ptsd PTSD & MAJOR DEPRESSION RATING???

[JULONG50209]

Hello everyone, I have been following these forums from quit some time now and wanted to know what everyone thinks my rating will be. I am currently unemployed and have been since i got out of service in 2012. I do not leave my house at all unless for my VA appointments. Here is my C & P exam.

LOCAL TITLE: C&P MENTAL DISORDERS - AMIE/CAPRI STANDARD TITLE: C & P EXAMINATION NOTE DATE OF NOTE: SEP 22, 2015@08:00 ENTRY DATE: SEP 22, 2015@12:12:13 AUTHOR: CODER,CHAD EXP COSIGNER: URGENCY: STATUS: COMPLETED Initial Post Traumatic Stress Disorder (PTSD) Disability Benefits Questionnaire * Internal VA or DoD Use Only * Name of patient/Veteran: LONG, JUSTIN THOMAS SECTION I: ---------- 1. Diagnostic Summary --------------------- Does the Veteran have a diagnosis of PTSD that conforms to DSM-5 criteria based on today's evaluation? [X] Yes [ ] No ICD code: 309.81 (F43.10) 2. Current Diagnoses -------------------- a. Mental Disorder Diagnosis #1: Post Traumatic Stres Disorder ICD code: 309.81 (F43.10) LONG, JUSTIN THOMAS CONFIDENTIAL Page 6 of 64 Mental Disorder Diagnosis #2: Major Depressive Disorder ICD code: 296.32 (F33.1) Mental Disorder Diagnosis #3: Alcohol Use Disorder b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): see medical 3. Differentiation of symptoms ------------------------------ a. Does the Veteran have more than one mental disorder diagnosed? [X] Yes [ ] No b. 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 and discuss whether there is any clinical association between these diagnoses: The diagnoses of PTSD and Major Depressive Disorder are mutually aggravating and symptoms and degree of impairment in functioning cannot be delineated without resorting to mere speculation. Veteran's substance use is considered an attempt to self-medicate symptoms of PTSD and Major Depressive Disorder, and is secondary to these disorders. c. Does the Veteran have a diagnosed traumatic brain injury (TBI)? [ ] Yes [X] No [ ] Not shown in records reviewed 4. Occupational and social impairment ------------------------------------- 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 [X] No [ ] No other mental disorder has been diagnosed 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: The diagnoses of PTSD and Major Depressive Disorder are mutually aggravating and symptoms and degree of impairment in functioning LONG, JUSTIN THOMAS CONFIDENTIAL Page 7 of 64 cannot be delineated without resorting to mere speculation. Veteran's substance use is considered an attempt to self-medicate symptoms of PTSD and Major Depressive Disorder, and is secondary to these disorders. 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 [ ] No [X] No diagnosis of TBI SECTION II: ----------- Clinical Findings: ------------------ 1. Evidence review ------------------ 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 yes, list any records that were reviewed but were not included in the Veteran's VA claims file: If no, check all records reviewed: [X] Military service treatment records [X] Military service personnel records [ ] Military enlistment examination [ ] Military separation examination [ ] Military post-deployment questionnaire [X] Department of Defense Form 214 Separation Documents [X] Veterans Health Administration medical records (VA treatment records) [ ] Civilian medical records [ ] Interviews with collateral witnesses (family and others who have known the Veteran before and after military service) [ ] No records were reviewed [ ] Other: LONG, JUSTIN THOMAS CONFIDENTIAL Page 8 of 64 b. Was pertinent information from collateral sources reviewed? [ ] Yes [X] No 2. History ---------- a. Relevant Social/Marital/Family history (pre-military, military, and post-military): Veteran reported that he was raised by mother. He said he received "whippings" as a child, but denied abuse during childhood. He reported good adjustment during childhood, denied history of developmental problems. Veteran has been married of for 4 years, they a 2-year-old son, and 9-month-old daughter. This is his first marriage. Veteran reported a history of verbal abuse in his marriage. He has threatened his wife in the past, but denied any recent threats. He said that currently he doesn't argue anymore, "I absorb everything she says, take it all in and go to a dark place." Veteran reported feeling irritable, negative. He has little interest in any activities he once enjoyed. He is withdrawn at home, keeps to himself, limited interaction with his children. He denied social/relationships outside of his marriage. He denied any hobbies at this time. b. Relevant Occupational and Educational history (pre-military, military, and post-military): Veteran reported good social adjustment and academic performance during in school. He was physically active, popular, and he played football throughout school. Some problems socially during high school, veteran said his family moved districts during high school. Veteran graduated in 2007. Per DD214, veteran served in the Army 1/29/2008 - 6/9/2012. He received an Honorable Discharge. Veteran deployed to Iraq 1/25/2009 5/9/2009. He said he deployed to Afghanistan in 2010. He reported he was Ranger, but later kicked out of Ranger Battalion for behavior problems, including an arrest for kicking