Post-traumatic stress disorder (PTSD) is a serious, potentially debilitating psychiatric disorder that can develop after experiencing one or more terrifying or horrific events. It is characterized by (1) re-experiencing the trauma(s) in the form of vivid intrusive memories, dissociative flashback episodes, or nightmares; (2) avoidance of trauma-related thoughts and memories; and (3) frequently feeling under threat manifested as, for example, hypervigilance and intense startle reactions.[1][2]
Some research suggests that VA disability benefits achieve their goal of helping veterans who have PTSD. The Veterans Benefits Administration (VBA), a component of the Department of Veterans Affairs, processes disability claims and administers all aspects of the VA disability program. Since 1988 VA disability claim decisions have been subject to federal court review.
Disability ratings theoretically represent a veteran's "average impairment in earnings capacity", on a scale from 0 to 100. Veterans who file a disability claim due to PTSD almost always receive a compensation and pension examination (C&P exam) by VA-employed or VA-contracted psychologists or psychiatrists. Social scientists and others have expressed concern about the consistency and accuracy of PTSD C&P exam findings, although the VA generally rejects such concerns as unfounded or exaggerated.
Recent efforts to change VA disability benefits for PTSD include urging the VA to place more emphasis on vocational rehabilitation and treatment versus cash payments; revising the General Rating Formula for Mental Disorders to better reflect problems experienced by veterans with PTSD, and considering a veteran's quality of life when determining the disability rating.
Post-traumatic stress disorder (PTSD) may develop following exposure to an extremely threatening or horrific event. It is characterized by several of the following signs or symptoms: unwanted re-experiencing of the traumatic event—such as vivid, intense, and emotion-laden intrusive memories—dissociativeflashback episodes, or nightmares; active avoidance of thoughts, memories, or reminders of the event; hyperarousal symptoms such as always being on guard for danger, enhanced (exaggerated) startle response, insomnia, trouble concentrating, or chronic irritability; anhedonia, social detachment, excessively negative thoughts about oneself or the world, marked guilt or shame, or a persistent depressed or anxious mood.[3][4] PTSD is the third-most compensated disability after hearing loss and tinnitus.[5]
Traumatic stressor
Matthew J. Friedman of the National Center for PTSD notes that PTSD is unique among mental health problems because of the great importance placed upon the cause, the traumatic stressor.[6]
A traumatic stressor is an event that meets Criterion A of the DSM-5 diagnostic criteria for PTSD, which requires, in part, that an individual "... was exposed to death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence ...."[7][8]
Veterans filing a disability claim for PTSD complete a form describing the traumatic stressors they endured during their military service.[9] VA has separate forms for PTSD generally and PTSD "secondary to personal assault".[10]
Diagnosis
Prior to 2014, VA C&P examiners determined if a veteran had PTSD based on DSM-IV diagnostic criteria for the disorder. VA updated most of its relevant regulations in August 2014 to reflect the publication of DSM-5.[11][a]
Since the founding of the country, the United States has compensated the men and women who have served in its armed forces and uniformed services.[16][17][18] Near the end of World War I, the U.S. Congress passed legislation establishing an indemnity model for veterans' disability benefits.[19] Since that year, compensation has been provided to veterans who have physical or mental disabilities that were incurred during, or aggravated by, military service, and which have adversely impacted their ability to work. The amount of compensation provided—both cash payments and VA-sponsored services—is based on the veteran's "average impairment in earnings capacity".[20]
Service-connection
Service-connected means that a veteran has a disease or injury that is connected to his or her military service; that is, the disease or injury was incurred in, or aggravated by, their military service.[21]
Effectiveness
Whether disability benefits adequately compensate veterans with PTSD for loss in average earning capacity has been debated. A 2007 study found that older veterans (age 65 and up) rated at 50% disabled or higher for PTSD, including individual unemployability (IU) benefits,[22] receive more in compensation (plus any earned income and retirement benefits such as Social Security or pensions) than non-disabled veterans earn in the workforce or receive in Social Security and other retirement benefits.[23] However, younger veterans (age 55 and below) generally receive less in compensation benefits (plus any earned income) than their non-disabled counterparts earn via employment. For example, the "parity ratio"[b] for a 25-year-old veteran rated 100% disabled by PTSD is 0.75, and for a 35-year-old veteran rated 100% disabled by PTSD the ratio is 0.69. The parity ratio for a 75-year-old veteran receiving IU benefits is 6.81.[23]
Research based on data collected in the 1990s indicates that veterans receiving disability benefits for PTSD experience a reduction in PTSD symptom severity and have lower rates of poverty and homelessness.[25] A 2017 study found that "denied" veterans (those who applied for—but did not receive—disability compensation) exhibit significantly worse overall health, functional limitations, poverty, and social isolation when compared to veterans who were awarded VA disability benefits.[26]
In addition to lost income, a Congressionally mandated commission,[27] argued that the VA disability benefits program should compensate veterans for non-economic losses, such as a decline in the veteran's quality of life. The U.S. Government Accountability Office (GAO) analyzed this recommendation and suggested that it be considered as one of three major changes to modernize the VA disability benefits program.[28]
Some scholars argue that the VA disability benefits program is counter-therapeutic because it provides no incentives to overcome symptoms and problems caused by the disorder, and, in fact, rewards veterans for staying sick.[29][30] In a similar vein, a military scholar suggests that current VA disability benefits policy inculcates in veterans a lack of self-efficacy and fosters dependency.[31][32] However, some VA researchers take issue with this assertion.[33]
Claims process
Eligibility
In order to be eligible for VA benefits, a veteran must have been discharged under "other than dishonorable conditions".[34] Stated differently if a veteran received a "Bad Conduct" discharge or a "Dishonorable" discharge they will, under most circumstances, not be eligible for VA benefits.[35]
Federal regulations describe three categories of military service, "active duty", "active duty for training", and "inactive duty training".[36] Eligibility for VA disability compensation requires that the veteran's service falls under one of these three categories. The definition of "active duty" military service includes "service at any time as a cadet at the United States Military, Air Force, or Coast Guard Academy, or as a midshipman at the United States Naval Academy".[37]
In line of duty and exceptions
