PTSD C&P Exam Prep

Clinical Diagnostic Interview (DSM-5 Criteria A-H)

What it measures: Whether the veteran meets full DSM-5 diagnostic criteria for PTSD based on stressor exposure and symptom clusters B through H

What to expect: The examiner will ask detailed questions about your traumatic event(s), your symptoms across each DSM-5 cluster, and how long symptoms have been present. Be prepared to discuss your worst symptoms, not just your average day. The examiner will check each DSM-5 criterion systematically.

Pain considerations: N/A - psychiatric exam

Occupational and Social Impairment Assessment (General Rating Formula)

What it measures: The degree to which PTSD symptoms reduce the veteran's ability to function at work and in social relationships, mapped to the 0/10/30/50/70/100 percent rating scale under 38 CFR - 4.130

What to expect: The examiner will ask about your employment history, current job status, reasons for job loss or inability to work, interpersonal relationships, ability to perform activities of daily living, and social isolation. They will select the impairment level that best fits your overall functioning.

Pain considerations: N/A - psychiatric exam

Psychological Testing (if administered)

What it measures: Standardized psychometric instruments to support or quantify diagnosis; commonly includes PCL-5 (PTSD Checklist for DSM-5), PHQ-9 (depression), GAD-7 (anxiety), or neuropsychological testing if cognitive symptoms are present

What to expect: You may be given paper questionnaires or asked questions from standardized instruments before or during the exam. Answer based on how you have been feeling over the time period specified (usually the past month), reflecting your typical worst functioning rather than a particularly good day.

Pain considerations: N/A - psychiatric exam

0%

A mental condition has been formally diagnosed but symptoms are not severe enough to interfere with occupational and social functioning or to require continuous medication. Alternatively, no mental disorder diagnosis.

From 38 CFR: Veteran has a PTSD diagnosis but reports no meaningful interference with work or social life and does not require ongoing medication.

10%

Occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication.

From 38 CFR: Veteran manages well most of the time but experiences increased PTSD symptoms during high-stress periods such as work deadlines or family conflict; medication controls most symptoms.

30%

Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily with normal routine behavior, self-care, and conversation.

From 38 CFR: Veteran misses work occasionally due to PTSD symptoms, has some social withdrawal, and experiences weekly nightmares but generally maintains self-care and holds conversations normally.

50%

Occupational and social impairment with reduced reliability and productivity.

From 38 CFR: Veteran is frequently late or absent from work, has been reprimanded for outbursts, has difficulty following multi-step instructions, and struggles to maintain friendships or romantic relationships.

70%

Occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking, and/or mood.

From 38 CFR: Veteran has been unemployed for extended periods due to inability to control anger, has alienated family members, neglects hygiene during bad periods, has had passive suicidal ideation, and cannot tolerate busy public environments.

100%

Total occupational and social impairment due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living; disorientation to time or place; memory loss for names of close relatives, own occupation, or own name; near-continuous panic or depression affecting ability to function independently.

From 38 CFR: Veteran cannot maintain any employment, requires assistance with daily living activities, experiences persistent suicidal or homicidal ideation, is disoriented during flashback episodes, and cannot function independently without caregiver support.

Intrusive Symptoms (DSM-5 Criterion B)

How to describe it: Describe the specific content of your intrusive memories or nightmares, how frequently they occur, how long they last, and how distressing they are on a 0-10 scale. Distinguish between unwanted intrusive memories (you know you are in the present) and flashbacks (you feel as if the event is happening now). Describe physiological reactions: racing heart, sweating, shaking, nausea when exposed to reminders.

Example: On my worst days I wake up from nightmares 3-4 times a night reliving [event]. During the day I have intrusive images that interrupt whatever I'm doing - sometimes 10 or more times. If I hear a car backfire or a door slam I immediately drop to the floor or leave the area. My heart races, I sweat, and it takes 30-45 minutes to calm down. On those days I cannot concentrate on anything for hours.

