CREW v. Army: Re: PTSD Diagnoses: 4/17/2009 - Legal Aspects of Adjudicating Claims for Psychiatric...

8/7/2019 CREW v. Army: Re: PTSD Diagnoses: 4/17/2009 - Legal Aspects of Adjudicating Claims for Psychiatric Disorders

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GOALS

IMPROVE VALIDITY AND RELIABILITY:

o Validity-is the decision/rating consistent- with the veteran's disability/functional

impairment in daily life?

o

Reliability-is the same decisionor

samerating assigned for the same facts orextent of disability by different decisionmakers



Impediments to validity and

reliability in psychiatric claims

Clinical/Scientific Factors:

-0 Lack of scientific knowledge of objective

factors which differentiate one psychiatric

disorder from another10 Lack of cross-reliability in descriptions of

manifestations of a psychiatric disorder



Impediments (cont.)Legal Factors:

oWeak clinical link between severity ofsymptoms and severity of disability

o General formula does not indicate which

symptoms are important for evaluating aspecific disorder

G Non-clinical pressures on regulatory

decision-makingo Regulations not congruent with clinical

criteria



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Claims to ReopenBoggs v. Peake, No. 07-7137 (Fed. Gir. Mar. 26, 2008)

o Conductive hearing lossv.

sensorineuralhearing loss

o Claims based upon distinctly and properly

diagnosed diseases or injuries mustbe

considered separate and distinct claims

Application could be problematic for psychiatric

claims due to lackof

uniformityof

Axis Idiagnoses and question of which one is the

proper diagnosis



VCAAVasquez-Flores v. Peake, 22 Vet. App. 37 (2008).

o No decision yet on an IR psychiatric disabilityclaim

" Rating criteria does not require specificmeasurement or test result - only need showing

that disability worse and the effect suchworsening has on veteran's employment anddaily life

o Could probably use statements, including thosemade at VA examinations, to show actualknowledge



Current DisabilityMcClain v. Nicholson, 21 Vet. App. 319 (2007)

o SC claim for psychiatric disorder that was

present at time claim filed, but resolved prior toBoard decision.

o Board denied on basis of no current disability.

o Court held that requirement for current disabilityis satisfied when claimant has a disability at thetime a claim for SC is filed or during thependency of the claim even though it resolves

prior to the final adjudication of the claim.o Provided the resolved disability is related to

service, staged ratings should be considered.



Lay EvidenceQ Significant Recent Cases: Buchanon v.Nicholson, 451 F.3d 1331 (2006); Jandreau v.Nicholson, 492 F.3d 1372 (2007); Barr v.Nicholson, 21 Vet. App. 303 (2007)

'" Veteran generally competent to testify tosymptoms, including in service - may besufficient bases for requesting VA examinationfor nexus opinion in SC claims

Q Specifically problematic with IR claims astypically rely on veteran's self-report of

symptoms and occupational and socialfunctioning (psychological testing or inpatientobservation not required)

Q VA examinations v. treatment records



Adequacyof

Medical OpinionsQ Examination does not address nexus, lay

statements, all theories of entitlement or all

disabilities. McLendon v. Nicholson, 20 Vet.App. 79 (2006).

Q Examiner makes a finding that is clearly

contradicted by the medical evidence of recordwithout adequate explanation or discussion of

other medical evidence (e.g., Vasquez-Flores v.

Peake, 22 Vet. App. 37 (2008).Q Opinion based on a incorrect premise/facts.

Kowalski v. Nicholson, 19 Vet. App. 171 (2005).



