>
> -----------------------------------------------------
> PTSD Case Review (VA)
>
> January 8, 2001
>
> Director (00/21) 211A
>
> All VBA Regional Offices and Centers TL 01-01
>
> SUBJECT: PTSD Case Review
>
> We recently completed a review of 143 initial claims for PTSD, with the
> assistance of reviewers from the field, under a special protocol. An
> additional 77 cases were informally reviewed.
>
> The attached training letter addresses some of our general findings as
well
> as problems revealed by the review. The 10 important rating points about
> PTSD emphasize major areas of concern. They are followed by more detailed
> information on our findings.
>
> Additional and broader training on PTSD will be conducted in the near
> future. This letter is not intended to make policy but to restate and
> clarify existing policy.
>
> /s/
>
> Robert J. Epley, Director
> Compensation and Pension Service
>
>
> Enclosure: Training Letter based on PTSD case Review
>
> 10 important rating points about PTSD
>
> 1. You are obligated (per 4.125) to assure that the diagnosis of PTSD is
> well-supported by the findings and is based on DSM-IV diagnostic criteria.
> Return examination reports that do not meet this requirement.
>
> 2. You must rate PTSD based on its overall effects on social and
> occupational functioning. Return examination reports that do not describe
> these effects in detail.
>
> 3. A veteran does not need to have any or all of the specific examples of
> signs and symptoms listed in the general rating formula for mental
disorders
> in order for a particular evaluation level of PTSD to be assigned.
>
> 4. Evaluate PTSD on the core requirements at each evaluation level, i.e.,
> the language that refers to the effects of a mental disorder on social and
> occupational functioning.
>
> 5. Make sure you have made reasonable efforts to obtain all pertinent
> evidence (consistent with the new duty to assist requirements), including
> private medical records the veteran may have referred to, before you make
an
> unfavorable decision.
>
> 6. Don't go through the I.U. process if there is clear evidence on the
> examination that the veteran is unable to work because of PTSD. A 100%
> evaluation would be more appropriate in such cases, and a future exam can
be
> requested when indicated.
>
> 7. Do not base a rating solely or mainly on the GAF score. The GAF score
> does not translate directly to the rating schedule criteria.
>
> 8. Do not ignore additional mental disorders that are diagnosed in someone
> with PTSD. Ask the examiner about the relationship to PTSD if not already
> addressed in the examination report.
>
> 9. Explain the reasons for all of your rating decisions.
>
> 10. You must notify the veteran in clear terms of the rating decisions and
> fully inform him or her of any action necessary to further or complete the
> claim for PTSD.
>
>
> What were our general findings in the review?
>
> *127 of the 143 decisions reviewed (89%) correctly disposed of the basic
> issue of service connection.
>
> *11% (16 decisions) contained a mistake.
>
> - 10 decisions incorrectly established service connection.
>
> - 6 decisions incorrectly denied service connection.
>
> *84% (63 decisions) correctly assigned the appropriate evaluation.
>
> *16% (12 decisions) assigned incorrect evaluations.
>
> - 10 decisions underevaluated the degree of disability, particularly at
the
> higher levels, e.g., 70%.
>
> - 2 decisions overevaluated the degree of disability.
>
> *53% of the claims were granted.
>
> *65% of the claims cited combat as the stressor; 10% cited sexual trauma.
>
> *When C&P examinations were conducted, 77% diagnosed PTSD.
>
> *Very few decisions contained any real analysis.
>
>
> What are some of the evaluation problems found?
>
> 1. Difficulty understanding why a particular evaluation was assigned.
>
> Most reviewed cases were correctly evaluated, but of those that were not,
> most were underevaluated. Granted that evaluating any mental disorder is
> difficult, the reason these cases were underevaluated is unclear because
of
> the failure to analyze evidence and explain the rating decision in the
> reasons and bases. As a rule, ratings laid out the evidence and gave the
> conclusion, but did not address how the rater reached the decision. The
> rating redesign initiative directly addresses this issue, as well as our
> organizational expectations concerning the fix.
>
> 2. Problem in applying rating schedule criteria
>
> One reason for erroneous evaluations may be confusion about the criteria
in
> the general rating formula for mental disorders. The signs and symptoms
> named at each level are examples of what might be seen at each level.
> However, the absence of those specific findings in an individual does not
