PTSD DBQ C&P Result ?? Opinions Please

[gpark009]

LOCAL TITLE: C&P EXAM

Review Post Traumatic Stress Disorder (PTSD) Disability Benefits Questionnaire

Name of patient/Veteran:

SECTION I: ----------

1.Diagnostic Summary

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Does the Veteran now have or has he/she ever been diagnosed with PTSD?

[X] Yes [ ] No ICD Code: F43.10

2. Current Diagnoses

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a. Mental Disorder Diagnosis #1: PTSD ICD Code: F43.10

Comments, if any: Mr. vvvvv service connected PTSD diagnosis is continued. However there is no need for a separate diagnosis to account for his sleep disturbance, as sleep disturbance is a symptom accounted for by PTSD (symptom E.6) and is therefore already accounted for by the diagnosis. Mr. vvvvv also described what appear to be alternating periods of hypomanic episodes and depressive episodes. From a review of his records this appears to be the first documentation of his issue, and it is unclear what it might mean. More evidence is needed prior to finalizing a diagnosis of a bi-polar spectrum disorder. Given his age and lack of prior reports it would be unexpected for him to develop such a condition at this point in life. There are a number of possible explanations for his mood concerns at this time so additional diagnostic data is needed prior to finalizing this possible diagnosis.

b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): see medical examination

3. Differentiation of symptoms

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a.       Does the Veteran have more than one mental disorder diagnosed

[ ] Yes[X] N

c. Does the Veteran have a diagnosed traumatic brain injury (TBI)

[X] Yes [ ] No [ ] Not shown in records reviewe

d. Is it possible to differentiate what symptom(s) is/are attributable to each diagnosis

[ ] Yes[X] No [ ] Not applicable (N/A

If no, provide reason that it is not possible to differentiate what portion of each symptom is attributable to each diagnosis: PTSD and TBI can be difficult to fully delineate due the presence of a number of shared symptoms or indicators. For example, irritability, cognitive deficits, insomnia, depression, fatigue, and anxiety are among the symptoms/complaints of persons with TBI as well as PTSD. However, there are also some symptoms distinct to each diagnosis, including

PTSD - Flashbacks, avoidance, hypervigilance, nightmares, and re-experiencing phenomeno

TBI - Headaches, sensitivity to light and/or noise, nausea/vomiting, visual disturbances, dizziness/vertigo

The TBI examiner noted the presence of light sensitivity, but then denied any residual symptoms of TBI. Therefore it is unclear what might account for the light sensitivity as this it typically a residual attributed to TBI (when present). Mr. vvvvv has a number of symptoms specific to PTSD including avoidance, hypervigilance, and re-experiencing phenomenon (thoughts/dreams). The remaining symptoms are shared and cannot be reliably attributed to one etiology. Therefore, it is not possible to fully delineate symptoms without resorting to speculation

4. Occupational and social impairment

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a. Which of the following best summarizes the Veteran's level of occupational and social impairment with regards to all mental diagnoses? (Check only one)

[X] Occupational and social impairment with reduced reliability and productivity

b. For the indicated level of occupational and social impairment, is it possible to differentiate what portion of the occupational and social impairment indicated above is caused by each mental disorder? [ ] Yes [ ] No[X] No other mental disorder has been diagnosed

c. If a diagnosis of TBI exists, is it possible to differentiate what portion of the occupational and social impairment indicated above is caused by the TBI? [ ] Yes[X] No [ ] No diagnosis of TBI

If no, provide reason that it is not possible to differentiate what portion of the indicated level of occupational and social impairment is attributable to each diagnosis: His symptoms are so intertwined that isolating their respective contribution to his functional challenges would require considerable speculation.

