ptsd C&p Exam Contradicts Matters Of Record

[Ethan'sGrandma]

Hello All,

I received a copy of my C&P and it blows my mind!! The doctor had asked very little questions, none seemed pertinent, but he sure came up with a lot of answers, without any true knowledge, nor an apparent true review of the file, even though he notes he did a review of it. Additionally, he did not concede the PTSD, even though it is one of the reasons for my ongoing treatment outside of the VA.

What really bothers me is that he put so much erroneous information in the exam report, it almost seems as if falsifying information, to make it all fit. For example, I have not worked since 2000, receiving SSA disability, but he notes "Employment: time lost from work--few hours...mild effect on social functioning and no effect on employment." That statement alone should speak volumes even to the VA who is aware that I am on disability that there is something seriously wrong with the exam, never mind all the other outright errors (lies) the doctor could not have possibly gotten from information from me, or my file. Of course, I've not heard anything more from them regarding the pending appeal.

What boggles my mind is...why? Why would a doctor make a report that, obviously, does not even fit the record? Wow, that is scary for even the new regs regarding PTSD if determined by a VA doctor. Obviously, by this example, a doctor can say pretty much anything they want, even when it's not matching what is already on record. So, how are we to dispute it? I have sent the VA a letter making note of what is contradictory, stating the exam was inadequate, and requesting another exam. Only time will tell if it will be arranged since it took six months just to be able to get a copy of the exam report.

So, does anyone have any experience in matters such as this? If so, what is the usual protocol? Will the VA go by this flawed exam, regardless of what else is on record? I am so upset about this, I'd like to send a copy, a copy of the contradictions of the exam with matters already of record, to the top VA man and ask how do they allow this? How do they allow a doctor like this to examine veterans? In any case, thanks much for any information anybody can share with me.

[Ethan'sGrandma]

Hello and Thank You for your response, again, Carlie. I am going to post on here some of what's written in my latest SSOC. My copier is not functioning, so I can't copy to here, so will type in the pertinent sections. The last SSOC is dated from Sep., 2009. After a NOD for that, due to some missed information, it triggered a C&P exam for me in Feb., 2010. I will omit some very personal information from it, due I am not able to have it on a public website. Also, some notes in parenthesis are mine. If you get a chance to view this, or comment, I'd appreciate it. Thank you very much.

DECISION: Service connection for PTSD and depression is denied.

Reasons and Bases:

A statement of the case was issued on August 8, 2008, advising you of the evidence considered and the reasons and bases for the denial of service connection for PTSD (abbreviated by me) and depression. You stated that you felt your complete file was not reviewed because your request for reassignment was not noted in the Statement of The Case dated August 8, 2008. Review of DA Form 4187...noted you volunteered for Foreign Service which was disapproved due to shortage of personnel within your unit. Treatment records from...noted that you had been suffering from major depressive disorder, recurrent, severe with psychotic features, and a schizoaffective disorder for years (VA missed the PTSD diagnosis, also, from medical records). It was noted that you were medically retired retired from...on March 1, 1996. Treatment records from...Army Hospital for the period 1/83 through 4/83 noted...that you had depression, anxiety, were unable to cope, and episodes of obsessive ideation toward your children. You also had thoughts of self harm, and were hospitalized. Statement dated May 21, 2009, from...noted that she had known you since Spring 1977. Ms....noted that you had confided with her about...Ms....attested "you did not sound the same after..., as you had entered into anxiety and depression." At your hearing...you reported that your stressful event while in the military was...You reported that you had complained of anxiety and depression to the TMC in 1979, but it was a PFC and nothing was done. You reported that was the only time you were treated for anxiety in service. (my military exit exam also notes the issues I was still having). You reported the actual treatment for anxiety and depression started in 1982. Although DA Form 4187...noted that you volunteered for foreign services, there was still no evidence of increased use of leave with no immediate reason, changes in performance evaluations, or disregard for military or civilian authority (parts of this last sentence were rebutted in the NOD before the C&P was scheduled). Also, there was no documented treatment for, or diagnosed mental disability shown in your service treatment records. The claim for service connection for PTSD and depression remains denied.

From the previous SSOC in August, 2008 which connect to the Sep, 2009 one:

Decision: Service connection for PTSD and Depression is denied.

Reasons and Bases:

Service connection for PTSD may be granted when the following criteria has been met: There is medical evidence diagnosing the condition in accordance with the guidelines established in the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association; There is evidence that shows a link between current symptoms and in-service stressor; and there is credible supporting evidence that the claimed in-service stressor occurred.

You report that you have PTSD and Depression as a result of...trauma that occurred while you were in the military. In your stressor statement you indicated that you experienced...trauma from...Your statements regarding the...trauma are plausible, however to service connect PTSD there must be credible evidence to support your assertion that the stressful events occurred. This does not mean that the evidence must actually prove that the incident occurred, but rather that the weight of evidence is positive to the extent that a reasonable doubt is shown. The complete evidence of record was reviewed. There was no evidence available from sources such as civilian police reports, reports from crisis intervention centers, testimonial statements from family members (yes, statement from family member and treating social worker, but not noted here, although family member statement noted later in SSOC). or clergy, and no copies of personal journal or diary entries from you.