in girlfriend's door in 2010, and disciplinary Article 15 for threatening wife, her friend and friend's children 2011. He was court ordered to anger management class. After the Army, veteran reported inability to ma intain employment. He indicated problems interacting with others, anxiety, anger problems, interfere with prior employment. He reported attending school in-person, but was missing classes and not turning in assignments. He is taking classes on-line currently, and reported maintaining 3.3 GPA. He denied any employment at this time. c. Relevant Mental Health history, to include prescribed medications and LONG, JUSTIN THOMAS CONFIDENTIAL Page 9 of 64 family mental health (pre-military, military, and post-military): Veteran denied pre-military history of mental health problems. He indicated his mother has depression. He denied receiving any MH treatment in the Army. Veteran reported first receiving MH tx through FVAMC. CPRS indicated individual and psychiatric treatment beginning in 2014. No treatment since July 2015, but active medications include psych. meds: Risperidone, Sertraline, Amitriptyline, and Divalproex. d. Relevant Legal and Behavioral history (pre-military, military, and post-military): Veteran denied pre-military legal/behavior problems. Veteran began having conduct problems while in the Army. He denied any since then. e. Relevant Substance abuse history (pre-military, military, and post-military): Veteran reported DUI in 2011. He currently drinks twice during the week, and throughout the weekends. He averages about 12-pack each time. f. Other, if any: N/A 3. Stressors ------------ Describe one or more specific stressor event(s) the Veteran considers traumatic (may be pre-military, military, or post-military): a. Stressor #1: Iraq, Tikrit; while on mission, taking live fire and shooting rounds at others. He entered the building, saw dead bodies, dead animals, and blood. Does this stressor meet Criterion A (i.e., is it adequate to support the diagnosis of PTSD)? [X] Yes [ ] No Is the stressor related to the Veteran's fear of hostile military or terrorist activity? [X] Yes [ ] No Is the stressor related to personal assault, e.g. military sexual trauma? [ ] Yes [X] No b. Stressor #2: Afghanistan, Kandahar; veteran witnessed multiple killings and death during this deployment. He reported on a mission, getting lost, firing at a guy running out of the back of the house, and his body chopped into pieces, veteran putting remains in body bag. Veteran was fired at and exchanged fire with enemy, recalls almost being shot, bullet inches from his head. Veteran later learned that innocent LONG, JUSTIN THOMAS CONFIDENTIAL Page 10 of 64 people were killed during the mission. Does this stressor meet Criterion A (i.e., is it adequate to support the diagnosis of PTSD)? [X] Yes [ ] No Is the stressor related to the Veteran's fear of hostile military or terrorist activity? [X] Yes [ ] No Is the stressor related to personal assault, e.g. military sexual trauma? [ ] Yes [X] No 4. PTSD Diagnostic Criteria --------------------------- 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] 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 LONG, JUSTIN THOMAS CONFIDENTIAL Page 11 of 64 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 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, distorted cognitions about the cause or consequences of the traumatic event(s) that lead to the individual to blame himself/herself or others. [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: LONG, JUSTIN THOMAS CONFIDENTIAL Page 12 of 64 [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 [X] Stressor #2 5. Symptoms ----------- For VA rating purposes, check all symptoms that actively apply to the Veteran's diagnoses: [X] Depressed mood [X] Anxiety [X] Panic attacks more than once a week [X] Chronic sleep impairment [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 worklike setting [X] Suicidal ideation 6. Behavioral Observations -------------------------- MENTAL STATUS ============= GENERAL APPEARANCE: Appropriate, Alert PSYCHOMOTOR ACTIVITY: None noted SPEECH: Appropriate rate and volume EYE CONTACT: Avoidant ATTITUDE TOWARD EXAMINER: Cooperative AFFECT: Restricted MOOD: Irritable, Anxious ATTENTION: Within normal limits ORIENTATION: X3 THOUGHT PROCESS: Within normal limits THOUGHT CONTENT: Within normal limits DELUSIONS: Denied JUDGMENT: Intact INTELLIGENCE: Average INSIGHT: Minimal LONG, JUSTIN THOMAS CONFIDENTIAL Page 13 of 64 HALLUCINATIONS: Denied IS THERE PRESENCE OF HOMICIDAL THOUGHTS? No IS THERE PRESENCE OF SUICIDAL THOUGHTS? No MEMORY: Within Normal Limits 7. Other symptoms ----------------- Does the Veteran have any other symptoms attributable to PTSD (and other mental disorders) that are not listed above? [ ] Yes [X] No 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 purpose of this VA C & P evaluation and limits of confidentiality were discussed, and Veteran indicated an understanding of exam purpose and these limits, and agreed to continue with the assessment. Veteran was given the opportunity to ask questions. Prior to exam completion Veteran was given the opportunity to add information they felt pertinent towards current VA claim. Examiner utilized DSM 5 for diagnostic purposes at this exam as required by RO/VISN 6. 

