ptsd C&P: Curious about terms and how they affect rating

[commodog]

Hey guys! Recently had 2 C&P exams, both which were actually quite pleasant and professional, at the D.C. VAMC. Both docs listened, in entirety, to everything I had to say, and clearly had read my medical history, service history, etc.

In the C&P examinations, I noticed some categories and terms, and was wondering if any of you guys wise in the ways of interpreting said exams (previous raters, even?) could explain what the statements mean, and how they weigh on an individual rating?
If you can, cool. If not, hey thanks for reading anyways.

So here they are (both of these are reevaluations):

From a TBI C&P:

4. Functional impact
Do any of the Veteran's residual conditions attributable to a traumatic brain injury impact his or her ability to work? [X] Yes [ ] No

What does this tell or infer to the rater? What purpose does it serve?
IU eligibility?
Higher percentage?

From a PTSD C&P:

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

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

 

I guess what I am looking for fellas, is just an idea of what these mean to the rater, and how much they impact my final rating? I'm not reading too much into it. I have learned from previous C&P's that it's just a waste of time to do so.

Thanks for your opinions/advice/perspective on this!

CommoDog

[broncovet]

You still need the magic words for TDIU:  
"The VEtran is unable to maintain substantial gainful employment due to service connected PTSD".  

I dont know if you have the magic words or not.  

By the way, I have the "magic words" but the board of veterans appeals said the doc who said it is a liar.  (They said it was not consistent with the rest of the facts of the case).  Then, they cited no doctor with a conflicting opinion.  

[Buck52]

My C&P was about the same too Gastone  I got 70% for Chronic PTSD

I should have NOD the decision according what the examiner put in my systoms boxes, but with my other 90% disability with TDIU P&T that made the criteria for Inferred SMC-S-1...So no gripe from me.

Yes I think it would help us if we had most or all this C&P Report commodog

[commodog]

Ask and ye shall receive...

PTSD C&P -
Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination Request? [X] Yes [ ] No

SECTION I: ----------
1. Diagnostic Summary ---------------------
Does the Veteran now have or has he/she ever been diagnosed with PTSD? [X] Yes [ ] No ICD Code: 309.81

2. Current Diagnoses --------------------
a. Mental Disorder Diagnosis
#1: PTSD ICD Code: 309.81

Comments, if any: with depressed mood

b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): See Veteran's medical record for pertinent medical conditions

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)? [X] Yes [ ] No [ ] Not shown in records reviewed
d. Is it possible to differentiate what symptom(s) is/are attributable to each diagnosis? [X] Yes [ ] No [ ] Not applicable (N/A)
If yes, list which symptoms are attributable to each diagnosis: Veteran's reported subjective symptoms of TBI to include blurred vision, learning difficulty, are visual impairment are likely attributed to his TBI. He presents with overlapping symptoms (poor concentration, memory problems, and impair judgment, and difficulty in social interactions) are attributed to both diagnoses.

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 deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood
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: Veteran's overlapping symptoms are attributed to both diagnoses
 

SECTION II: -----------
Clinical Findings: ------------------
1. Evidence Review ------------------ Evidence reviewed (check all that apply): [X] VA e-folder (VBMS or Virtual VA) [X] CPRS
2. Recent History (since prior exam) ------------------------------------
a. Relevant Social/Marital/Family history: Veteran continues to live with his fiance. He indicated that they have been together for awhile and plans on getting married on 2 September 2017. "She is patient and kind." They have a seven year old daughter." Socially, Veteran indicated that he "doesn't do nothing." "I have no friends or interests in anything. I have tried but nothing."

c. Relevant Mental Health history, to include prescribed medications and family mental health: 

Veteran is currently in treatment at the DC VA and sees Dr. XXXXXX. He indicated a reduction in nightmares due to his medication. He is currently treated with Hydrochlorothiazide 25mg. Escitalopram Oxalate 20mg, Prazosin Hcl 1mg, and Aripiprazole 5mg.

d. Relevant Legal and Behavioral history: Veteran denied changes since his last examination.
e. Relevant Substance abuse history: Veteran reported drinking one beer once a month. He denied illicit drug use and "I try to stay away from alcohol as much as possible."
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 Criterion 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 violence, in one or more of the following ways: [X] Directly experiencing the traumatic event(s)

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] 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] Reckless or self-destructive behavior.
[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] Impaired impulse control, such as unprovoked irritability with periods of violence

5. Behavioral observations --------------------------
No response provided.

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: ---------------------------------------------------
Veteran's irritability, poor impulse control, suspiciousness, avoidance, and sleep disturbance negatively impacts his ability to function in an occupational environment. Veteran has had incidents that he had become verbally and physically aggressive towards others to include his neighbor and teacher.