There are exceptions to the general rule that injuries or diseases incurred in, or aggravated by, military service are eligible for VA disability compensation benefits. For example, such injuries or diseases must meet the "in line of duty" criteria. "In line of duty" means an injury or disease incurred or aggravated during a period of active military, naval, or air service unless such injury or disease was the result of the veteran's own willful misconduct or ..."was a result of his or her abuse of alcohol or drugs".[38]
Evidence
In order for a veteran to receive disability benefits for PTSD, the Veterans Benefits Administration (VBA), an organizational element of the VA, based on their review of medical and psychological evidence, must conclude that the veteran indeed has PTSD that developed as a result of military service. Reaching such a determination usually requires that the veteran receive a Compensation and Pension examination (C&P exam),[39] conducted by a psychologist or psychiatrist at a local VA medical facility or by a psychologist or psychiatrist in independent practice who conducts evaluations for a VA-contracted private vendor.[40]
Benefits claim procedures
VA provides a detailed description of the benefits claims process on its website.[41] Briefly, a Veterans Service Representative (VSR),[42] a VBA employee, reviews the information submitted by a veteran to determine if the VBA needs any additional evidence (e.g., medical records) to adjudicate the claim.[43]
VA has a legal obligation to help veterans obtain any evidence that will support their claim.[44] For example, the VSR might request a veteran's military personnel records, Social Security disability records, or private medical records.[45] The VSR will almost always request a Compensation and Pension examination (C&P exam),[46] also referred to as a "VA claim exam".[47]
After the VBA obtains all relevant documentation (evidence), the "rating activity" renders a decision regarding the veteran's claim. The VBA's M21-1 Adjudication Procedures Manual defines the "rating activity" as "... a group of specially qualified employees vested with the authority to make formal decisions, called 'rating decisions,' and take other actions on claims that require a rating decision".[48]
Obtaining assistance
Veterans may receive assistance with filing a VA disability compensation claim from a Veterans Service Officer. As the VA states, "[veterans] ... can work with a trained professional ... to get help filing a claim for disability compensation".[49] VA publishes an annual directory of accredited veterans' service organizations and state departments of veterans affairs[50] and VA has a "VSO search" feature[c] on their eBenefits site.[51] Veterans service organizations and state agencies employ veterans service officers who provide assistance to veterans without charge. Some veterans' advocates recommend that veterans learn how to file claims on their own so that they retain full control over the process.[52]
Veterans may appeal the VBA's decision regarding their compensation claim, and they may ask to be represented by an accredited Veterans Service Officer, attorney, or claims agent in the appeals process. The VA does not require a veteran to be represented on appeal.[55]
VA prohibits attorneys or claims agents from charging a veteran for professional services prior to the adjudication of the veteran's claim.[56]
Unless they agree to work on a pro bono basis, attorneys and claims agents who represent veterans before the Veterans Benefits Administration, Board of Veterans Appeals, and Court of Appeals for Veterans Claims require payment for their services. At the federal court level, most attorneys work for Equal Access to Justice Act fees. These are attorney fees ordered by the court to be paid by the federal government when the government's position in litigation was not substantially justified.[56]
Disability rating
General rating formula for mental disorders
Code of Federal Regulations, Title 38 – Pensions, Bonuses, and Veterans' Relief
If the VBA determines that a veteran has service-connected PTSD, then they assign a disability rating, expressed as a percentage. This disability rating determines the amount of compensation[57] and other disability benefits the VA provides the veteran. The disability rating indicates the extent to which PTSD has deprived the veteran of their average earnings capacity.[57][58]
The VA assigns disability ratings based on criteria set forth in the Code of Federal Regulations, Title 38, Part 4—Schedule for Rating Disabilities,[59] often referred to as the "VA Schedule for Rating Disabilities" or VASRD.[60] The rating schedule for mental disorders is called the "General Rating Formula for Mental Disorders" (38 C.F.R. § 4.130),[61] which specifies criteria for disability ratings of 0%, 10%, 30%, 50%, 70%, or 100%.[d][e]
Some argue that by relying on the current Rating Formula, "VA uses decades-old regulations developed for mental disorders that do not resemble PTSD", and consequently, "[i]rrelevant criteria ... may outweigh ... more relevant factors, leading VA to undercompensate veterans with valid diagnoses of PTSD."[63] Similarly, veterans service organizations have argued, for example, that a "... veteran service connected for schizophrenia and another veteran service connected for another psychiatric disorder should not be evaluated using the same general formula" and have supported efforts to revise the Rating Formula.[64]
Concern has been expressed by some RSVRs[65] (VBA "raters" who adjudicate claims) that automated software discourages their use of independent judgment to evaluate the claim as a whole, a charge senior VA officials reject.[66]
In 2012 the General Accountability Office reported that "VA's modifications of the medical information in the disability criteria have been slow and have not fully incorporated advances in technology and medicine. Moreover, the rating schedule has not been adjusted since its creation in 1945 to reflect ongoing changes in the labor market."[67]
On February 15, 2022 the Department of Veterans Affairs (VA) proposed to substantially change their disability rating schedule regarding mental disorders, including revising the General Rating Formula for Mental Disorders.[68] This "proposed rule", part of the executive branch's rulemaking process, will not become law until after VA reviews public comments, makes revisions, and publishes a "final rule".[69]
Claims for an increased disability rating
A veteran currently receiving compensation for service-connected PTSD may file a claim for an increase in his or her disability rating if PTSD symptom severity and related functional impairment has worsened.[70]
Individual unemployability
Under certain conditions,[71] veterans receiving service-connected disability compensation for PTSD may file a claim for individual unemployability.[22] If the VBA concludes that PTSD, either alone or in combination with other service-connected disabilities, would make it "... impossible for the average person to follow a substantially gainful occupation...",[72] the veteran will receive disability compensation at the 100% rate, even though their schedular rating is less than 100%.[73][74]
PTSD C&P exam
