Little History: This was my second C&P Exam. The first one granted me 30% about 2 years ago. That exam was only like 20 minutes so this one caught me off guard. I have been getting worse the past year. I got time on the street from my job for about 5 days to recover from a panic attack I had at work. I get into fights with coworkers so now I work in a tower by myself away from everyone and about a month ago, I nearly committed suicide. I had called the suicide hotline and made an appointment with the Mental Health and now I am doing weekly group therapy, monthly individual therapy and they have me on a couple different medications for the panic attacks and anxiety. I recently applied for an increase in PTSD and added anxiety and panic attacks as a secondary. Couple of questions: I was only scheduled a C&P exam for the PTSD, will I need to do another one for the anxiety or panic attacks? Also, here is my C&P Exam results and was wondering if someone with more experience can take a look at it and tell me what you think. It looks like a 50% possibility but not for sure. Thanks.
LOCAL TITLE: PSYCH C&P EXAM MA
STANDARD TITLE: C & P EXAMINATION NOTE
DATE OF NOTE: JUN 27, 2016@12:00 ENTRY DATE: JUN 27, 2016@14:39:27
AUTHOR: EXP COSIGNER:
URGENCY: STATUS: COMPLETED
Review Post Traumatic Stress Disorder (PTSD)
Disability Benefits Questionnaire
Name of patient/Veteran:
SECTION I:
----------
1. Diagnostic Summary
---------------------
Does the Veteran now have or has he/she ever been diagnosed with
PTSD?
[X] Yes[ ] No
2. Current Diagnoses
--------------------
a. Mental Disorder Diagnosis #1: PTSD
Comments, if any: SC 30%
b. Medical diagnoses relevant to the understanding or management
of the
Mental Health Disorder (to include TBI):
No response provided.
3. Differentiation of symptoms
------------------------------
a. Does the Veteran have more than one mental disorder
diagnosed?
[ ] Yes[X] No
c. Does the Veteran have a diagnosed traumatic brain injury
(TBI)?
[ ] Yes[ ] No[X] 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[ ] 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?
No response provided.
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[ ] No
If no, check all records reviewed:
[ ] Military service treatment records
[ ] Military service personnel records
[ ] Military enlistment examination
[ ] Military separation examination
[ ] Military post-deployment questionnaire
[ ] Department of Defense Form 214 Separation Documents
[ ] 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:
b. Was pertinent information from collateral sources reviewed?
[ ] Yes[X] No
2. Recent History (since prior exam)
------------------------------------
a. Relevant Social/Marital/Family history:
E. Social Functioning:
The veteran is currently married to second wife. 9 years.
They
separated for 6 weeks due to his anger and other PTSD like
behaviors
late Sept 2015.
He describes his current relationships as: "since the
suicide thing. It has picked up. I have started talking to
her more. My
anger, outbursts. I would nitpick everything. We fight
about not going
out more.
Four kids in today (two from first marriage ages 13, 11)
and second
marriage two kids (6,3). All the kids live with them.
He noted he has many outbursts with the kids because he
expects too
much, he is more like a drill sgt than a father. Overall
the thinks
their relationship is "good"
He may not physically isolate himself from family but does
emotional
isolate himself (does not want to be vulnerable)
Friends and Hobbies: no friends; does not trust people.
He started gardening. He and his wife watch movies.
b. Relevant Occupational and Educational history:
Occupation: Prison guard in XXXXX. Has been there 1.5
years. Works in
tower alone
Has the veteran lost time from work due to mental health
issues? 5 days
of paid leave for anxiety attack at work; estimates he
misses an hour a
day at work due to "zoning out" (dissociation or intrusive
thoughts)
Any difficulties at work? yes
What causes difficulties? Anxiety, he has ad anger
outbursts at work
(he was transferred to the tower)
Are these difficulties mild/moderate/severe? Mild to
moderate
How is your efficiency/reliability/productivity at work?
good
How do you get along with supervisor/coworkers?depends on
the person
Does your problems only occur during times of significant
stress?yes
Current Financial Status:
Income:job, disability from VA
Basic needs being met:yes
c. Relevant Mental Health history, to include prescribed
medications and
family mental health:
ACTIVE PROBLEM LIST
1) Annual Physical-No Problem (P)
2) Psoriasis vulgaris
3) Chronic post-traumatic stress disorder
4) Suicidal thoughts
ACTIVE MEDICATIONS:
Active Outpatient Medications (including Supplies):
SERTRALINE HCL 100MG TAB TAKE ONE-HALF TABLET BY MOUTH
ACTIVE
EVERY MORNING FOR MOOD
TRAZODONE HCL 100MG TAB TAKE ONE-HALF TABLET BY MOUTH AT
ACTIVE
BEDTIME FOR MOOD OR SLEEP.