[Navy04]

Glad you made it thru the exam, it looks like you will be granted 30-50% for PTSD. Good luck and God Bless

[Buck52]

you will probably be rated on the PTSD and not the Depression  I think they only rate  one or the other and remember they rate on the symptoms and not the disability itself.

jmo  I would say you may get a 70%to 100% rating  a lot of it in my opinion depends on the rater  what kind of a rater you get to read it &  if he reads all of it?   if he does you should get a 100%  just my opinion.

Beings you can't work because of this  sc disability  do you get SSDI? IF you do  you should ask for TDIU P&T 

 

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

[flores97]

I agree with Buck, I have 50% service connection for MDD/Memory Loss secondary to Systemic Lupus, after reading your c&p notes, you have significantly more severe symptoms, should be 100% if you get a decent rater, if not, you should definitely appeal, Good Luck to you, also the rating schedule for MDD(unsure if there is a different schedule for PTSD) can be googled and has also been posted many times here on hadit. It would be a good idea to read it over, to ensure you are rated fairly.

[Buck52]

JULONG50209

I moved your post to PTSD Claims

it should be viewed more here.

Also you should  edit your name OUT  of the C&P Exam .

Thanks

 

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

[TALON II FE]

Glad you made it thru the exam, it looks like you will be granted 30-50% for PTSD. Good luck and God Bless

I believe this is where it will fall as well.  This is why:  [X] Occupational and social impairment with reduced reliability and productivity

This is also supported by things like the "Behavioral Observations" section.

  I know this is not what you want to hear, there are avenues you will be able to pursue if you disagree or believe that these parts do not accurately represent your condition.

[Buck52]

I base my opinion on what was answered in these box's All favorable to the veteran

''Occupational and social impairment with ''reduced'' reliability and productivity'' should favor the veteran!

 

[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 [X] Stressor #2 5. Symptoms ----------- For VA rating purposes, check all symptoms that actively apply to the Veteran's diagnoses: [X] Depressed mood [X] Anxiety [X] Panic attacks more than once a week [X] Chronic sleep impairment [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] Suicidal ideation 6. Behavioral Observations -------------------------- MENTAL STATUS =====

 GENERAL APPEARANCE: Appropriate, Alert PSYCHOMOTOR ACTIVITY: None noted SPEECH: Appropriate rate and volume EYE CONTACT: Avoidant ATTITUDE TOWARD EXAMINER: Cooperative AFFECT: Restricted MOOD: Irritable, Anxious ATTENTION: Within normal limits ORIENTATION: X3 THOUGHT PROCESS: Within normal limits THOUGHT CONTENT: Within normal limits DELUSIONS: Denied JUDGMENT: Intact INTELLIGENCE: Average INSIGHT: Minimal  CONFIDENTIAL Page 13 of 64 HALLUCINATIONS: Denied IS THERE PRESENCE OF HOMICIDAL THOUGHTS? No IS THERE PRESENCE OF SUICIDAL THOUGHTS? No MEMORY: Within Normal Limits 7. Other symptoms ----------------- Does the Veteran have any other symptoms attributable to PTSD (and other mental disorders) that are not listed above? [ ] Yes [X] No 8. Competency ------------- Is the Veteran capable of managing his or her financial affairs? [X] Yes [ ] No 9. Remarks, (including any testing results) if any --

 

I hope this poster will let us know, this C&P Exam could help other veterans in the same situation!

 

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

 

Edited November 7, 2015 by Buck52