SECTION II: ----------

Clinical Findings:

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1.       Evidence review

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In order to provide an accurate medical opinion, the Veteran's claims folder must be reviewed. a. Medical record review:

 

-------------------------

Was the Veteran's VA e-folder (VBMS or Virtual VA) reviewed? [X] Yes[ ] No

Was the Veteran's VA claims file (hard copy paper C-file) reviewed? [ ] Yes[X] No

If no, check all records reviewed: [X] Other: VBMS/CPRS records were reviewed.

b. Was pertinent information from collateral sources reviewed? [ ] Yes[X] No

2.       Recent History (since prior exam)

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a. Relevant Social/Marital/Family history: In terms of his social relationships he noted he is currently married to his 3rd wife, and has two step-children who are grown, and a biological son from his first wife who has just turned 15 and lives with the veteran. He has been married this time for about 5 years. He noted that their relationship has been problematic over the last year; "It is almost weekly that we argue and talk about divorce. We have had verbal domestic after verbal domestic; the primarily reason I probably haven't gone to jail is because I was a law enforcement officer in the small town where I live and everyone knows us." Socially he has one "military buddy that I served with; him and my wife are why I've started trying to get more treatment. We talk on the phone or on line and that's about it. I don't have any other friends. He does remains in monthly contact with his biological family. "They come up once a month to get my son and then drop him off. That is pretty much when I see them unless there is an emergency." He is not working so he does not have any co-workers.

b. Relevant Occupational and Educational history: He medically retired from the Army in 2008 due to a heart condition. He went to work for his hometown police department "and I was doing pretty good. I got some help here and I thought things were going well. I had some problems in 2010 and was doing some drinking but I just embedded myself in work. My physical health condition got the best of me so I had trouble at work. I resigned my position there. I tried to get a job with vvvvvvvvvvvpolice department, and I had a start date, but they do a lot more extensive background check. They put me on admin leave for a while, and then said 'can't do it, background don't clear'. I did some wildlife control, went through Voc-Rehab and everything, and did pretty well with that until my syncope took over." He has not worked since 2014. He noted that he is scheduled to see Voc-Rehab in vvvvvvv on the of September.

c. Relevant Mental Health history, to include prescribed medications and family mental health: He has worked with behavioral health in the past, but hasn't been in since approximately 2009. He recently met with a psychiatrist. He stated that "It was easy in that job to hide." He became "embedded" in work which he feels helped him manage his symptoms. Now that he is not working he cannot distract himself from his thoughts. He is currently prescribed Sertraline, Prazosin, mirtazapine, and divalproex.

d. Relevant Legal and Behavioral history: Denied any legal problems.

e. Relevant Substance abuse history: Denied drug use; has used alcohol in the past, "but I haven't used any in a good while." He was drinking heavily saying "I had to drink in order to fall asleep." He hasn't used alcohol in 4 months by his report. He noted "I was getting hammered; 1/2 bottle and some beer, and you drink the 1/2 bottle so you numb everything and drink the beer faster. I'm pretty proud that I've been able to wean off of that though."

f. Other, if any: No response provided.

3.       PTSD Diagnostic Criteria

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Please check criteria used for establishing the current PTSD diagnosis. The diagnostic criteria for PTSD, are from the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5). The stressful event can be due to combat, personal trauma, other life threatening situations (non-combat related stressors.) 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 #6 - "Other symptoms".

 

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 effect of the dream are related to the traumatic event(s).

[X] Intense or prolonged psychological distress at exposure 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.

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] The duration of the symptoms described above in Criteria B, C, and D are more than 1 month.

Criterion G:

[X] The PTSD symptoms described above cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Criterion H: No response provided.

4.       Symptoms

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For VA rating purposes, check all symptoms that actively apply to the Veteran's diagnoses:

[X] Depressed mood

[X] Anxiety

[X] Suspiciousness

[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 establishing and maintaining effective work and social relationships

[X] Difficulty in adapting to stressful circumstances, including work or a work like setting

[X] Impaired impulse control, such as unprovoked irritability with periods of violence

5.       Behavioral Observations:

--------------------------- see remarks section

6.       Other symptoms

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Does the Veteran have any other symptoms attributable to PTSD (and other mental disorders) that are not listed above? [ ] Yes[X] No

7. Competency ------------- Is the Veteran capable of managing his or her financial affairs?

[X] Yes [ ] No

8. Remarks, (including any testing results) if any:

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Mr. cccc brought a 'journal' and some notes that helped him track his functioning/moods.