> exclude a rating at any given level.
>
> It is the described effects on social and occupational functioning at each
> level of whatever signs and symptoms the veteran has that should determine
> the rating. In particular, the examples of signs and symptoms given do not
> encompass the common diagnostic findings specific to PTSD, but apply to
any
> mental disorder. Therefore, you must look beyond the generic signs and
> symptoms in the rating schedule and look at the effects of PTSD in that
> individual. As with other disabilities, there is often a difference
between
> the findings that establish the diagnosis of PTSD and those that indicate
> its level of severity.
>
> Example: Vietnam combat veteran reported or showed:
>
> sleep disturbances to point of getting only 3-4 hours of sleep a night
>
> avoidance of most people and social events, distant and estranged from
> others
>
> restricted range of affect
>
> aggressive outbursts at work indicating impaired judgment in thinking
> (almost threw a man off a building, drove a vehicle into something else
and
> caused damage)
>
> withdrawn, decreased concentration, hypervigilance
>
> mood depressed and hopeless, suicidal ideation
>
> fatigued and irritable
>
> hallucinatory flashbacks
>
> impairment in reality testing
>
> Some of these are examples (in the general rating formula for mental
> disorders) of signs and symptoms at the 70-percent evaluation level, and
> others are more akin to the 100-percent level. Some of his significant
> problems are not in either list of examples. Taking into account all of
the
> findings, it is clear he is at least severely, if not totally, impaired in
> both social and occupational functioning. He was given a 70% evaluation.
> Others might judge a 100% evaluation as more appropriate, particularly in
> view of the episodes of violence.
>
> The National PTSD Center points out to examiners in soon-to-be-released
> guidelines for PTSD examiners that the presence of violence toward self
and
> others in the veteran's history is a significant feature that should drop
> the GAF score into the lower ranges, even if functioning in other areas
> appears better. This indicates the Center's belief that violence should be
> regarded as an indication of very serious disease.
>
> 3. Reluctance to grant 100%
> Many cases of PTSD were rated at 70% even when there were clear
indications
> on the examination that the veteran had severe symptoms and had total
> occupational impairment because of PTSD symptoms.
>
> Examples: One veteran had not been working for 2 years because of PTSD
> symptoms; one was reported as unable to work and getting progressively
> worse; one had not worked for 7 or 8 months since seeing "Saving Private
> Ryan"; one was complying with his treatment plan but was said not to be
> sufficiently stable (e.g., had suicidal ideation) to maintain competitive
> employment; one was said to have an inability to function in almost all
> areas; and one had impairment of reality testing, active flashbacks,
> depression, hopeless mood, etc.
>
> Each of these was rated at 70% but could have been rated at 100%. GAF
scores
> in these cases ranged from 30 to 45. (30 was the lowest GAF score given
for
> any case in this review.) Most were eventually given I.U., but there
seemed
> to be great reluctance to grant a schedular 100-percent evaluation even
when
> there was ample medical evidence of severe disability due to PTSD, and a
> clear indication of impaired functioning sufficient for a schedular
> 100-percent evaluation.
>
> The old Physician's Guide stated in the chapter on mental disorders: "In
the
> case of anxiety disorders, except for severe phobias, it is unusual for a
> person to be completely incapacitated." However, VA's National PTSD Center
> states that anxiety disorders, severe phobias, PTSD, OCD
> (obsessive-compulsive disorder), panic disorder (esp. with agoraphobia),
and
> social phobia all can be debilitating, sometimes to the point of complete
> incapacitation. Currently, over 29,000 veterans with PTSD are rated at
100%
> and over 6000 with generalized anxiety disorder are rated at 100%.
> Therefore, it is no longer correct to say that total incapacitation for
> anxiety disorders is unusual.
>
> What problem was found on notification letters?
>
> A common problem noted in the review was the failure to provide correct
and
> adequate notification letters. A letter notifying a claimant about a
rating
> should not simply refer to an attached copy of a rating for all
information,
> only for a more detailed explanation of what is summarized in the
> notification letter itself. (See M21-1, Part III, 11.09a and FL 00-58.)
>
> What are the examination-related problems?
>
> 1. Availability of claims file
>