PRE-MILITARY MENTAL HEALTH HISTORY:
POST-MILITARY MENTAL HEALTH HISTORY:
History of Psychiatric care:
His history of psychiatric care has included:
PSYCHOTROPIC MEDICATIONS: trazodone, sertraline
a. Side effects of medication: not taking them as
they make him
feel "strange". He noted he has talked to his provider.
PSYCHIATRIC INPATIENT TREATMENTS: none
PSYCHIATRIC OUTPATIENT CARE: Received 4 to 6 sessions in
KY Vet
center about 2014. Had received medications from KY VA.
He had no had
therapy until coming back to the Marion VAMC and he has
had interaction
with a NP for medication and the PTSD clinical team. He is
scheduled to
start group therapy.
individual therapy/ symptoms and medicati
on monitoring
Suicidal Thoughts, intentions, plans or intent
a.
Presence of SI: called hotline june 2015. Occasional
thoughts mostly
passive. Was going to run car into wall or ditch.
b. Comments
SUICIDE RISK ASSESSMENT COMPLETED
Suicide Risk Screening Questions Are you feeling hopeless
about the present or future?
Homicidal thoughts, intentions, plans, intent
a. Presence of HI: No
b. Comments:
Subjective Complaints: a. Describe fully.
HOW DO YOU SEE YOUR SYMPTOMS AFFECTING YOUR DAILY LIVING?
"Anger
affects everything. It ruins everything. I don't' go
anywhere and my
wife wants to. If we go out I am good for an hour then I
have to go, I
feel closed in. I yell at the kids too much."
ANY REMISSION FROM SYMPTOMS? No have become worse
IMPAIRMENT IN THOUGHT? no
CURRENT STRESSORS? Increase in MH symptoms, SI,
relationships, kids
causing more anxiety and depression
SPONTANEOUS REPORTING OF SYMPTOMS: "Suicidal thoughts, I
see things
that are not there but I think they are there; I smell
thinks that
makes me think I am there. I hallucinate about stuff and I
cry over it,
I get angry so easily and I take it out on my kids. I
don't like being
around people, even at work. I keep a tight group I guess.
I stare off
into space sometimes and it seems like a long time. I try
to have my
wife drive more often. The suicidal stuff started
happening more."
END OF SPONTANEOUS REPORTING.
"some days I feel I am doing good, other days I am crying
and sobbing
the entire time. I keep getting better but I am not. My
wife left me
for 6 weeks. We patched things up. My first wife left me.
I don't
know."
"I feel there is no escape. The day of the suicide
hotline. I saw her.
I felt there was no escape, ever"
He cannot understand why his symptoms are much worse than
in 2012.
He noted memory loss for childhood events in the past few
years. He
noted poor short term memory.
CRITERION B:RE-EXPERIENCING PHENOMENA
INTRUSIVE THOUGHTS: explained and gave description of
intrusive
thoughts. "I will have a week where I don't have anything
and then a
week where it is 4 to 5 times a week or day"
FLASHBACKS: he noted dissociative periods throughout the
day.
Flashbacks upon waking in the morning. Flashback
occurrence varies
greatly.
NIGHTMARES: "my wife's says I am screaming and yelling in
my sleep. I
speak Arabic in my sleep, My heart is pounding." He
noted waking up
sweating profusely daily. Only vaguely remembers the
nightmares. Wife
tells him in the morning about his behaviors.
Does not endorse depersonalization, derealization.
PHYSIOLOGICAL/PSYCHOLOGICAL REACTIVITY: anger, depression,
tears, heart
pounding, increased sweating.
CRITERION C:AVOIDANCE
He avoids being around blood; crowds (this is more about
hypervigilance); 4th of july and fireworks; talking and
thinking about
trauma.
