at the end of this article for suggested readings.
Review of Records
In this section, we will discuss various sources of back-
ground information about the veteran available via print or
electronic records. How one obtains this information will
depend on whether one is a VA employee (or contractor) or
a private clinician.
Claims File
The veteran’s claims file or “C-file”potentially contains
extremely valuable information. One advantage of conduct-
ing C&P exams is that the VBA has usually done a fair
amount of background research and data collection regard-
ing a veteran’s claim before the examiner receives the case.
7
Federal Register: July 13, 2010 (Volume 75, Number 133) [Rules and
Regulations] [Page 39843–39852] From the Federal Register Online
via GPO Access [wais.access.gpo.gov] [DOCID:fr13jy10-13]
194 Psychol. Inj. and Law (2011) 4:187–216
A corollary disadvantage is that the C-file often contains an
abundance of information, consisting of hundreds (or even
thousands) of pages. Nonetheless, it is incumbent upon the
examiner to review the C-file. Full-time C&P examiners
have an advantage because they become adept at knowing
which pages of documents they can skim or skip but even
then, reviewing the entire C-file can take a fair amount of
time (which is one reason why allotting only an hour or two
per exam is unwise). Important information to look for in a
C-file includes the following:
Veteran’s statements Some veterans pen statements regard-
ing their mental disorder and the effect it has on their life.
Whether in response to VA forms (such as Statement in
Support of Claim for Service Connection for PTSD, VBA
Form 21-0781) or in hopes of supporting their claims, these
veterans’statements are an important part of the official
record. They also are important because, under the stress
of a C&P exam, some veterans forget to mention a traumatic
event, symptom, or functional deficit that might prove cru-
cial to their case.
Collateral statements, including “buddy letters”Veterans
often ask family members or friends to write statements in
support of their claim. Some such letters can be heart-
wrenching as they describe in everyday language the func-
tional deficits the Veteran has suffered as a result of PTSD or
other mental disorder. Clearly, since the emphasis of the
C&P exam is on social and occupational impairment, such
information is vitally important. A particular type of state-
ment that one might hear a veteran make reference to is a
“buddy letter,”which is a letter or statement written by a
fellow service member, often describing a stressor that (re-
portedly) led to the development of the veteran’s PTSD,
although a buddy letter can also describe symptomatic and
functional changes noticed by the fellow service member.
Personnel records Unfortunately, not all C-files contain
military personnel records, but when they do, it is important
to compare the veteran’s documented tour of duty with the
information he or she provides in an interview. In most
instances, the Veteran’s personnel records will match his or
her accounting of events, which enhances the Veteran’s
credibility. Performance evaluations (both before and after
a claimed stressor), reports of disciplinary actions, training
records, and other historical information may also reflect
favorably on a Veteran’s claim. Nonetheless and as an
example, each of the authors has had occasions when a
Veteran claimed to have experienced a traumatic stressor
in a specific location, on a specific date, but their personnel
record indicated that were stationed at a completely different
location at that time. Other types of discrepancies in the
historical record also may give rise to a conclusion that it is
“less likely than not”that a nexus exists between a veteran’s
service and his or her claimed injury.
DD-214 The DD-214 is a Department of Defense form that
shows the dates of the veteran’s military service, their rank
at discharge, medals and other awards, official MOS
(Military Occupational Specialty), and service branch. The
DD-214 is usually found on the right flap of the C-file.
Again, discrepancies between claimed and actual military
roles, the nature of military discharge, and service dates can
be garnered from the DD-214.
Private medical records As noted earlier, the VA has an
obligation to help a veteran obtain records that might sup-
port his or her claim. This assistance often involves obtain-
ing copies of a veteran’s private medical records, which can
contain vital information, e.g., symptoms, diagnoses,
descriptions of functional impairments, course of an illness,
etc. Although specialists’records (e.g., from a dermatolo-
gist) are not as likely to contain relevant information, one
should at least skim those documents as there may be
relevant information regarding psychiatric symptoms caus-
ing somatic problems (e.g., skin rash secondary to stress).
But carefully read primary care physicians’notes as they
often contain important information about a veteran’s psy-
chosocial functioning.
VA medical records Some veterans will have lengthy VA
medical histories, but it is important to review those progress
notes and other records too, particularly those from mental
health and primary care providers. This review can take some
time, sometimes even an hour or two, but it remains a critical
part of the evaluation process (and, yet again, another reason
to allow sufficient time for these exams).
Previous C&P exam reports When conducting a Review
exam, one should always review past mental health-related
C&P exam reports, partly because a crucial question for
Review exams is whether or not the veteran’ssymptomsand
functional abilities have changed since the last exam. Also at
least skim non-psychiatric medical C&P exam reports for
relevant psychosocial information. Reports from physical
medicine, i.e., Traumatic Brain Injury exams and General
Medical exam reports, and reports from neurologists require
closer review because they likely will contain relevant psy-
chosocial and medical information.
Service treatment records One of the most critical pieces of
information is the veteran’s history of medical treatment
while in the military, since the sine non qua of these evalua-
tions is whether or not a mental disorder developed while
the veteran was in the military (although see the caveat
below). Older records, e.g., Vietnam War era STRs (also
Psychol. Inj. and Law (2011) 4:187–216 195
sometimes referred to as SMRs) are infamous for containing
scanty mental health information, but you never know when
you might discover something relevant in a review of those
yellowed pages. Operation Enduring Freedom—
Afghanistan and Operation Iraqi Freedom veterans are like-
ly to have more relevant information in their STR folder
because of advancements in electronic medical records sys-
tems, mental health screening, and mental health awareness
in recent years.
Keep in mind that absence of mental health records in a
veteran’sSTRsdoesnot negate receipt of a service-
connected disability award. In fact, the vast majority of
Vietnam veterans with successful service-connected PTSD
claims were not diagnosed with a mental disorder during
their military service. For one thing, PTSD was not a
recognized diagnosis in the 1960s and 1970s. Also, recall
that, for PTSD claims, a 2010 regulations change means
that veterans need only demonstrate that they were in a war
zone for their stressor to be conceded by the VA. The
examiner must still determine if the veteran’sreportof
the stressor is credible.
Military Records Missing Due to 1973 Fire
Although some veterans claim their service records were
destroyed in the July 1973 fire at the National Personnel
Records Center in Missouri, research has indicated that the
only records affected by the fire were US Army personnel
who were discharged between November 1912 and January
1960 and US Air Force personnel who were discharged
from September 1947 to January 1964 (Stender & Walker,
1974). Additional research has indicated that 94% of those
records destroyed in the fire have been reconstructed. The
fire did not affect records of military personnel serving in
combat in Vietnam (McNally, 2003).
C-File Not Provided
Unfortunately, even VA-employed examiners are sometimes
not provided the veteran’s C-file. In such cases, one must
always consider whether or not to insist on receipt and review
of the C-file before concluding an examination. While some
exams can be completed without the C-file, e.g., Review
exams in which abundant clinical information is available
via medical records, one should always consider the possibil-
ity that a crucial piece of information will be missed without
receipt and review of the C-file.
Computerized Patient Record System
Most VA examiners are familiar with the Computerized
Patient Record System (CPRS) so we will not spend time
reviewing its features. Instead we will simply offer two
suggestions: (1) Be sure to set the date range for Notes to
as far back as the veteran has been seen at your facility so
that you review all the relevant progress notes and (2) check
the previous Global Assessment of Functioning (GAF)
scores under Reports > Clinical Reports > Outpatient
Encounters/GAF Scores. Also note that previous C&P
exams can sometimes be found under Reports > Clinical
Reports > Comp & Pen Exams.
VistaWeb
VistaWeb is an online medical records database accessible
by VA employees that contains medical records from the
Department of Defense (DOD) and other VA facilities
(CPRS contains records from one’s own VA facility only).
VistaWeb is available from within CPRS on the upper right
portion of the screen, immediately above the “Remote Data”
button. Although one can use the “Remote Data”feature to
access DOD and VA medical records, VistaWeb provides a
superior user interface and, it seems, more comprehensive
information.
Specific areas within VistaWeb that you will probably
want to check include Progress Notes, Visits/Admissions,
Discharge Summaries, GAF Scores (under Outpatient
Encounters/GAF), and Consults, although we recommend
exploring the other categories as this is not an exhaustive
list. Previous C&P exams can be found under either
Progress Notes or Visits/Admissions.
CAPRI
The CAPRI electronic records system is available to VA
staff and is another way to access medical records, including
VistaWeb, as well as VBA documents. The CAPRI system
provides the ability to search all of the local VA medical
records for a specific word or phrase (e.g., “PTSD”or
“suicidal ideations”). The search feature is found under the
“Clinical Documents”tab.
Informed Consent
Ethical standards of most mental health professions require
that patients or evaluees receive informed consent prior to
the initiation of a mental health evaluation (e.g., for
psychologists, Standard 9.03 of the Ethical Principles;
American Psychological Association, 2002). For your
protection, we recommend documenting the veteran’s
informed consent by having him or her sign a form to
that effect. An informed consent document also helps
orient the veteran to the exam, prevents misunderstand-
ing, reduces the likelihood of a post-exam complaint, and
communicates respect to the veteran.
196 Psychol. Inj. and Law (2011) 4:187–216
Here are some items to consider as part of your informed
consent document:
&Identify your profession. For example, if you are a
psychiatrist, it might help the veteran to know that you
are a medical doctor because then he or she knows that
you will be knowledgeable about the complications of
an illness such as diabetes.
&Describe your relationship to the veteran, i.e., as an
independent evaluator, not a treating clinician.
&Explain how the results of your examination will be
communicated and to whom a report will be sent and
how the veteran can obtain a copy of the report.
&Explain limits to confidentiality.
&Clarify the purpose of the evaluation.
&Warn the veteran about the negative consequences of
symptom exaggeration or fabrication.
&Describe the potential risks associated with the evalua-
tion, namely experiencing painful emotions.