> The examiner had the claims file for review in less than half the cases.
> Since these were all initial PTSD claims, this was a significant omission.
> We are addressing this issue with VHA and will also discuss it on the
> satellite broadcast.
>
> 2. Inadequacy of exams
>
> Examinations were largely adequate, but of those that were not adequate,
few
> were returned for correction or completion.
>
> Example: One examiner said the veteran seemed to have some minor PTSD
> symptoms-but did not name them. This was the only reference to PTSD in the
> examination, and the veteran was SC and evaluated for PTSD based on this
> exam. The examination should have been returned to get more specific
> information.
>
> 3. Failure to apply DSM-IV criteria
> In good exams, the examiner listed the DSM-IV criteria and supplied
examples
> of the veteran's own signs and symptoms that met those criteria. When this
> procedure is followed, the rater should have few reservations about the
> validity of the diagnosis.
>
> In several cases, the examiner clearly used DSM-III-R criteria, and they
> were accepted as adequate for rating, contrary to regulations (38 CFR
> 4.125). If you read the DSM-III-R and DSM-IV diagnostic criteria, the
> differences will be obvious. The language used by the examiner will
usually
> make it clear which version is the basis of the diagnosis.
>
> Example: Examiner began explanation of PTSD diagnosis by stating that the
> veteran has experienced an event that is outside the range of usual human
> experience and would have been markedly distressing to almost anyone.
These
> are DSM-III-R, but not DSM-IV, criteria and are a clear indication that
the
> diagnosis is not based on DSM-IV criteria.
>
> What are some problems related to the use of GAF Scores?
>
> 1. Failure to explain how GAF score was used.
>
> The GAF score was always reported in ratings when it was available, but
how
> it was used or taken into account, if it was, was rarely explained. In
some
> cases, however, the GAF score was the only apparent justification for the
> evaluation.
>
> Example: Rating stated GAF of 60 is indicative of moderate symptoms, and
> therefore 30% is assigned.
>
> The GAF scale is generally acknowledged to be an unreliable tool for
> assessment, although it may have value for treatment and prognostic
> purposes. No rating should be based primarily or even substantially on the
> GAF score.
>
> 2. Timeframe of GAF score.
>
> The GAF is simply an indicator of an examiner's assessment of overall
> functioning, and the period of time it represents differs with different
> examiners. Common timeframes are either current level of functioning or
best
> level of functioning during the past year. Which is intended is not always
> explained in the examination report.
>
> While current functioning is the more useful of the two for our purposes,
it
> is really only of interest if the veteran has been relatively stable over
> the past year or since the last examination. Remember that we are to
> consider all evidence of record, including any periods of remission, to
> attain a comprehensive picture of functioning. Taking this into account
> might lead you to an evaluation that is not consistent with the examiner's
> GAF score but which is more appropriate to rating requirements.
>
> How should the GAF score be used?
>
> You might want to look upon the GAF score as a finding that you could use
as
> a crosscheck against your own evaluation based on the reported signs and
> symptoms. The GAF score, your evaluation based on the rating schedule, and
> the reported signs and symptoms should theoretically all correlate with
one
> another. If they do not, you should carefully reexamine the evidence, and
> perhaps explain in the rating why your evaluation is at substantial
variance
> with the GAF score, when it is, perhaps, for example, because of different
> timeframes. If the GAF score is not supported by other information in the
> examination report, it has little or no value.
>
> However, there is no reason to change an evaluation because a GAF score
> differs in the assessed level of functioning from your evaluation, because
> your assessment may be based on more complete information than the
examiner
> has.
>
> Example: One examiner reported that the criteria that best describe the
> veteran are mild impairment with occasional decrease in efficiency due to
> such symptoms as depressed mood, anxiety, chronic sleep impairment, and
mild
> memory loss (part of the 30% criteria from the general rating formula for
> mental disorders), which reflects a GAF score of 55. In essence, he was
> making a rating schedule determination and correlating the GAF to it,
rather
> than linking the GAF score to the clinical findings.
>
> What are the problems in duty to assist?