CRITERION D:ALERTATIONS IN
COGNITION/DETACHMENT/BLAME/INABILITY FOR
POSITIVE
EMOTIONS
"I try to keep everyone close, my circle of people is
small; I have
major trust issues; I don't go out and do anything with
anyone. We have
had arguments over this (going out); I talk to people even
coworkers
like they are dumb. I get pissed off very easily. If they
do something
wrong, I get so angry. My kids, if they don't do what I
tell them I get
so mad, I am throwing stuff, yelling. They will do stuff
they don't
know they are doing and it will bother me like startling.
I think I am
getting shot at in the moment."
Trusts wife. No one else. Feels no one is trustworthy.
Feels this way
100% of the time. "Constant patrols and talking to people,
there was no
one to trust them." This how he relates this to combat.
He feels damaged; there is no trust in people; the world
and people are
unsafe.
"I have not talked to my parents in months. My brother
came out last
week to check on me. They act like I am secluding them. I
don't pick up
the phone and call people. My wife called my brother and
told him I was
having problems. He flew out here."
Feels anger the most; does not have ability to feel peace,
joy and
love; no positive feelings.
He keeps people at a distance. "I don't think everyone is
out to get
me. I don't trust them. I will not be vulnerable"
He describes some "blank spots" in his memory during
certain trauma.
Believes himself to have been a person who could help
anyone. This
trauma with the woman who had her intestines outside of
her body; first
of all it was a woman, second of all he felt utterly
helpless which
decimated his thoughts about his core self.
Lack of interest in playing guitar; used to play golf.
(he noted lack
of motivation, not really trauma based)
Has to be in control. "everything goes my way I know
every one will be
safe" Control represents safety
CRITERION E: INCREASED AUTONOMIC AROUSAL
IRRITABILITY/ANGER: themes of anger not being in control.
Control,
stupidity, disrespectful, poor work ethic are all themes
of anger.
"Anger, I have to let out. Irritability, I don't have to
express." He
yells, screams and throws things. Has outbursts a few
times a week.
RECKLESS BEHAVIOR:
HYPERVIGLANCES: "I always have my back against the wall, I
will not be
vulnerable. I will wait 20 + min at a restaurant for table
with my back
at the wall." Noted when not against wall, very
uncomfortable "I can't
do it, I will be moving around constantly looking around.
I can't have
people behind me." He is even hypervigilant with staff he
works with.
He feels this way 100% of the time. Relates to the
deployment "I guess
the waiting for something to happen all the time. Every
day, take out a
vehicle, get blown up, get another vechile and do it
again."
EXAGGERATED STARTLE RESPONSE: fire works, people behind
him; when
startled acts defensively 100% of the time/.
IMPAIRED CONCENTRATION: poor at times other times "okay"
poor sleep,
intrusive thoughts, flashbacks take away from
concentrating. "I work in
the tower I will see her, I will see a Humvee. I see a
cloud over the
rocks I think a Humvee is coming. When people are on the
radio and they
yell and I get startled."
SLEEP DISTURBANCES: on average goes to bed 10pm; no sleep
until 1230- 1
am; out of bed 6 to 630am. "If I don't have anything
bothers me, I
will sleep fine. If something wakes me up at 3am, my
adrenaline is
going, I just stay away (this occurs multiple times a
week). Never
feels rested. Poor sleep quality and quantity.
d. Relevant Legal and Behavioral history:
Veteran denied any legal entanglements since
discharge/last exam.
e. Relevant Substance abuse history:
POST MILITARY SUBSTANCE USAGE HISTORY:
Veteran denied substance abuse problems/treatment
The veteran denied use or abusing illicit drugs and abuse
of
prescription drugs.
Has not drank in 7 years.
f. Other, if any:
No response provided.
3. PTSD Diagnostic Criteria
---------------------------
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
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] Inability to remember an important aspect of
the traumatic
event(s) (typically due to dissociative amnesia
and not to
other factors such as head injury, alcohol, or
drugs).
[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] 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:
[X] The disturbance is not attributable to the
physiological
effects of a substance (e.g., medication,
alcohol) or
another medical condition.
4. Symptoms
-----------
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] Flattened affect
[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
worklike setting
[X] Inability to establish and maintain effective
relationships
[X] Suicidal ideation
5. Behavioral Observations:
---------------------------
Note 1: Unless otherwise stated, all historical information
in this DBQ is
based on the veteran's statements during the examination.
General Appearance: Clean, neatly groomed
Psychomotor activity: bouncing of legs
Speech: unremarkable
Attitude toward examiner: cooperative
Affect: flat
Mood: anxious
Attention: intact
Orientation: The veteran was oriented to person, place and
time
Thought Processes: unremarkable, logical, goal directed,
relevant
Though Content: unremarkable
Judgment: partially impaired
Intelligence: average as evidenced by vocabulary,
grammar, and ability to utilize and understand
abstract reasoning.