 

TBI C&P-

--------------- Evidence reviewed (check all that apply):
[X] VA e-folder (VBMS or Virtual VA)
[X] CPRS SECTION I: Diagnosis and medical history ----------------------------------------

1. Diagnosis ------------
Does the Veteran now have or has he/she ever had a traumatic brain injury (TBI) or any residuals of a TBI? [X] Yes [ ] No [X] Traumatic brain injury (TBI) ICD code: S06.2X1D
Date of diagnosis: 2003 [X]
Other diagnosed residuals attributable to TBI, specify: Other diagnosis #1: Mild cognitive impairment ICD code: G31.84 Date of diagnosis: 2003

2. Medical history ------------------ Describe the history (including onset and course) of the Veteran's TBI and residuals attributable to TBI (brief summary): In 2003, while deployed to Iraq, he fell from the rear of a truck, a distance of about 14 feet, and struck the back of his head. He was unconscious for an unknown period of time, probably minutes, and was dazed for a considerable period, has no memory until the next day. He noted an immediate change of personality, with extreme irritability, mood swings, which continue to the present time. He also has been diagnosed with PTSD. He also has noted balance problems and vertiginous episodes, had severe episode of vertigo in 2010. He has difficulty concentrating, has some difficulties with short-term memory. Brief neuropsych testing in 2011 showed deficits in short-term memory and sustained attention. No headaches. Smell and taste normal. He notes some problems with visuospatial orientation, has to use GPS while driving.

SECTION II: Assessment of facets of TBI-related cognitive impairment and subjective symptoms of TBI -----------------------------------------------------------------------------

1. Memory, attention, concentration, executive functions --------------------------------------------------------
[X] Objective evidence on testing of mild impairment of memory, attention, concentration, or executive functions resulting in mild functional impairment If the Veteran has complaints of impairment of memory, attention, concentration or executive functions, describe (brief summary): He notes problems with concentration and with short-term memory. Neuropsychological testing showed deficits in sustained concentration and short term verbal and visual memory.

2. Judgment -----------
[X] Normal

3. Social interaction ---------------------
[X] Social interaction is occasionally inappropriate If the Veteran's social interaction is not routinely appropriate, describe (brief summary): He is eaasily irritable and sometimes has explosive anger.

4. Orientation --------------
[X] Always oriented to person, time, place, and situation

5. Motor activity (with intact motor and sensory system) --------------------------------------------------------
[X] Motor activity normal

6. Visual spatial orientation -----------------------------
[X] Mildly impaired: Occasionally gets lost in unfamiliar surroundings, has difficulty reading maps or following directions. Is able to use assistive devices such as GPS (global positioning system) If the Veteran has impaired visual spatial orientation, describe (brief summary): He notes some difficulty with spastial orienteation and must use GPS while driving.

7. Subjective symptoms ----------------------
[X] Subjective symptoms that do not interfere with work; instrumental activities of daily living; or work, family or other close relationships. Examples are: mild or occasional headaches, mild anxiety If the Veteran has subjective symptoms, describe (brief summary): Memory and concentration problems, also personality changes and mood swings.

8. Neurobehavioral effects --------------------------
[X] One or more neurobehavioral effects that occasionally interfere with workplace interaction, social interaction, or both but do not preclude them If the Veteran has any neurobehavioral effects, describe (brief summary): He notes extreme irritability, mood swings, isolative behavior, sometimes has explosive outbursts of temper.

9. Communication ----------------
[X] Able to communicate by spoken and written language (expressive communication) and to comprehend spoken and written language.

