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Question
InbetweenIraqandahardplace
Hello first time poster but have been frequently been on this site the last few months. It has been very helpful and im hoping you guys with some more knowledge can help me out one more time.
I went to my C&P exam on the 1st of March and learned i could get my c&p notes (which i learned on this site i could through the blue button) after reading it im utterly shocked. Basically i feel as if he thought i was making this up or playing it up. To be honest im pretty offended and feeling much defeated right now. I personally didnt want to go through any of this but after my tinnitus got worse i went to my VSO we did the claim and i started receviving 10%. My wife which knows the issues i go through then finally urged me to get some real help for myself and put a claim in for my ptsd. I was very relutncant to talk to my VSO about my stessors but still went through with it. Same for my C&P i was very nervous talking about these things with a complete stranger but i knew it had to be done and i wanted to be best prepared hence why i came to this site.
Once arrived he wouldnt let my wife enter which i was hoping could come in for support but she couldnt and i understand that part. We then had a 22 minute c&p where his only words throughout were "i see" or "what happen after that?". I thought he was very dry and somewhat stand offish but at the same time im sure thats in his job description.
I was completely honest about everything and even got emtional while talking to a stranger about these experinces he basically said he had suspicsion. I just dont get it. Its hard for me to believe in this system that isnt believing me. Im sure there is an appeal process but do i really want to put myself out there for another stranger in hopes that the contadict a fellow doctor?
Theres also a contradiction in there where he says i claim i was in iraq from jan 2003 til march 2005. He corrects it saying i was the from Jan to March 2005. When neither of those are true i said Jan 2004 til March 2005 which is true and can be easily proven. On my stressor for april 20th he said "i helped the injured" which is true just way less descriptive that i removed a mans arm and he died anyway, i had to scan eyeballs from a makeshift bag of body parts. All these things he barely asked which were in my orginal stressor statment.
Im very lost and i know this is very lengthy but i hoping just one person can take a look at my c&p below and tell me what they think. How much does a c&p weigh in the final decision? What percentage if any? What i should do next?
Thank you very much for anyone that can help
Initial Post Traumatic Stress Disorder (PTSD) Disability Benefits Questionnaire * Internal VA or DoD Use Only * 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 2. Current Diagnoses -------------------- a. Mental Disorder Diagnosis #1: No diagnosis Comments, if any: The veteran was administered the MMPI-2-RF, although it appears he understood and responded to the items in a consistent manner, the remainder of the profile is not able to be interpreted due to an over-reporting of symptomatology that is not common even in individuals with known severe psychopathology. There are a number of potential reasons for this profile to include it being a "plea for help", it may be a phenomenologic style to over report and to be traumatized (this pattern is frequently seen in Dependent and Histrionic Personality Disorders and Depressive Mood Disorders) or the individual is trying to look worse than they are for some secondary reason. Unfortunately it is impossible to determine the reason behind this pattern of responding in this case without resorting to speculation. The fact that no diagnosis is offered should not be used as an indication that the veteran does (or does not) have a psychological diagnosis, but rather it is not possible to determine the presence (or absence) of any diagnosis or the severity of any symptom or level of functioning without resorting to speculation. The Hospital treatment records indicate the veteran has reported having suffered from anxiety since he was a teenager, the same records suggest some oppositional and anger issues. Unfortunately any treatment notes from his childhood have not been admitted for review it may be beneficial to attempt to obtain copies of his treatment records with Mr. Robinson as the Hospital treatment records indicates this is the individual who treated him as a teenager. b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): see medical record 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) No response provided. 