Insight: pt understands he has a problem.
Inappropriate Behavior
a. Does the pt have inappropriate behavior: Mild,
Moderate (anger)
Obsessive or Ritualistic Behavior
a. Does the pt have obsessive/Ritualistic behaviors: No
Impulsivity
a. Extend of impulse control: Fair
b. Episode of violence: No
Problems with ADL's; Yes or No
Memory
a. Remote: Normal
b. Recent: Normal
c. Immediate: Normal
1. Other disorders or symptoms and the extent they
interfere with
activities
particularly:
a. substance abuse disorders none
a. somatoform disorders none
b. personality disorders deferred
Testing deemed necessary: no
Veteran response to interview: "it went well, detailed"
6. Other symptoms
-----------------
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:
---------------------------------------------------
Interview started: on time
Explained to veteran:
examiner has no decision making capacity regarding the
veteran's
rating; the examiner will be asking numerous questions, some
of which will
provoke emotional response; the veteran was asked to please
understand t
he examiner is not make any personal judgments regarding the
veteran but
due to the vast amount of
questions some might feel they are being judged and the
veteran is
encouraged to
understand this is not the case it is simply a matter for
trying to gather
information for the examination the veteran requested; the
veteran was
informed
the examiner is not native of this geographical area thus
mannerisms are
different and no offense is meant if the examiner appears to
be abrupt or
blunt; Veteran
was informed of these things at the onset of the interview:
the veteran
voiced understanding
of the above statements: yes
The veteran brought documents with him/her to interview: no
OPINION:
After carefully reviewing the C-file, medical records, the
clinical
interview,
and medical literature, it is my opinion that:
PTSD, moderate
Question
Rakkasan
Little History: This was my second C&P Exam. The first one granted me 30% about 2 years ago. That exam was only like 20 minutes so this one caught me off guard. I have been getting worse the past year. I got time on the street from my job for about 5 days to recover from a panic attack I had at work. I get into fights with coworkers so now I work in a tower by myself away from everyone and about a month ago, I nearly committed suicide. I had called the suicide hotline and made an appointment with the Mental Health and now I am doing weekly group therapy, monthly individual therapy and they have me on a couple different medications for the panic attacks and anxiety. I recently applied for an increase in PTSD and added anxiety and panic attacks as a secondary. Couple of questions: I was only scheduled a C&P exam for the PTSD, will I need to do another one for the anxiety or panic attacks? Also, here is my C&P Exam results and was wondering if someone with more experience can take a look at it and tell me what you think. It looks like a 50% possibility but not for sure. Thanks.
LOCAL TITLE: PSYCH C&P EXAM MA
STANDARD TITLE: C & P EXAMINATION NOTE
DATE OF NOTE: JUN 27, 2016@12:00 ENTRY DATE: JUN 27, 2016@14:39:27
AUTHOR: EXP COSIGNER:
URGENCY: STATUS: COMPLETED
Review Post Traumatic Stress Disorder (PTSD)
Disability Benefits Questionnaire
Name of patient/Veteran:
SECTION I:
----------
1. Diagnostic Summary
---------------------
Does the Veteran now have or has he/she ever been diagnosed with
PTSD?
[X] Yes[ ] No
2. Current Diagnoses
--------------------
a. Mental Disorder Diagnosis #1: PTSD
Comments, if any: SC 30%
b. Medical diagnoses relevant to the understanding or management
of the
Mental Health Disorder (to include TBI):
No response provided.
3. Differentiation of symptoms
------------------------------
a. Does the Veteran have more than one mental disorder
diagnosed?
[ ] Yes[X] No
c. Does the Veteran have a diagnosed traumatic brain injury
(TBI)?
[ ] Yes[ ] No[X] 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[ ] 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?
No response provided.
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[ ] No
If no, check all records reviewed:
[ ] Military service treatment records
[ ] Military service personnel records
[ ] Military enlistment examination
[ ] Military separation examination
[ ] Military post-deployment questionnaire
[ ] Department of Defense Form 214 Separation Documents
[ ] 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:
b. Was pertinent information from collateral sources reviewed?
