Disability Exams Research

Updated March 8, 2024

This page highlights new disability exams research published in peer-reviewed academic journals, books, and related publications, with an emphasis on disability among United States military veterans.

On this page:

PTSDexams.net is an educational site with no advertising and no affiliate links. Dr. Worthen conducts Independent Psychological Exams (IPE) with veterans, but that information is on his professional practice website.

Trauma Exposure and Transdiagnostic Distress

Journal of Traumatic Stress

Crowe, M. L., Hawn, S. E., Wolf, E. J., Keane, T. M., & Marx, B. P. (2024). Trauma exposure and transdiagnostic distress: Examining shared and posttraumatic stress disorder–specific associations. Journal of Traumatic Stress. Advance online publication. https://doi.org/10.1002/jts.23009

We examined transdiagnostic and posttraumatic stress disorder (PTSD)–specific associations with multiple forms of trauma exposure within a nationwide U.S. sample ( N = 1,649, 50.0% female) of military veterans overselected for PTSD.

A higher‐order Distress factor was estimated using PTSD, major depressive disorder (MDD), and generalized anxiety disorder (GAD) symptoms as indicators.

A structural equation model spanning three assessment points over an average of 3.85 years was constructed to examine the unique roles of higher‐order Distress and PTSD‐specific variance in accounting for the associations between trauma exposure, measured using the Life Events Checklist (LEC) and Deployment Risk and Resiliency Inventory Combat subscale (DRRI‐C), and psychosocial impairment.

The results suggest the association between trauma exposure and PTSD symptoms was primarily mediated by higher‐order distress (70.7% of LEC effect, 63.2% of DRRI‐C effect), but PTSD severity retained a significant association with trauma exposure independent of distress, LEC: β = .10, 95% CI [.06, .13]; DRRI‐C: β = .11, 95% CI [.07, .14].

Both higher‐order distress, β = .31, and PTSD‐specific variance, β = .36, were necessary to account for the association between trauma exposure and future impairment. Findings suggest that trauma exposure may contribute to comorbidity across a range of internalizing symptoms as well as to PTSD‐specific presentations.

Why is this Research Important for C&P Examiners?

The authors of this article stated: "PTSD is a necessary but not sufficient construct in that it captures reactions distinct from higher-order distress but does not represent the full range of trauma-related psychopathology."

Based on this research (Crowe, Hawn, Wolf, Keane, & Marx, 2024), we could (accurately) say that trauma independently causes PTSD, and that trauma directly causes depression. This is direct causation between an event and a mental disorder.

Event ⇢ Mental Disorder

Thus, a C&P psychologist could legitimately opine:

"It is more likely than not that traumatic experiences the veteran endured caused her major depressive disorder."

However, I suggest that you do not write your opinion like that.

When it comes to causality, C&P psychologists should consider the legal landscape. Specifically: "What type of causality is legally important?" 

Direct (independent) causation is obviously important when conducting an initial PTSD exam since the primary objective is to determine if service-related1 trauma directly caused post-traumatic stress disorder. 

But when you conduct an initial PTSD exam with a veteran and discover that he or she has PTSD and another mental disorder, you should think about causation differently.

You should think about the causal relationship between two mental disorders, where one mental disorder causes (or aggravates) a second mental disorder.2

Mental Disorder A Mental Disorder B

If a C&P examiner opines that the veteran's service-related trauma caused major depressive disorder, such an opinion would complicate claim adjudication.

This is true because VBA adjudicates original (initial) claims for other mental disorders under a different standard of proof3 than initial PTSD claims.4

In addition, like all psychological evaluations, psychologists should answer the referral question. For Initial PTSD C&P exams the implied referral question is:

"If the veteran has another mental disorder (in addition to PTSD), is that mental disorder proximately due to or the result of PTSD?"