PRESENT MENTAL HEALTH CONCERNS

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FREQUENCY, SEVERITY, AND DURATION OF NON-PTSD PSYCHIATRIC/MEDICAL SYMPTOMS:

Moods: Mr. vvvv noted that "the last week of July was awesome; I had all the energy in the world. I bought a used XXXXXXX and started working and tinkering on it. My wife asked me if I was on meth because I had so much energy, but I wasn't. She reamed me for buying the XXXXXXX because I shouldn't have spent that money. That lasted about a week." He noted "it is probably about every 3-4 weeks I'll have episodes like this. I won't need medication, and won't need meds for headaches or anything. I didn't have any syncope. I'm up . . . just up. That is why she asked if I was on meth. I wasn't even eating. I was drinking coffee, and just constantly going. It was crazy." He indicated that he has only started experiencing these episodes "probably a month before I was released from the vvvvvv police department, so that would have been in NOV 2013." He cannot identify any triggering event for these episodes. "When I'm going . . . it was like I was a crack head. I worked dope for years (in the police force) and I know what those people look like. I just kept going and going and going." These episodes end suddenly. "I'm out for three days after that. When I crash from something like that there is no alarm clock, there is no waking me up. I might wake up and use the restroom, get something to drink, and then I'm out in the chair. Then I just feel like total crap after that." Usually I have a pulsating headache that feels like it is about to pop. He describes being very depressed for a while after that until the depression "gradually wears off". The severe depressed phase of this can last "3-4 days", and then he moderates into a less depressed state. If he experiences syncope in the middle of his depressed phase it is even worse. He described episodes of major depression alternating with hypo-manic episodes for the past 3 years (approximately). He described his lack of emotional reaction to his grandmother passing away, "which freaked out my wife and my dad.

Anxiety: "I stay away from crowds." He stated "I told a guy off in the parking lot before I came in here today. I'm waiting for a car to pull out and a guy pulls up behind me and starts yelling. I exited my car and told him I was waiting for a car to pull out the parking sport." He described being very easily irritated and described situations where he was very easily bothered/irritated. He described being quite willing to verbally confront people when he is irritated.

He cannot attend his son's football games due to the noise/chaos/crowds; "just a lot of people; I've had a panic attack at his first game this year, so I can't go now." He also noted that he does not go to the grocery store, and when he does he just sits in the truck while his wife goes in. He also stated "If you ever see me in Wal-Mart before about 9pm you know it has been a really good day." In public he noted "I'm looking for concealed; ankle knives, chest knives, lighters, ankle holsters. I worked narcotics for years so I'm looking for everything. . . . Tattoos, knives . . . you name it and I'm looking. It annoys the shit out of my wife. She does it a little bit, but I know where the exit is and how I'm going to get to it." He describes evaluating potential threats and how he will respond. "I suppose that being a cop after all this probably didn't help anything." He remains very easily startled by noises. "4th of July I locked myself in my room. It took the police to get me out of my room. I was freaked out; I could see myself in the back of my mind saying 'what the heck are you doing Gary?', but I heard popping and I had a sudden panic that I was being shot at and returning fire. I had two pistols with me. I was in there for almost 14 hours that weekend. A friend of mine on who was law enforcement got me out. Nothing was reported because it was a friend of mine. I can't remember everything, but I can just remember the fear. It freaked me out, that is the worst one I've ever had. I've had others, but not like that." Does go out to eat, but must go at low traffic times. He described an incident today prior to coming to this appointment where he verbally confronted someone in the restaurant who was being too loud for his liking.

PSYCH EXAM

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GENERAL APPEARANCE: Appropriately dressed/groomed

PSYCHOMOTOR ACTIVITY: Unremarkable

SPEECH: Unremarkable

ATTITUDE TOWARD EXAMINER: Polite, Attentive, and Cooperative

 

AFFECT: Congruent

MOOD: "In the middle; I've been stressed about this thing of course."

