This is in response to the proposed changes to the VA’s Schedule for Rating Disabilities: Mental Disorders.
I agree that changes are needed, however the proposed changes miss the mark. First, the proposals err in relying on the DSM-5, WHODAS 2.0 and CAPS-5 for inspiration related to assessing functional impairment. The DSM-5, WHODAS 2.0 and CAPS-5 are not examples of the state of the art when it comes to describing functional impairment. Their primary focus was not on functional impairment itself, and in particular not assessing functional impairment in a forensic setting (such as in disability claims). The VA’s proposed system is destined to be plagued with excessive subjectivity and inconsistencies between raters. The proposal does not include substantial anchors guiding examiners in their use of the the overly vague, qualitative severity descriptors inherent in the system. While this is fine in a clinical setting (where DSM-5, WHODAS 2.0 and CAPS-5 are intended to be used), it will have extensive negative implications in the context of disability claims. These tools were not developed for use in the setting of disability claims. While rating functional impairment related to mental health disorders is not easy, using a tool like WHODAS 2.0, for example, only launders the poorly-supported subjective opinions of examiners into something that pretends to be relevant and useful. It is not. If the VA truly thought that the WHODAS 2.0 is an important and valuable measure, they’d be using it for all of the physical impairments as well and proposing to use it for sleep apnea and their other proposed changes at this time (yet the VA is not doing that because the WHODAS 2.0 is an overly subjective tool with limited utility in forensic settings). The VA should go back to the drawing board and utilize a more streamlined set of functional domains with greater guidance for examiners anchoring what different levels of impairment in those domains actually looks like. For inspiration the VA could look to what the Social Security Administration uses for their functional domains.
While suggesting the use of a structured clinical interview for PTSD, the CAPS-5, is a noble goal, having accurate diagnoses related to PTSD has not really been the major issue for C&P examinations. This also could lead to having an additional, separate measure of vague qualitative functional descriptions for PTSD with limited utility in actually describing restrictions and limitations/ what someone can and can’t do. Given that contract C&P examiners are not well-paid and that examiners contracting with third party organizations like QTC, VES and LHI are often in a volume business where they try to complete as many disability exams as possible, as quickly as possible, there may be an incentive for them to avoid doing the CAPS-5 by avoiding a PTSD diagnosis. We’ve already seen evidence of times when examiners had an incentive to diagnose an unspecified trauma and stressor related disorder rather than a full PTSD diagnosis. For example, sometimes third party contractors assign a mental disorders DBQ instead of an initial PTSD DBQ; if the examiner needed the PTSD DBQ they’d have to wait on hold for a prolonged period of time with the contract organizations or otherwise wait a considerable period of time in order to get the PTSD DBQ approved and assigned. That examiner would have to deal with not just deciding whether the examinee met the full criteria for PTSD, but also an introduced bias of burning the time involved with the bureaucracy of the third party contractor over the fact that they needed the DBQ assigned to them to be changed. The CAPS-5 takes a considerable amount of time to administer, and while certainly walking examiners extensively through the PTSD symptoms, it adds one more potential incentive for time-sensitive examiners to avoid making a PTSD diagnosis. Therefore, the VA should either require structured clinical interviews for all mental disorders—not just PTSD—or not require a structured interview. The VA should also consider streamlining the DBQ’s so that just one DBQ is used for all mental disorders including PTSD; this could help reduce the impact of these perverse incentives for contract examinations to either diagnose or not diagnose PTSD (either by monetarily rewarding an examiner for a PTSD diagnosis or through punishing one by requiring an excessive administrative burden for the examiner to get the correct DBQ assigned to them).
Most importantly, the VA’s proposal contains non-evidence based and dangerous guidance that is not consistent with how other disability claims are addressed outside the VA. One reason it is dangerous is that it opens the door to an even more subjective and biased approach toward mental disorders. The proposals note “when evaluating intensity under the proposed criteria, examiners and VA adjudicators should be cognizant of the fact that some symptoms may overlap between domains. VA will provide training or additional guidance to help avoid the artificial inflation of the severity of a condition through the double-counting of symptoms.” However, this is a misapplication of the avoidance of pyramiding in relation to the evaluation of the same disability under different diagnoses. However, different functional domains are not the same thing as different diagnoses. This guidance of avoiding “double-counting” as it pertains to functional domains is simply wrong and reflects a bias and misunderstanding of mental disorders. For example, it would be unheard of to suggest that since a severe knee impairment was counted toward an inability to stand and walk, we wouldn’t count functional impacts that impairment had I other areas such as in relation to climbing. However, just as in physical impairments one symptom or set of symptoms from one diagnosis can have a significant impact on multiple, different abilities. For example, severe panic attacks in social settings can impact cognition through hampering concentration and problem solving while also impacting interpersonal interactions as the person is having panic during social situations. They would also have trouble navigating environments since those environments were triggering panic attacks. In addition, adapting to stress is also often addressed in self-care, though this appears to be absent from the VA’s guidance which tends to read more like activities of daily living. With the limited guidance the VA gave this domain will likely be confounded with the Task Completion and Life Activities domain. Symptoms of a mental disorder can and often do have an impact on multiple functional domains. This does not lead to “artificial inflation of the severity of a condition,” it leads to accurately reflecting how a symptom of a condition can impact multiple domains of a persons’ life. The VA’s proposal offers guidance with a misinterpretation of pyramiding and this guidance should be eliminated. If the VA is worried about overlap between domains, then it should go back to the drawing board and propose more evidence-based functional domains in the first place.
Todd Finnerty, Psy.D.