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The Roles of Mental Health

Professionals

o Clinical care:

• assessment and treatment

• sessions over time: weeks, months, years

,0 Compensation & Pension exams• forensic, not clinical

• 1-2 sessions only so less familiarity with the

veteran

• The need for good military & VA records



Orientation to Careo Health promotion, preventive care

oAssess for diagnostic entities: PTSDDepression, Substance Use Disorders &

apply evidence based treatments per

Clinical Practice GuidelinesQ Rehabilitation/recovery approach to those

with mental disorders (involve family)

oAvoid over-pathologizing, teach coping

skills)



Continuum of Careo 155 VA Medical Centers

o Inpatient & residential care

0600 + clinics including Community Based

Outpatient Clinics (CBOCs)

0230 Veterans Outreach Centers

. 0 Vet Centers



OEF/OIF MH Data,

FY 2002 to 4th Quarter FY 2007

0799,791 returnees - 299,585 in VA care

.Q 120,049 with provisional MH diagnosis

• 59,838 PTSD (26,084 in '07)

• 3,721 ASD• 39,940 Depression

• 22,216 Affective Psychoses

• 9379 Drug/Alcohol Abuse

• 14,325 Drug/Alcohol Dependence



Multiaxial Assessment of

Mental Disorders

Axis I: Clinical Disorders

• defined by observable, unique clusters

of symptoms and patterns of behavior• must cause distress and/or impair

functioning

• service connectable



Diagnostic Criteria (cant.)

AXIS II: Personality Disorders• life long patterns of maladaptive

behavior• observable behaviors

• not service connectable



Diagnostic Criteria (cant.)

Axis III: General Medical Conditionscan be service-connected or -not

Axis IV: Psychosocial & Environmental

Problems



Diagnostic Criteria (cont.)

Axis V: Global Assessment of

Functioning (GAF)

• A great improvement over pre-DSM III era • Attempts to structure assessment of

severity based on symptoms & functioning



PsychosisoExamples: schizophrenia, delusional

disorder

oCharacterized mainly by the presenceof delusions or prominent

hallucinations



Psychoses (cont.)

o Delusions: a fixed, false belief not

accepted by members of one's culture

o Hallucinations: a sensory perception

without an actual external stimulation ofthe relevant sensory organ (audio or

visual)

Q Illusion: misinterpretation of a realsensory stimulus



Biology of Mental Disorderso Genetic studies show chromosome links

associated with schizophrenia & also forbipolar disorder.

o 50%-650/0 concordance in twin studies vs.100% for Huntington's disease:environmental influence

oCT scans, MRI: stable brain structural

markers: ventricular enlargement&

schizophrenia associated with negativesymptoms



Biology of Mental Disorders II

<) Dexamethasone Suppression Test: elevated

cortisol blood levels the day after DST challengein 40-90% of patients with Major Depressive

Disorder. State dependent.

Q PTSD: Stress associated with Sudden CardiacDeath - with stress (e.g. combat scenes) pulse,

blood pressure go up faster, higher & stay

elevated longer than in person without PTSD



Major Depressive Disorder

5or more symptoms:1. Depressed mood*

2. Loss of interest or pleasure*

3. Weight loss or gain 50/0 of body weight

4. Insomnia or hypersomnia

5. Psychomotor agitation or retardation



MOD (cont.)

6. Fatigue/loss of energy7. Feelings of worthlessness or guilt

8. Diminished ability to think or

concentrate

9. Recurrent thoughts of death or suicide



Bipolar DisorderManic episodes required (Sip. I), may

be accompanied with depressiveepisodes (Sip.lI)

Q Def.: Abnormal and persistently elevated,

expansive or irritable mood for 1 week and 3

or more of the following symptoms:



Bipolar/Manic Symptoms

1. Inflated self-esteem or grandiosity2. Decreased need for sleep

3. More talkative/pressured tospeech

4. Flight of ideas, racing thoughts5. Distractibility



Bipolar/Manic Symptoms (cant.)

6. Increased goal directed activity

(e.g., work, social, sex) or

psychomotor agitation

7. Excessive pleasurable, high-risk

activities: unrestrained buying,

sexual indiscretions, "foolishinvestments"



Schizoph ren ia Diagnostic symptoms include two

or more of the following during a 1-month period:

1. Delusions (fixed false beliefs: you are

Napoleon)

2. Hallucinations (hearing/ seeing that

are n'ot there (voices telling you areNapoleon)



Schizophrenia (cant.)