Examiner listens for: Specific DSM-5 B-criterion symptoms: intrusive memories, nightmares, flashbacks, psychological distress at cues, physiological reactivity at cues. Examiner will check fields for recurrent distressing memories, nightmares, dissociative reactions, psychological distress at cues, and physiological reactions.

Avoid: Do not say 'I have bad dreams sometimes' - describe frequency, content, and resulting impairment. Do not say 'I get jumpy' without explaining the severity of your startle response and its functional impact.

Avoidance (DSM-5 Criterion C)

How to describe it: Describe both internal avoidance (avoiding thoughts, memories, or feelings about the trauma) and external avoidance (avoiding people, places, situations, conversations, or objects that remind you of the trauma). Be specific about what you avoid and how this limits your daily life, employment, and relationships.

Example: I cannot watch the news or any military-themed movies. I avoid driving on certain roads or going to crowded places like malls or grocery stores. I refuse to talk about my service with my family. I have declined two promotions because they required travel to locations that reminded me of [event]. I have not attended a Fourth of July event in years because of fireworks.

Examiner listens for: Whether the veteran avoids internal reminders (thoughts/feelings) AND/OR external reminders (people/places/situations). Both are separate DSM-5 criteria. Examiner will check fields for avoidance of distressing memories/thoughts and avoidance of external reminders.

Avoid: Do not say 'I just don't like to talk about it' - describe the deliberate, effortful nature of your avoidance and its cost to your life. Failing to mention external avoidance may result in missing a criterion check.

Negative Cognitions and Mood (DSM-5 Criterion D)

How to describe it: Describe persistent negative beliefs about yourself ('I am permanently damaged'), others ('No one can be trusted'), or the world ('Danger is everywhere'). Describe persistent feelings of shame, guilt, fear, or horror. Describe your inability to feel happiness, love, or satisfaction. Describe feeling cut off or detached from people you were once close to.

Example: I genuinely believe I am broken and will never be normal again. I blame myself for what happened to my unit. I feel nothing at my children's milestones - no joy, no pride, just numbness. I sit in the same room as my spouse but feel completely alone. I can't remember the last time I felt happy or laughed sincerely.

Examiner listens for: Inability to remember trauma aspects (dissociative amnesia), persistent negative beliefs, distorted self-blame, persistent negative emotional states, markedly diminished interest in activities, feelings of detachment, and persistent inability to experience positive emotions. Examiner will check fields for all seven DSM-5 D-criterion items.

Avoid: Do not skip over emotional numbing or anhedonia - many veterans focus only on anger and startle and do not mention the inability to feel positive emotions, which is a separately rated criterion. Do not say 'I'm fine with my family' if you actually feel distant from them.

Arousal and Reactivity (DSM-5 Criterion E)

How to describe it: Describe angry outbursts: what triggers them, how intense they are, whether they have become physical, and their frequency. Describe hypervigilance: constantly scanning for threats, sitting with your back to the wall, being unable to relax in public. Describe your exaggerated startle response with specific triggers. Describe concentration problems and their impact on work. Describe your sleep problems in detail: how long it takes to fall asleep, how often you wake, nightmares, total hours of sleep.

Example: On bad nights I sleep 2-3 hours total, waking in a panic multiple times. During the day I cannot concentrate long enough to read a full page. I snapped at a coworker last month and had to be sent home. I sit facing the door in every room and constantly check windows when I'm at home. A neighbor's smoke alarm sent me diving behind my couch last week.

Examiner listens for: Irritable behavior/angry outbursts, reckless or self-destructive behavior, hypervigilance, exaggerated startle response, concentration problems, and sleep disturbance. Examiner will check all six DSM-5 E-criterion fields.

Avoid: Do not minimize angry outbursts - if they have escalated to near-physical or physical altercations, say so. Do not say 'I don't sleep great' - quantify hours, awakenings, and the functional consequences of sleep deprivation the next day.

