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9. Confirming the diagnosis -
Before a finding that a claimant has a particular psychiatric condition, the claims assessor must ensure that all of the diagnostic criteria in DSM-IV or DSM-5, whichever is used in the relevant SoP, for that condition are addressed.
To assist with this in PTSD cases, a diagnostic check list (Attachment C) must be completed and placed on the claimant's DVA compensation file, usually the medical file.
In establishing a diagnosis, claims assessors should keep in mind that:
- Diagnoses are established on the balance of probabilities; and
- All of the requisite symptoms must be present at a point in time for a diagnosis to be made.
If there is insufficient information in a report to show that the diagnostic criteria for one or more psychiatric conditions have been met, the reporting psychiatrist should be asked to address this in a revised report. It may be that another diagnosis is more appropriate.
A condition must not be refused on the grounds that one of the diagnostic criteria is not met. If there is an incomplete diagnosis or one diagnostic criterion is not met, the claim cannot be determined. The claims assessor must seek further information from the psychiatrist, or a second opinion, to ensure a complete diagnosis.
In preparing a letter seeking further information from the reporting psychiatrist, the claims assessor may wish to seek the assistance of a departmental medical adviser, who may be able to assist and/or clear the letter in certain complex cases.
Care should be taken to ensure that each reporting psychiatrist is provided with any relevant evidence of which the claims assessor is aware. This will include service and other medical documents and reports. Failure to provide a reporting psychiatrist with such evidence increases the risk of an incomplete investigation.
Payment should only be made when a complete report that complies with the Guidelines has been received.
If a further report from the initial reporting psychiatrist is unsatisfactory, a second opinion should be obtained. The procedures for obtaining a second opinion are set out in paragraph 15 of these Guidelines.