&Provide information about mental health resources
should the veteran experience distress as a result of the
exam.
&Encourage the veteran to ask questions about the con-
sent form and include an item in the form that docu-
ments this opportunity.
See Fig. 3for a sample consent form. That sample is
simply one of many ways to document informed consent.
Stressful Nature of the Exam
For many veterans, a C&P exam is a stressful and upsetting
experience. For example, in PTSD cases, the examiner asks
the veteran to describe the traumatic events that (reportedly)
led to the development of PTSD. As one veteran remarked,
“You’re asking me to talk about the stuff I spend every day
trying to forget.”Our recommendations are to:
&Include a statement in your consent form that acknowl-
edges the stressful nature of the exam.
&Provide the veteran with a Veteran’s Helpline card
8
should he wish to talk with someone after the exam
(mention that you provided the card in your consent
form).
&Also tell the veteran verbally that you understand that
parts of the exam might be stressful or upsetting and that
you will try to keep those aspects of the exam as brief as
possible, although you will also give the veteran ample
time to describe his or her experiences.
&Inform the veteran that he is free to request a break at
any point during the exam process.
&Respond to emotional distress with measured empathy.
By “measured”we mean that since this is not a psycho-
therapy session, you do not want to respond in such a
way that would convey that you are there to provide
ongoing counseling. At the same time, you do not want
to come across as uncaring as such a response would not
only be disrespectful, a non-empathic response also
might cause the veteran to withdraw emotionally and
not share with you the full impact of his mental disorder
(s), thus providing an incomplete view of the veteran’s
impairment.
Political Climate at the Department of Veterans Affairs
Clinical Versus Forensic Orientation
VA mental health examiners work for the VHA. The VHA
mission is to “Honor America’s Veterans by providing ex-
ceptional health care that improves their health and well-
being”(http://www.va.gov/health/aboutVHA.asp). There is
no official mission statement for the mental health-related
C&P exam process, but if one was to create such a state-
ment, it might be something like: “To provide evidence-
based mental health assessments of veterans claiming
service-connected disabilities in order to help the Veterans
Benefits Administration make accurate benefit determina-
tions.”Clearly, these missions are not the same. VA employ-
ees who conduct C&P examinations (full-time C&P
examiners or mental health treatment providers who are
required to complete C&P examinations as extra duty)
should bear this difference in mind. Some VA officials
(VHA and VBA) do not appear to understand this distinc-
tion and assume that C&P examiners are providing health-
care services to veterans. This lack of understanding can
create tensions when, for example, examiners talk about the
importance of screening for significant symptom exaggera-
tion or feigning.
In fact, the VA has terminated the contract of at least one
C&P examiner because she screened for symptom exagger-
ation and feigning (Poyner, 2010). VA officials at her site
told this psychologist that “the use of instruments designed
to detect feigning ‘do not give the veteran the benefit of the
doubt’.”(Poyner, 2010, p. 131). This stance by at least these
VA officials might reflect a misguided notion that C&P
examiners are supposed to be providing clinical services,
when, in fact, they are performing a forensic mental health
assessment function.
This political opposition to the assessment of feigning is
not universal across VA facilities. However, if you encounter
8
You can order cards at http://www.suicidepreventionlifeline.org/
Materials/Default.aspx or, if you are affiliated with a VA Medical
Center, from that Center’s Suicide Prevention Coordinator.
Psychol. Inj. and Law (2011) 4:187–216 197
such opposition, be prepared to explain in careful detail the
importance of screening for exaggeration and feigning on
empirical, ethical, professional, and public policy grounds.
Empirical evidence for significant symptom exaggeration
and feigning in these and similar disability exams is abundant;
see “Screening and Assessment of Exaggeration and
Feigning”section below for details.
From a professional perspective, examiners have an obli-
gation to conduct a fair, balanced, and impartial evaluation. A
misguided attempt to “give the veteran the benefit of the
doubt”ignores the facts, namely that there is an incentive to
exaggerate or feign given the monetary reward for successful-
ly fooling an examiner and receiving disability benefits. To
ignore this incentive is naïve and unscientific as it denies the
abundant scientific evidence to the contrary. The DSM-IV
even contains a warning about the potential for symptom
exaggeration or feigning when diagnosing PTSD:
“Malingering should be ruled out in those situations in which
financial remuneration, benefit eligibility, and forensic deter-
minations play a role.”(American Psychiatric Association,
2000,p.467).
From an ethical perspective, consider the APA Ethics
Code guideline that “[p]sychologists’work is based upon
established scientific and professional knowledge of the
discipline”(Standard 2.04; American Psychological
Association, 2002). It is clearly established in the scientific
literature (see below for citations) that a high percentage of
compensation-seeking veterans over-report symptoms of
mental disorders. Thus, if one ignores that scientific evi-
dence, then one is not basing one’s work on “established
scientific and professional knowledge.”
From a public policy perspective, a failure to screen for
exaggeration and feigning potentially wastes taxpayer dol-
lars and contributes to the national debt by awarding under-
served benefits (which can include not only tax-free cash
payments but also free healthcare and educational funds for
Compensation & Pension Exam Consent Form
I understand that:
1. I will receive a psychological evaluation (exam) from Jane Doe, Psy.D., a clinical psychologist.
2. Dr. Doe works for the Veterans Health Admini stration (VHA), which is part of the VA
(Department of Veterans Affairs).
3. The purpose of this exam is to provide the Veterans Benefits Administration (VBA), which is
also part of the VA, with information they need to make a decision regarding my claim for
Compensation & Pension (C&P) benefits.
4. I am not a patient or client of Dr. Doe. I will not be receiving counseling or psychotherapy
from Dr. Doe. The only reason for this exam is to conduct a psychological evaluation for
Compensation & Pension (C&P) purposes.
5. If I want to receive mental health treatment from the Veterans Health Administration, I can
call any VA medical center or clinic to request an appointment.
6. This exam and its contents are private and confidential except under the following
circumstances:
a. If I am in imminent danger of harming my self or another person, Dr. Doe must take
whatever steps necessary to prevent harm and this might mean breaking
confidentiality.
b. If I share information that would lead a reasonable person to suspect that a child or
disabled adult is being abused or neglected then Dr. Doe must report that information
to Protective Services.
c. If I appeal my case to the Federal courts, some aspects of this exam could become a
matter of public record.
7. Dr. Doe will write an exam report and send it to the VBA Regional Office that is handling my
claim.
8. A copy of the exam report will be placed in my VHA electronic medical record.
9. I must be honest in answering questions on all psychological questionnaires, tests, and
interviews during this exam. Any attempt to exaggerate or fabricate symptoms of mental
disorders could have negative consequences for my claim.
10. This exam might be stressful for me. I might feel upset (sad, anxious, irritable, depressed,
etc.) as a result of answering questions during the exam.
11. Dr. Doe has given me a National Suicide Prevention Lifeline Card , which has a phone number I
can call if I feel suicidal or overwhelmed.
12. I am entitled to Travel Pay for this exam, even if I am not currently service-connected. [Go to
the Travel Office before you leave to receive your payment.]
13. If I had any questions about this consent form, I have asked them and Dr. Doe has answered
them to my satisfaction.
PRINT Name ___________________ _________________________ ______________
SIGN Name ____________________ _________________________ ______________
Toda
y
’s Date ____ ____________________________
Fig. 3 Sample consent form
198 Psychol. Inj. and Law (2011) 4:187–216
a veteran’s children). Equally important, allowing undeserv-
ing veterans to receive disability benefits dishonors those
veterans with genuine disabilities.
Opposition to Psychological Testing
Examiners might also encounter resistance to the use of any
psychological testing by VA officials who claim that it is
unnecessary. If you face such opposition, you might inquire
of the VA official if he or she also tells physicians whether
or not they are allowed to utilize medical tests (e.g., labs,
sleep studies, or X-rays) in their C&P examinations. Asking
such a question might expose a bias against psychological
testing, which seems to be based on prejudice, not science
(see the “Psychological Testing”section below for addition-
al information).
The Possible Iatrogenic Effects of the VA Disability
Program
Some have argued that the VA compensation program un-
wittingly discourages and impedes treatment progress by
veterans with mental disorders, particularly PTSD
(Mossman, 1994; Frueh, Grubaugh, Elhai, & Buckley,
2007; Satel, 2011). Some VA-affiliated psychologists dis-
agree with this argument (Marx et al., 2008; also see the
response by Frueh, Buckley, Grubaugh, & Elhai, 2008). Our
main point here is that examiners should be aware of this
controversy because they may well notice that many of the
veterans they evaluate do not seem to have benefitted from
psychiatric and/or psychological treatment. If such a poten-
tially puzzling pattern is observed, bear in mind that it may
occur because of the VA program’s built-in incentive to
remain sick in order to receive disability compensation, as
opposed to the treatment approach itself being ineffective.
9
Screening and Assessment of Exaggeration and Feigning
There is abundant research literature demonstrating that
compensation-seeking veterans exhibit high rates of symp-
tom over-reporting (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). However, it is important to keep in mind
that it is often difficult to discern a veteran’s reason(s) for
over-reporting symptoms. In particular, one should not nec-
essarily assume that because a veteran over-reported symp-
toms that he or she intended to feign a mental disorder.
There are various reasons why a veteran might over-
report symptoms. For example, Frueh, Hamner, Cahill,
Gold, and Hamlin (2000) suggested that Vietnam War vet-
erans might exaggerate symptoms during a C&P exam
because of:
&The severity of their illness—“…the combination of
psychiatric comorbidity, interpersonal maladjustment,
symptom chronicity, and degree of trauma exposure”
all contribute to symptom over-reporting (Frueh et al.,
2000, p. 859).