>
> In some cases where it seemed indicated, all private medical records were
> not requested, the SMRs were not requested, there was no CURR request,
> pertinent service personnel records were not requested, or all VA medical
> records were not requested. You should not deny a claim until you are sure
> that all requested evidence has been received (or the reason why it could
> not be obtained noted), the claimant has been afforded the opportunity to
> obtain and submit evidence, and you have sought relevant evidence from
> available sources.
>
> How often was CURR used for stressor verification?
>
> CURR stressor verification was used in 4 of the 6 cases where it was
> required. CURR verified the stressor in one of these 4 cases.
>
> How should other diagnosed mental disorders be handled?
>
> When comorbid (co-existing) mental disorders were present, the examiner
did
> not always comment on their relationship to PTSD. Ratings often failed to
> address co-existing disorders in any way or to ask the examiner to
determine
> whether they were related to or part of PTSD. Since depression, for
example,
> and substance abuse are both common accompaniments to PTSD and are
sometimes
> due to or part of PTSD, mental disorders diagnosed in addition to PTSD
> cannot be ignored in ratings. If the examiner doesn't make it clear
whether
> they are distinct and unrelated entities, the examination should be
returned
> to clarify that.
>
> A related problem is the need to reconcile varying diagnoses. If the
> examination upon which you are basing a rating makes a different diagnosis
> from a diagnosis or diagnoses in other evidence of record, clarification
is
> in order. This is required by 38 CFR 4.25(b), which states: " the rating
> agency shall determine whether the new diagnosis represents progression of
> the prior diagnosis, correction of an error in the prior diagnosis, or
> development of a new and separate condition. If it is not clear from the
> available records what the change of diagnosis represents, the rating
agency
> shall return the report to the examiner for a determination." This was not
> routinely done.
>
> What are examples of erroneous grants and denials?
>
> 1. Premature grants
>
> PTSD may occur as an acute condition that resolves after a severely
> stressful experience. Therefore, it cannot always be assumed to be a
chronic
> disease.
>
> Example: SC at 50% granted. Had PTSD in svc. Has no current diagnosis.
> Veteran did not appear for exam. Reason for separation was personality
> disorder.
>
> Example: SC at 10% granted. Had PTSD in service related to Lebanon embassy
> bombing. Exam is inadequate-gives history of PTSD-but it is unclear
whether
> he now has PTSD.
>
> 2. SC grants but with failure to reconcile diagnoses. Example: SC at 10%
> granted in Vietnam combat veteran. Treatment records showed PTSD. VAE
showed
> anxiety disorder. Diagnoses should have been reconciled.
>
> Example: SC at 50% granted. WWII Navy veteran. Had multiple diagnoses on
> different exams-PTSD, substance abuse, depression, etc.-not reconciled.
> Stressor not confirmed.
>
> Example: SC at 50% granted for PTSD with major depression. Stressors were
> explosion on ship and abandonment by wife. Rating does not discuss SMRs
(had
> a medical board) or VA examination, does not state why PTSD is SC, and
does
> not indicate the basis of the evaluation.
>
> 4. SC grant based on inadequate exams
>
> Example: 2 cases where SC at 10% was granted where the diagnosis was made
> only by the VHA POW exam coordinator (who is not a mental health
> professional). One did have an examination by a mental health
professional.
> While inadequate, it did not diagnose PTSD.
>
> Example: SC at 10% granted. Record of hospitalization for depression, and
> VAE showed bipolar disorder and PTSD. Criteria for PTSD were not laid out
> and psychological tests did not support a PTSD diagnosis. Report should
have
> been returned for clarification and explanation.
>
> Examples of incorrect or questionable evaluations
>
> Underevaluations
>
> Example: SC 30% in WWII combat veteran. Examiner said PTSD has severe
impact
> on functioning. Evaluation of at least 50% seems warranted.
>
> Example: SC 70%. Vietnam combat veteran. Examiner says there is inability
to
> function in almost all areas. GAF 30, the lowest GAF given in this group
of
> reviewed cases. To consider I.U. Should have been given 100%.
>
> Overevaluation
>
> Example: SC 70% in 86 year old WWII veteran with Purple Heart. GAF 62.
> Barely meets PTSD criteria. Has mild dementia. Grossly overevaluated
because
> there is no indication he is severely disabled, even taking into account
his
> mild dementia
******************Subject: [AFVN] Global Assessment of Functioning Scale (GAF)