ATTENTION: Attention Intact

ABLE TO DO SERIAL 7'S? Yes

ABLE TO SPELL A WORD FORWARD AND BACKWARD? Yes

ORIENTATION:

INTACT TO PERSON: Yes

INTACT TO TIME: Yes

INTACT TO PLACE: Yes

THOUGHT PROCESS: Unremarkable

 

THOUGHT CONTENT: Unremarkable

DELUSIONS: None

JUDGMENT: Understands outcome of behavior

INTELLIGENCE: Average

INSIGHT: Fair

DOES THE PATIENT HAVE SLEEP IMPAIRMENT? Yes; With his medication he is sleeping approximately 7 hours a night, which is an increased of an hour or two compared to before he started taking medication. He noted "The alarm clock will not wake me up, but go about two blocks away and slam the lid on a trash can and I'll be awake." He continues to experience regular nightmares; nearly every night. He noted "I don't always remember them. Before the meds I vividly remembered them, but now I won't. I know I had one and it scared me and woke me up, but I won't remember now that I've started the meds." He also has episodes every 3-4 weeks where he cannot sleep at all due to an apparent hypo-manic episode.

TYPE OF HALLUCINATIONS: None

DOES THE PATIENT HAVE INAPPROPRIATE BEHAVIOR? No

INTERPRETS PROVERBS APPROPRIATELY? Yes

DOES THE PATIENT HAVE OBSESSIVE/RITUALISTIC BEHAVIOR?

Yes; Checks locks repeatedly; very concerned about home security. He noted "I'll get home and lock the door. 10 minutes later I'll check it again. Then I can be sitting on the couch and I'll get up and check it again. My bold lock. . I'll test it and make sure it is locked. Gun locks are checked several times a day. Ordinance is inventoried at least once a week. I beep my car lock several times during the day. I have a bad obsession with mail. I'll go check it, and then go check it again. One time I checked it 5 times one day; my wife apparently counted it. It was like I forgot I guess." DOES THE PATIENT HAVE PANIC ATTACKS? Yes; Noted that he has the more serious panic attacks "when I get put in a serious situation. Probably 1-3x a month." The more severe types of them last 1-2 hours. He describes classic panic symptoms during those episodes. He has a number of smaller ones "throughout the month." The number of attacks "just depends on where I'm at. If I'm around people and noise I'll start freaking out and having more." He painfully avoids certain situations in order to avoid experiencing panic attacks.

IS THERE PRESENCE OF HOMICIDAL THOUGHTS? Denied

IS THERE PRESENCE OF SUICIDAL THOUGHTS? Acknowledged some transient ideation, but denied any plan, or intent. He noted that over the 4th of July he "put the gun to my head" but didn't pull the trigger." That was his only attempt.

EXTENT OF IMPULSE CONTROL: Poor

EPISODES OF VIOLENCE: yes

EXAMPLES OF EFFECTS ON MOTIVATION/MOOD OR OTHER COMMENTS:

Can become verbally aggressive quickly and easily; very outspoken. Stated "I grabbed my wife once when she woke me up, but I've never physically hit her or anything." He does have a history of physical aggression. He described a tendency to become verbally aggressive quickly, and stated "Then I try to get away. If you let me go then it will be OK. If you follow me then it may not be. It doesn't take long, and within 30 minutes I'll feel terrible whether the argument was my fault of not."

ABILITY TO MAINTAIN MINIMUM PERSONAL HYGIENE? Yes

IS THERE PROBLEM WITH ACTIVITIES OF DAILY LIVING?

HOUSEHOLD CHORES: TOILETING: GROOMING: SHOPPING: Strongly prefers to avoid crowds. SELF-FEEDING: BATHING: DRESSING/UNDRESSING:

ENGAGING IN SPORTS/EXERCISE: "I used to work out until my syncope popped up."