&Generalized distress—“…acute levels of perceived
global distress lead veterans to overestimate their actual
level of psychopathology across multiple domains…”
(Frueh et al., 2000, p. 861)
&Sociopolitical 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.”(Frueh et al., 2000, p. 867)
–Similarly, Hyer et al. (1988) suggested that one
reason for symptom over-reporting:
…might be that Vietnam combat veterans are just now
‘learning’to respond to years of dormant thoughts and
feelings about their condition. During this dissonance
reduction process they are ‘seduced’into exaggera-
tion, overreports, and even factitious reports when
confronted with their pathology. In a sense they must
make an effort to ‘really’be a Vietnam veteran again
and must sell themselves and their helpers. Given that
many other veterans are also involved in this process,
this can become a ‘cathartic or contagion process,’
where the facts and fiction are interchangeable.
&Compensation-seeking status—some veterans believe
that they must “really make their case”when being
evaluated for compensation and pension purposes.
They therefore unconsciously over-report psychological
symptoms (Frueh et al., 2000, p. 863).
Similarly, Franklin et al. (2002) conducted research on
MMPI-2 scores of veterans undergoing a C&P exam. Their
results suggested that “…a majority of veterans with elevated
F scale scores are not intentionally overreporting their symp-
toms, but likely are achieving high elevations due to extreme
distress”(Franklin et al., 2002, p. 283). They classified 77.2%
of their sample (consisting of all MMPI-2 profiles with F≥80
and consistent responding) as belonging to an “extreme dis-
tress”group (Fp≤6) and 22.8% to an “over-reporting”group
(Fp≥7).
9
However, one should note that recent research indicates that in
general, VA compensation recipients with PTSD experience “clinically
meaningful reductions in PTSD symptoms and less poverty and home-
lessness”(Murdoch et al., 2011, p. 1072).
Psychol. Inj. and Law (2011) 4:187–216 199
Given these multiple reasons for over-reporting, one might
reasonably ask, “How can one best differentiate symptom
over-reporting due to ‘extreme distress’or related reasons
from over-reporting due to an intentional attempt to exagger-
ate symptoms or outright feign a mental disorder?”We offer
the following suggested protocol to help answer this question.
Screening and Assessment for Exaggeration and Feigning:
Suggested Psychometric Protocol
1. Administer the MMPI-2 or PAI. The MMPI-2 has been
found to better discriminate between genuine and feign-
ing groups in simulation designs (Eakin et al., 2006;
Lange et al., 2010); therefore, it is the preferred instru-
ment. Examiners who use the PAI might consider supple-
menting it with a feigning-specific screener such as the
Miller Forensic Assessment of Symptoms Test (M-FAST;
Miller, 2001; Guy, Kwartner, & Miller, 2006)orthe
Structured Inventory of Malingered Symptomatology
(SIMS; Widows & Smith, 2005). If you use the SIMS,
be sure to use the higher cutoff score recommended in
research by Wisdom, Challahan, and Shaw (2010). The
remainder of this suggested psychometric protocol will
assume use of the MMPI-2.
2. Compare the MMPI-2 validity scale scores you ob-
tain to the classifications listed in Table 2.Youwill
need to decide if you want to use the Intermediate
or Conservative cut scores.
(a) One or more scales in the Conservative Cut range
represents very strong evidence of symptom exag-
geration to the point that making an accurate men-
tal disorder diagnosis is unlikely.
(b) One or more scales in the Intermediate Cut range
represent strong evidence of symptom exaggera-
tion. However, if you want to obtain additional
psychometric evidence, you might consider admin-
istering the Morel Emotional Numbing Test for
PTSD (MENT; Morel & Shepherd, 2008a,b;
Messer & Fremouw, 2007), M-FAST, or the
Structured Interview of Reported Symptoms
(SIRS; Rogers, Bagby, & Dickens, 1992)or
SIRS-2 (Rogers, Seward, & Gillard, 2010). If using
the SIRS, we strongly encourage you to familiarize
yourself with recent research on the SIRS (e.g.,
Rogers, Payne, Berry, & Granacher, 2009a;Rogers,
Payne, Correa, Gillard, & Ross, 2009b;Green&
Rosenfeld, 2011) and the SIRS-2 (DeClue, 2011),
i.e., do not rely solely on the manual for guidance.
This psychometric protocol has an empirical basis, e.g.,
the Table 2Conservative Cut scores are based on scores at
or above the 99th percentile for a large general clinical sample
(Greene, 2008; Table 10.13, p. 180) and 2.0 standard devia-
tions above the mean score for genuine PTSD patients
(Resnick, West, & Payne, 2008; Table 7.5, p. 119). Thus, the
Tab le 2cut scores take into account the tendency of combat
veterans with PTSD to elevate MMPI-2 validity scales (Frueh
et al., 2000;Franklinetal.,2002; Resnick, West, & Payne,
2008). Note that the Conservative Cut scores are, indeed, very
conservative scores. For example Arbisi, Ben-Porath, and
McNulty (2006) found that lower cut scores successfully
differentiated compensation-seeking veterans instructed to an-
swer MMPI-2 items honestly versus those instructed to exag-
gerate PTSD symptoms and avoid detection. Rubenzer (2009)
is another resource to consult as the author recommends a
specific response-style battery to assess for feigned PTSD.
Table 2 MMPI-2 validity scale scores: screening for exaggeration or
feigning
MMPI-2
scale
Normal Extreme
distress
Intermediate
cut
Conservative
cut
F≤80 81–117 118–129 ≥130 (raw≥32)
FB ≤80 81–117 118–139 ≥140 (raw≥24)
F-K ≤11 12–20 21–26 ≥27
F(p) ≤69 70–98 99–105 ≥106 (raw≥9)
Ds ≤79 80–96 97–106 ≥107 (raw≥40)
FInfrequency, FB Back-Page Infrequency, F-K Dissimulation Index
(Gough, 1950), F(p) Infrequency-Psychopathology (Arbisi & Ben-
Porath, 1995), Ds Gough Dissimulation Scale (Gough, 1954)
All values are T-scores except for F-K values which are raw scores.
Raw scores are provided for the “conservative cut”level since T-scores
in this range are not provided on standard MMPI-2 computer-generated
reports. The “extreme distress”level indicates a range of scores which
suggest that the individual probably endorsed more symptoms or
problems than they actually experience, but this over-endorsement is
most likely due to “extreme distress”(Franklin, Repasky, Thompson,
Shelton, & Uddo, 2002) or what is often referred to as a “cry for help”
response set (Graham, 2006). Note that the values given are higher than
those in Graham (2006) because this table takes into account the
tendency of genuine PTSD patients to elevate MMPI-2 validity scales
at higher levels than other clinical populations, as discussed by Frueh,
Hamner, Cahill, Gold, and Hamlin (2000) and Franklin et al. (2002).
The “intermediate cut”scores are at least at the 98th percentile for a
very large clinical sample (Greene, 2008, Table 10.13, p. 180) and 1.5
standard deviations above the mean for genuine PTSD samples
(Resnick, West, & Payne, 2008, Table 7.5, p. 119). The term “inter-
mediate cut”is from the Resnick et al. (2008) chapter. The “conserva-
tive cut”scores are at or above the 99th percentile for a very large
clinical sample (Greene, 2008, Table 10.13, p. 180) and at least 2.0
standard deviations above the mean for genuine PTSD samples
(Resnick, West, & Payne, 2008, Table 7.5, p. 119). The term “conser-
vative cut”is from the Resnick et al. (2008) chapter. All of these
MMPI-2 scales, except for Ds, have been validated as efficient for
the detection of symptom exaggeration for combat veterans undergoing
evaluation for PTSD (Tolin, Steenkamp, Marx, & Litz, 2010). The
authors of that study found that the Ds-r scale was not a good discrim-
inator; they did not evaluate the longer Ds scale, which has proved to
be a good discriminator in other studies (e.g., Wetter, Baer, Berry,
Robison, & Sumpter, 1993)
200 Psychol. Inj. and Law (2011) 4:187–216
Unless there is substantial evidence in favor of the claimed
diagnosis, we suggest listing in the diagnosis section of the
DBQ, “No Diagnosis on Axis I (V71.09)”or “Diagnosis
Deferred on Axis I (799.9)”if any of the MMPI validity
indices are in the Conservative Cut range of Table 2.Ifany
of the validity scales are in the Intermediate Cut range, you
will need to decide if such scores prevent you from rendering
an accurate diagnosis or not. We cannot offer a definitive
answer regarding whether to use the Intermediate Cut
MMPI-2 cut scores because reasonable arguments can be
made for and against regarding the Intermediate Cut scores
as representing significant over-reporting or exaggeration.
In the preceding paragraph, we used the phrase “substan-
tial evidence in favor of the claimed diagnosis.”By “sub-
stantial evidence,”we mean one or more of the following:
&The veteran sought mental health treatment for the
claimed (or similar) condition well in advance of filing
a claim for disability benefits.
&The veteran was diagnosed with the claimed (or similar)
mental disorder while in the military.
&The veteran presents collateral statements from disinter-
ested parties (i.e., people who do not benefit if the VBA
determines the veteran has a service-connected disabil-
ity), which convincingly describes symptoms consistent
with the claimed disorder and these symptoms began
during or shortly after military service.
In general, individual examiners should determine for
themselves a method to determine if the veteran’sover-
reporting is due to generalized distress or related factors or if
the veteran’s symptom over-reporting is in a range associated
with significant exaggeration or feigning of mental disorders.
The above protocol is simply one way to accomplish thisgoal.
Whatever you do, do not ignore elevated validity scale
indices. Unfortunately, ignoring this evidence happens fairly
often, as evidenced by research conducted by Arbisi et al.
(2004), which found that C&P examiners very frequently did
not comment at all on MMPI-2 profiles which produced Fp
scores above 7. One would have expected these C&P exam-
iners to interpret an Fp>7 score and explain its implications for
the examination and to, at least in some cases, conclude that
they could not render an accurate diagnosis with this evidence
of symptom exaggeration. However, Arbisi et al. (2004)found
that there were no differences in diagnosis or service connec-
tion status between veterans with problematic MMPI-2 pro-
files (Fp>7) and those with clearly valid profiles (Fp≤2).