> Subject: Forwarded Message from Jack Henshaw
>
>      I have had several requests pertaining to the Global Assessment of
> Functioning Scale (GAF) Scale which is used widely in the VA when
> determining
> a veterans level for PTSD compensation.  So, I decided that I'd just
submit
> it to the entire list as it contains information that affects most of us
> Vietnam veterans with PTSD.  All of your GAF Scores are available to you
and
> are required by your psychiatrist to submit them to the VARO annually.
>
>      I can't stress how important it is for every veteran to take their
> records after each visit to the VA and sign a release of Information for a
> copy of treatment for that day.
>
>      Global Assessment of Functioning Scale (DSM-IV Axis V). This
100-point
> scale measures a patients overall level of psychological, social, and
> occupational functioning on a hypothetical continuum. The GAF Report
> decision
> tree is designed to guide clinicians through a methodical and
comprehensive
> consideration of all aspects of a patients symptoms and functioning to
> determine a patients GAF rating in less than 3 minutes. The GAF Report
> addresses the growing need for accuracy and reliability in determining and
> reporting on GAF ratings by ensuring all aspects of a patients functioning
> are considered. Use the “current” or “past week” rating to indicate
current
> management needs, the “at discharge” rating to document progress and
quality
> of care, and the “highest level in past year” rating as a target for
> termination of treatment. The GAF scale is particularly useful for managed
> care-driven diagnostic evaluations to determine eligibility for treatment
> and
> disability benefits and to delineate the level of care required for
> patients.
>
>      On completion of the GAF Report questions, a 10-point range is
> automatically determined. Then, using the sliding rating scale, you can
> quickly indicate the specific GAF rating within this 10-point range, using
> clinical judgment and hypothetical comparison with other patients in the
> range. Explanation screens provide clarification of specific questions
> throughout the assessment. The report, which summarizes a patients
results,
> can be produced immediately after an assessment.
>
>      It is important for every veteran filing for a claim for
> service-connected benefits to be aware of his or her GAF score.
>
>     Global Assessment of Functioning
>
> Scale Consider psychological, social, and occupational functioning on a
> hypothetical continuum of mental health-illness. Do not include impairment
> in
> functioning due to physical (or environmental) limitations. You do not
need
> to know the numbers but rather what the GAF measures and is used for.
>
> Code (Note. Use intermediate codes when appropriate, e.g., 45, 68, 72.)
>
> 91-100  Superior functioning in a wide range of activities, life's
problems
> never seem to get out of hand, is sought out by others because of his or
her
> many positive qualities. No symptoms
>
> 81-90   Absent or minimal symptoms (e.g., mild anxiety before an exam),
good
> functioning in all areas, interested and involved in a wide range of
> activities, socially effective, generally satisfied with life, no more
than
> everyday problems or concerns (e.g., an occasional argument with family
> members)
>
> 71-80   if symptoms are present, they are transient and expectable
reactions
> to psychosocial. stressors (e.g., difficulty concentrating after family
> argument); no more than slight impairment in social occupational, or
school
> functioning (e.g., temporarily falling behind in schoolwork).
>
> 61-70   Some mild symptoms (e.g., depressed mood and mild insomnia) OR
some
> difficulty in social occupational, or school functioning (e.g., occasional
> truancy or theft within the household), but generally functioning pretty
> well, has some meaningful interpersonal relationships.
>
> 51-60   Moderate symptoms (e.g., flat affect and circumstantial speech,
> occasional panic attacks) OR moderate difficulty in social, occupational,
or
> school functioning (e.g., few friends, conflicts with peers or
co-workers).
>
> 41-50   Severe symptoms (e.g., suicidal ideation, severe obsessional
> rituals,
> frequent shoplifting) OR any serious impairment in social, occupational or
> school functioning (e,g., no friends, unable to keep a job).
>
> 31-40   Some impairment in reality testing or communication (e.g., speech
is
> at times illogical, obscure, or irrelevant) OR major impairment in several
> areas, such as work or school, family relations, judgment, thinking, or
mood
> (e.g., depressed man avoids friends, neglects family, and is unable to
work;
> child frequently beats up younger children, is defiant at home, and is
> failing at school).
>
> 21-30   Behavior is considerably influenced by delusions or hallucinations
> OR
> serious impairment in communication or judgment (e.g., sometimes
incoherent,
> acts grossly inappropriately, suicidal preoccupation) OR inability to
> function in almost all areas (e.g., stays in bed all day, no job, home, or
> friends).
>
> 11-20   Some danger of hurting self or others (e .g., suicidal attempts
> without clear expectation of death; frequently violent; manic excitement)
OR
> occasionally fails to maintain minimal personal hygiene (e.g., smears
feces)
> OR gross impairment in communication (e.g., largely incoherent or mute).
>
> 1-10    Persistent danger of severely hurting self or others (e.g.,
> recurrent
> violence) OR persistent inability to maintain minimal personal hygiene OR
> serious suicidal act with clear expectation of death.
>
> 0   Inadequate information.
>
> The News and mail posted on this list do not reflect
> the opinions of The National Veterans Organization unless
> clearly stated.
>
> Articles reposted are done so under The Fair Use Clause
> for Copyright.
>
>        "... if all my possessions were taken from me with one exception, I
> would choose to keep the power of communication, for by it I would soon
> regain all the rest."
>
>        It is not entirely impossible that, perhaps sometimes in the next
> decade, professors of medicine will have difficulty in explaining why the
> treatment with oxygen was not widely adopted much earlier.
>
*****************************