As noted above, the VBA almost always requires a compensation and pension examination (C&P exam), also known as a "VA claim exam",[47] for veterans claiming service-connected PTSD. C&P exams are forensic mental health evaluations.[75][76] There are two types of PTSD C&P exams: Initial and Review. The Initial PTSD exam must be conducted by a VA psychologist or psychiatrist certified by the VHA Office of Disability and Medical Assessment (DMA)[77] to evaluate veterans for this purpose.[78]
The Review PTSD exam may be completed by VA or non-VA psychologists and psychiatrists. Clinical or counseling psychology interns, psychiatric residents, licensed clinical social workers, nurse practitioners, physician assistants, and clinical nurse specialists may also conduct review PTSD exams, although they must be "closely supervised" by a psychologist or psychiatrist.[79]
Medical Disability Examination (MDE) contracts
The definition of "VA psychologist or psychiatrist" includes psychologists and psychiatrists in the private sector who conduct C&P exams for a Medical Disability Examination (MDE) company under contract with the VA.[80] As of November 2024[update] the VA-contracted MDE companies are Optum Serve (formerly LHI),[81][82] Veterans Evaluation Services (VES),[83] Loyal Source,[84] and Leidos QTC Health Services[85] (QTC) (Magellan Health manages the QTC network of providers).[86] MDE companies conduct about 90% of C&P exams (for all conditions, i.e., not just PTSD and other mental disorders).[87]
Presumption of competence
In most federal legal proceedings a psychologist or psychiatrist must demonstrate that they are competent to testify as an expert witness by satisfying standards specified in the Federal Rules of Evidence, particularly Rule 702, "Testimony by Expert Witnesses" (FRE 702).[88] However, VA medical examiners are presumed competent to provide expert witness testimony[89][90] without having to meet FRE 702 standards.[91][92][93]
Concerns about reliability
Researchers, current and former VA psychologists, investigative journalists, and individual veterans have expressed concerns about the inter-rater reliability and validity of C&P exams for PTSD.[94][95] For example:
Some current or former VA psychologists assert that VA medical centers do not allocate enough time for C&P psychologists and psychiatrists to conduct a thorough, evidence-based assessment, with less time presumably reducing the reliability and validity of the results.[96]
Research has demonstrated marked regional variance with regard to the proportion of veteran claimants who receive VA disability compensation for PTSD.[97][98]
A survey of C&P examiners (psychologists) revealed that 85% "never" or "rarely" used the Clinician-Administered PTSD Scale (CAPS),[99][100] for PTSD compensation and pension exams,[99] even though a VA Best Practice Manual recommends its use during C&P exams,[101] and research has shown that using the CAPS improves PTSD C&P exam reliability and validity.[102]
Four possible outcomes of a psychological evaluation, including false positive and false negative conclusions.
Evaluation conclusion
Actual (true) condition
Evaluee has the claimed mental disorder
Evaluee does not have the claimed mental disorder
Evaluee has the claimed mental disorder
True positive
False positive
Evaluee does not have the claimed mental disorder
False negative
True negative
An empirical study published in 2017[103] suggested C&P examiner racial bias might have led to an increased rate of false negative[104] conclusions (regarding PTSD diagnosis and service connection) for Black veterans, and a high rate of false positive[105] conclusions for White veterans. This finding corresponds with past research,[106][107] subsequent research,[108] and legal scholarship[109] discussing the potential for implicit racial biases on the part of mental health clinicians in general, and C&P psychologists and psychiatrists in particular.
Some VA facilities prohibit examiners from using symptom validity tests to screen or assess for malingering and other forms of dissimulation.[110][111]
Several researchers have published empirical studies in peer-reviewed scholarly journals pointing to significant rates of both false positive and false negative PTSD C&P exam conclusions.[112][113][114]
Social scientists conducted independent PTSD assessments of veterans who had filed disability benefits claims for PTSD, some of whom had been awarded service-connected compensation for PTSD and some had not. The study found significant rates of both false positive and false negative VBA adjudicative decisions.[115] Although VBA adjudicators rely on other sources of evidence, in addition to C&P exam results, VBA almost always requests a C&P exam for PTSD claims,[116] and C&P exam results significantly influence VBA determinations.[117][118]
Individual combat veterans,[119][120] newspaper articles,[121][122] and editorials,[123][124] assert that a sizable percentage of veterans filing PTSD disability claims exaggerate or feign PTSD symptoms.
A 2019 report commissioned by Congress found that for traumatic brain injury (TBI) exams, a condition that often co-occurs with PTSD, "although VBA has systems in place to review the consistency of its process, it does not appear to measure reliability or validity," and they recommended that VA institute "a program of standard patients[f] to directly measure the reliability and validity of the examination ... and the use of experienced, second-level reviewers to conduct fully independent evaluations to evaluate the criterion validity of actual veterans' evaluations."[125]
Disability Benefits Questionnaire
Mental health professionals document the results of Initial and Review PTSD C&P exams on a Disability Benefits Questionnaire (DBQ).[126] VA developed Disability Benefit Questionnaires (DBQs) to streamline the VBA ratings process and thereby complete the claims process faster. In addition, veterans may ask their treating clinicians to complete a DBQ and possibly bypass the need for a C&P exam.[127] However, it is important to note that the VA discourages their mental health clinicians from completing DBQs for their patients.[128]
Some authors have expressed concern that the DBQ symptom list (for example, Section VII on the Review PTSD DBQ)[129] contains a series of signs, symptoms, and descriptions of functional impairment without any guidance regarding when these items should be endorsed.[130]
The Veterans Benefits Administration (VBA) discontinued publicly available DBQs in April 2020, explaining that the lengthy approval process for publicly available government forms often meant DBQs contained outdated information. In addition, VBA indicated that in recent years "... a growing industry of individuals and companies marketing the service of completing DBQs for Veterans ... [were] engaged in questionable, even fraudulent, practices ...."[131] VBA's decision to remove publicly available DBQs came in the wake of a VA Office of Inspector General report that recommended the action.[132] However, the U.S. Congress negated VA's decision, passing a law in December 2020 requiring the agency to post the DBQs on the VA website.[133]
Notes
^Claims that were appealed before August 4, 2014 would still use DSM-IV PTSD diagnostic criteria. See 79 Fed. Reg. 45093 at 45094 ("The Secretary does not intend for the provisions of this interim final rule to apply to claims that have been certified for appeal to the Board of Veterans' Appeals or are pending before the Board of Veterans' Appeals, the United States Court of Appeals for Veterans Claims, or the United States Court of Appeals for the Federal Circuit.")