Screening and Assessment for Exaggeration and Feigning:
Interview Approaches
A substantial literature exists regarding interview strategies
for detecting feigning or malingering, particularly when it
comes to PTSD cases (Hall & Hall, 2007;Guriel&
Fremouw, 2003; Resnick, West, & Payne, 2008;Taylor,
Frueh, & Asmundson, 2007; Knoll & Resnick, 2006;
Rogers, 2008; Simon, 2003). We highly recommend that
the reader consult the aforementioned references for detailed
guidance, but some general interview guidelines from this
literature include the following:
&Remain “…composed, impartial, and respectful…”
(Knoll & Resnick, 2006, p. 639).
&Ask open-ended questions and let the veteran talk.
Malingerers or exaggerators will often eventually con-
tradict themselves, whereas genuine patients will not
(Hall & Hall, 2006, p. 531). In this regard, also “…avoid
leading questions that give clues to correct responses”
(Resnick, West, & Payne, 2008, p. 117).
&Understand that discussions of combat-related trauma
can, understandably, be very emotional for the veteran
and the examiner. While one should not ignore the
presence of strong affect, one should also remain objec-
tive and not let one’s natural response, e.g., empathy and
a desire to “help”the veteran, rule the day when it comes
to diagnosis and an opinion regarding service connec-
tion (Knoll & Resnick, 2006, p. 639).
&Ask the veteran to provide specific examples of symp-
toms. It is harder to describe specific instances of a
symptom than it is to recite a symptom (remember that
PTSD symptom lists are ubiquitous on the Internet and
elsewhere), although one should keep in mind that gen-
uine PTSD patients sometimes have difficulty describ-
ing specific symptoms because of the emotionally
charged nature of their experience and a tendency to
avoid exposure to such affect.
&During the interview, look for behavioral manifestations
of the alleged disorder, e.g., irritability, inability to fo-
cus, or exaggerated startle response with claimed PTSD
(Resnick, West, & Payne, 2008, p. 117).
Screening and Assessment for Exaggeration and Feigning:
Clinical Signs
The literature references cited in the above section also con-
tain descriptions of clinical signs of significant exaggeration
or feigning. Again, we recommend that the reader consult
those sources for detailed guidance. Table 3provides an
example of some of these clinical signs, although note that
these indicators have not been empirically validated.
Screening and Assessment for Exaggeration and Feigning:
Diagnostic Decisions
What should an examiner do, in terms of a diagnosis, if the
examination reveals signs of significant exaggeration or
Psychol. Inj. and Law (2011) 4:187–216 201
feigning? As noted above, usually the best course of action
is to list “No Diagnosis on Axis I (V71.09)”or “Diagnosis
Deferred on Axis I (799.9)”; explain your reasons for not
being able to determine a diagnosis; and indicate in your
Medical Opinion section that you cannot formulate an opin-
ion without resorting to mere speculation (one of the legally
preferred phrases as discussed earlier in this article).
Understand that the courts are not particularly fond of use
of the phrase “cannot formulate an opinion without resorting
to mere speculation”(Jones v. Shinseki,2010)andthat
jurists expect the examiner to thoroughly explain why he
or she cannot form an opinion without resorting to mere
speculation.
On relatively rare occasions, you might have enough
evidence to assign a diagnosis of Malingering (V65.2) on
Axis I. Table 4provides examples of such evidence. We
highly recommend that examiners take a very conservative
approach with regard to diagnosing a veteran with
Malingering given the potentially significant repercussions
from assigning an erroneous diagnostic label.
Overemphasis on Symptom Exaggeration and Feigning?
As discussed previously, some VA officials look askance at
examiners who screen and assess for symptom exaggeration
or feigning. Anecdotally, one of the criticisms the authors of
this article have heard is “you are focusing too much on
malingering.”In fact, some readers of this article might be
thinking, “They are spending a lot of time discussing
symptom exaggeration and feigning.”We believe that this
emphasis is appropriate for the following reasons:
&There is so much resistance to screening for dissimula-
tion within the VA that we feel compelled to make a
strong, detailed case for its importance.
&There is abundant research evidence that compensation-
seeking veterans frequently over-report symptoms, often
to a significant degree. While a good portion of these
veterans elevate validity indices due to “extreme dis-
tress”or related reasons, there are still a significant
minority of veterans who over-report symptoms to such
ahighdegreethatthe“extreme distress”hypothesis
breaks down as a reasonable explanation for them. In
fact, even in their article arguing for an understanding of
the “extreme distress”phenomenon, Franklin et al.
(2002) noted that 22.8% of their sample elevated Fp
above 7 and were not included in the “extreme distress”
group due to this psychometric evidence of probable
exaggeration.
&If over 20% of veterans in a C&P sample (Franklin et al.,
2002) showed signs of symptom exaggeration—to an
extent that their self-report of PTSD or other mental
disorder symptoms probably should be considered
Table 3 Clinical indicators of malingered combat-related PTSD
Genuine PTSD Malingered PTSD
Minimize relationship of
problems to combat
Emphasize relationship of
problems to combat
Blame self Blame others
Dreams: themes of
helplessness, guilt
Dreams: themes of grandiosity,
power
Deny emotional impact
of combat
“Act out”alleged feelings
Reluctant to discuss combat
memories
“Relish”discussing combat tales
Survivor guilt relates to
specific incidents
Generalized guilt over surviving
war
Avoidance of environmental
stimuli
No avoidance of environmental
stimuli
Anger over helplessness Anger toward authority
The above chart was originally published in Resnick, West, and Payne
(2008, p. 126), reprinted by permission. The original authors of the
chart caution that “[t]he clinical indicators for malingered combat-
related PTSD are based primarily on individual case reports and
anecdotal descriptions…[t]hus they should be considered tentative
and must be weighed along with the totality of the available data”
(Resnick, West, & Payne, 2008, pp. 125–126)
Table 4 Potential evidence for a diagnosis of malingering
Strongly suggestive but not definitive signs of malingering
Veteran claims he or she cannot work but he or she engages in a wide
range of social and recreational activities
Significant exaggeration of mental disorder symptoms that is not due
to extreme distress or other factors, e.g., MMPI-2 validity indices in
the “conservative cut”range (see Table 2) or SIRS classification in
the feigning range
Reliable collateral source describes the veteran functioning well with
only mild symptoms
History of deceit in order to obtain financial gain, e.g., conviction for
embezzlement
Veteran states that he has applied for Individual Unemployability
“because I need more money”with no explanation as to why he is so
disabled that he cannot work
Definitive signs of malingering
Veteran admits to fabricating symptoms in order to receive
compensation benefits
Videotape of veteran that clearly contradicts reported symptoms. For
example, veteran claims mental disorder and a back injury that
requires him to always use a wheelchair. He presents to the exam in
a wheelchair. He is subsequently observed and videotaped trotting to
his car in the VA parking lot (this example is based on an actual
exam the second author conducted)
Personnel records contradict the veteran’s statements about his tour of
duty, e.g., a veteran states he participated in the defense of a US
Embassy (that subsequently caused PTSD) but personnel records
show he was never stationed at that embassy
Veteran scores above chance level on a symptom validity test, e.g., a
score of 37 or above on the MENT
202 Psychol. Inj. and Law (2011) 4:187–216
suspect—then one must consider the implications of
ignoring the possibility that over 20% of individuals
presenting for a mental health-related C&P exam are
unlikely to have a service-connected disability. If those
claimants are not identified as significantly exaggerating
or feigning and they are subsequently awarded compen-
sation benefits, we dishonor all the veterans with genu-
ine disorders as well as waste billions of dollars of US
taxpayers’money over the lifetime of those benefits.
Importance of Consulting the Research Literature
Not only is it sound professional practice to keep up with the
scientific research literature in one’s discipline, the courts
have emphasized the importance of C&P examiners con-
sulting the research literature when appropriate. For exam-
ple, in Jones v. Shinseki (2010), the court wrote “The
examiner may also have an obligation to conduct research
in the medical literature depending on the evidence in the
record at the time of examination”(Jones v. Shinseki,2010).
Meeting with the Veteran
Ideally, one should have completed a record review prior to
meeting with the veteran. Such a review is not always
possible in advance but even a quick scan of the veteran’s
medical records and C-file will help you identify potentially
important issues. Some familiarity with a veteran’s case also
helps you build rapport with the veteran.
Orientation to the Exam
When you first meet with the veteran, after introducing
yourself and welcoming him or her to your office, we
recommend the following seven steps to orient the veteran
to the examination: First, confirm the identity of the veteran
by asking him or her to recite their full name, date of birth,
and Social Security number. Also look at their photo ID to
insure that their picture looks reasonably similar to their
appearance in your office. In some VA facilities, identity
confirmation has already been conducted by front office
staff.
Second, tell the veteran your understanding of the purpose
of their appointment, e.g., “My understanding is that you are
here for a Compensation and Pension examination for PTSD.”
The appointment letters veterans receive are sometimes not
specific about the type of exam they will be receiving. Some
veterans have several exams scheduled, e.g., General Medical,
Audiology, etc., so to prevent confusion, it helps to clarify
from the beginning what type of exam you will be conducting.
Third, provide a brief description of the examination
procedures. For example, you might say:
The examination is divided into two parts; first you
will complete some psychological questionnaires or
psychological tests. This will be done partly on a
computer in another room and partly via paper and
pencil forms in my office. The second part of the exam
consists of an interview in which I will be asking you
about your upbringing, your military experience, and,
especially, about the type of symptoms you’ve been
experiencing and how they have affected your
functioning.
Fourth, let the veteran know that he or she can request to
take a break at any time, that they are free to ask questions at
any point in the exam process, and that if they are accom-
panied by their spouse or other family member or friend that
you can also interview that person if they wish (provided
you are given time for such interviews at your facility).
Fifth, review the limits of confidentiality with the
veteran.