I say implied because the actual questions asked on the Initial PTSD DBQ are:

3a. Does the Veteran Have More Than One Mental Disorder Diagnosed?
YES  NO (If “yes,” Complete Item 3b)
3b. Is it Possible to Differentiate What Symptom(s) is/are Attributable to Each Diagnosis?
(If "Yes," list which symptoms are attributable to each diagnosis and discuss whether there is any clinical association between these diagnoses)

The question about "clinical association" essentially asks:

"Is the other mental disorder proximately due to or the result of the PTSD?"

See 38 C.F.R. § 3.310 for the phrase "proximately due to or the result of."5

Finally, if you determine, during an Initial PTSD C&P exam, that a veteran has PTSD and another mental disorder, in most cases you should provide an opinion like this:

"It is more likely than not that the veteran's Major Depressive Disorder is proximately due to or the result of her Posttraumatic Stress Disorder."


1. I use the term service-related instead of service-connected because at the C&P exam stage, examiners proffer an expert witness opinion about the relationship between military service and a veteran's mental disorder(s), but the adjudicator—the Veterans Benefits Administration—makes the legal determination of service connection.

2. Two mental disorders can also exhibit bidirectional causality. Bidirectional causality means that two variables or factors influence each other mutually. It is not just that one variable (A) causes a change in another variable (B), but also that variable B, in turn, changes variable A: 

Mental Disorder A 🡘 Mental Disorder B.

3. Posttraumatic stress disorder, 38 C.F.R. § 3.304(f)(3).

4. Principles relating to service connection, 38 C.F.R. § 3.303 (Jan. 11, 2024), and, for combat-related disorders, § 3.304(d).

5. Disabilities that are proximately due to, or aggravated by, service-connected disease or injury, 38 C.F.R. § 3.310 (Jan. 11, 2024).

Webermann, A. R., Gianoli, M. O., Rosen, M. I., Portnoy, G. A., Runels, T., & Black, A. C. (2024). Military sexual trauma-related posttraumatic stress disorder service-connection: Characteristics of claimants and award denial across gender, race, and compared to combat trauma. PLOS ONE, 19(1), e0280708. https://doi.org/10.1371/journal.pone.0280708

The current study characterizes a cohort of veteran claims filed with the Veterans Benefits Administration for posttraumatic stress disorder secondary to experiencing military sexual trauma, compares posttraumatic stress disorder service-connection award denial for military sexual trauma-related claims versus combat-related claims, and examines military sexual trauma-related award denial across gender and race.

We conducted analyses on a retrospective national cohort of veteran claims submitted and rated between October 2017-May 2022, including 102,409 combat-related claims and 31,803 military sexual trauma-related claims.

Descriptive statistics were calculated, logistic regressions assessed denial of service-connection across stressor type and demographics, and odds ratios were calculated as effect sizes.

Military sexual trauma-related claims were submitted primarily by White women Army veterans, and had higher odds of being denied than combat claims (27.6% vs 18.2%).

When controlling for age, race, and gender, men veterans had a 1.78 times higher odds of having military sexual trauma-related claims denied compared to women veterans (36.6% vs. 25.4%), and Black veterans had a 1.39 times higher odds of having military sexual trauma-related claims denied compared to White veterans (32.4% vs. 25.3%).

Three-fourths of military sexual trauma-related claims were awarded in this cohort. However, there were disparities in awarding of claims for men and Black veterans, which suggest the possibility of systemic barriers for veterans from underserved backgrounds and/or veterans who may underreport military sexual trauma.

Functional Disability in U.S. Military Veterans

Meisler, A. W., Gianoli, M. O., Na, P. J., & Pietrzak, R. H. (2023). Functional disability in US military veterans: the importance of integrated whole health initiatives. Primary Care Companion For CNS Disorders25(4), 22m03461. https://doi.org/10.4088/PCC.22m03461

Objective: To examine the prevalence and sociodemographic, medical, and psychiatric correlates of disability in activities of daily living (ADLs) and instrumental ADLs (IADLs) in the US veteran population.

