DSM-5

[Kelvin]

I had this done back in May, Im confused on if I have PTSD or Depression. Pls let me know what this is. XXXX (Took my name out)

 

Chief Complaint: Depression, intrusive thoughts Present Illness: 45-year-old veteran who is 80% SC overall but has no psychiatric disabilities. Had no history of mental health treatment until referred to a mental health social worker at the JACC with whom XXXX met on February 5th of this year. Social worker documented at that time: "Patient reported that he had been having dreams about an event that occurred while active duty off the coast of Africa. Patient reported that while aboard the USS Firebolt they came across a boat full of refugees that capsized as they were attempting to board the ship. He reported that a child was thrown to him from another crew member who was onboard a smaller patrol boat and he dropped the child into the water. He reported that he watched the child go under the boat. He reported he also witnessed a woman who was too weak to climb onboard the boat and he watched her go under the boat. He reported that he could have saved them

had he gone into the water, however the crew members had been given orders not to leave the boat. He reported that he had never talked to anyone about this

until last year when he told his spouse. This was the first time disclosing it to someone other than her. Patient reported that he had been isolating himself

from his spouse." XXXX was referred to the counselor at this clinic with whom he's met on three occasions and will be beginning IPT in the near future. XXXX continues to experience depressed mood, irritability, isolative

behaviors, intrusive thoughts, and occasional nightmares. His isolation stems more from his irritability than from avoidance of particular triggers, although he does admits having difficulty going to the beach. XXXX cites a number

of issues in his current relationship with his wife as they live with two teenagers who from his wife's previous marriage. XXXX and his wife differ on expectations from and discipline of the children which has caused more than

one verbal conflict. Finds himself more irritable at work as well which has led

to his being more verbally impulsive. Has never sought help for his mood in the

past and is not particularly clear why he sought help recently. Past Psychiatric History: No history of treatment prior to his evaluation in February. Denies history of SI/SA. Denies history of substance use. 

MENTAL STATUS EXAMINATION:

The veteran appeared well-developed, well-nourished, clean, and dressed appropriately. The veteran was alert and oriented in all spheres and able to establish rapport. Eye contact was adequately maintained and there was

no obvious psychomotor abnormality. Mood was "sad". Affect was reactive and congruent. Speech was fluent and normal in tone, rate and volume.

Thought processes were logical and goal-directed with intact associations.

There was no evidence of thought disorder or perceptual disturbances. There was no expressed delusional content. Suicidal and homicidal ideations were denied within the past thirty days and there has been no self-injurious behavior. Immediate, recent and remote memories were grossly intact as was attention and concentration. Insight was good. Judgment and impulse control were adequate.

DIAGNOSTIC IMPRESSION (DSM-5):

MDD, recurrent, mild Could certainly consider diagnosis of PTSD given XXXX's experience, although he doesn't exhibit the hypervigilance, exaggerated startle response, and their appears to have been elements in his history that would be more consistent with a major depressive disorder that has been ongoing for some time but perhaps exacerbated by his traumatic experiences. From a medication standpoint this distinction is not likely to be particularly important however. After discussion about various treatment options will provide trial of Sertraline, but XXXX was encouraged to remain engaged in the psychotherapeutic milieu.

PLAN:

Start Sertraline 50mg po daily

[Buck52]

Gastone

I believe the  VA MH License Clinicians can DX PTSD under the close supervision of a VA License Board certified psychiatrist or license  doctorate-level psychologist.

I believe it states that on a form 21-0960 P 3  PTSD DBQ

(LCSW), a nurse practitioner, a clinical nurse specialist, or a physician assistant, under close supervision of a board-certified or board-eligible psychiatrist or licensed doctorate-level psychologist. NAME OF PATIENT/VETERAN (If "Yes," continue to complete this Questionnaire) (If no diagnosis of PTSD, and the veteran has another Axis I and/or II diagnosis, then continue to complete this Questionnaire and/or VA Form 21-0960P-1, Eating Disorders Disability Benefits Questionnaire) Page 1 SECTION I - DIAGNOSTIC SUMMA

Unless I'm reading this wrong?

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

 

Edited July 14, 2016 by Buck52

[Buck52]

Want your claim processed faster? The Fully Developed Claim (FDC) Program is the fastest way to get your claim processed and there is no risk to participate! To participate in the FDC Program, if you are making a claim for veterans disability compensation or related compensation benefits, simply submit your claim in accordance with the "FDC Criteria" shown below. If you are making a claim for veterans non service-connected pension benefits, use VA Form 21-527EZ, Application for Pension. If you are making a claim for survivor benefits, use VA Form 21-534EZ, Application for DIC, Death Pension, and/or Accrued Benefits. VA forms are available at www.va.gov/vaform

This information is printed on the top of VA 21-526ez Form.

[Gastone]

Buck, your right as to actual Treatment and completion of other MH issue DBQ's requested at the VAMC MH Clinic. However, when it comes to the PTSD C & P DBQ, completely different Reg, C & P DBQ's can only be completed by the C & P Psychiatrist or Psychologist PhD, due to it's "Forensic" nature. For PTSD Claims Awards and Rating purposes, the VA C & P Dr's DBQ or Contract Dr's DBQ "Trumps" all other non C & P Dr's DX's and opinions.

Been a while since I looked at the VA PTSD DBQ Regs, as I recall, Treating MH Psychiatrists or Psychologists PHD, although eligible to complete a PTSD DBQ, were instructed to hand off their Vet's request for the PTSD DBQ to another Dr. that did not have a Dr. - Patient relationship with the Vet.

Makes sense, all the time, effort and trust established with the Vet, could go up in smoke, if the DBQ didn't meet the Vets expectations. What kind of relationship would they have, if the Vet saw that his Dr indicated on the DBQ that he thought the Vet was over reporting his symptoms?

Semper Fi

[Kelvin]

On 7/14/2016 at 5:22 PM, Buck52 said:

Want your claim processed faster? The Fully Developed Claim (FDC) Program is the fastest way to get your claim processed and there is no risk to participate! To participate in the FDC Program, if you are making a claim for veterans disability compensation or related compensation benefits, simply submit your claim in accordance with the "FDC Criteria" shown below. If you are making a claim for veterans non service-connected pension benefits, use VA Form 21-527EZ, Application for Pension. If you are making a claim for survivor benefits, use VA Form 21-534EZ, Application for DIC, Death Pension, and/or Accrued Benefits. VA forms are available at www.va.gov/vaform

This information is printed on the top of VA 21-526ez Form.

Hi Buck, I just got my appointment scheduled for my MH and it was so quick. I went to the VA Monday with all my paperwork and the VA rep uploaded all of it. I got a call from the VA today and scheduled my MH in 2 weeks,  but I was wondering why was it so quick.