Sixth, tell the veteran that aspects of the exam might be
emotionally upsetting or painful. Explain that you will try to
keep those aspects of the interview as brief as possible but
that you want to make sure that you obtain all the relevant
information that is important to adjudicating their claim.
Provide the veteran with a Helpline card so they have an
available resource at hand should they feel upset and wish to
speak with a supportive professional or paraprofessional
after the exam.
Seventh, have the veteran review and sign your Informed
Consent document. Emphasize that they should take their
time to review the document and ask any questions they
might have about it.
Collateral Interviews
When they first are called to your office, some veterans will
be accompanied by their spouse or other family member and
will ask you if that person can come in with them. Our view
is that is usually quite helpful to have such a person accom-
pany the veteran during the orientation to the exam. This
procedure allows the family member to benefit from the
orientation in a manner similar to the veteran, e.g., they will
have a general idea of what their loved one will be doing
during the exam, they will understand the limits of confi-
dentiality, and they will understand that their veteran might
experience some emotional discomfort during the exam.
Allowing a spouse or family member to accompany the
veteran for the orientation can also communicate respect to
the veteran and an acknowledgement that their family is a
very important part of their life.
In most instances, a veteran’s spouse or other family
member can convey important information that frequently
serves to support the veteran’s claim. Therefore, if at all
Psychol. Inj. and Law (2011) 4:187–216 203
possible, we highly recommend that examiners interview
spouses or other family members.
Unfortunately, some VA facilities allot such a small
amount of time to conduct the C&P exam that conducting
collateral interviews is not possible. This unfortunate cir-
cumstance is yet again another reason why examiners
should be given sufficient time to complete a comprehensive
C&P examination.
For those examiners who are given sufficient time to con-
duct a thorough exam, some prefer to conduct collateral inter-
views with the veteran present, while others prefer to
interview the spouse or family member separately. Pros and
cons of each approach are outlined in Table 5. Given that
neither approach offers a clear-cut advantage over the other,
Rosales (2011) recommends a combined approach in which
the examiner talks with the veteran and his or her significant
other together during the orientation part of the exam, then
interviews the veteran separately and the significant other
separately, and finally, brings them both back into the office
at the end to see if they have any questions or final comments.
Psychological Testing
Many examiners report resistance from VA officials regard-
ing the use of any psychological testing during C&P exams.
We will therefore outline some advantages of employing
psychological questionnaires or tests during C&P exams.
Accurate as Medical Tests In general, psychological tests are
as accurate as medical tests (Meyer et al., 2001). In fact, these
authors found in their meta-analytic study that the validity of
the MMPI-2 F scale ranks highly among all medical tests. The
authors of the referenced article point out that “clinicians who
rely exclusively on interviews are prone to incomplete under-
standings”(Meyer et al., 2001,p.128).
Screening for Dissimulation As discussed above, screening
for significant symptom exaggeration or feigning is cru-
cial for any forensic evaluation where substantial health-
care and financial benefits can be awarded. Psychological
tests such as the MMPI-2 and the SIRS have proven to
possess highly accurate classification rates (Tolin et al.,
2010; Rogers et al. 2009a), whereas an individual clini-
cian’s classification accuracy has almost never been sub-
ject to scientific study. Additionally, we know that in
general actuarial judgment outperforms clinical judgment
(Dawes, Faust, & Meehl, 1989).
Psychological tests also effectively identify individuals
who are under-reporting symptoms. Such minimization of
problems can be difficult to detect during a clinical interview.
Diagnostic Hypotheses Psychological testing can be partic-
ularly helpful in generating hypotheses regarding diagnoses
that might not be readily apparent upon clinical interview.
Personality Descriptions Similarly, psychological tests such
as the MMPI-2 and PAI often produce detailed descriptions
of personality, which can be relevant to hypotheses regard-
ing possible personality disorders or traits negatively
impacting the veteran’s social or occupational functioning.
Symptom Severity Since psychological tests are norm-
referenced, they can help the examiner ascertain how severe
a veteran’s symptoms are. For example, if during the clini-
cal/diagnostic interview a veteran reports mild depressive
symptoms but his PAI DEP scale is elevated at a T-score of
Table 5 Advantages and disadvantages of conducting collateral interviews with or without the veteran being present
Veteran present during collateral interview: advantages Veteran present during collateral interview: disadvantages
Can assess via behavioral observation, the type and quality of
interaction between the veteran and his or her spouse or other family
member
The spouse might have given different descriptions of a veteran’s
symptoms and functional impairments if he or she had been
interviewed separately, i.e., the collateral interview will be
“contaminated”
Spouses or other family members often can elaborate on or correct a
veteran’s imperfect memory of events
Some examiners have had veterans file licensing board complaints
against them because they were displeased with the examiner’s
recommendations. The presence of a spouse during the entire
interview could bolster the veteran’s claim in such a situation, which
could be potentially unfair to the examiner
Some veterans feel quite anxious during an exam and the presence of a
spouse or family member helps to reduce their anxiety
Some veterans will feel inhibited and will be less likely to talk about
marital problems, for example, if their spouse is present
The veteran and spouse may disagree and even argue with each other,
which takes up precious time
Interviewing collaterals alone: advantages Interviewing collaterals alone: disadvantages
The examiner can compare the collateral interview with the interview
of the veteran to look for consistencies or inconsistencies
Conducting separate interviews takes more time
The spouse or family member might feel more open to discuss marital
or other family problems if the veteran is not present
Some veterans will be less forthcoming without their spouse being
present due to anxiety, limited social skills, or memory problems
204 Psychol. Inj. and Law (2011) 4:187–216
85, that disparity might indicate that the veteran is under-
reporting his psychiatric symptoms. Identifying such under-
reporting is important since it might indicate that the veteran
is also minimizing functional impairments, which if not
identified as such could result in a lower disability rating
and fewer benefits for the veteran.
Cognitive Functioning Deficits in cognitive functioning are
often directly related to social and occupational impairment
(McLennan, Mathias, Brennan, Russell, & Stewart, 2010). It
is therefore important to at least screen for mild cognitive
impairment using an instrument such as the Montreal
Cognitive Assessment (Nasreddine et al., 2005).
Occupational and Social Functioning Although the VBA
tends to focus on a veteran’s GAF score, research suggests that
the GAF scale lacks concurrent validity (Roy-Byrne,
Dagadakis, Unutzer, & Ries, 1996) and predictive validity
(Moos, McCoy, & Moos, 2000), probably in large part
because the scale conflates psychiatric symptoms with so-
cial and occupational functioning (Niv, Cohen, Sullivan, &
Young, 2007). The concerns about the use of the GAF
scores for C&P exams are great enough that Miller, Wolf,
Martin, Kaloupek, and Keane (2008) asserted that results of
their research
…should raise concern about the VA’s reliance on the
GAF as a benchmark for the assessment of PTSD-
related functional impairment. …If VA C&P determi-
nations are to be based on the level of functional
impairment produced by PTSD, then multidimension-
al measures of impairment, disability, and quality of
life should be incorporated into assessment strategies
so that the many important domains of functioning
that can be adversely affected by the disorder are
evaluated (Miller et al., 2008, p. 368).
Thus, research indicates that the GAF scale by itself does
not provide a valid assessment of functioning. Psychometric
instruments are available that measure social/occupational
impairment and quality of life, which will be reviewed
below. C&P examiners are well advised to consider using
them given the crucial role of psychosocial functioning in a
veteran’s disability rating.
Conclusion Regarding Psychological Testing Thus, there
are several reasons why psychological testing can be very
helpful in C&P exams. It is generally best to conduct such
testing prior to one’s interview of the veteran so that hy-
potheses generated by the test results can be investigated
further. At some VA centers, veterans complete psycholog-
ical testing, administered by a trained paraprofessional, sev-
eral days before their interview with the C&P examiner.
Such an arrangement maximizes the time examiners can
spend interviewing veterans and collateral sources and
reviewing relevant records.
Mental Status Exam
Information obtained during a standard psychiatric/psycho-
logical mental status exam (MSE) is very important, in part
because several of the symptoms mentioned in the Rating
Schedule pertain to items evaluated in a MSE, such as
memory, abstraction ability, orientation, delusions, halluci-
nations, etc. We recommend that clinicians review guide-
lines for conducting a thorough MSE, e.g., Andrews (2008),
if they do not conduct them as a routine part of their
practice.
Psychosocial History
Of course, taking a good developmental history is an im-
portant part of any comprehensive mental health evaluation.
Aspects of a veteran’s psychological and social history that
are particular important for C&P exams include:
&Traumatic events prior to or after military service and
the effects of such events on the veteran’s psychological,
social, and occupational functioning
&Any history of substance abuse or dependence prior to
military service
&Signs or symptoms of a personality disorder prior to
military service
&The veteran’s peer relationships, intimate/marital rela-
tionships, recreational pursuits, and, especially if possi-
ble, occupational functioning prior to military service
Current Psychosocial Functioning
A description of a veteran’s interpersonal, recreational, and
occupational activities is a crucial aspect of a C&P exam.
Often this is best done by quoting the veteran directly. For
example, asking him or her about the number and quality of
their friendships might yield a response such as, “I really
don’t have any friends, just associates really. But I don’t
really trust any of them.”If you have already established,
based on earlier interview questions, that such a veteran had
good peer relations as a child and adolescent, but since his
return from Vietnam in his young 20s he has not had close
friends, then this information adds credence to the veteran’s
claim that PTSD has impaired his social functioning.
Conversely, a veteran who reports several friendships, mul-
tiple social activities, and rewarding recreational pursuits
probably has not suffered significant psychosocial impair-
ment as a result of a reported mental disorder.
Ideally, one should also measure psychosocial function-
ing using norm-referenced, reliable instruments with
Psychol. Inj. and Law (2011) 4:187–216 205
demonstrated validity. Such instruments provide the oppor-
tunity to compare a veteran’s functioning with the general
public or specific groups, e.g., psychiatric patients. We list
below some such instruments to consider.