[ ] Yes[X] No
2. Recent History (since prior exam)
------------------------------------
a. Relevant Social/Marital/Family history:
E. Social Functioning:
The veteran is currently married to second wife. 9 years.
They
separated for 6 weeks due to his anger and other PTSD like
behaviors
late Sept 2015.
He describes his current relationships as: "since the
suicide thing. It has picked up. I have started talking to
her more. My
anger, outbursts. I would nitpick everything. We fight
about not going
out more.
Four kids in today (two from first marriage ages 13, 11)
and second
marriage two kids (6,3). All the kids live with them.
He noted he has many outbursts with the kids because he
expects too
much, he is more like a drill sgt than a father. Overall
the thinks
their relationship is "good"
He may not physically isolate himself from family but does
emotional
isolate himself (does not want to be vulnerable)
Friends and Hobbies: no friends; does not trust people.
He started gardening. He and his wife watch movies.
b. Relevant Occupational and Educational history:
Occupation: Prison guard in XXXXX. Has been there 1.5
years. Works in
tower alone
Has the veteran lost time from work due to mental health
issues? 5 days
of paid leave for anxiety attack at work; estimates he
misses an hour a
day at work due to "zoning out" (dissociation or intrusive
thoughts)
Any difficulties at work? yes
What causes difficulties? Anxiety, he has ad anger
outbursts at work
(he was transferred to the tower)
Are these difficulties mild/moderate/severe? Mild to
moderate
How is your efficiency/reliability/productivity at work?
good
How do you get along with supervisor/coworkers?depends on
the person
Does your problems only occur during times of significant
stress?yes
Current Financial Status:
Income:job, disability from VA
Basic needs being met:yes
c. Relevant Mental Health history, to include prescribed
medications and
family mental health:
ACTIVE PROBLEM LIST
1) Annual Physical-No Problem (P)
2) Psoriasis vulgaris
3) Chronic post-traumatic stress disorder
4) Suicidal thoughts
ACTIVE MEDICATIONS:
Active Outpatient Medications (including Supplies):
SERTRALINE HCL 100MG TAB TAKE ONE-HALF TABLET BY MOUTH
ACTIVE
EVERY MORNING FOR MOOD
TRAZODONE HCL 100MG TAB TAKE ONE-HALF TABLET BY MOUTH AT
ACTIVE
BEDTIME FOR MOOD OR SLEEP.
PRE-MILITARY MENTAL HEALTH HISTORY:
POST-MILITARY MENTAL HEALTH HISTORY:
History of Psychiatric care:
His history of psychiatric care has included:
PSYCHOTROPIC MEDICATIONS: trazodone, sertraline
a. Side effects of medication: not taking them as
they make him
feel "strange". He noted he has talked to his provider.
PSYCHIATRIC INPATIENT TREATMENTS: none
PSYCHIATRIC OUTPATIENT CARE: Received 4 to 6 sessions in
KY Vet
center about 2014. Had received medications from KY VA.
He had no had
therapy until coming back to the Marion VAMC and he has
had interaction
with a NP for medication and the PTSD clinical team. He is
scheduled to
start group therapy.
individual therapy/ symptoms and medicati
on monitoring
Suicidal Thoughts, intentions, plans or intent
a.
Presence of SI: called hotline june 2015. Occasional
thoughts mostly
passive. Was going to run car into wall or ditch.
b. Comments
SUICIDE RISK ASSESSMENT COMPLETED
Suicide Risk Screening Questions Are you feeling hopeless
about the present or future?
Homicidal thoughts, intentions, plans, intent
a. Presence of HI: No
b. Comments:
Subjective Complaints: a. Describe fully.
HOW DO YOU SEE YOUR SYMPTOMS AFFECTING YOUR DAILY LIVING?
"Anger
affects everything. It ruins everything. I don't' go
anywhere and my
wife wants to. If we go out I am good for an hour then I
have to go, I
feel closed in. I yell at the kids too much."
ANY REMISSION FROM SYMPTOMS? No have become worse
IMPAIRMENT IN THOUGHT? no
CURRENT STRESSORS? Increase in MH symptoms, SI,
relationships, kids
causing more anxiety and depression
SPONTANEOUS REPORTING OF SYMPTOMS: "Suicidal thoughts, I
see things
that are not there but I think they are there; I smell
thinks that
makes me think I am there. I hallucinate about stuff and I
cry over it,
I get angry so easily and I take it out on my kids. I
don't like being
around people, even at work. I keep a tight group I guess.