> GAF SCORES
> GAF refers to GLOBAL ASSESSMENT of FUNCTIONING. GAF Scores only recently
> have become important because only recently has the VA been required by
the
> COURT of VETERANS APPEALS to follow its own regulations. 38 CFR 4.125
> requires adherence to the DSM-IV, and the GAF Score is part of what is
known
> as the multi-axial diagnosis. However, the GAF Score should be
substantiated
> by the mental health diagnostician in the mental status report. The GAF
> Score really serves to summarize for the diagnostician to identify witn
more
> precision what was the intended meaning in the mental status report. The
two
> must be consistent. If the diagnosis of a mental disorder does not conform
> to DSM-IV or is not supported by the findings on the examination report,
the
> rating agency shall return the report to the examiner to substantiate the
> diagnosis. This is the regulation that requires VA psychiatrist to use the
> American Psychiatric Association's DSM-IV and the Multi-Axial Dignostic
> System which includes GAF Scores. Also, if the GAF is not supported by
> findings on the examination report or if the findings on the examination
> report simply are not factual, then that is the basis for an appeal. If a
> veteran with PTSD and a GAF Score of 41-50 were to be rated 50% by the
VARO,
> he should appeal citing, among other regulation, 38 CFR 4.16(b). It is the
> established policy of the Department of Vetran Affairs that all veterans
who
> are unable to secure and follow a substanitially gainful occupation by
> reason of service-connected disabilities shall be rated totally disabled.
> Thereofre, rating boards, or rating specialist, should submit to the
> director, Compensation and Pension Services, for extra-schedular
> consideration, all cases of veterans who are unemployable by reason of
> service-connected disabilities, but who fail to meet the percentage
> standards set forth in paragraph (a) of this section. The rating board, or
> specialist, will include a full statement as to the veteran's
> service-connected disibilities, employment history, educational and
> vocational attainment and all other factors having a bearing on the issue.
> Let's say that a vet is assigned a GAF Score of 35 and that the vet is
> awarded a service-connected rating of 70% retroactive two years, the date
of
> his initial filing. The vet then files for IU benefits with the
application
> which the VA had, for the first itme, forwarded with the 70% award letter.
> The VA awards IU, but with an effective date set on the date that the VA
> received the IU application. The vet is screwed out of two years, or more,
> retroactive benefits -- the difference between 70% and 100%.
> HERE'S WHAT TO DO
> FIRST, in the process of deciding the first part of the claim, was any
> evidence, or arguments at all, submitted which made reference to the vet's
> employability as it was adversely affected by the service-connected mental
> disorder? If the answer to that question is "YES", then, SEE SERVELLO V
> DERWINSKI, 3 Vet. App 196 (9-21-92), finding than (1) After an informal
> claim for an increased evaluation is of record, VA is required by statue
and
> regulation to evaluate the evidence of record dating back one (1) year
> before the claim's filing to determine whether an earlier effective date
for
> an increase in benefits is in order. (2) The one year time limit for
filing
> a formal claim after the receipt of an informal calim, does not start
until
> VA has furnished the claimant with the appropriate application for the
> benefit sought.
> SECOND. SEE COLLARO V WEST, 136 F.3d 1304 (Fed. Cir. 2-19-98). In this
case
> the U.S. Court of Appeals for the Federal circuit discussed VA Circular
> 21-80-7 (9-9-80), directing Regional Offices to review the appropriateness
> of grant of individual Unemployability in order to reestablish control
over
> the "many questionable or erroneous grants of individual Unemployability."
> The circular directed Regional Offices to assign a one hundred percent
> (total) schedular evaluation "if unemployability is directly attributable
to
> a service-connected, neuro-psychiatric condition, as UNEMPLOYABILITY IS A
> CRITERION FOR THE TOTAL EVALUSTION." This circular was not published in
the
> Federal Register, or the code of Federal Regulation, and the public was
> never invited to comment on the agency's new rating procedures, as might
be
> required by the Administrative Procedures Act , 5 U.S.C. SS 701-706, see 5
> U.S.C. SS552 (a)(1) (publication requirements), or similar agency
> regulations adopted pursuant to chapter 72 of Title 38 of the United
States
> Code, see e.g. 38 C.F.R. SS 1.12, 1.551 (1980) implementing provision of 5
> U.S.C. SS 553 and 552 respectively.
> The criteria for a 100% schedular evaluation under any of the categories
of
> mental disorders are and have been total social and industrial
> inadaptability. Thus, if the only compensible service-connected disability
> is a mental disorder, and it can be shown that the RO, in rating that
> disability, did not evaluate the vet's unemployability as it had been
> adversely affected by the service-connected mental disorder, the argument
> must be made that the RO used the wrong standard in evaluating the degree
of
> disability -- CLEAR AND UNMISTAKABLE ERROR.
**********************