^The CNA report cited herein describes the "parity ratio" as: "A ratio of exactly 1 would be perfect parity, indicating that the earnings of disabled veterans, plus their VA compensation, gives them the same lifetime earnings as their peers. A ratio of less than one would mean that the service-disabled veterans receive less than their peers on average, while a ratio of greater than one would mean that they receive more than their peers."[24]
^The abbreviation "VSO" stands for Veterans Service Organization or Veterans Service Officer.
^Note that the General Rating Formula for Mental Disorders, and its associated percentages, are unrelated to the concept of "parity ratio" mentioned earlier in the article. The term "parity ratio" is used by economists generally and in the economic study of veterans receiving compensation for PTSD discussed in the Effectiveness section of this article.[23] While important for policy-makers to consider, the Rating Formula is not based on parity ratio as determined in that research.
^These percentages are the disability ratings VA assigns for PTSD and other mental disorders. If a veteran has more than one disability, e.g., PTSD and tinnitus, the ratings for each are not combined in an additive manner to determine the overall disability rating, but are instead combined according to a mathematical calculation grounded in "whole person theory".[62]
^The report explained that "standard patients would be professional actors or people portraying veterans with disability claims" (p. 91).
References
^World Health Organization, "6B40 Post traumatic stress disorder," International Classification of Diseases, 11th Revision, 2018, rev. April 2019.
^van der Kolk, Bessel A. "The History of Trauma in Psychiatry." In Handbook of PTSD Science and Practice, edited by Matthew J. Friedman, Terence M. Keane, and Patricia A. Resick, 19–36. New York: Guilford, 2007. ISBN9781609181741
^Shalev, Arieh Y. and Charles R. Marmar. "Conceptual History of Post-Traumatic Stress Disorder." In Post-Traumatic Stress Disorder, edited by Charles B. Nemeroff and Charles Marmar, 3–30. New York: Oxford University Press, 2018. ISBN978-0-19-025944-0
^Friedman, Matthew J. "PTSD History and Overview". National Center for PTSD. Archived from the original on October 3, 2019. Retrieved October 3, 2019.
^Posttraumatic stress disorder, 38 C.F.R. § 3.304(f), ("Service connection for posttraumatic stress disorder requires medical evidence diagnosing the condition in accordance with §4.125(a) of this chapter; a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred.")
^Diagnosis of mental disorders, 38 C.F.R. § 4.125(a), ("Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), American Psychiatric Association (2013), is incorporated by reference into this section ....")
^"VA disability compensation for PTSD". U.S. Department of Veterans Affairs. September 27, 2019. Archived from the original on August 30, 2019. Retrieved October 3, 2019. When you file a disability claim, you'll also need to fill out one of these additional forms: A Statement in Support of Claim for Service Connection for Post-Traumatic Stress Disorder (VA Form 21-0781) or A Statement in Support of Claim for Service Connection for Post-Traumatic Stress Disorder Secondary to Personal Assault (VA Form 21-0781a)
^Duty periods, 38 C.F.R. § 3.6(b)(2) ("... Full-time duty (other than for training purposes) as a commissioned officer of the Regular or Reserve Corps of the Public Health Service ...").
^Duty periods, 38 C.F.R. § 3.6(b)(3) ("Full-time duty as a commissioned officer of the Coast and Geodetic Survey or of its successor agencies, the Environmental Science Services Administration and the National Oceanic and Atmospheric Administration ...").
^Economic Systems Inc (2004). VA Disability Compensation Program: Legislative History. Washington, DC: VA Office of Policy, Planning and, Preparedness.
^An Act To amend and modify the War Risk Insurance Act, ch. 16, 41 Stat. 371, 373 (1919) ("A schedule of ratings of reductions in earning capacity from specific injuries or combinations of injuries of a permanent nature shall be adopted and applied by the bureau. Ratings may be as high as 100 per annum. The ratings shall be based, as far as practicable, upon the average impairments of earning capacity resulting from such injuries in civil occupations and not upon the impairment in earning capacity in each individual case ...").
^"38 CFR § 3.303 - Principles relating to service connection". Legal Information Institute at Cornell Law School. Archived from the original on October 2, 2019. Retrieved October 2, 2019. Service connection connotes many factors but basically it means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service in the Armed Forces, or if preexisting such service, was aggravated therein.
^ ab"Individual Unemployability". Veterans Benefits Administration – Compensation. Department of Veterans Affairs. Archived from the original on August 7, 2019. Retrieved August 15, 2019.
^Fried, Dennis Adrian, Marian Passannante, Drew Helmer, Bart K. Holland, and William E. Halperin. "The Health and Social Isolation of American Veterans Denied Veterans Affairs Disability Compensation". Health & Social Work 42, no. 1 (2017). https://doi.org/10.1093/hsw/hlw051
^Scott (USA, Ret.), LTG James Terry (October 10, 2007). "Findings Of The Veterans' Disability Benefits Commission". Testimony before the Committee on Veterans' Affairs, U.S. House of Representatives: U.S. Government Printing Office. Archived from the original on September 24, 2015. Retrieved June 20, 2015. We believe that the level of compensation should be based on the severity of the disability and should make up for the average impairments of earnings capacity and the impact of the disability on functionality and quality of life. ... Current compensation payments do not provide a payment above that required to offset earnings loss. Therefore, there is no current compensation for the impact of disability on the quality of life for most veterans. While the permanent quality of life measures are developed, studied, and implemented, we recommend that compensation payments be increased up to 25 percent with priority to the more seriously disabled.
