Please check criteria used for establishing the current PTSD diagnosis. Do
NOT mark symptoms below that are clearly not attributable to the Criteria A
stressor/PTSD. Instead, overlapping symptoms clearly attributable to other
things should be noted under #7 - Other symptoms. The diagnostic criteria
for PTSD, referred to as Criteria A-H, are from the Diagnostic and
Statistical Manual of Mental Disorders, 5th edition (DSM-5).
Criterion A: Exposure to actual or threatened a) death, b) serious
injury,
c) sexual violation, in one or more of the following ways:
[X] Directly experiencing the traumatic event(s)
[X] Witnessing, in person, the traumatic event(s) as they occurred to
others
Criterion B: Presence of (one or more) of the following intrusion
symptoms
associated with the traumatic event(s), beginning after the
traumatic event(s) occurred:
[X] Recurrent, involuntary, and intrusive distressing memories of the
traumatic event(s).
[X] Recurrent distressing dreams in which the content and/or affect of
the dream are related to the traumatic event(s).
[X] Dissociative reactions (e.g., flashbacks) in which the individual
feels or acts as if the traumatic event(s) were recurring. (Such
reactions may occur on a continuum, with the most extreme
expression being a complete loss of awareness of present
surroundings).
[X] Intense or prolonged psychological distress at exposure to
internal
or external cues that symbolize or resemble an aspect of the
traumatic event(s).
[X] Marked physiological reactions to internal or external cues that
symbolize or resemble an aspect of the traumatic event(s).
Criterion C: Persistent avoidance of stimuli associated with the
traumatic
event(s), beginning after the traumatic events(s) occurred,
as evidenced by one or both of the following:
[X] Avoidance of or efforts to avoid distressing memories, thoughts,
or
feelings about or closely associated with the traumatic event(s).
[X] Avoidance of or efforts to avoid external reminders (people,
places, conversations, activities, objects, situations) that
arouse
distressing memories, thoughts, or feelings about or closely
associated with the traumatic event(s).
Criterion D: Negative alterations in cognitions and mood associated with
the traumatic event(s), beginning or worsening after the
traumatic event(s) occurred, as evidenced by two (or more)
of
the following:
[X] Persistent and exaggerated negative beliefs or expectations about
oneself, others, or the world (e.g., "I am bad,: "No one
can be
trusted,: "The world is completely dangerous,: "My whole
nervous
system is permanently ruined").
[X] Persistent negative emotional state (e.g., fear, horror, anger,
guilt, or shame).
[X] Markedly diminished interest or participation in significant
activities.
[X] Feelings of detachment or estrangement from others.
[X] Persistent inability to experience positive emotions (e.g.,
inability to experience happiness, satisfaction, or loving
feelings.)
Criterion E: Marked alterations in arousal and reactivity associated with
the traumatic event(s), beginning or worsening after the
traumatic event(s) occurred, as evidenced by two (or more)
of
the following:
[X] Irritable behavior and angry outbursts (with little or no
provocation) typically expressed as verbal or physical aggression
toward people or objects.
[X] Hypervigilance.
[X] Exaggerated startle response.
[X] Problems with concentration.
[X] Sleep disturbance (e.g., difficulty falling or staying asleep or
restless sleep).
Criterion F:
[X] Duration of the disturbance (Criteria B, C, D, and E) is more than
1 month.
Criterion G:
[X] The disturbance causes clinically significant distress or
impairment in social, occupational, or other important areas of
functioning.
Criterion H:
[X] The disturbance is not attributable to the physiological effects
of
a substance (e.g., medication, alcohol) or another medical
condition.
Criterion I: Which stressor(s) contributed to the Veteran's PTSD
diagnosis?:
[X] Stressor #1
5. Symptoms
-----------
For VA rating purposes, check all symptoms that actively apply to the
Veteran's diagnoses:
[X] Depressed mood
[X] Anxiety
[X] Suspiciousness
[X] Panic attacks more than once a week
[X] Chronic sleep impairment
[X] Mild memory loss, such as forgetting names, directions or recent
events
[X] Impaired judgment
[X] Disturbances of motivation and mood
[X] Difficulty in adapting to stressful circumstances, including work or
a
worklike setting
6. Behavioral Observations
--------------------------
Veteran was casually dressed with good grooming and hygiene. He was
[
somewhat
agitated but cooperative. No unusual behaviors noted. Speech was somewhat
pressured with rather loud volume, possibly due to veteran's audio
issues.
Mood was anxious with congruent affect. Thought process was goal-directed
and logical. No SI/HI noted. No hallucinations or delusions noted. Veteran
was fully oriented in all spheres. Memory and concentration, fair.
Insight
and judgment, fair.
7. Other symptoms
-----------------
No response provided
8. Competency
-------------
Is the Veteran capable of managing his or her financial affairs?
[X] Yes [ ] No
9. Remarks, (including any testing results) if any
--------------------------------------------------
The veteran confirmed identity by stating full name and social security
number, when asked, prior to beginning the exam. The limits of
confidentiality were also explained to the veteran at this time and the
veteran indicated both understanding and consent prior to beginning the
evaluation. The interview was conducted using CVT technology.
Veteran completed the BAI, the BDI2, and the PCLM. On the BAI, his score
of 34/63 indicates moderate anxiety with the most salient item endorsed
being feeling hot. On the BDI2, his score of 22/63 indicates moderate
depression with the most salient items endorsed being so restless or
agitated that it is sometimes hard to stay still, sleeps a lot less than
usual, appetite is much less than before, and it's hard to keep his
mind
on anything for very long. On the PCLM, his score suggests the diagnosis
of PTSD with the most salient items endorsed being repeated disturbing
memories/ thoughts/ images/ dreams/ of a military trauma, flashbacks of
same, having a physical reaction when reminded, avoiding situations or
activities that remind, feeling distant or cut off from others, trouble
falling or staying asleep, hypervigilance, and easily startled or
jumpiness. These symptoms are consistent with his assertions during the
interview.
Veteran's symptoms cause occupational and social impairment with
reduced
reliability and productivity due to such symptoms as: depressed mood,
anxiety, suspiciousness, panic attacks more than once a week, chronic
sleep impairment, mild memory loss, impaired judgment, disturbances of
motivation and mood, and difficulty in adapting to stressful
circumstances.
[
NOTE: VA may request additional medical information, including additional
examinations if necessary to complete VA's review of the Veteran's