Methods: Data were analyzed from 4,069 US veterans who participated in the 2019–2020 National Health and Resilience in Veterans Study (NHRVS). Multivariable and relative importance analyses (RIAs) were conducted to identify independent and strongest correlates of ADL and IADL disability.

Results: A total of 5.2% (95% CI, 4.4%–6.2%) and 14.2% (95% CI, 12.8%–15.7%) of veterans reported ADL and IADL disability, respectively. Older age, male sex, Black race, lower income, and deployment-related injuries were associated with ADL and IADL disabilities, as were certain medical and cognitive conditions. Results of RIAs revealed that sleep disorders, diabetes, posttraumatic stress disorder (PTSD), older age, and cognitive disorders were most strongly associated with ADL disability, while chronic pain, PTSD, lower income, and sleep and cognitive disorders were most strongly associated with IADL disability.

Conclusions: Results of this study provide an up-to-date estimate of the prevalence and sociodemographic, military, and health correlates of functional disability in US veterans. Improved identification and integrated clinical management of these risk factors may help mitigate disability risk and promote the maintenance of functional capacity in this population.

The image above and its caption are from a preprint of this article:

Petrich, L., Jin, J., Dehghan, M., & Jagersand, M. (2022, May). A quantitative analysis of activities of daily living: Insights into improving functional independence with assistive robotics. In 2022 International Conference on Robotics and Automation (ICRA) (pp. 6999-7006). IEEE.

LicenseCC BY-SA 4.0, which requires, among other conditions, that you give appropriate credit and provide a link to the license.

These concepts (ADLs & IADLs) are increasingly important in disability exams research.

C&P Exams for MST-related PSTD: Examiner Perspectives

Webermann, A. R., Nester, M. S., Gianoli, M. O., Black, A. C., Rosen, M. I., Mattocks, K. M., & Portnoy, G. A. (2023). Compensation and Pension Exams for Military Sexual Trauma-Related Posttraumatic Stress Disorder: Examiner Perspectives, Clinical Impacts on Veterans, and StrategiesWomen's Health Issues33(4), 428–434. https://doi.org/10.1016/j.whi.2023.02.002

It is estimated that in one in three women veterans experience military sexual trauma (MST), which is strongly associated with posttraumatic stress disorder (PTSD). A 2018 report indicated the Veterans Benefits Administration (VBA) processed approximately 12,000 disability claims annually for PTSD related to MST, most of which are filed by women. Part of the VBA adjudication process involves reviewing information from a Compensation and Pension (C&P) exam, a forensic diagnostic evaluation that helps determine the relationship among military service, diagnoses, and current psychosocial functioning. The quality and outcome of these exams may affect veteran well-being and use of Veterans Health Administration (VHA) mental health care, but no work has looked at examiner perspectives of MST C&P exams and their potential clinical impacts on veteran claimants.

Thirteen clinicians (“examiners”) who conduct MST C&P exams through VHA were interviewed. Data were analyzed using rapid qualitative methods.

Examiners described MST exams as more clinically and diagnostically complex than non-MST PTSD exams. Examiners noted that assessing “markers” of MST (indication that MST occurred) could make veterans feel disbelieved; others raised concerns related to malingered PTSD symptoms. Examiners identified unique challenges for veterans who underreport MST (e.g., men and lesbian, gay, bisexual, transgender, and queer [LGBTQ+] veterans), and saw evaluations as a conduit to psychotherapy referrals and utilization of VHA mental health care. Last, examiners used strategies to convey respect and minimize retraumatization, including a standardized process and validating the difficulty of the process.

Examiners’ responses offer insight into a process entered by thousands of veterans annually with PTSD. Strengthening the MST C&P process is a unique opportunity to enhance trust in the VBA claims process and increase likelihood of using VHA mental health care, especially for women veterans.

LicenseCC BY-SA 4.0, which requires, among other conditions, that you give appropriate credit and provide a link to the license.


Previous posts about disability exams research can be found at: Disability Exams Research Archives.

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