^"VA disability compensation: Actions needed to address hurdles facing program modernization (GAO-12-846)". U.S. Government Accountability Office. September 10, 2012. Archived from the original on October 13, 2019. Retrieved January 8, 2020. Three key approaches for modernizing VA's disability programs recommended by disability commissions and others—providing quality of life payments, providing integrated vocational services with transitional cash assistance, and systematically factoring the effects of assistive technology and medical interventions into rating decisions—hold opportunity and challenges. Experts and veteran groups GAO interviewed believe each approach holds at least some opportunity for serving veterans more fairly, equitably, and effectively.
^Mossman, D. (1994). "At the VA, it pays to be sick". The Public Interest. 114: 35–47. Archived from the original on August 13, 2014. Retrieved August 13, 2014. Sadly, a program with good intentions has yielded a series of perverse incentives that reward illness, encourage patients to view themselves as incapacitated, and poison the relationships between patients and their caregivers.
^Satel, S. (February 2011). "PTSD's diagnostic trap". American Enterprise Institute. Archived from the original on August 13, 2014. Retrieved August 13, 2014. Told he is disabled, the veteran and his family may assume—often incorrectly—that he is no longer able to work. At home on disability, he risks adopting a "sick role" that ends up depriving him of the estimable therapeutic value of work.
^Gade, Daniel. "A Better Way to Help Veterans"(PDF). National Affairs. 16 (Summer, 2013): 53–69. Retrieved August 13, 2014. ... VA benefit policies ... distort incentives and encourage veterans to live off of government support instead of working to their full capability.[permanent dead link]
^Gade, Daniel M.; Huang, Daniel (2021). Wounding Warriors : how bad policy is making veterans sicker and poorer. Washington, DC: Ballast Books. ISBN978-1-955026-99-4.
^Dep't Veterans Affairs, Off. Inspector Gen., Inadequate Oversight of Contracted Disability Exam Cancellations, Rpt. No. 18-04266-115 at 2 ("VBA has contracted billions of dollars to schedule, conduct, and document exams for veterans to obtain a medical diagnosis and to determine the severity of a claimed disability.") and at 19 (Table A.1. Medical Disability Examination (MDE) Background Timeline) (June 10, 2019).
^The VA Medical Examination And Disability Rating Process: Hearing before the Subcomm. Disability Assistance & Memorial Aff. of the H. Comm. Veterans Aff., 110th Congress 63-65 (2008) (statement of Michael McGearyArchived February 23, 2017, at the Wayback Machine, Senior Program Officer & Study Dir., Comm. Med. Evaluation Veterans Disability Benefits, Bd. Mil. & Veterans Health, Inst. of Med., Nat'l Acad.) ("Applicants for disability compensation are asked to provide their medical records and, under the duty-to-assist law, VBA helps them obtain those records, especially their service medical records. In nearly every case, VBA has applicants undergo a compensation and pension, or C&P, examination performed by a Veterans Health Administration (VHA) or contractor clinician.")
^ abVeterans Benefits Administration (VBA) (December 2016). "Your VA Claim Exam: Know What's Next (Claim Exam Fact Sheet)"(PDF). www.VA.gov. Archived(PDF) from the original on June 22, 2017. Retrieved October 11, 2017. The VA claim exam, also called a C&P exam, is different from a regular medical appointment because the examiner won't prescribe any medicine or treat you for your disability. This exam occurs only if you file a compensation or pension claim.
^Dep't Veterans Aff., Veterans Benefits Admin., M21-1 Adjudicative Procedures Manual, pt. III, subpt. iv, chap. 1, sec. a. Definition: Rating Activity (September 28, 2018).
^"Frequently Asked Questions - Board of Veterans' Appeals". Board of Veterans Appeals (va.gov). Retrieved May 10, 2020. Although it is not required, you may decide to be represented by an accredited Veterans Service Organization (VSO), attorney, or claims agent.
^"Schedule of ratings – mental disorders". Code of Federal Regulations, Title 38: Pensions, Bonuses, and Veterans' Relief, Part 4 – Schedule for Rating Disabilities, Subpart B – Disability Ratings, Mental Disorders. Government Printing Office, Electronic Code of Federal Regulations (e-CFR). Note: Scroll down about one page to find the General Rating Formula for Mental Disorders – it appears immediately under 9440 Chronic adjustment disorder. This placement is misleading because it appears as if the Rating Formula applies to Chronic Adjustment Disorder only, which is not the case. The Rating Formula applies to all mental disorders. Archived from the original on September 23, 2015. Retrieved December 28, 2013.
^Huang, Daniel (May 11, 2015). "Automated System Often Unjustly Boosts Veterans' Disability Benefits: Reduction of VA staff input allows more patients to exaggerate symptoms". No. May 12, 2015 [print edition]. Wall Street Journal. p. A6. Retrieved May 13, 2015. An effort by the Department of Veterans Affairs that aimed to speed the processing of disability-benefits applications also loosened controls that prevent veterans from exaggerating symptoms to receive more money, say current and former VA employees. A software system introduced in 2012 that automates veterans' disability levels for compensation relies almost solely on a patient's self-reported ailments, the employees say, even in the face of contradictory information. While the new system reduced paperwork and increased output, it limited the information that the VA's employees who determine compensation eligibility and dollar amounts—called raters—can consider, according to these employees. The result, raters contend: a more inaccurate process that approves higher levels of disability than veterans' military records, medical histories and other evidence might show—in some cases increasing payments to veterans by thousands of dollars a month. The process, they maintain, also ignores stated VA rules in which claims must be evaluated 'in light of the [veteran's] whole recorded history'. Senior VA officials counter that the software system still relies on raters' expertise to determine the accuracy of claims. They say it is designed to facilitate, but not replace, that process. Raters 'have every right to change [the symptoms] if there is other evidence in the file', one official said.