Psychosocial Functioning Assessment Instruments
Quality of Life Inventory
The Quality of Life Inventory (QOLI) measures
life satisfaction in 16 different areas, e.g., Health,
Self-Esteem, Money, Work, Love, Children, Home,
etc. (Frisch, 1994). It yields a raw score along with
conversions to T-scores and percentile scores. The
manual provides interpretive summaries for four
levels: very low, low, average, and high quality of
life. An advantage of the QOLI is that one can
determine a veteran’s overall quality of life as com-
pared to the general population. When veterans
score in the very low or low range, such a result
supports their claim that a mental disability has
impaired their quality of life. When veterans score
in the average or high range, one begins to wonder
how impaired their functioning could be if they
enjoy relatively good life satisfaction.
The reliability and validity of the QOLI are very good
and well-established in the research literature (Frisch,
Cornell, Villanueva, & Retzlaff, 1992;Frisch,1994;
Frisch et al., 2005; McAlinden & Oei, 2006). The
QOLI is used in a wide variety of scientific studies (e.
g., Lopez et al., 2011; Thomas, Skilbeck, & Slatyer,
2009; Petry, Alessi, & Hanson, 2007). It is relatively brief
and self-administered, and it measures both the impor-
tance of a given domain to the individual as well as
subjective satisfaction. As with any psychological test
result, QOLI scores and resulting descriptive interpreta-
tions should not be used as the sole basis for one’s
assessment of a veteran’spsychosocialfunctioning.
World Health Organization Disability Assessment
Schedule—II
The World Health Organization Disability Assessment
Schedule—II (WHODAS-II), also referred to as
WHODAS 2.0, has the potential to be quite useful in
C&P exams because it is a reliable and valid measure of
disability (Ustün et al., 2010). Unfortunately, the
WHODAS website (http://www.who.int/icidh/whodas/)
has not been updated in 10 years. One of the difficulties
caused by this lack of an update is that normative data are
not available for the WHODAS, unless you decide to use
the instrument for a research study and register with the
World Health Organization. Even if you can access the
normative data, scoring of the WHODAS-II requires the
use of a statistical scoring package such as SPSS (Ustün et
al., 2010), which most examiners do not have access to.
Inventory of Psychosocial Functioning
The Inventory of Psychosocial Functioning (IPF) is a
new instrument being developed by the VA’s National
Center for PTSD (B. Marx, personal communication,
April 4, 2011). Advantages of the IPF include the fact
that it was developed based on input from focus groups
of veterans, the normative sample is composed of vet-
erans, and it measures psychosocial functioning across
seven domains: marital or other romantic relationships,
family, work, friendships and socializing, parenting,
education, and self-care. The initial validation study
on the IPF will be completed soon, with the results
being published shortly thereafter, and the instrument
will also then be available for examiners to use.
Functional Assessment Inventory
The Functional Assessment Inventory (FAI) is a
behaviorally anchored, counselor-rated measure of an
individual’s work-related functional capacities devel-
oped at the University of Minnesota’s Department of
Physical Medicine and Rehabilitation (Crewe &
Athelstan, 1984). It is used by vocational rehabilitation
counselors to determine eligibility and to develop reha-
bilitation plans for individuals with disabilities.
Factor analytic research with the FAI has identified
six factors for the instrument:
&Adaptive behavior—level of social support, perception
of capabilities and limitations, ability to effectively in-
teract with employers and co-workers, judgment, and
the congruence of behavior with rehabilitation goals
&Cognition—learning ability, ability to read and write in
English, memory, and spatial reasoning
&Communication—vision, hearing, speech, language
functioning, and personal appearance
&Motor functioning—upper extremity functioning, hand
functioning, motor speed, ambulation, or mobility
&Physical capacity—capacity for exertion; endurance;
loss of time from work for medical, therapeutic, or
personal reasons; access to job opportunities; and need
for special working conditions
&Vocational qualifications—stability of condition, work
history, acceptability to employers (physical, demo-
graphic, or historical characteristics), job-specific skills,
economic disincentives (e.g., may lose benefits if take a
job), and work habits.
The factor analytic structure of the FAI differs to
some extent depending on which disability group (e.g.,
mentally retarded, orthopedic) one examines. The factor
definitions listed above are for psychiatric patients, as
described in research by Neath, Bellini, and Bolton
(1997).
Descriptive statistics (means, standard deviations) are
available for psychiatric patients seeking vocational
206 Psychol. Inj. and Law (2011) 4:187–216
rehabilitation services (Neath et al., 1997;Bellini,
Bolton, & Neath, 1998). Thus, an examiner can compare
a veteran’s FAI scores with a psychiatric normative
sample.
Advantages of the FAI include the fact that it is
available at no cost (a simple Internet search will lead
you to the manual and forms) and its content is more
specific to the question of employability. Disadvantages
of the FAI include the fact that there are no veteran
normative samples to date and the predictive validity
of the instrument with regard to VBA rating decisions is
not known.
Specific Exam Considerations
Initial PTSD Exams
PTSD is the third most prevalent VA service-connected
disability (based on the number of veterans receiving
benefits), preceded only by tinnitus and hearing loss
(Veterans Benefits Administration, 2010). Initial PTSD
exams are the most common mental health-related C&P
exam. We recommend that examiners consult the sug-
gestions for conducting mental health-related C&P
exams in general, as discussed earlier in this article,
and consider the following recommendations for Initial
PTSD exams in particular.
Open-Ended Questions
Before proceeding with a detailed PTSD diagnostic inter-
view, it is best to ask open-ended questions, which allow the
veteran to describe experiences in their own words and
which do not clue the veteran to the fact that you are asking
questions related to a PTSD diagnosis (Knoll & Resnick,
2006). These questions can be asked during the mental
status exam or when screening and assessing for comorbid
mental disorders. Here are some examples of open-ended
questions examiners might ask:
&“What is your normal sleep pattern?”
&“What is your sleep like in general?”
&“During the daytime, what types of problems or con-
cerns do you have for yourself?”
&“What kinds of things do you find yourself thinking
about during the daytime or when you are trying to go
to sleep?”
&“What are your interactions like with family, neighbors,
co-workers?”
&“You have applied for service connection for PTSD. Tell
me what it is like for you to have PTSD.”
&“You mentioned having problems with anger, what hap-
pens when you get angry?”
If questions like these are asked during the mental status
exam or during a general diagnostic interview, the veteran
will usually not know that you are asking about potential
PTSD symptoms. Our experience is that veterans with gen-
uine PTSD will usually answer questions like those pre-
sented above in the affirmative. For example, when asked,
“Are you bothered by unwanted thoughts which keep com-
ing back to you and you can’t get out of your mind?”they
will respond with answers such as, “Yeah, thoughts about
the war …I keep thinking about it even though I don’t want
to.”The minority of veterans who are exaggerating or
feigning symptoms will often not answer open-ended ques-
tions in the affirmative but, once a PTSD-specific diagnostic
interview has begun, will suddenly endorse symptoms they
had previously not mentioned.
Assessing Comorbid Disorders
Psychiatric comorbidity is common with veterans suffering
from PTSD (Ginzburg, Ein-Dor, & Solomon, 2010; Gros,
Simms, & Acierno, 2010; Stecker, Fortney, Owen,
McGovern, & Williams, 2010). It is therefore very impor-
tant to screen for and assess other mental disorders as part of
an Initial PTSD exam. Some examiners use a structured
diagnostic interview for this purpose, such as the
Structured Clinical Interview for DSM-IV Axis I Disorders
(SCID-I; First, Spitzer, Gibbon, & Williams, 2002) or the
Schedule for Affective Disorders and Schizophrenia
(Endicott & Spitzer, 1978), since such interviews exhibit
greater reliability and validity (diagnostic accuracy) than
unstructured interviews (Miller, Dasher, Collins, Griffiths,
& Brown, 2001; Rogers, 2001). Structured interviews gen-
erally take longer than unstructured interviews so their use is
proscribed for some examiners working on strict time
restrictions.
Specialized Testing for Feigned PTSD
The MENT is symptom validity test specifically designed to
detect individuals attempting to feign PTSD and was devel-
oped with a VA population (Morel & Shepherd, 2008a,b;
Messer & Fremouw, 2007). We recommend that examiners
consider using the MENT in Initial PTSD exams, along with
the other measures mentioned earlier, e.g., the MMPI-2.
Some examiners have worried that veterans might have read
about the MENT on the Internet (or have learned about it
from other veterans) and subsequently know how to answer
the test items so as to not appear as if they are feigning.
However, we suspect that the percentage of examinees who
have garnered detailed information about the test is relatively
small.
There is another concern about the MENT, namely that it
is not yet known how many combat veterans with genuine
Psychol. Inj. and Law (2011) 4:187–216 207
PTSD intentionally perform poorly on the test because they
naively believe that they are “supposed to”fail the test
because they have PTSD. This concern is similar to that
with the MMPI-2 validity scales, i.e., either due to “extreme
distress”or a belief that they must “prove their case”many
genuine PTSD patients significantly elevate MMPI-2 valid-
ity scales (Frueh, Hamner, Cahill, Gold, & Hamlin, 2000;
Franklin et al., 2002). Our anecdotal experience is that some
veterans produce a MENT score above the recommended
cutoff when all other evidence indicates they have genuine
PTSD and we wonder if there is a subset of veterans who—
despite warnings about the negative consequences of exag-
geration or feigning—nonetheless feel compelled to under-
perform on the MENT out of a misguided notion that
genuine PTSD patients should “fail”this particular test.
Because of this concern, we recommend the following
with regard to the MENT:
&Adopt a conservative cutoff score. We recommend a score
of 18 since that was the mean score of the malingering
sample in the research used to develop the MENT.
&Do not conclude that a veteran is exaggerating symp-
toms or feigning PTSD if the MENT is the only indica-
tor of dissimulation.