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 [ ] No [X] No diagnosis of TBI SECTION II: ----------- Clinical Findings: ------------------ 1. Evidence Review ------------------ Evidence reviewed (check all that apply): [X] VA e-folder (VBMS or Virtual VA) [X] CPRS [X] Other (please identify other evidence reviewed): The veteran brought in some paperwork for me to review, he was encouraged to give the paperwork to his BSO so that it could be submitted VBA included in his VBMS file. The records contains several Internet printouts detailing different events that occurred at Abu Ghraib during the period of time the veteran's unit was assigned there. It also contained information already in the VBMS file - the notes from the 2007 two day hospital admission. There was also a letter from the veteran's employer detailing her observations of his "behaviors and character traits which prevent me from employing Kris as a full-time employee." Her letter notes that he can be confrontational with other staff and although they are typically verbal they can need to a "disruption of the social climate within the workplace." She notes the veteran can be "selective about the task he performs in that such tasks are usually once allow him to work alone from the other staff members." The veteran apparently no longer drives himself in this presents an inconvenience as it appears other employees have to provide him transportation. He apparently has an above average rate of absenteeism as compared to the other staff members. It is for these reasons she is not able to employ him on a full-time basis, in addition she has to be selective as to which employees are impaired to work with the veteran. Evidence Comments: The veteran's electronic medical records (CPRS & VistAWeb) were reviewed. The veteran was referred for a compensation and pension examination. The veteran was informed verbally of the nature and purpose of the examination and confidentiality limits. He appeared to have a basic understanding of the purpose of the examination and confidentiality limits. He was provided with a chance to ask questions about the evaluation procedures. All questions were answered to reasonable satisfaction or referred to other resources. He was informed that this examiner is not his treating clinician or the legal determiner of compensation or pension benefits. Instead, he was informed that this examiner is an independent provider of clinical information and expertise to assist those who review and make legal compensation and pension claim decisions and would not be participating in his healthcare. He was given information about the Veteran's 24 hour Crisis Line. The veteran indicated understanding of these terms and explicitly and freely consented to the evaluation. The judgments of symptoms and opinions in this evaluation report are offered to a reasonable degree of psychological certainty and are only based upon the information available at the time of the evaluation. The DSM 5 criteria have been considered in this evaluation. This report was dictated using Dragon Naturally Speaking dictation s oftware, the report has been proofread however due to time constraints there still may be some typographical errors due to the nature of the dictation software. 2. History ---------- a. Relevant Social/Marital/Family history (pre-military, military, and post-military): The veteran is a 32-year-old married male, he and his wife have been married for the past 4 years when asked about his relationship with his wife currently he says it is "not great." The veteran said "I don't share a lot, I was an only child and don't share a lot, just stuck with me. I do better alone. I love my wife ... just quirks." The veteran and his wife have 2 children together ages 2 and 1. The veteran also has an 11-year-old son from a previous marriage. The veteran says he has visitation every other weekend and during the summers. The veteran says he is an only child but then qualified by saying "I have a half-brother, but I don't know where he is." Apparently his half-brother is from his father's later marriage however he has not had any contact with this half sibling in the past 17 years, prior to this they only had sporadic contact. The veteran says his parents divorced "when I was very little, I was a baby." The veteran lived with his mother, she remarried when he was 7 years old he got along well with his stepfather however they divorced when the veteran was 20 years old. He maintains a good relationship with his mother. The veteran says he has not had any contact with his father for "at least 10 years, he said he had only minimal contact with his father during his childhood. [The November 2007 psychiatric hospitalization notes indicates that his father may have shot himself; however the records also indicate that it may have been a paternal great grandfather who committed suicide by gunshot. He saying notes indicates that the veteran's father lived in Florida and had been in jail for domestic violence issues. Employing that his father was never around and often gave him hope false hopes apparently however he said that he and his father talked on the phone every day but it tended to be mostly sports orientated conversation.] When asked to describe his childhood the veteran says it was "pretty good, my mom provided well for me." He denied a history of physical or sexual abuse. b. Relevant Occupational and Educational history (pre-military, military, and post-military): Veteran graduated from high school in 2003, when asked how he did in school he said "not well, I just never showed" up to classes. The veteran says his mother never knew about it because "I had a good system" ? he had friends who worked