^Total disability ratings for compensation based on unemployability of the individual, 38 CFR § 4.16 (2018),"38 CFR § 3.1 - Definitions". law.cornell.edu. Archived from the original on August 19, 2019. Retrieved January 24, 2019.
^Stressor Determinations for Posttraumatic Stress Disorder, 75 Fed. Reg. 39843, 39848 (July 13, 2010) ("... a C&P examination is forensic evidence for purposes of determining whether a veteran is entitled to disability compensation for PTSD and, if so, how much.")
^Functional Organizational Manual(PDF). 3.1. Washington, DC: Department of Veterans Affairs. 2016. pp. 238–240. Archived(PDF) from the original on February 10, 2017. Retrieved December 21, 2017. The Office of Disability and Medical Assessment (DMA) (10NC8) provides executive leadership to VHA's disability programs worldwide, including both the traditional Compensation and Pension (C&P) and the Integrated Disability Evaluation System (IDES) programs.
^"Review Post Traumatic Stress Disorder (PTSD) Disability Benefits Questionnaire (VA Form 21-0960P-3)"(PDF). Veterans Health Administration. October 2012. Archived(PDF) from the original on October 21, 2014. Retrieved August 24, 2014. The following health care providers can perform REVIEW examinations for PTSD: a board-certified or board-eligible psychiatrist; 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; 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 licensed doctorate-level psychologist; or 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 psychiatrist or licensed doctorate-level psychologist.
^Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008), ("both VA medical examiners and private physicians offering medical opinions in veterans benefits cases are nothing more or less than expert witnesses.").
^Veterans Benefits Admin., Dep't Veterans Aff., M21-1 Adjudication Procedures Manual, Definition: Rules of Evidence, pt. V, subpt. ii, chap. 1, sec. A, no. 1, subsec. b ("the codified Federal rules of evidence used in Federal court proceedings do not apply in VA proceedings.").
^Veterans Benefits Admin., Dep't Veterans Aff., M21-1 Adjudication Procedures Manual, Questions About Competency and/or Validity of Examinations, pt. IV, subpt. i, chap. 3, sec. A, no. 1, subsec. o ("there is a presumption that a selected medical examiner is competent").
^Institute of Medicine and National Research Council (May 8, 2007). PTSD Compensation and Military service. National Academies Press. pp. 204–05. Archived from the original on August 14, 2011. Retrieved November 16, 2014.
^Sparr, L. F.; White, R.; Friedman, M. J.; Wiles, D. B. (1994). "Veterans' psychiatric benefits: enter courts and attorneys". The Bulletin of the American Academy of Psychiatry and the Law. 22 (2): 205–222. ISSN0091-634X. PMID7949410. Among regional offices, there has been considerable variability in adjudicating claims. For example from 1986 to 1990, the PTSD claim approval rate in 58 VA regional offices varied from 36.2 percent to 73.5 percent.
^Murdoch, Maureen; Hodges, James; Cowper, Diane; Sayer, Nina (February 2005). "Regional variation and other correlates of Department of Veterans Affairs Disability Awards for patients with posttraumatic stress disorder". Medical Care. 43 (2): 112–121. doi:10.1097/00005650-200502000-00004. ISSN0025-7079. PMID15655424. S2CID22099834. ... rates of PTSD service connection varied almost twofold across regions between 1994 and 1998. Consistent with earlier research, this variation could not be explained by regional dissimilarities in veterans' sociodemographic or military characteristics, rates of major medical comorbidity, or combat-injury status. We extend these findings to show that the regional variation in PTSD disability awards likewise could not be attributed to regional differences in veterans' current PTSD symptom severity or level of disability.
^ abJackson, J. C.; et al. (October 2011). "Variation in practices and attitudes of clinicians assessing PTSD-related disability among veterans". Journal of Traumatic Stress. 24 (5): 610. doi:10.1002/jts.20688. PMID21913226. Standardized interviews were seldom employed, with 85% and 90% reporting that they 'never' or 'rarely' use the Clinician Administered PTSD Scale (CAPS) and the Structured Clinical Interview for the DSM-IV Axis I Disorders (SCID), respectively ... (citations omitted).
^Watson, P.; McFall, M.; McBrine, C.; Schnurr, P. P.; Friedman, M. J.; Keane, T.; Hamblen, J. L. (2002). Best Practice Manual for Posttraumatic Stress Disorder (PTSD) Compensation and Pension Examinations(PDF). Department of Veterans Affairs. p. 20. Archived(PDF) from the original on April 23, 2015. Retrieved May 13, 2015. [t]he Clinician Administered PTSD Scale (CAPS) is recommended as the interview method of choice, for conducting compensation and pension examinations for PTSD. The CAPS is a structured clinical interview designed to assess symptoms of PTSD corresponding to DSM-IV criteria. The CAPS has a number of advantages over other diagnostic interview methods for PTSD ... (citation omitted).
^Speroff, T.; et al. (December 2012). "Impact of evidence-based standardized assessment on the disability clinical interview for diagnosis of service-connected PTSD: A cluster-randomized trial". Journal of Traumatic Stress. 25 (6): 607–15. doi:10.1002/jts.21759. PMID23225029. The findings of this study show that administering a standardized disability assessment resulted in more complete coverage of functional impairment and PTSD symptoms. Standardized assessment elicited an increase in relevant information and nearly eliminated variation between examiners and medical centers. Furthermore, this study found that standardized assessment substantially diminished the uncertainty in diagnosis, and increased concordance of diagnosis ...