Structured PTSD Diagnostic Interview
As noted above, well-researched psychiatric structured
interviews are more reliable and valid than unstructured
interviews, and this is also true for PTSD diagnostic inter-
views (Weiss, 2004; Erbes, Dikel, Eberly, Page, & Engdahl,
2006). We therefore recommend that examiners employ a
structured PTSD interview as part of their Initial PTSD
exam. There are several reliable and valid instruments avail-
able, e.g., the SCID-I PTSD module, the PTSD Symptom
Scale-Interview Version (Foa & Tolin, 2000), and the
Clinician-Administered PTSD Scale for DSM-IV (CAPS;
Blake, Weathers, Nagy, & Kaloupek, 1995; Weathers,
Keane, & Davidson, 2001). The CAPS is the most com-
monly used instrument in the VA (it was developed by the
VA’s National Center for PTSD) and is the easiest to use for
most VA staff because the CAPS interview form, manual,
and training videos are all available at no charge on the VA
intranet website (http://vaww.ptsd.va.gov/Assessment.asp).
In addition to its superior reliability, validity, and avail-
ability, we recommend using the CAPS because it helps the
examiner to:
&Assess both symptom frequency and severity using reli-
able rating methods.
&Clarify diagnostic criteria, e.g., ascertaining the veter-
an’s emotional response to the trauma (DSM-IV
Criterion A2).
&Differentiate symptoms, e.g., discerning whether reported
flashbacks occur during waking hours or only in dreams.
&Determine how and to what extent symptoms interfere
with functioning (which is very important for rating
purposes).
&Determine the duration of symptoms
&Identify “hidden”symptoms, e.g., suppressed anger.
&Rate the extent to which symptoms are trauma-related or
not, e.g., apathy (loss of interest in previously enjoyed
activities) is a PTSD symptom but it also can occur for
other reasons such as depression.
&Clarify when symptoms began (symptom onset) and
how long they have lasted (symptom duration).
&Rate subjective distress, impairment in social function-
ing, and impairment in occupational functioning.
&Indicate if there are any factors present that affect the
validity of the veteran’s responses.
&Assess associated PTSD symptoms, e.g., survivor guilt
or derealization.
These CAPS advantages lead to more accurate diagnoses.
Accuracy can also be fine-tuned by considering the use of
one of several scoring methods for the CAPS. Nine scoring
methods, or rules, have been described in the literature, each
of which demonstrates good to excellent reliability
(Weathers, Ruscio, & Keane, 1999). However, 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. We agree
with the aforementioned authors that “it is incumbent on test
users to select the most appropriate scoring rule for a given
assessment task and to explicitly identify and defend their
choice”(Weathers, Ruscio, & Keane, 1999, pp. 130–131).
For example, one might argue that for Initial PTSD exams
the “SCID Symptom-Calibrated”rule is ideal because it com-
bines the highest sensitivity (0.91) with the best specificity
(0.84), possesses the highest negative predictive value (0.89),
and has the highest diagnostic efficiency (0.88). In addition,
the rule is in the middle of the leniency to strictness dimension.
On the other hand, some examiners might choose to
utilize the “F1/I2”scoring rule because it is one of the most
lenient of the nine possible scoring rules (Weathers et al.,
1999). As such, the “F1/I2”scoring rule allows for the
examiner to interpret the results of the CAPS with more
benefit of the doubt for the veteran. The most important
point is that all examiners should read the Weathers, Ruscio,
and Keane (1999) article and decide which scoring rule they
believe best fits for a C&P exam.
Subsyndromal Post-traumatic Stress
After conducting a detailed PTSD assessment, you might
discover that the veteran does not meet all DSM-IV
208 Psychol. Inj. and Law (2011) 4:187–216
diagnostic criteria for PTSD but he or she does experience
post-traumatic stress symptoms to such a degree that they
cause him or her significant distress or functional impair-
ment. Such cases have been referred to in the literature as
“subsyndromal post-traumatic stress disorder”(Pietrzak,
Goldstein, Malley, Johnson, & Southwick, 2009)or“sub-
threshold post-traumatic stress disorder”(Yarvis, Bordnick,
Spivey, & Pedlar, 2009). The appropriate DSM-IV diagno-
sis in these instances is Anxiety Disorder Not Otherwise
Specified.
False Attribution
Some Initial PTSD exams involve veterans who have come
to believe they have PTSD when, in fact, they do not have
the disorder. Based on anecdotal experience, these veterans
usually do not significantly over-report symptoms of PTSD
or other mental disorders. They often do not know a lot
about PTSD, e.g., what causes it or all of its symptoms.
These veterans have often learned a little about PTSD
from the popular media, friends, or veteran service officers.
They know PTSD involves stress experienced during de-
ployment in a combat zone, and they know they were
deployed to a combat zone. Lately they have been feeling
depressed or anxious. They begin to think they might have
PTSD. After all, the diagnosis seems to make sense, i.e.,
they experienced stress, they believe that deployment-
related stress can cause PTSD, they feel bad (depressed,
anxious); therefore, they conclude that they might very well
have the disorder. The fact that there is so much media
attention about soldiers suffering from the disorder adds to
their belief that they have it. They consequently file a PTSD
claim with the VBA.
Such individuals are exhibiting what might be called
“false attribution”, i.e., in an effort to explain their current
problems, they falsely attribute the cause of their depression
or anxiety to their wartime service.
10
This process is often
completely innocent, and the veteran is neither fabricating a
mental disorder nor lying about the cause of their psychic
distress. They genuinely believe that their current difficul-
ties were caused by their military service.
We mention this type of case for two reasons: First, if
examiners do not conduct a detailed PTSD diagnostic inter-
view, they might misdiagnose such a veteran as suffering
from PTSD when, in fact, they have a depressive or anxiety
disorder that is not service-connected. Second, if an exam-
iner does conduct a detailed PTSD diagnostic interview and
discovers that the veteran does not meet the diagnostic
criteria for the disorder, he or she might leap to the conclu-
sion that the veteran is trying to feign PTSD when this is not
the case.
Fear of Hostile Military or Terrorist Activity
On both the Initial and Review DBQs for PTSD, examiners
are asked whether or not the claimed stressor (that led to the
development of PTSD) is related to the Veteran’s fear of
hostile military or terrorist activity. The legal phrase “fear of
hostile military or terrorist activity”can be confusing. On its
face, it seems that one must determine if the veteran is
currently afraid of hostile military or terrorist activity.
However, some veterans with PTSD may respond, if asked,
“No, I’m not afraid of that”(or words to that effect). In such
instances, should the examiner then answer “No”to the
“fear of hostile military or terrorist activity”question?
That would not be the correct response because the
phrase “fear of hostile military or terrorist activity”has a
very specific meaning. VHA Information Letter 10-2010-
016 (October 14, 2010) states:
‘Fear of hostile military or terrorist activity’means
that a Veteran experienced, witnessed, or was con-
fronted with an event or circumstances that involved
actual or threatened death or serious injury, or a threat
to the physical integrity of the Veteran or others and
the Veteran’s response to the event or circumstances
involved a psychological or psycho-physiological
state of fear, helplessness, or horror. The event or
circumstances include, but are not limited to, the
following:
(1) Actual or potential improvised explosive device;
(2) Vehicle-embedded explosive device;
(3) Incoming artillery, rocket, or mortar fire;
(4) Small arms fire, including suspected sniper fire; or
(5) Attack upon friendly aircraft.
Readers will recognize that this definition incorporates
criterion A of the DSM-IV diagnostic criteria for PTSD. Of
course, if an examiner has diagnosed a veteran with PTSD,
the veteran will, by definition, have met criterion A.
Therefore, in most instances if an examiner has diagnosed
a veteran with PTSD, the examiner should answer “Yes ”to
the “fear of hostile military or terrorist”question.
The Information Letter also seems to specify combat-
related incidents as part of the definition of the phrase.
Therefore, if the PTSD stressor involved a non-combat
incident, e.g., the veteran was assaulted by another service
member, an examiner would answer “No”to the “fear of
hostile military or terrorist”question. In such instances, a
“No”answer will not necessarily preclude the receipt of
compensation benefits.
10
Note that “false attribution”is different from “false imputation.”The
latter term refers to attributing current mental disorder symptoms to an
alleged stressor when the individual knows that such a causal connec-
tion does not exist (Resnick, 1997).
Psychol. Inj. and Law (2011) 4:187–216 209
PTSD Review Exams
PTSD Review exams are conducted for three reasons:
&The veteran has requested an increase in his or her rating
percentage (asserting that their functional abilities have
deteriorated due to their mental disability).
&The veteran has filed a claim for Individual
Unemployability (asserting that they are unable to work
because of their mental disability).
&The Veterans Benefits Administration has requested an
exam. There are some detailed regulations that govern
when the VBA may request a PTSD Review exam but
discussing them is beyond the scope of this article.
If the veteran’s Initial PTSD exam report reflects a thor-
oughly conducted examination, particularly with regard to a
review of the claims file, then a PTSD Review exam will
require somewhat less time to complete than an Initial exam.
However, it has been our experience that the evaluation
conducted by the Initial examiner often does not include a
thorough review of the claims file. In those cases, a Review
exam takes just as long as an Initial exam.
We recommend that examiners conduct a PTSD Review
exam in a manner similar to an Initial PTSD exam with the
following exceptions:
&If it is clear from the Initial PTSD exam report that the
examiner thoroughly reviewed the Claims File, then you
will not need to repeat such a thorough review.
&If the Initial PTSD exam report contains a well-
developed psychosocial history for the veteran, you do
not need to also take a detailed developmental history.
&Whereas the Initial PTSD exam focuses on whether or
not the veteran has PTSD and, if so, whether or not it
was caused by his or her military service, the PTSD
Review exam focuses on the veteran’s symptoms and
functioning since the last exam.
