The Department of Veterans Affairs (VA) should place less emphasis on
occupational impairment alone and use more comprehensive and consistent
methods to evaluate veterans filing claims for disability from posttraumatic
stress disorder, according to a report from the Institute of Medicine (IOM)
released last month.
Psychosocial and occupational aspects of functional impairment should be
"The emphasis on occupational impairment in the current criteria
penalizes veterans who may be symptomatic or impaired in other ways but who
are capable of working, and that could serve as a disincentive to both work
and recovery," said Nancy Andreasen, M.D., Ph.D., who chaired the IOM
Committee on Veterans' Compensation for Posttraumatic Stress Disorder. She is
also the Andrew H. Woods Chair of Psychiatry and director of the Neuroimaging
Research Center at the University of Iowa Carver College of Medicine.
The report also found "abundant scientific evidence" that PTSD
or its symptoms could appear many years after the incident that caused the
Andreasen presented the committee's report to the Veterans' Disability
Benefits Commission in Washington, D.C., on May 10.
The commission, on behalf of the VA, is examining diagnostic, clinical, and
compensation issues regarding PTSD among military veterans. The wide-ranging
study began after the VA's inspector general reported in 2005 that
beneficiaries receiving compensation for PTSD rose from 120,265 in 1999 to
215,871 in 2004—an increase of 80 percent.
Last June, another IOM committee found that DSM-IV criteria for
diagnosing PTSD were well founded and should remain the standard for diagnosis
(Psychiatric News, July 21, 2006). A third study, on treatment
issues, should be completed by autumn, said the commission chair, retired Army
Lt. Gen. James Terry Scott. The final commission report and its
recommendations are due by October 1, Scott told Psychiatric
The new report sought to address inadequacies in how the VA evaluates and
compensates veterans for service-connected PTSD. Current methods used by the
VA Schedule of Rating Disabilities were "crude" at best, said the
IOM committee, partly because they placed all mental disorders under a single
heading and often were applied inconsistently.
The present rating system relies heavily on the General Assessment of
Functioning (GAF), a scale that was developed for schizophrenia and
depression, not PTSD, said Andreasen, who helped write the definition of PTSD
that appeared in the DSM-III.
"The GAF has limited usefulness in assessing PTSD for
compensation," she told the commission. However, the GAF was so embedded
in the VA's current operations that its use should be temporarily continued,
as long as raters understand both its uses and its limitations and are trained
to use it uniformly and consistently.
"In the long term, the VA will need to find a replacement for the
GAF, but that will take research," said Andreasen, the former editor in
chief of the American Journal of Psychiatry. "We need new
criteria specific to PTSD and based on DSM-IV."
Such a multidimensional framework should include general functional
impairment, pain and suffering, quality of life, and treatment intensity and
complexity, as well as work limitations, she said.
Most persons with PTSD also have other psychiatric disorders, such as
depression or anxiety. The current VA compensation system is based on a
separate evaluation of each diagnosis, yet there is no way to separate these
comorbid disorders, as is possible, for example, with a broken leg and
She recommended that the VA establish a certification program specifically
for raters who evaluate PTSD compensation claims and take steps to keep them
up to date and their judgments consistent.
PTSD evaluations are not carried out in a standardized manner now, said
Andreasen. To assess a patient, some raters take 20 minutes, while others take
"The VA should allocate the time and resources for experienced
professionals to thoroughly examine each patient filing for a PTSD
claim," she said. Psychological testing is often desirable as part of
this process but is not a substitute for clinical evaluation, she explained to
Andreasen said that the committee also considered whether receiving
disability compensation would discourage veterans from seeking treatment.
While some drop out of treatment once they begin receiving compensation, many
more often seek treatment because they are able and motivated to do so. A
state-of-the art initial compensation examination would reduce inappropriate
claims and malingering, she said. Greater coordination of veterans' health and
benefit services might also reduce disincentives and maximize incentives for
veterans to seek treatment and achieve optimal functioning.
The committee also recommended, she continued, that the VA set a certain
long-term minimum level of benefits available to all veterans with
service-connected PTSD to provide a safety net that would take into account
the relapsing/remitting nature of PTSD. Patients might be reevaluated on a
case-by-case basis, but the committee opposed regular reevaluations as
stigmatizing, Andreasen said.
Finally, the VA must upgrade its systems of data collection, analysis, and
publication, she advised. Some VA data were unavailable to her committee
because they were not collected, retained, or retrievable, she said.
The executive summary of the IOM report is posted at<http://books.nap.edu/execsumm_pdf/11870.pdf>.▪