3.

Disorganized speech (frequentderailment or incoherence)

4. Grossly disorganized or catatonic

behavior (standing in place, immobilefor long periods)

5. Negative symptoms (flat affect, alogia,

avolition)



Types of Schizophrenia

o Paranoid (key feature: delusions)

o Disorganized (disorganized speech,

behavior, flat affect)

o Catatonic (immobility, posturing)

o Undifferentiated (none of the above)

o Residual (Some symptoms remain)



PTSD Diagnostic criteria require:

o A traumatic stressor: experienced or witnessed

threat to life or serious injury to self/others and

response was intense fear, helplessness, horror

o 1 or more re-experiencing symptoms (recurring

intrusive thoughts of the event, nightmares,

acting/feeling as if event were taking place again

(flashback), physiological distress at cues

symbolizing the event



PTSD (cant.)

o Persistent avoidance of stimuli associated with

the event (3 or more of: avoid thoughts, people,inability of recall, feelings of detachment,

restricted affect)

Q Symptoms of increased arousal (2 or more of:difficulty falling/staying asleep, irritability,

difficulty concentrating, hypervigilance,

exaggerated startle response)



Common Symptoms of PTSD

• Insomnia • Stress symptoms

• Memory Problems • Emotional numbing

• Poor concentration • Avoidance

• Depression • Intrusive symptoms

• Anxiety

• Irritability



Mild Traumatic Brain InjuryPost-concussion Syndrome (peS)

• Insomnia• Impaired Memory

• Poor concentration

• Depression• Anxiety

• Irritability

• Headache• Dizziness

• Fatigue

• Noise/Lightintolerance



Personality Disorderso Enduring pattern of inner

experience and behavior thatdeviates markedly from the

expectations of the individual'sculture.

o

Manifestedin

2 or more of thefollowing areas:



Personality Disorders (cont.)

1. Cognition: ways of perceiving &

interpreting self, others & events

2. Affectivity: range, intensity, lability

& appropriateness of emotionalresponse

3. Interpersonal functioning4. Impulse control



Personality Disorders (cant.)

oThe pattern is inflexible & pervasiveacross a broad range of personal &

social situations

o The pattern leads to clinically

significant distress/impairment in

social/occupational functioning



Personality Disorders (cont.)

oThe pattern is stable, of long duration,

& traceable to adolescence or early

adulthood

o Not due to another disorder e.g.,

substance use, etc.



• •

Personality Disorder: Cluster A

oParanoid: pervasive distrusU

susPiciousness

oSchizoid: detachment from social

relationships

oSchizotypal: social, interpersonal

deficits: cognitive, perceptual

distortions, eccentricities



Personality Disorder: Cluster B oAntisocial: disregard for/violation of rights

of

others4 Borderline: instability of interpersonal

relationships, self image, affect: marked

impulsivity.g Histrionic: excessive emotionality &

attention seeking behavior

o Narcissistic: grandiosity, need for

admiration, lack of empathy for others



Personality Disorder: Cluster C oAvoidant: social inhibition, feelings of

inadequacy, hypersensitivity to negativeevaluations

<) Dependent: excessive need to be taken of

leads to submissive/clinging behavior;fears of separation

o Obsessive Compulsive: preoccupation

with orderliness, perfectionism, mental/

interpersonal control



Substance Use Disorderso Substance Dependence: Cluster of

cognitive, behavioral and physiologicalsymptoms (tolerance/withdrawal)

indicating continued use of the substance

despite substance-related problemso Substance Abuse: Maladaptive

substance use despite repeated adverse

consequences

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CREW v. Army: Re: PTSD Diagnoses: 4/17/2009 - Legal Aspects of Adjudicating Claims for Psychiatric...

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