Importance of Temporal Focus
Review PTSD examinations are specifically focused on the
changes in social and occupational functioning, as well as
symptom frequency and severity, since the last C&P exam-
ination. However, it has been our experience that veterans
will frequently discuss PTSD-related symptoms from 10,
20, or 30 years ago rather than focusing on those symptoms
having occurred since they were last evaluated. For exam-
ple, when discussing problems related to anger, a veteran
may admit to difficulty with anger. When asked to describe
the anger, they relate a story about getting into a fight with a
neighbor or co-worker, but further discussion of the fight
reveals that the incident occurred in the 1970s when the
veteran first came back from Vietnam. When redirected to
describe current behaviors related to anger, the veteran
might respond that they walk away from incidents they
know will cause them to become angry. The intensity of
this symptom (anger) is clearly different between these two
responses, highlighting the importance of ascertaining the
exact time frame of reported symptoms.
Psychological Assessment of Dissimulation
Examiners sometimes wonder if psychological testing for
symptom exaggeration or feigning is necessary for Review
exams. We believe such screening is important in Review
exams because the veteran could exaggerate symptoms in an
attempt to garner a benefits increase. In addition, if the
Initial PTSD examiner did not conduct screening for symp-
tom exaggeration or feigning, then the possibility exists that
the veteran might not truly suffer from PTSD. Plus, psycho-
logical testing occasionally identifies veterans who are
under-reporting symptoms. We therefore highly recommend
that examiners conduct psychological testing for response
style in Review exams as well.
Importance of a Detailed PTSD Diagnostic Interview
Examiners also sometimes wonder if a detailed PTSD diag-
nostic interview is necessary for Review exams. We believe
it is for two reasons: First, VBA raters must determine if a
veteran’s condition has worsened since the last exam in
order to increase his or her rating percentage. They therefore
need to compare symptom severity and, especially, func-
tional impairment from the time of the last exam to the
present. VBA raters are not able to conduct such a compar-
ison if the Review examiner does not provide sufficient
information about the veteran’s current symptomatology
and functional impairments. A detailed PTSD diagnostic
interview, e.g., using the CAPS, is the best way to solicit
information from the veteran about his or her current PTSD
symptoms and related functional impairments.
Second, the DBQ for PTSD Review exams specifically
asks examiners to list the PTSD symptoms a veteran cur-
rently experiences. If an examiner does not conduct a diag-
nostic interview, he or she will not be able to provide that
information and the DBQ will be insufficient.
Initial Mental Disorder Exams
Initial Mental Disorder exams are in many ways quite sim-
ilar to Initial PTSD exams in that the examiner is asked if (a)
the veteran suffers from the claimed disorder(s) and (b) if
the claimed disorder(s) were incurred during or aggravated
by military service. It is important to note that military
service does need to have caused the mental disorder; the
210 Psychol. Inj. and Law (2011) 4:187–216
disorder need only have begun during a veteran’s military
service (or have been aggravated by military service). In
addition, the current mental disorder must be the same
disorder from which the veteran suffered during his or her
military service. For example, if a veteran had an adjustment
disorder in response to a specific stressor during military
service, he or she would not be eligible for compensation if
he or she developed an adjustment disorder in response to a
different, post-service stressor.
On the other hand, If Army doctors diagnosed a veteran
with major depressive disorder (MDD) during his or her
military service and the veteran submits a claim for MDD
8 years post-service, then the examiner must determine if the
veteran’s current MDD is the same illness that he or she
suffered from during military service or if it is a completely
new disorder. Given that MDD often reoccurs (Mueller et
al., 1999; Solomon et al., 2000) and given the equipoise
doctrine, most examiners would probably conclude in such
a case that it is at least as likely as not that the veteran’s
current MDD is a continuation of the in-service illness.
A common reason for requesting an Initial Mental
Disorders exam is that the veteran claims that a service-
connected medical condition, e.g., diabetes or chronic back
pain, has caused them to develop a mental disorder such as
depression. Such a claim is possible because if a service-
connected medical condition causes a second illness then
that second disorder is compensable (Disabilities that are
proximately due to, or aggravated by, service-connected
disease or injury, 38 C.F.R. § 3.310, 2010).
Secondary condition cases are challenging because there
is often more than one possible cause for the veteran’s
mental disorder. In such cases, it is important to conduct a
detailed psychosocial history, particularly for the time peri-
od preceding and after the development of the medical
condition. In this way, the examiner can identify potential
causes of the veteran’s mental disorder, in addition to the
medical illness. Once other potential causes are identified,
the examiner should ask open-ended questions about the
effects of the event or circumstance on the veteran. It is also
often helpful to draw a time line depicting such events,
along with the time of the diagnosis of the medical condition
and the first appearance of mental disorder symptoms. See
Fig. 4for an example of such a time line.
Mental Disorder Review Exams
Mental Disorder Review exams are quite similar to PTSD
Review exams in that the primary question is “How has the
veteran’s psychological condition changed since the last
exam?”As before, it is important to screen for symptom
exaggeration or feigning and to conduct a thorough diag-
nostic interview with an emphasis on both symptoms and
functional impairments caused by those symptoms.
Mental Disorder Review exams should be conducted in a
manner similar to the Initial Mental Disorder exam with the
following exceptions:
&If it is clear from the Initial Mental Disorder exam report
that the examiner thoroughly reviewed the claims file
then you will not need to repeat such a thorough review.
&If the Initial Mental Disorder exam report contains a
well-developed psychosocial history for the veteran,
you do not need to also take a detailed developmental
history.
Other Exams
Other types of exams that are beyond the scope of this
article include:
&Individual Unemployability—as a result of a service-
connected mental disability, is the veteran unable to
establish and maintain gainful employment? This ques-
tion is usually asked as part of a Review exam.
&Financial Competence—is the veteran (or a dependent
of a deceased veteran) capable of appropriately manag-
ing their benefits payments? All DBQs ask examiners to
determine if a veteran is capable of handling his benefit
payments appropriately, but this determination generally
does not require a specialized financial competency
Time Line of a Hypothetical Initial Mental Disorders Case in which the Veteran has Filed a
Claim for Depression Secondary to Chronic Low Back Pain
---------------------------------------------------------------------------------------------------------------------------------
2005 2006 2007 2008 2009 2010 2011
Father's
death
Lost job
First seen
for low back
pain
Separated from
wife (divorced
one year later)
Told his physician
he felt depressed.
Started on Celexa.
Filed claim for
low back pain
Filed claim for
depression secondary
to low back pain
Separated
from military
Fig. 4 Time line of a hypothet-
ical initial mental disorders case
in which the veteran has filed a
claim for depression secondary
to chronic low back pain
Psychol. Inj. and Law (2011) 4:187–216 211
evaluation. However, there are instances in which the
VBA asks for a C&P exam specifically because there is
some question about the individual’s ability to manage
their finances, e.g., a veteran with dementia or a gam-
bling addiction or an adult child of a deceased veteran
who has a developmental disability.
&Eating Disorders—this type of exam has its own DBQs
(Initial and Review). They should be conducted similar
to a Mental Disorder exam, preferably by an examiner
with experience assessing individuals with an eating
disorder.
&Military Sexual Trauma or Personal Assault—these are
special types of PTSD examinations in which a veteran
reports that he or she was sexually or personally
assaulted during their military service. There are some
unique aspects to these exams which unfortunately
space limitations prohibit us from covering; however,
the following website contains some pertinent informa-
tion: http://vbaw.vba.va.gov/bl/21/rating/rat06h.htm.
&Iatrogenic Harm from VA Treatment—if a veteran is
harmed by treatment at a VA healthcare facility, any
resulting disease or condition is compensable. These cases
usually involve non-psychiatric medical conditions but on
rare occasions psychological injury is alleged.
&Cause of Death Opinion—a surviving spouse may file
for VA benefits (Dependency Indemnity Compensation)
if he or she believes their spouse’s death was a direct
result of their service-connected disability (e.g., a veter-
an service connected for major depression commits sui-
cide). These cases require an opinion if the veteran’s
death is at least as likely as not a result of his or her
service-connected disability.
Conclusion
VA Compensation & Pension examinations present chal-
lenges to even experienced forensic mental health profes-
sionals because of their complexity, unique legal
parameters, amount of material to review, the political cli-
mate at some VA facilities, and insufficient time to complete
a thorough exam at some locations. Nonetheless, these are
very important evaluations since they involve the lives of
men and women who have sacrificed much to protect and
defend their country. We owe it to veterans and the
American taxpayers to provide consistent, reliable, and
accurate mental health-related C&P exams, and we hope
this article plays at least a small role in achieving that
objective.
Acknowledgments The authors thank Francis Gilbert, Sofia Marsano,
and Chad Hagans for their superb feedback and suggestions.
Appendix: Recommended Resources
Mental Disability Evaluations in Particular
American Academy of Psychiatry and the Law (2008).
AAPL practice guideline for the forensic evaluation of psy-
chiatric disability. Journal of the American Academy of
Psychiatry and the Law,36(4), S3–S50. Available at:
http://www.jaapl.org/content/36/Supplement_4/S3.full.pdf
Association of VA Psychologist Leaders (AVAPL) elec-
tronic email list for VA mental health compensation and
pension examiners and other interested parties. To subscribe
write to webmaster1@avapl.org
Department of Veterans Affairs (2002). Best practice
manual for posttraumatic stress disorder (PTSD) compen-
sation and pension examinations. Washington, D.C.:
Author.
Foote, W. E. (2008). Evaluations of individuals for dis-
ability in insurance and Social Security contexts. In R.
Jackson (Ed.), Learning forensic assessment (international
perspectives on forensic mental health) (pp. 449–479). New
York: Taylor & Francis Group.
Gold, L. H., & Shuman, D. W. (2009). Evaluating mental
health disability in the workplace: Model, process, and
analysis. New York: Springer.
Forensic Mental Health Evaluations in General
American Academy of Psychiatry and the Law (2005).
Ethics guidelines for the practice of forensic psychiatry.
Bloomfield, CT: Author.
Committee on Ethical Guidelines for Forensic
Psychologists (1991). Specialty guidelines for forensic psy-
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