I stare off
into space sometimes and it seems like a long time. I try
to have my
wife drive more often. The suicidal stuff started
happening more."
END OF SPONTANEOUS REPORTING.
"some days I feel I am doing good, other days I am crying
and sobbing
the entire time. I keep getting better but I am not. My
wife left me
for 6 weeks. We patched things up. My first wife left me.
I don't
know."
"I feel there is no escape. The day of the suicide
hotline. I saw her.
I felt there was no escape, ever"
He cannot understand why his symptoms are much worse than
in 2012.
He noted memory loss for childhood events in the past few
years. He
noted poor short term memory.
CRITERION B:RE-EXPERIENCING PHENOMENA
INTRUSIVE THOUGHTS: explained and gave description of
intrusive
thoughts. "I will have a week where I don't have anything
and then a
week where it is 4 to 5 times a week or day"
FLASHBACKS: he noted dissociative periods throughout the
day.
Flashbacks upon waking in the morning. Flashback
occurrence varies
greatly.
NIGHTMARES: "my wife's says I am screaming and yelling in
my sleep. I
speak Arabic in my sleep, My heart is pounding." He
noted waking up
sweating profusely daily. Only vaguely remembers the
nightmares. Wife
tells him in the morning about his behaviors.
Does not endorse depersonalization, derealization.
PHYSIOLOGICAL/PSYCHOLOGICAL REACTIVITY: anger, depression,
tears, heart
pounding, increased sweating.
CRITERION C:AVOIDANCE
He avoids being around blood; crowds (this is more about
hypervigilance); 4th of july and fireworks; talking and
thinking about
trauma.
CRITERION D:ALERTATIONS IN
COGNITION/DETACHMENT/BLAME/INABILITY FOR
POSITIVE
EMOTIONS
"I try to keep everyone close, my circle of people is
small; I have
major trust issues; I don't go out and do anything with
anyone. We have
had arguments over this (going out); I talk to people even
coworkers
like they are dumb. I get pissed off very easily. If they
do something
wrong, I get so angry. My kids, if they don't do what I
tell them I get
so mad, I am throwing stuff, yelling. They will do stuff
they don't
know they are doing and it will bother me like startling.
I think I am
getting shot at in the moment."
Trusts wife. No one else. Feels no one is trustworthy.
Feels this way
100% of the time. "Constant patrols and talking to people,
there was no
one to trust them." This how he relates this to combat.
He feels damaged; there is no trust in people; the world
and people are
unsafe.
"I have not talked to my parents in months. My brother
came out last
week to check on me. They act like I am secluding them. I
don't pick up
the phone and call people. My wife called my brother and
told him I was
having problems. He flew out here."
Feels anger the most; does not have ability to feel peace,
joy and
love; no positive feelings.
He keeps people at a distance. "I don't think everyone is
out to get
me. I don't trust them. I will not be vulnerable"
He describes some "blank spots" in his memory during
certain trauma.
Believes himself to have been a person who could help
anyone. This
trauma with the woman who had her intestines outside of
her body; first
of all it was a woman, second of all he felt utterly
helpless which
decimated his thoughts about his core self.
Lack of interest in playing guitar; used to play golf.
(he noted lack
of motivation, not really trauma based)
Has to be in control. "everything goes my way I know
every one will be
safe" Control represents safety
CRITERION E: INCREASED AUTONOMIC AROUSAL
IRRITABILITY/ANGER: themes of anger not being in control.
Control,
stupidity, disrespectful, poor work ethic are all themes
of anger.
"Anger, I have to let out. Irritability, I don't have to
express." He
yells, screams and throws things. Has outbursts a few
times a week.
RECKLESS BEHAVIOR:
HYPERVIGLANCES: "I always have my back against the wall, I
will not be
vulnerable. I will wait 20 + min at a restaurant for table
with my back
at the wall." Noted when not against wall, very
uncomfortable "I can't
do it, I will be moving around constantly looking around.
I can't have
people behind me." He is even hypervigilant with staff he
works with.
He feels this way 100% of the time. Relates to the
deployment "I guess
the waiting for something to happen all the time. Every
day, take out a
vehicle, get blown up, get another vechile and do it
again."
EXAGGERATED STARTLE RESPONSE: fire works, people behind
him; when
startled acts defensively 100% of the time/.