with the attendance records and would remove his name from the absence list. The veteran said that "in between my junior and senior year I went to basic training, after that I just kind and knew what my future would be." He says he only needed a half of a credit to graduate so he really was not missing very much class. He denied ever repeating any grades or participating in any special education services. He described himself as being active on the baseball team as well as being a member of the choir while in high school he had a job working for Wendy's. The veteran says he decided to join the military because of September 11. The veteran says he decided to join the Reserves over active duty because "I didn't want to leave home." The veteran served in the Army Reserves from December 2001 until March 2005, his MOS was 71L, administration. He was honorably discharged with the final rank of E-4. The veteran says he was deployed to Iraq from January 2003 until March 2005 [His service records suggest he was active from January until March 2005]. Following his discharge from the military the veteran says he had a couple of jobs under the table saying "I bartended. I was delusional and thought I could play cards at the time." Apparently he played poker trying to make a living at this however apparently this did not work out the veteran said "for a while I didn't do anything. A low point where I didn't do anything." He says this low point occurred between 2006 and 2008/2009. After this the veteran said "I was going from job to job, I was selling phones, I went to every phone company." The veteran says since 2011 he has been working at a pizza shop 3 days a week from 8 AM to 1 PM where he makes pizza though. He got this job through some friends. The Hospital treatment records from November 2007 just that the veteran may have been trying to reenlist into the military shortly before being hospitalized. The records indicate that he went to the point of having "a going?overweight party, got rid of his apartment and his car, and just found out he could not really?enlisted because of a past domestic violence charge of years ago." Records go on to note "the patient reports that he was counting on leaving 12/03/2007, and that this was a very big blow to him." The record also continues by saying "the patient reports on top of this, he realizes that it is not right he has been unable to work over the last year and a half, and he has become frustrated." Prior to being admitted to the hospital he had gotten into a verbal fight with his mother and girlfriend. He had gone to a MBA basketball game earlier in the day and had a couple of drinks and came home feeling just over well. He was feeling helpless and hopeless with sporadic sleep and nightmares especially since returning back from Iraq. c. Relevant Mental Health history, to include prescribed medications and family mental health (pre-military, military, and post-military): The veteran says he does not currently participate in any psychological treatment. He is not prescribed any psychiatric medication. The veteran says he used to see a counselor but his counselor (Paul Robinson) had to close his practice after being diagnosed with older people sclerosis. The veteran says he started seeing this counselor after he was admitted to the hospital in November 2007. [The hospital admission records actually indicates the veteran has reported a history of anxiety since she was a teenager "possibly even some oppositional and anger issues apparently he was court ordered as a teenager into drug and alcohol counseling with Mr. Robinson the veteran also reported apparently having reinitiated some counseling with Mr. Robinson for about one year it is then when Mr. Robinson had to close his practice]. The veteran said he had been prescribed Wellbutrin but he stopped taking that sometime in 2012 because "that was making me zombified." He got the prescription when he was hospitalized. The veteran says he did not pursue treatment because "I was ready to put the stuff behind me or at least try." The Hospital treatment records from November 2007 just that the veteran may have been trying to reenlist into the military shortly before being hospitalized. The records indicate that he went to the point of having "a going?overweight party, got rid of his apartment and his car, and just found out he could not really?enlisted because of a past domestic violence charge of years ago." Records go on to note "the patient reports that he was counting on leaving 12/03/2007, and that this was a very big blow to him." The record also continues by saying "the patient reports on top of this, he realizes that it is not right he has been unable to work over the last year and a half, and he has become frustrated." Prior to being admitted to the hospital he had gotten into a verbal fight with his mother and girlfriend. He had gone to a MBA basketball game earlier in the day and had a couple of drinks and came home feeling just over well. He was feeling helpless and hopeless with sporadic sleep and nightmares especially since returning back from Iraq. d. Relevant Legal and Behavioral history (pre-military, military, and post-military): The