10. Consciousness -----------------
[X] Normal SECTION III: Additional residuals, other findings, diagnostic testing, functional impact and remarks -----------------------------------------------------------------------------

1. Residuals ------------
Does the Veteran have any subjective symptoms or any mental, physical or neurological conditions or residuals attributable to a TBI (such as migraine headaches or Meniere's disease)?
[X] Yes [ ] No
[X] Dizziness/Vertigo
[X] Mental disorder (including emotional, behavioral, or cognitive)

2. Other pertinent physical findings, scars, complications, conditions, signs, symptoms and scars -----------------------------------------------------------------------------
a. Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms related to any conditions listed in the Diagnosis Section above?
[ ] Yes [X] No

b. Does the Veteran have any scars (surgical or otherwise) related to any conditions or to the treatment of any conditions listed in the Diagnosis Section above?
[ ] Yes [X] No

c. Comments, if any: No response provided

3. Diagnostic testing ---------------------
a. Has neuropsychological testing been performed?
[X] Yes [ ] No

If yes, provide date: 2011
Results: Deficits in sustained concentration and with short-term visual and verbal memory.   

4. Functional impact --------------------
Do any of the Veteran's residual conditions attributable to a traumatic brain injury impact his or her ability to work?
[X] Yes [ ] No
If yes, describe impact of each of the Veteran's residual conditions attributable to a traumatic brain injury, providing one or more examples:
His explosive temper outbursts have led to job terminations.

5. Remarks, if any: ------------------- Veterans neuropsychological deficits may be due in part to his TBI and in part to PTSD, and it is difficult to estimate how much each of these etiologies contributes.

 

...and that's it folks.

Let me know what you think!

Edited October 10, 2016 by commodog

[Gastone]

No problem with the Fiduciary appointment (per Question 7), that's good. You just can't work with people, currently. Dependent on your age, recent PTSD SC's are very seldom rated as T & P. VA MH Clinicians always believe (Think Job Security) improvement is possible with comprehensive  treatment.

If you haven't done so, File an IU FDC now, don't wait for the 70% PTSD " Inferred IU Claim" Award Letter. All your supporting Evidence is with the VA, so you should be able to get an FDC IU Award within 6 mos or less.

If you end up with a Scheduler or Combined 100% SC from your PTSD Rating, the IU Claim will be moot. All you'll be out, is the 1/2 Hr filing the IU FDC on your E-Ben site.

Semper Fi

[commodog]

5 hours ago, Gastone said:

No problem with the Fiduciary appointment (per Question 7), that's good. You just can't work with people, currently. Dependent on your age, recent PTSD SC's are very seldom rated as T & P. VA MH Clinicians always believe (Think Job Security) improvement is possible with comprehensive  treatment.

If you haven't done so, File an IU FDC now, don't wait for the 70% PTSD " Inferred IU Claim" Award Letter. All your supporting Evidence is with the VA, so you should be able to get an FDC IU Award within 6 mos or less.

If you end up with a Scheduler or Combined 100% SC from your PTSD Rating, the IU Claim will be moot. All you'll be out, is the 1/2 Hr filing the IU FDC on your E-Ben site.

Semper Fi

What I would like more than anything is even just TDIU for the purpose of allowing me more flexibility in getting treatment. I don't know if these symptoms will ever go away, and I'm sure some of you guys have been dealing with this crap for decades more than I have (I am 38, for the record), and are a little more clued in as to the 'permanence' of PTSD. I am fairly certain my TBI symptoms will never go away.

I'm working with the VA as much as I can in communicating my difficulties in life brought on by my symptoms. I've been going to my appointments and communicating with the doc as clearly and concisely as possible. I've been taking my meds religiously, and even those barely take the edge off.

What started this all, Gastone, was my application for TDIU.
I applied for that and appealed for Sleep Apnea.

Next thing i know, I am receiving a C&P for increase to PTSD and TBI.

So it started with me putting something like this in ebenefits:

Individual Unemployability (rep),
Sleep Apnea (rep)

Next week I check it and it says:

Individual Unemployability (rep), TBI (inc)
Sleep Apnea (rep), PTSD (inc)

Make sense?

[Gastone]

That's good, to a point. Did you actually file out the IU Claim Application where you list the last 5 yrs or so of employment and actual Earned Income for past couple years?

Did you list the employers that have terminated you, say over the last 4 yrs?

It certainly wouldn't hurt being proactive, filing the IU App with all the Employment & Earned Income info, could get a IU rating quicker.

Semper Fi