^Marx, Brian P.; Engel-Rebitzer, Eden; Bovin, Michelle J.; Parker-Guilbert, Kelly S.; Moshier, Samantha; Barretto, Kenneth; Szafranski, Derek; Gallagher, Matthew W.; Holowka, Darren W. (2017). "The influence of veteran race and psychometric testing on veterans affairs posttraumatic stress disorder (PTSD) disability exam outcomes". Psychological Assessment. 29 (6): 710–719. doi:10.1037/pas0000378. PMID28594214. ... among veterans diagnosed with PTSD by an independent evaluator, Black veterans were significantly less likely than White veterans to receive both a C&P PTSD diagnosis and to be given PTSD service connection status. Further, among veterans not meeting diagnostic criteria for SCID PTSD, Black veterans tended to be more likely than White veterans to be denied both C&P PTSD status and PTSD service connection status.
^O'Toole, Marie T., ed. (2013). Mosby's Medical Dictionary (Kindle edition) (9th ed.). St. Louis, MO: Elsevier Health Sciences. Kindle Locations 77966-77971. ISBN978-0-323-08541-0. false negative - an incorrect result of a diagnostic test or procedure that falsely indicates the absence of a finding, condition, or disease. The rate of occurrence of false-negative results varies with the diagnostic accuracy and specificity of the test or procedure. As the accuracy and specificity of a test increase, the rate of false-negatives decreases. Certain tests are known to yield false negative results at a certain rate; in all tests a small number will occur by chance alone.
^Colman, Andrew M. (2015). "False positive". A Dictionary of Psychology (4th ed.). Oxford University Press. doi:10.1093/acref/9780199657681.001.0001. ISBN9780199657681. false positive, n. - An incorrect classification of an element as a member of a class to which it does not in fact belong, as when a decision procedure results in a person being wrongly diagnosed as having a disorder.
^Murdoch, Maureen; Hodges, James; Cowper, Diane; Fortier, Larry; van Ryn, Michelle (April 2003). "Racial disparities in VA service connection for posttraumatic stress disorder disability". Medical Care. 41 (4): 536–549. doi:10.1097/01.MLR.0000053232.67079.A5. ISSN0025-7079. PMID12665717. S2CID22491388. After adjusting for respondents' sociodemographic characteristics, symptom severity, functional status, and trauma histories, black persons' rate of service connection for PTSD was 43% compared with 56% for other respondents (P = 0.003).
^Wandler, Hillary A. (Spring 2013). "The Role of Culture in Advocating for Accurate Diagnosis and Rating of Veterans' Psychological Disabilities". Mental Health Law & Policy Journal. 2: 18. Archived from the original on August 12, 2020. Retrieved October 12, 2017. The real potential for injustice comes when patient's whose culture's heavily influence the way they communicate distress meet clinicians who use a universalist or one-size-fits-all approach to assessment and diagnosis. As a patient may report symptoms differently across cultures, a clinician may interpret what the patient reports differently depending on the clinician's approach to assessment and diagnosis. The effect is even more significant when the patient and the clinician are from different cultures.
^Arbisi, P. A.; Murdoch, M.; Fortier, L.; McNulty, J. (2004). "MMPI-2 validity and award of service connection for PTSD during the VA compensation and pension evaluation". Psychological Services. 1 (1): 56–67. doi:10.1037/1541-1559.1.1.56.
^Marx, Brian P.; Bovin, Michelle J.; Szafranski, Derek D.; Engel-Rebitzer, Eden; Gallagher, Matthew W.; Holowka, Darren W.; Schnurr, Paula P.; Rosen, Raymond C.; Keane, Terence M. (January 19, 2016). "Validity of Posttraumatic Stress Disorder Service Connection Status in Veterans Affairs Electronic Records of Iraq and Afghanistan Veterans". The Journal of Clinical Psychiatry. 77 (4): 517–522. doi:10.4088/jcp.14m09666. ISSN0160-6689. PMID26797388. This study examined the extent to which veterans' posttraumatic stress disorder (PTSD) service connection (SC) status corresponded to their PTSD diagnostic status, as determined by a semi-structured diagnostic interview. ... For current PTSD, results showed a slightly higher proportion of false positives—individuals who did not meet SCID criteria but who did have SC for PTSD—than false negatives—individuals who met SCID criteria but did not have SC for PTSD. For lifetime PTSD, the proportion of false negatives was approximately twice the proportion of false positives. ... PTSD diagnostic and SC status are discordant for a significant minority of veterans.
^The VA Medical Examination And Disability Rating Process: Hearing before the Subcomm. Disability Assistance & Memorial Aff. of the H. Comm. Veterans Aff., 110th Congress 63–65 (2008) (statement of Michael McGeary, Senior Program Officer & Study Dir., Comm. Med. Evaluation Veterans Disability Benefits, Bd. Mil. & Veterans Health, Inst. of Med., Nat'l Acad.)(GPO Serial No. 110–70Archived February 23, 2017, at the Wayback Machine) ("Applicants for disability compensation are asked to provide their medical records and, under the duty-to-assist law, VBA helps them obtain those records, especially their service medical records. In nearly every case, VBA has applicants undergo a compensation and pension, or C&P, examination performed by a Veterans Health Administration (VHA) or contractor clinician.")
^Washington v. Nicholson, 21 Vet. App. 191, 197 (2007) (Hagel, J., concurring) ("Because of the immense importance of medical evidence in the VA claims process," [medical examinations and opinions] "can bear significantly upon the outcome of the claim for VA benefits.")
^U.S. Government Accountability Office, Military sexual trauma: Improvements made, but VA can do more to track and improve the consistency of disability claim decisions (p. 18) (2014) (GAO-14-447Archived June 18, 2017, at the Wayback Machine) ("VBA adjudicators generally rely on examiners' assessments when deciding whether to approve a claim ...").