veteran denied significant behavioral problems while in school other than "my absence as my senior year." He admitted to receiving an article 15 while in a rat saying "me and another guy got into a tussle, and a knife got brought into play." The veteran says he was upset with the other soldier "not doing his job" The veteran says he was arrested for domestic violence but the charges were reduced to negligent assault." Apparently the veteran and his girlfriend at that time had broken up however he claims they were still sharing an apartment, he came home one night earlier than he normally did to find her with her new boyfriend area and apparently the veteran brandished a gun [in the material provided by the veteran for my review today there are copies of the police report. The police report suggests the veteran actually went looking for his ex-girlfriend finding her over at her friend's house. The police report indicates that the veteran was described as choking his girlfriend as well as having made threats with a gun to his ex-girlfriend. This occurred on 07/05/2006. The hospital records indicates he had a driving under the influence charge as well as other charges as a minor, these are apparently the charges that led to the court ordered treatment with Mr. Robinson] e. Relevant Substance abuse history (pre-military, military, and post-military): When asked about his current alcohol use the veteran said "I don't really, once or twice a year." The veteran said he would drink "when I go out, if I go out, but I don't go out much." When asked how much he drinks when he drinks the veteran said he will have "6 beers, I don't drink a lot if I do not drink" he says he has not drank since this past summer after the basketball championship game. The veteran denied any current drug use but did admit to having smoked marijuana when he was younger. He says he quit in 2010 because his wife, then girlfriend "just got me to" quit. The veterans Hospital treatment records indicates he was using marijuana quite significantly smoking on a daily basis between 1-8 "blunts" a day estimating there were 3 joints and everyone "blunt." At the time of the hospital admission he was also drinking about twice a week drinking 5-6 beers at a time. He admitted sometimes he would overdo his drinking but he attributed that to the fact he worked as a bartender. The veteran had been drinking and smoking marijuana since the age of 15.] f. Other, if any: ----------------------------- | Note | ----------------------------- **IMPORTANT NOTE** ---> There is a glitch in the DBQ reporting software such that if the examiner does not check off any of the boxes in Section II, Number 4 ("PTSD Diagnostic Criteria") [below], because the Veteran does not exhibit those symptoms, the software will produce "No response provided", which makes it sound as if the examiner simply forgot to answer those items, which is not the case. In this instance the software should, instead, produce something like, "The veteran's responses on the objective psychological testing do not allow for this section to be completed without resorting to speculation." ----------------------------- | Note | ----------------------------- **IMPORTANT NOTE** ---> There is a glitch in the DBQ reporting software such that if the examiner does not check off any of the boxes in Section II, Number 5 ("Symptoms") [below], because the Veteran does not exhibit those symptoms, the software will produce "No response provided", which makes it sound as if the examiner simply forgot to answer those items, which is not the case. In this instance the software should, instead, produce something like, "The veteran's responses on the objective psychological testing do not allow for this section to be completed without resorting to speculation." 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: The veteran says there are 5 or 6 potential traumatic events from his military service however he says his VSO has encouraged him to focus on the 3 "major ones." The veteran says on 04/20/2005 the prison was mortared, he says 22 people were killed in 93 people were injured (the descriptions he provided from the Internet suggest these were all prisoners, no American service members appear to have been injured). The veteran says he had to provide aide to some of the injured. 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: Veteran says there was another situation where they were unloading prisoners from a helicopter when they ordered. He said every once gathered. The veteran says he and his friend assisted a 12-year-old prisoner who was shot in the back. They said they had to carry him "a little over a mile" to try to get to the infirmary however the child died during the trip [the veteran says he has never told this story to anyone else but his VSO as he does not like to think about this story. He did become rather emotional when discussing this event] 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 c. Stressor #3: The veteran says that before operation Iraqi Freedom Saddam Hussein use the prison as a place where he conducted mass executions. Apparently many of the victims were buried on site and the veteran says the weekend