TRAVELING: DRIVING: "Most of the time my wife drives. I will drive it is a short distance or an emergency because of my syncope.

OTHER RECREATIONAL ACTIVITIES: "I used to hunt and fish but I don't anymore. I was a big time football guy but I don't even watch it on TV anymore."

DESCRIPTION OF OTHER PROBLEM WITH ACTIVITIES OF DAILY LIVING:

MEMORY

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REMOTE MEMORY: Normal

RECENT MEMORY: Normal

IMEDIATE MEMORY: Normal

EXAMPLE(S) OF MEMORY DISORDER: Described forgetting his grandmother's name while giving her eulogy, which was very embarrassing.

SOCIAL WORK SURVEY

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WERE SOCIAL WORK SURVEY RESULTS TAKEN INTO CONSIDERATION IN THE DIAGNOSIS/ASSESSMENT? No survey done

WERE ALL TESTS RESULTS INCLUDED ON THE EXAM REPORT? Yes

MENTAL DISORDER: MENTAL COMPETENCY

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DOES THE VETERAN KNOW THE AMOUNT OF THEIR BENEFIT PAYMENT? Yes

DOES THE VETERAN KNOW THE AMOUNTS OF MONTHLY BILLS? Yes

DOES THE VETERAN PRUDENTLY HANDLE PAYMENTS? Yes

DOES THE VETERAN PERSONALLY HANDLE MONEY AND PAYS BILLS? Yes

IS THE VETERAN CAPABLE OF MANAGING FINANCIAL AFFAIRS? Yes

EXAMPLE(S) TO SUPPORT THIS CONCLUSION: The Veteran and his wife manages their own finances currently. He noted "I binge sometimes, like on the vvvvv. We are making ends meet, but it is getting tight." Most of his financial 'binges' are in the $100-$150 range.

IS A SOCIAL WORK ASSESSMENT NECESSARY TO RENDER AN OPINION? No

** All diagnoses obtained were based on the criterion contained in DSM-V; The GAF scale is not part of the DSM V and has been discontinued. **

 

Edited September 26, 2015 by gpark009
Cleaned it up

[gpark009]

Like i said earlier this Psychiatrist was very thorough. I can look at this wag and see in my opinion its 50%-70% range, just curious about everyone else opinion.

This exam was part of multiple exams for my disabilities. I am already service connected 50% PTSD.

I also claim my TBI which I still haven't gotten service connected yet, hopefully even if they put my TBI and PTSD together at least it'll finally be rated. I also claimed chronic fatigue, headaches, anxiety, and depression as secondaries.

Even though this is the PTSD forum, i think knowing my history is important for people to give an opinion. I also put in a claim for and increase for my Coronary Heart Disease with Syncope which I'm rated 60% for.  Secondaries to the syncope were also the fatigue and, headaches.

So I have no idea how the VA is going to bundle all this up together, I'M sure there is a way.

[gpark009]

No update as yet, I did look at ebennies and looks like October 8 is the date the rather will have all info uploaded by.

[stillhere]

gpark,

I would agree with you at 50% to 70%!

 

Good Luck!

Stillhere

 

 

[Buck52]

I think maybe a lower rating like 30% if the raters reads this entire report, because in the first paragraph  he states about the veterans age, in determining DSM 5 PTSD age is not suppose to be a deciding factor , if an examiner says things that are controversial to the veteran  the raters take note of it and lowball the veteran.

 

jmo

.....................Buck

[Navy04]

Glad you made it thru the Review bud, but I have to agree with Buck on this one. Either you will be continued at 50%, or even reduced. Good luck and keep us posted. God Bless

[gpark009]

So be it if it's a reduction, if its fair I'm good with.

I do have a particular question, I have a claim for TBI also, and in my records it shows it and in VA records it also shows.

Given this report, what the examiner said will they take that in account for my TBI Claim?

c. Does the Veteran have a diagnosed traumatic brain injury (TBI)

[X] Yes [ ] No [ ] Not shown in records reviewed