IMPAIRED CONCENTRATION: poor at times other times "okay"
poor sleep,
intrusive thoughts, flashbacks take away from
concentrating. "I work in
the tower I will see her, I will see a Humvee. I see a
cloud over the
rocks I think a Humvee is coming. When people are on the
radio and they
yell and I get startled."
SLEEP DISTURBANCES: on average goes to bed 10pm; no sleep
until 1230- 1
am; out of bed 6 to 630am. "If I don't have anything
bothers me, I
will sleep fine. If something wakes me up at 3am, my
adrenaline is
going, I just stay away (this occurs multiple times a
week). Never
feels rested. Poor sleep quality and quantity.
d. Relevant Legal and Behavioral history:
Veteran denied any legal entanglements since
discharge/last exam.
e. Relevant Substance abuse history:
POST MILITARY SUBSTANCE USAGE HISTORY:
Veteran denied substance abuse problems/treatment
The veteran denied use or abusing illicit drugs and abuse
of
prescription drugs.
Has not drank in 7 years.
f. Other, if any:
No response provided.
3. PTSD Diagnostic Criteria
---------------------------
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
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] Inability to remember an important aspect of
the traumatic
event(s) (typically due to dissociative amnesia
and not to
other factors such as head injury, alcohol, or
drugs).
[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] 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:
[X] The disturbance is not attributable to the
physiological
effects of a substance (e.g., medication,
alcohol) or
another medical condition.
4. Symptoms
-----------
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] Flattened affect
[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
worklike setting
[X] Inability to establish and maintain effective
relationships
[X] Suicidal ideation
5. Behavioral Observations:
---------------------------
Note 1: Unless otherwise stated, all historical information
in this DBQ is
based on the veteran's statements during the examination.
General Appearance: Clean, neatly groomed
Psychomotor activity: bouncing of legs
Speech: unremarkable
Attitude toward examiner: cooperative
Affect: flat
Mood: anxious
Attention: intact
Orientation: The veteran was oriented to person, place and
time
Thought Processes: unremarkable, logical, goal directed,
relevant
Though Content: unremarkable
Judgment: partially impaired
Intelligence: average as evidenced by vocabulary,
grammar, and ability to utilize and understand
abstract reasoning.
Insight: pt understands he has a problem.
Inappropriate Behavior
a. Does the pt have inappropriate behavior: Mild,
Moderate (anger)
Obsessive or Ritualistic Behavior
a. Does the pt have obsessive/Ritualistic behaviors: No
Impulsivity
a. Extend of impulse control: Fair
b. Episode of violence: No
Problems with ADL's; Yes or No
Memory
a. Remote: Normal
b. Recent: Normal
c. Immediate: Normal
1. Other disorders or symptoms and the extent they
interfere with
activities
particularly:
a. substance abuse disorders none
a. somatoform disorders none
b. personality disorders deferred
Testing deemed necessary: no
Veteran response to interview: "it went well, detailed"
6. Other symptoms
-----------------
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:
---------------------------------------------------
Interview started: on time
Explained to veteran:
examiner has no decision making capacity regarding the
veteran's
rating; the examiner will be asking numerous questions, some
of which will
provoke emotional response; the veteran was asked to please
understand t
he examiner is not make any personal judgments regarding the
veteran but
due to the vast amount of
questions some might feel they are being judged and the
veteran is
encouraged to
understand this is not the case it is simply a matter for
trying to gather
information for the examination the veteran requested; the
veteran was
informed
the examiner is not native of this geographical area thus
mannerisms are
different and no offense is meant if the examiner appears to
be abrupt or
blunt; Veteran
was informed of these things at the onset of the interview:
the veteran
voiced understanding
of the above statements: yes
The veteran brought documents with him/her to interview: no
OPINION:
After carefully reviewing the C-file, medical records, the
clinical
interview,
and medical literature, it is my opinion that:
PTSD, moderate
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flores97
Rakkasan, I am by no means an expert on ptsd, but I am SC 50% for a mental health issue MDD to account for memory loss, and based on the symptoms reported on your exam, I would say that looks more lik
Andyman73
According to the regs, they must, by law, give you the highest possible rating based on your symptoms. This tells us that you should be rated at 70% due to the SI. Again, should be, by law. We all k
Andyman73
Rakkasan, I had an alcohol related incident, which netted me an Article 15/NJP. Out of that I enjoyed a 3 week outpatient treatment program. So I was presented with an opportunity to go a differe
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