would uncover skeletal fragments of these individuals that had been killed years before. Does this stressor meet Criterion A (i.e., is it adequate to support the diagnosis of PTSD)? [ ] Yes [X] No Is the stressor related to the Veteran's fear of hostile military or terrorist activity? [ ] Yes [X] No Is the stressor related to personal assault, e.g. military sexual trauma? [ ] Yes [X] No d. Additional stressors: If additional stressors, describe (list using the above sequential format): The veteran also described another situation where his job duties required him to verify and individuals identity via a retinal scan. He says one time he was brought a large body bag that he thought contained just one individual however he says there were multiple body parts and he had to do the retinal scans to try to identify who had been killed. 4. PTSD Diagnostic Criteria --------------------------- No response provided. 5. Symptoms ----------- No response provided. 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 -------------------------------------------------- On a brief mental status exam he was able to freely recall 3 of 3 words presented after a brief delay. He was able to recall 4 digits forward and 4 digits backward. He was able to complete a serial 7 subtraction task with no errors to 7 places. He was able to spell the word WORLD forwards and backwards. He was able to complete simple 2 digit addition and subtraction. His responses to proverbs were fair (GLASS HOUSE - "hypocritical" and SPILLED MILK - "like a wussy, soft I guess"). He denied current suicidal and homicidal ideations. The veteran says he was suicidal in 2007 because "I was pretty bad." He says he has not had suicidal ideation although he said "I do think about death a lot, like when I'm gone, the story I leave behind." He denied hallucinatory experiences. When asked to describe his mood on most days the veteran's said "a lot of people call me pessimistic. I'd say I'm more mad than anything. I don't want to have the problems I have. I'm mad at my luck." When asked what for him from seeking treatment previously particularly following his discharge from the inpatient hospitalization the veteran said "I don't want to talk about this stuff to more people I don't know. I don't share any of this with my wife." When asked what changed to cause his recent reconsideration the veteran said "now that we have 2 daughters I can't afford to get help but I oh it to my wife, but I don't know if I'll get any better" even if he does participate in any treatment. The veteran says he does not do much during the day saying "I'm pretty tired, I'm not sure if it's old age or if my sleep seems caught up." The veteran says he does not sleep "very well at all. I have a very hard time just getting to sleep." When asked what types of things prevent him from sleep the veteran said "I think about some things", he says he typically thinks about "events from the day and events from the past, I'll pull it apart." The veteran says that he is wife and he have noticed he has a pattern where he will sleep for 3-4 days for 4-5 hours at night he then sleeps one day for about 14 hours only to have the pattern start over. When asked if he has any dreams or nightmares said "probably, its not every night, probably 2-3 nights a week." He says the dreams typically involve the same scenario "I'm always with my family, I can see things I seen in Iraq but they can't." He offered an example that in his dream he may be with his family and he sees things/body parts coming out of the sand but nobody else can see them. The veteran says he has some good friends but he does not see them very often saying "if they wanted to come over to my house that would be cool" but apparently they would rather go out. He says when they do get together they typically watch sports together. The veteran was administered the MMPI-2-RF, although it appears he understood and responded to the items in a consistent manner, the remainder of the profile is not able to be interpreted due to an over-reporting of symptomatology that is not common even in individuals with known severe psychopathology. There are a number of potential reasons for this profile to include it being a "plea for help", it may be a phenomenologic style to over report and to be traumatized (this pattern is frequently seen in Dependent and Histrionic Personality Disorders and Depressive Mood Disorders) or the individual is trying to look worse than they are for some secondary reason. Unfortunately it is impossible to determine the reason behind this pattern of responding in this case without resorting to speculation. The fact that no diagnosis is offered should not be used as an indication that the veteran does (or does not) have a psychological diagnosis, but rather it is not possible to determine the presence (or absence) of any diagnosis or the severity of any symptom or level of functioning without resorting to speculation. NOTE: VA may request additional medical information, including additional examinations if necessary to complete VA's review of the Veteran's application. /es/ David J Dietz, PhDLink to comment
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