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ptsd Occupational and social impairment / Symptoms
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OIFX3
Hello everyone I am new to this site and I was wondering if I could get some insight about my claim. I pulled up my C&P notes on a PTSD claim that I filled and was trying to match what the doctor wrote to my benefits expectations. It seems im mixed between 10% and 30%. Is there anybody that could give their opinion on why I should expect. Thanks!
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
2. Current Diagnoses
--------------------
a. Mental Disorder Diagnosis #1: PTSD
Comments, if any:
At least as likely as not incurred in combat tours (3 x in Iraq
between 03 and 07); Purple Heart in first, and CAB in second. Cav
Scout
Mental Disorder Diagnosis #2: Panic Disorder
Comments, if any:
Recurring transient episodes of intense fear associated with
breathing difficulty, palpitation, perspiration
Mental Disorder Diagnosis #3: Unspecified Depressive Disorder
Comments, if any:
SYMPTOMS: Sadness; diminished energy and self esteem; symptoms
shared with PTSD - diminished sleep, hope, concentration,
interests
b. Medical diagnoses relevant to the understanding or management of the
Mental Health Disorder (to include TBI): TBI and others
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:
See shared symptoms as above
c. Does the Veteran have a diagnosed traumatic brain injury (TBI)?
[X] Yes [ ] No [ ] Not shown in records reviewed
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:
The question with regards to impact of any TBI will be referred to
a TBI examiner to address
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 due to mild or transient symptoms
which decrease work efficiency and ability to perform occupational
tasks only during periods of significant stress, or; symptoms
controlled by medication
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:
Depression (Prevalence of depression-PTSD co-morbidity:
implications for clinical practice guidelines and primary
care-based interventions. Campbell DG - J Gen Intern Med -
01-JUN-2007; 22(6): 711-8 ) and panic disorder (Co-morbid panic
attacks among individuals with posttraumatic stress disorder:
associations with traumatic event exposure history, symptoms, and
impairment. - Cougle JR - J Anxiety Disorder - 01-MAR-2010; 24(2):
183-8) frequently co-occur with PTSD. While each co-morbidity
further limits Vet's psychosocial functioning, gauging the
exclusive and adverse impact of each co-morbidity on Vet's
functioning separate from that of another is not feasible.
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:
The question with regards to impact of any TBI will be referred to
a TBI examiner to address
SECTION II:
-----------
Clinical Findings:
------------------
1. Evidence Review
------------------
Evidence reviewed (check all that apply):
[X]
VA e-folder (VBMS or Virtual VA)
[X] CPRS
2. History
----------
a. Relevant Social/Marital/Family history (pre-military, military, and
post-military):
in an intact family. Had good
childhood.
Keeps up with parents and a younger brother who all in the same town.
No conduct issues in childhood nor in service. Married for past 13
years to an LPN, and they have 2 sons - 6 and 2 yo. Good relationship
within family. Reclusive outside. Living in Waverly, TN with his
family
since separation from service in 2009
conduct issues in childhood nor in service. Married for past 13
years to an LPN, and they have 2 sons - 6 and 2 yo. Good relationship
within family. Reclusive outside. Living with his
family
b. Relevant Occupational and Educational history (pre-military, military,
and
post-military):
EDUCATION: HS in 2002; associate degree in 2011.
MILITARY: Honorably served ARMY from 02 to 09; E5; Cav Scout for first
5 years and then transport coord. Other details as above.
Post service: Two long term jobs - first for 3 years as a storage desk
clerk; got tired. Current job for past 3 years as a chemical plant
operator. No negative feedback so far.
c. Relevant Mental Health history, to include prescribed medications and
family mental health (pre-military, military, and post-military):
Connected with TVHS MH services as an outpatient
d. Relevant Legal and Behavioral history (pre-military, military, and
post-military):
N/A
e. Relevant Substance abuse history (pre-military, military, and
post-military):
N/A
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: 3 Iraqi tours - see other details in diagnostic section
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 Criterion 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 Criterion 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 violence, 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
[X] Learning that the traumatic event(s) occurred to a close
family member or close friend; cases of actual or
threatened death must have been violent or accidental;
or,
experiencing repeated or extreme exposure to aversive
details of the traumatic events(s) (e.g., first
responders
collecting human remains; police officers repeatedly
exposed to details of child abuse); this does not apply
to
exposure through electronic media, television, movies, or
pictures, unless this exposure is work related.
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 negative emotional state (e.g., fear, horror,
anger, guilt, or shame).
[X] Persistent inability to experience positive emotions
(e.g., inability to experience happiness, satisfaction,
or
loving feelings.)
Criterion E: Marked alterations in arousal and reactivity associated with
the traumatic event(s), beginning or worsening after the
traumatic event(s) occurred, as evidenced by two (or more)
of
the following:
[X] Irritable behavior and angry outbursts (with little or no
provocation) typically expressed as verbal or physical
aggression toward people or objects.
[X] Hypervigilance.
[X] Exaggerated startle response.
[X] Problems with concentration.
[X] Sleep disturbance (e.g., difficulty falling or staying
asleep or restless sleep).
Criterion F:
[X] Duration of the disturbance (Criteria B, C, D, and E) is
more than 1 month.
Criterion G:
[X] The disturbance causes clinically significant distress or
impairment in social, occupational, or other important
areas of functioning.
Criterion H:
[X] The disturbance is not attributable to the physiological
effects of a substance (e.g., medication, alcohol) or
another medical condition.
Criterion I: Which stressor(s) contributed to the Veteran's PTSD
diagnosis?:
[X] Stressor #1
5. Symptoms
-----------
For VA rating purposes, check all symptoms that actively apply to the
Veteran's diagnoses:
[X] Depressed mood
[X] Anxiety
[X] Panic attacks more than once a week
[X] Chronic sleep impairment
[X] Mild memory loss, such as forgetting names, directions or recent
events
[X] Difficulty in adapting to stressful circumstances, including work or
a worklike setting
6. Behavioral Observations
--------------------------
No response provided.
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
--------------------------------------------------
No remarks provided.
NOTE: VA may request additional medical information, including additional
examinations if necessary to complete VA's review of the
Veteran's
application.
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silverdollar22
I think your right in the ballpark with your guess. This is the reason: Occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to p
broncovet
I agree with silver dollar. It looks good as far as service connection, your doctor has documented a stressor in 3 tours in Iraq. You have a current diagnosis. Did you supply evidnece of a "in serv
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