Ask Your VA Claims Question | Current Forum Posts | Search | Rules | View All Forums
VA Disability Articles | Chats and Other Events | Donate | Blogs | New Users
- 0
ptsd C&p Exam For Ptsd
Rate this question
Ask Your VA Claims Question | Current Forum Posts | Search | Rules | View All Forums
VA Disability Articles | Chats and Other Events | Donate | Blogs | New Users
Rate this question
Question
Navywife55
I am attaching a copy of my husband's c&p exam. I welcome any advise, because I don't see a GAF score as many on this site mention in their exams, nor do I see a statement from the Psychiatrist that did the exam stating " more likely than not". The Psychiatrist did suggest that my husband continue with Mental Health for further treatment. He mentioned that he did not make the final decision on the claim and told us the steps that should occur after the exam once it is sent to VBA. There are some detail things that my husband told the psychiatrist that I chose to leave out due to the graphic details.
Thanks for any advise.
1. Diagnostic Summary
---------------------
Does the Veteran have a diagnosis of PTSD that conforms to DMS-5 criteria
based on today's evaluation?
[X] Yes [ ] No
b. Medical diagnoses relevant to the understanding or management of the
Mental Health Disorder (to include TBI): Low testosterone and Vit D
3. Differentiation of symptoms
------------------------------
a. Does the Veteran have more than one mental disorder diagnosed?
[ ] Yes [X] No
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 occasional decrease in work
efficiency and intermittent periods of inability to perform
occupational tasks, although generally functioning satisfactorily,
with normal routine behavior, self-care and conversation
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
Clinical Findings:
Relevant Mental Health history, to include prescribed medications and
family mental health (pre-military, military, and post-military):
In-patient psych care for substance use in 96 (twice) and 2002
SATP in TVHS. Extensive treatemnt in TVHS initially for
substance use disorder and mood disorder. Currently, receiving care for
PTSD (MST) and depression.
d. Relevant Legal and Behavioral history (pre-military, military, and
post-military): DUI X 2
3. Stressors
------------
a. Stressor #1: MST - see above
Is the stressor related to personal assault, e.g. military sexual
trauma?[X] Yes [ ] No
If yes, please describe the markers that may substantiate the
stressor.
Marital discord; poor self esteem
Substance use (self medication: - see citation:Hein DA et al: Do Treatment Improvements in PTSD Severity AffectSubstance Use Outcomes? A Secondary Analysis from a Randomized
Clinical Trial in NIDA's Clinical Trials Network. Am J Psychiatry
2010; 167:95-101
4. PTSD Diagnostic Criteria
Criterion A: Exposure to actual or threatened a) death, b) serious injury,
c) sexual violatrion, in one or more of the following ways:
[X] Directly experiencing the tramuatic 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) occurrence
[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, distorted cognitions about the cause or consequences of
the traumatic event(s) that lead to the individual to blame
himself/herself or others.
[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.
[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.
5. Symptoms
-----------
For VA rating purposes, check all symptoms that apply to the Veterans
diagnoses:
[X] Depressed mood
[X] Anxiety
[X] Suspiciousness
[X] Flattened affect
[X] Disturbances of motivation and mood
[X] Difficulty in adapting to stressful circumstances, including work or a
worklike setting
6. Behavioral Observations
--------------------------
Withdrawn
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, if any
------------------
While depressive symptoms were elicited in Vet's examination today,
depression is not being diagnosed as a co-occurring disorder due to the
following:
In a seminal research, it was found that PTSD and comorbid PTSD/depression
are effectively one and same thing. The data suggest that depressive
symptoms are often integral to PTSD and that to separate depression out as
a distinct disorder when it occurs with PTSD is a somewhat arbitrary
distinction. The researchers concluded: "While PTSD and co-morbid
PTSD/depression are indistinguishable, the findings support the existence
of depression as a separate construct in the acute, but not the chronic,
aftermath of trauma".
Reference: O'Donnell ML, Creamer M, Pattison Phillipa: Posttraumatic
stress disorder and depression following trauma: Understanding
comorbidity. Am J Psychiatry 2004; 161:1390-1396
NOTE: VA may request additional medical information, including additional
examinations if necessary to complete VA's review of the Veteran's
application.
Link to comment
Share on other sites
Top Posters For This Question
2
2
1
1
Popular Days
Feb 23
5
Feb 22
1
Top Posters For This Question
Navy04 2 posts
Navywife55 2 posts
Tbird 1 post
john999 1 post
Popular Days
Feb 23 2014
5 posts
Feb 22 2014
1 post
5 answers to this question
Recommended Posts
Create an account or sign in to comment
You need to be a member in order to leave a comment
Create an account
Sign up for a new account in our community. It's easy!
Register a new accountSign in
Already have an account? Sign in here.
Sign In Now