Assessment of Functional Impairment in Compensation and Pension Examinations
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1 Assessment of Functional Impairment in Compensation and Pension Examinations Brian P. Marx, PhD National Center for PTSD VA Boston Healthcare System and Boston University School of Medicine
2 Objectives 1) Understand how PTSD impacts functioning 2) Describe best practices for assessing mental disorder-related functional impairment 3) Discuss limitations of the GAF 4) Compare measures that assess functioning, including the WHODAS 2 5) Describe results from a recent study
3 PTSD and Functional Impairment PTSD related to impairment in multiple domains PTSD avoidance/numbing symptoms of particular relevance Subthreshold PTSD is associated with impaired functioning Schnurr et al. (2008)
4 VA/DoD 2010 Clinical Practice Guideline Recommendations Consistent with NCPTSD guidelines for PTSD C&P exams Use evidence-based tools to assess functional impairment Multi-method approach Self-report, Interview Objective records Observer ratings examinee narrative
5 C&P Examiner Practices CAPS SCID FI Scales Any Testing Jackson et al., 2011 Yes No
6 C&P Examiner Beliefs Qual. Maling. Detect. Qual. Overall Int. Nec. Test. Nec. Yes No Jackson et al. 2011
7 Global Assessment of Functioning (GAF) Included in prior versions of DSM Clinician Rating from Important limitations unreliable, never meant to assess functioning in PTSD, single item measure, confounds symptoms and functioning
8 IOM Findings IOM committee findings on the GAF Deficiencies in existing measures of functional impairment No obvious replacement for GAF
9 Existing Measures of Functional Impairment Short Form Health Survey (36) (SF-36) Social Adjustment Scale Sickness Impact Profile Sheehan Disability Scale Quality of Well-Being Scale Self-Rated Disability Scale Social Functioning Quest. UCLA Social Attainment Scale Inventory of Psychosocial Functioning (IPF) World Health Organization Disability Assessment Scale 2 (WHODAS 2) Social and Occupational Functioning Scale (SOFAS) Longitudinal Interval Followup valuation Range Impaired Functioning Tool (LIFE-RIFT) Disability Profile Patient Reported Outcome Measurement Information System (PROMIS)
10 Caveats for existing scales Resource intensive/require training Difficult scoring Require license for use Too narrow or brief Confound symptoms and functioning Focus on physical impairments Respondents asked to make causal attribution
11 DSM-5 Multiaxial system is now defunct GAF (previously on Axis V) now dropped from DSM-5 DSM-5 now includes the WHODAS 2 for further study The definition of mental disorder still includes the disturbance causes clinically significant distress or impairment.
12 WHODAS 2 Mirrors ICF system DSM-5 recommends Self report and interview versions 12 item or 36 items Self and Proxy versions Computer assisted version available Widely used 5 point scale Assesses numerous domains Cognition Mobility Self care Getting along Life activities Participation in society
13 Inventory of Psychosocial Functioning (IPF) 80-item self-report measure Current (past month) functioning Various scoring possibilities 7-item brief version available For problems related to psychiatric disturbance Domains assessed: intimate partner relationships, parenting, extended family, socializing and friendships, work, education and training, self-care
14 Enhancing Equitable and Effective PTSD Disability Assessment (E3 PTSD) Compare the process and outcomes of initial PTSD C&P exam with CAPS and WHODAS 2 vs. exams without the CAPS and WHODAS 2 Interested in quality, consistency, cost, implementation feasibility Speroff et al., 2012
15 E3 PTSD Design Cluster, randomized controlled trial conducted at 6 VA medical centers Randomization was at the level of the clinician Two examiner groups (CAPS/WHODAS 2 vs. AAU) The reference standard was NC PTSD expert diagnosis
16 Completeness of Functional Assessment Standardized non-standaridized Speroff et al., % 3% Completeness of the Functional Assessment Interview
17 Rates of Unable to Determine for Functional Domains Standardized non-standardized Commuinication Mobility Self Care Getting Along Activities Work Social Speroff et al., 2012
18 Correlations GAF WHODAS IPF PTSD SC% GAF WHODAS IPF.34 ps <.01
19 Comparisons between Service Connected for PTSD and Non Service Connected on the GAF and WHODAS Approved Denied GAF WHODAS IPF
20 Summary PTSD associated with impairment VA/DoD Guidelines suggest comprehensive assessment GAF problematic Numerous available measures, including WHODAS 2, each with their own strengths and limitations Standardized assessment makes a difference
21 For further information VA intranet ptsd.va.gov
22 Thank You! (U.S. Air Force photo/master Sgt. Cecilio Ricardo)
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