##### Claims Processing Task Force Begins Work #####

Retired Vice Admiral Daniel L. Cooper, center, chairman of the 10-member
Claims Processing Task Force, leads the first meeting of the group in VA
Central Office.


May 2001

VA Secretary Anthony Principi has made it clear that one of his top priorities is to make the processing of applications for
veterans' benefits faster, easier and more accurate. He took the first major step toward that commitment on April 16 when he
signed a charter establishing a special Claims Processing Task Force, and welcomed the group at their first working session.
"I believe it may be necessary for VBA to wage its own war on the backlog of claims standing between America's veterans and the
benefits they have earned," said Principi. "This war will not be a shooting one, but it will be an important one."

The 10-member task force,headed by retired Vice Admiral Daniel L. Cooper, will examine a wide range of issues affecting the
speedy processing of claims, from medical examinations and information technology, to efforts to shrink the backlog and increase the accuracy
of decisions. The panel's findings and recommendations are due to the Secretary in about 120 days.

Do you have an idea or suggestion on how VA can
improve claims processing? Share it directly with
Secretary Principi by sending an e-mail message
to Claims@mail.va.gov

#### PTSD and Dental Problems #####

VA Researchers Link PTSD to Tooth Erosion

Brushing after every meal may not be enough to prevent
tooth decay and gum disease for those diagnosed with Post
Traumatic Stress Disorder. A new study conducted by researchers
at the Buffalo, N.Y., VAMC shows the emotional toll
of PTSD can lead to episodes of teeth grinding and jawclenching,
both of which can cause serious tooth damage.

Dr. Sebastian Ciancio, a dentist at the Buffalo VAMC,
presented the findings in March at the annual meeting of the
American Association for Dental Research. By studying patients
previously diagnosed with PTSD and others who were not,
researchers discovered those with PTSD had greater erosion of
the surface of their teeth, more plaque and an increased
likelihood of getting the gum disease gingivitis.

According to Ciancio, people diagnosed with PTSD should avoid acidy foods and be gentle when brushing to ward off erosion on the surface of their teeth.

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