Available medical evidence notes history of bipolar and schizoaffective disorder in 2002, when you began to receive care at the VAMC (again, missed the PTSD diagnosis from prior to VA care). In 2002 you also reported that...In 2006 your mother wrote a letter stating that she baby sat for your first child in 1979 and could recall having conversations with you indicating that you confided in her of...

Indicators of behavioral changes or "markers" as they are sometimes referred, are often clues which assist in determining whether the preponderance of evidence provides that a traumatic incident occurred. For the purposes of reviewing the evidence regarding a claimed..., any changes in behavior while on active duty subsequent to the claimed...are considered. The DA201 service personnel file was negative for findings of sudden requests for change in MOS or duty assignment (It was there as I found it when VA sent me a copy of file after my request for the copy), increased use of leave with no immediate reason (rebutted this statement), changes in performance evaluations, or disregard for military or civilian authority. ...Your Service Medical Records were also considered. There was no documented treatment for, or diagnosed mental health disability noted in your SMRs (I was never treated for my chief complaint, nor referred to Psych. for the symptoms). It is noted on April 9, 1979, that you reported being nervous and depressed. You were assessed to have a tension headache, and treated for this, with no further changes in behavior, or any additional unexplained medical or psychiatric episodes noted prior to your discharge (it was noted in my exit exam from service which followed later that year).

After a review of the behavioral indicators with all the available stressors, there remains no positive weight of evidence to support the conclusion of a stressor while in military service...The service personnel file provided negative findings regarding your period of military service (the missed items), including after the reported episodes of...There were no sudden changes in performance, and you received no adverse counseling or disciplinary actions. The service medical records contained no findings of any unexplained physical phenomenon or psychiatric symptomatology (wrong information here since that was the reason for my visit to the TMC). Although there is one notation, documented in your SMRs, where you reported nervousness and depression, the date of the report is noted to be at the time that your mother was ill and unable to care for your infant child, and you were seeking a hardship discharge (VA got the dates of the SMRs report wrong although clearly noted in the SMR, as well as my request for reassignment, which came before my mother's illness, which had nothing to do with what happened to me prior to, or my request for discharge later). Without credible supporting evidence of a claimed stressor during military service and a link between the evidence and a diagnosis of PTSD (I already carried the diagnosis of PTSD for years, which VA missed from my medical files, which I re-sent to them and pointed it out from my personal copies with my NOD), the claim of service connection must be denied.

[carlie]

EG,

This pretty much sounds like some of my denials for PTSD due to MST.

I'm still fighting this one.

Without being able to read everything verbatim from the Reasons and Bases

it makes it more of a guessing game to try and figure a way to go.

Oh - also check out the Evidence Sections real close too, you don't need to post it here just

check over and note for yourself what evidence they missed in the decisions, SOC and SSOC's.

It does seem like an awfully long time.

Have you considered trying to see the or speak with the VSCM (Veterans Service Center Manager)

at your VARO ?

[Ethan'sGrandma]

Thank you, again, Carlie, for your input. My claim is also MST which is why I didn't post the actual personal stuff in the website...can't deal with that idea, yet. Yes, it's gone on quite some time and I'd just like for the VA to get it moving to the BVA, if they are not going to reconsider any evidence, so I can get on the docket, before too many more years go by. I sent them the latest reports from my doctors (both VA and civilian) just a couple of days ago and am confident that they are favorable to my claim, but doesn't mean VA will agree. Today I phoned the 800# to see if I could obtain a status and suffice it to say the lady answering must not have been having a very good day, even as I was courteous, respectful, and what have you. She did clarify for me the actual date of my Form 9 appeal, being much longer than I thought, without searching through the masses of papers that I have regarding this claim, never mind that exact dates are not part of my memory now.

I thought it'd been 1-1/2 years, but her records show it was submitted in 2007. When asked why my claim has not moved to BVA, she stated that VA is not sending any more cases to BVA because they are swamped? I'm aware that the whole system is backlogged, but can this be true? I am out of Indiana, and am lucky to get through to the 800#, not even ever close to getting the Service Center Manager on the phone to speak to him. The RO is about 3-1/2 hours from me, so no real chance of me paying a visit in person, even if somebody were willing to talk to me. I made the trip back in July, 2009 for the RO hearing, but would not think to attempt that again. since it was an additional hardship to me whose agoraphobia is coming back again, more and more, so can't imagine further risk with what I consider such a longer trip than just making it to my local appointments. Tomorrow, I have an appointment with my Vet Center counselor, who has stated she will also prepare a packet for me from my visits there to send to VA as additional evidence. I don't know how VA will view any more information than they've already gotten, but it can't hurt, since it was there that I was given written tests regarding the issues.

Well, don't know where this claim will end up, never can be sure, but will persist and not give up this fight, until the end of my life, or until my claim reaches the highest level of appeals and I am still denied. It's not supposed to be a fight, but it feels that way to me because much of the stuff they needed is there, but it's either been omitted, or disregarded, which feels like being invalidated some more, but am gonna keep at it. I'm grateful for this website and what I can learn from others, such as yourself. Thank you much, Carlie, for all your input.

[sharon]

http://www.theveteransvoice.com/VA-Manual-for-PTSD-Compensation-and-Pension-Exams.html

This should help.

[carlie]

I made the trip back in July, 2009 for the RO hearing, but would not think to attempt that again.

EG,

What issues were involved with this RO Hearing ?

Did it include PTSD ?