^Hernandez, Christopher (February 26, 2014). "PTSD, Reading Comprehension and the Great American Love of Victimhood". Breach Bang Clear. Archived from the original on October 13, 2017. Retrieved October 13, 2017. I'm proud as hell of being a veteran. I'm proud of the men and women I served with. ¶ I didn't join the military so that my country could give me a free ride for the rest of my life, I joined to defend it from its worst enemies. I expected pain, fear and hardship from war. I believe our job as soldiers is to endure that pain, fear and hardship so our citizens don't have to. We are the barrier between our people and foreign threats. ¶ Being part of that barrier doesn't require heroism. But it does require integrity, courage and strength. The same integrity, courage and strength my great uncle Leo undoubtedly showed before he marched to his death on Bataan, and my great uncle Jesse showed when he jumped into Sicily, Normandy and Holland, and my great uncle Richard showed as he fought his way through Korea. And by generations of other American warriors on battlegrounds from Lexington to the Korengal Valley. ¶ Every time a veteran makes a false claim of PTSD, that barrier is weakened. Every time a veteran is exposed as a fraud, the barrier loses precious integrity. Every story that hints we're all damaged by PTSD, that we're all unstable, that we're all victims, gouges chunks from the barrier's foundation.
^Overcoming PTSD: Assessing VA's Efforts to Promote Wellness and Healing, H. Comm. Veterans Affairs, 115th Cong. 5 (2017) statement of Brendan O'Byrne, Veteran, United States Army ("[During group psychotherapy sessions] I heard stories that sounded a lot like a bad day rather than a traumatic moment. As weeks went by, I realized the sad truth about a portion of the veterans there, they were scammers, seeking a higher rating without a real trauma. This was proven when I overheard one vet say to another that he had to 'pay the bills' and how he 'was hoping this in-patient was enough for a 100% rating'. I vowed never to participate in group counseling through the VA again. ... The trend I have seen among the combat veterans, the most traumatized group, [is to] stay away from the VA, or at the very least, [stay away from] the group counseling settings. They have no patience for the fraudulent veterans scamming the system to get a pay check and they are definitely not going to open up about their worst days to those who know nothing about them.")
^Zarembo, Alan (August 3, 2014). "As disability awards grow, so do concerns with veracity of PTSD claims". Los Angeles Times. Archived from the original on November 11, 2014. Retrieved November 19, 2014. Even some veterans whose diagnosis falls under deep suspicion have managed to keep their disability ratings. In one case that Moering reviewed in 2009, he searched military records and concluded that a Navy veteran on the disability rolls for PTSD had lied to VA clinicians about having served in the elite SEALs and concocted his combat history. The VA responded by reducing his PTSD rating from 50% to 30%, records show.
^McVay, Mark (June 21, 2014). "When PTSD benefits are abused". Denver Post. Archived from the original on June 20, 2015. Retrieved June 20, 2015. I ran into John a few years back for the first time since the early 1970s when we both returned to Michigan from Vietnam. But John was clearly excited to see me. 'Hey man,' he said, 'have you applied for PTSD benefits yet? You can get a couple thousand a month. All you have to do is go to this counseling program for two weeks. Nothing to it. You ought to go.'
^Harbaugh, Ken (June 1, 2015). "The Risk of Over-Thanking Our Veterans". The New York Times. Archived from the original on June 7, 2015. Retrieved June 20, 2015. And while most vets who receive disability checks deserve them, one of the worst kept secrets among those seeking a disability rating is that the system can be beaten. Claim the right combination of symptoms, whether you are suffering or not, and there is a decent chance you can get a monthly disability check, tax free, for the rest of your life. There are even blogs out there to walk you through the process of claiming an injury that cannot be disproved.
^"VA Claims Process: Review of VA's Transformation Efforts: Hearing before the S. Comm. on Veterans' Affairs, 113th Cong. 12 (13 Mar 2013) (statement of Allison A. Hickey, Under Secretary for Benefits, Veterans Benefits Admin., U.S. Dep't Veterans Affairs)"(PDF). U.S. Senate Committee on Veterans Affairs. March 13, 2013. p. 12. Archived(PDF) from the original on August 26, 2014. Retrieved August 24, 2014. DBQs replace traditional VA examination reports and are designed to capture all the needed medical information relevant to a specific condition at once and up front so that claims can be developed and processed in a more timely and accurate manner, with the end result being faster service for Veterans. DBQs change the way medical evidence is collected, giving Veterans the option of having their private physician complete a DBQ that provides the medical information needed to rate their claims—minimizing the need for a VA exam which adds additional time to the claim development process. Information in the DBQs maps to the VA Schedule for Rating Disabilities, and provides all of the necessary information to decide a disability claim.
^"Documentation of Medical Evidence for Disability Evaluation Purposes (VHA Directive 2013-002)"(PDF). Veterans Health Administration. January 14, 2013. p. 4: 4(e)(1)(c). Archived from the original on October 19, 2013. Retrieved August 24, 2014. For mental health disability examination requests, it is recommended that the Veteran's treating provider not complete the disability examination to maintain the integrity of the patient-provider relationship.
^Worthen, M. D.; Moering, R. G. (December 2011). "A Practical Guide to Conducting VA Compensation and Pension Exams for PTSD and Other Mental Disorders". Psychological Injury and Law. 4 (3–4): 192. doi:10.1007/s12207-011-9115-2. S2CID18074279. Archived from the original on October 11, 2020. Retrieved June 10, 2014. One section of every mental health-related DBQ is a symptom 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 endorse 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.
^Off. Inspector Gen., Dep't Veterans Aff., Rep. No. 19-07119-80, Telehealth Public-Use Questionnaires Were Used Improperly to Determine Disability Benefits13 (Feb. 18, 2020) https://www.va.gov/oig/pubs/VAOIG-19-07119-80.pdf
^Publication and Acceptance of Disability Benefit Questionnaire Forms of Department of Veterans Affairs, Johnny Isakson and David P. Roe, M.D. Veterans Health Care and Benefits Improvement Act of 2020, Pub. L. No. 116-315, § 2006 (Jan. 5, 2021).
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