Functional Impairment - Work and Employment

How to describe it: Describe your complete employment history since the traumatic event(s). Include jobs lost, disciplinary actions, demotions, inability to maintain employment, reasons you left or were terminated, and any periods of unemployment. If currently employed, describe how PTSD affects your reliability, productivity, ability to take direction, and relationships with supervisors and coworkers.

Example: I was fired from my last two jobs. At the first, I missed work 2-3 days a month and had a verbal altercation with a supervisor. At the second, I could not concentrate on safety procedures and was terminated for repeated errors. I've been unemployed for 18 months. I applied for four jobs but could not get through the interviews without hyperventilating.

Examiner listens for: Pattern of occupational dysfunction across multiple jobs, inability to maintain employment, specific PTSD-driven job failures, and how the veteran functions in a work-like setting under stress. Examiner will document occupational and social impairment level and check field for difficulty adapting to stressful circumstances including work.

Avoid: Do not say 'I'm having a hard time finding work' without connecting it directly to PTSD symptoms. Do not focus only on current employment - prior job losses related to PTSD are critical evidence.

Functional Impairment - Social and Family Relationships

How to describe it: Describe the quality and status of your relationships with your spouse/partner, children, family, and friends. Describe relationships that have ended, become strained, or been abandoned due to PTSD. Describe social isolation, inability to trust others, and how you interact in social settings. If applicable, describe the impact of your PTSD on your marriage or parenting.

Example: My spouse and I separated last year - they said they couldn't live with my anger and emotional absence. I have not seen my siblings in over a year because family gatherings feel overwhelming. I have one friend I text occasionally but have not seen in months. I do not attend my children's school events because crowded spaces trigger me.

Examiner listens for: Inability to establish and maintain effective relationships, social isolation, estrangement from family, and total or near-total loss of social support network. This directly informs the occupational and social impairment level documented in the DBQ.

Avoid: Do not say 'I have some family stress' - describe specific incidents, relationship losses, and the role PTSD played in each. Do not omit the impact on your children or your ability to parent effectively.

Activities of Daily Living and Self-Care

How to describe it: Describe any periods where you could not maintain basic hygiene, prepare meals, clean your home, pay bills, or perform other daily tasks. Be specific about frequency and duration. Describe any periods where you did not leave your home for days or weeks. Mention caregiver assistance if applicable.

Example: During my worst periods, I go 3-4 days without showering. My apartment was in such poor condition that my neighbor called my family to check on me. I sometimes forget to eat for a full day. There have been weeks where I didn't leave my apartment except to get the mail.

Examiner listens for: Neglect of personal appearance and hygiene, intermittent inability to perform activities of daily living, disorientation, and need for caregiver support. These are high-weighted symptoms at the 70% and 100% rating levels.

Avoid: Do not say 'I take care of myself fine' if you have periodic breakdowns in self-care. Intermittent inability to function - even if not constant - can support a 70% rating.

Suicidal Ideation and Self-Harm

How to describe it: If you have experienced suicidal ideation - passive (wishing you were dead, not caring if you died) or active (thinking about methods or plans) - report this accurately and completely. Describe frequency, any history of attempts or self-harm, whether you have a plan, and any hospitalization history. This is critical clinical information AND a significant rating factor.

Example: I have passive thoughts of not wanting to be alive several times a month. I have never made a plan or attempt. I was hospitalized voluntarily in [year] for a crisis. I have told my VA therapist about these thoughts.

Examiner listens for: Suicidal ideation is a specifically checked field on the DBQ and is a symptom associated with the 70% impairment level. Persistent danger of hurting self or others is a 100% indicator. Accurate reporting is essential - this affects both your rating and your safety.

Avoid: Do not minimize suicidal ideation out of fear of hospitalization - you can describe passive ideation without having a plan. Failure to report suicidal ideation may result in an underrated condition and missed treatment opportunities.