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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
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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
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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)
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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
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C&P Examiner Practices
0
10
20
30
40
50
60
70
80
90
100
CAPS SCID FI Scales Any Testing
Yes
No
Jackson et al., 2011
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C&P Examiner Beliefs
0
10
20
30
40
50
60
70
80
90
100
Qual. Maling.Detect.
Qual. Overall Int. Nec. Test. Nec.
Yes
No
Jackson et al. 2011
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Global Assessment of
Functioning (GAF)
• Included in prior versions of DSM
• Clinician Rating from 0-100
• Important limitations
• unreliable, never meant to assess
functioning in PTSD, single item measure,
confounds symptoms and functioning
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IOM Findings
• IOM committee findings on the GAF
• Deficiencies in existing measures of
functional impairment
• No obvious replacement for GAF
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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 Follow-
up valuation – Range
Impaired Functioning Tool
(LIFE-RIFT)
• Disability Profile
• Patient Reported Outcome
Measurement Information
System (PROMIS)
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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
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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…”.
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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
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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
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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
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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
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Completeness of Functional
Assessment
0102030405060708090
100
Completeness of the Functional Assessment
Interview
Standardized non-Standaridized
76%
3%
Speroff et al., 2012
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Rates of Unable to Determine
for Functional Domains
0
20
40
60
80
100
Com
mui
nicat
ion
Mobi
lity
Sel
f Car
e
Get
ting A
long
Act
iviti
es
Wor
k
Soci
al
Standardized non-Standardized
Speroff et al., 2012
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Correlations
GAF WHODAS IPF PTSD
SC%
GAF -.45 -.45 -.57
WHODAS .62 .27
IPF .34
ps < .01
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Comparisons between Service Connected for PTSD
and Non Service Connected on the GAF and WHODAS
0
10
20
30
40
50
60
70
GAF WHODAS IPF
Approved
Denied
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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
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For further information
• VA intranet
• ptsd.va.gov
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Thank You!
(U.S. Air Force photo/Master Sgt. Cecilio Ricardo)