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tylerb333

any opinions on this... have a claim for increase and TDIU

Question

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

    2. Current Diagnoses
    --------------------
    a. Mental Disorder Diagnosis #1: Posttraumatic Stress Disorder
         ICD Code: F43.10

       Mental Disorder Diagnosis #2: Opioid Use Disorder, Severe, In early
          remission, on maintenance therapy
         ICD Code: F11.20

    b. Medical diagnoses relevant to the understanding or management of the
       Mental Health Disorder (to include TBI):
       No response provided.
       
    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?
       [X] Yes  [ ] No  [ ] Not applicable (N/A)
       
           If yes, list which symptoms are attributable to each diagnosis and
           discuss whether there is any clinical association between these
           diagnoses: The veteran's symptoms are primarily related to his PTSD
           since he has not used substances in more than six months.
           
    c. Does the Veteran have a diagnosed traumatic brain injury (TBI)?
       [ ] Yes  [X] No  [ ] 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)
       
       [X] Occupational and social impairment with reduced reliability and
           productivity

    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?
       [X] Yes  [ ] No  [ ] No other mental disorder has been diagnosed
       
           If yes, list which portion of the indicated level of occupational and
           social impairment is attributable to each diagnosis: The veteran's
           impairment is related to his PTSD.
           
    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

 

  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).

       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, distorted cognitions about the cause or
                       consequences of the traumatic event(s) that lead the
                       individual to blame himself/herself or others.
                   [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] 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] Disturbances of motivation and mood
       [X] Difficulty in establishing and maintaining effective work and social
           relationships

    5. Behavioral observations
    --------------------------
       The veteran arrived 10 minutes late for his appointment and was pleasant
       upon meeting. The veteran was oriented to person, place, situation, and
       time. His grooming and hygiene were adequate. He made appropriate eye
       contact and presented with a depressed mood with a congruent affect. His
       speech was within normal limits for tone, volume, and rate. His thoughts
       were logical, linear, and goal-directed. He did not evidence any 
psychotic
       symptoms, including responding to auditory or visual hallucinations and
       delusional beliefs.
        
       On a brief mental status exam he was able to freely recall two of three
       words presented after a brief delay. He was able to recall six digits
       forward and three digits backward. He was able to complete a serial seven
       subtraction task with no errors to seven places. He was able to spell the
       word WORLD forwards and backwards. He was able to complete a two-digit
       addition and subtraction tasks. He was able to compare an apple and 
banana
       and was able to reason abstractly when comparing a poem and a statue. His
       response to the proverb "don't cry over spilled milk" was good. He was 
not
       able to provide a response to the proverb "people in glass houses should
       not throw stones."
       
       
    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:
    ---------------------------------------------------
       The veteran was administered a psychological measurement that is useful
       for interpreting the veracity of other data provided by an examinee 
during
       a psychological or neuropsychological examination. This assessment can
       assist in evaluating and making a clinical opinion regarding the veracity
       of an examinee's purported symptoms. Research has determined that this
       tool is a useful instrument to administer in order to screen for possible
       feigning of PTSD symptoms. The following results should be interpreted in
       light of the fact that the measurement that was chosen is a screening 
tool
       and not designed as a definitive measure of whether or not an individual
       is feigning mental illness. The Veteran's total score was not elevated
       beyond the cut-off score. Therefore, his PTSD symptoms are considered to
       be credible. 

       The veteran was administered the Minnesota Multiphasic Personality
       Instrument-2-Restructred Form (MMPI-2-RF), which is a self-report
       psychological assessment used to identify a variety of psychological
       syndromes. The veteran was provided a quiet, private room to complete the
       testing. It appears the veteran understood the items and responded to the
       items in a consistent manner. The veteran over-reported psychological
       dysfunction, which is evidenced by a considerably larger than average
       number of infrequent responses. The veteran also possibly overreported
       symptoms associated with non-credible memory complaints. Although there 
is
       evidence of over reporting of symptoms, the profile is considered valid
       and will be interpreted.

       Overall, the veteran endorsed considerable emotional distress that is
       likely perceived as a crisis. The veteran reported feeling sad and
       dissatisfied with his currently circumstances. He reported a lack of
       positive emotional experiences, a lack of energy, and a lack of interest
       in activities. He also reported experiencing various negative emotional
       experiences including anxiety, anger, and fear. The veteran also reported
       a significant history of antisocial behavior. This behavior includes
       involvement with the criminal justice system, difficulty with authority
       figures, conflictual interpersonal relationships, impulsivity, juvenile
       delinquency, and substance abuse. The veteran also endorsed various
       unusual thought and perceptual processes.

       The veteran endorsed a diffuse pattern of cognitive difficulties 
including
       memory complaints. He also reported past suicidal ideation and feelings 
of
       helplessness. The veteran endorsed feelings of anxiety, being anger 
prone,
       and experiencing multiple fears that restrict his activity inside and

       outside of the home. He also reported being unassertive and shy. The
       veteran endorsed not enjoying social events and avoiding social
       situations. He also reported disliking being around people. On a scale of
       personality pathology, the veteran endorsed being self-critical and
       guilt-prone. He also endorsed being pessimistic and feeling depressed.

       The veteran is currently diagnosed with Posttraumatic Stress Disorder and
       Opioid Use Disorder, Severe, In early remission, on maintenance therapy.
       The veteran currently lives alone and is not involved in a romantic
       relationship. He maintains phone contact with his daughter. He has a 
close
       relationship with his mother, sister, and two friends. He is currently
       working for his mother's company. He reported experiencing symptoms of
       PTSD. He is attempting to cope with his emotions without the use of 
drugs.
        

       The veteran has been employed numerous times and has been fired for
       tardiness or alcohol and drug use. He is currently working 5-6 hours per
       week for his mother's company. According to the previous C&P exam, he is
       not able to work many hours due to not being permitted to work inside of 
a
       bank due to his felony record. The veteran reported that he was "working"
       during his 10 years in prison selling drugs. He denied having any
       difficulties while in prison. The veteran is capable of following
       instructions and performing simple tasks. He is able to concentrate on a
       simple task and respond appropriately to coworkers and supervisors.  


       
       

 
/es/ ALLISON C HOULE, PHD
C&P Psychologist 

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you got a lot of good info working for you  And then there is a little bad

info but the Dr may have help you out. Its more good than bad. I just didn't

see where he address whether you are not able to work or not . I may have miss it

but Good luck

Edited by porgee

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at the end it says:

    The veteran has been employed numerous times and has been fired for
       tardiness or alcohol and drug use. He is currently working 5-6 hours per
       week for his mother's company. According to the previous C&P exam, he is
       not able to work many hours due to not being permitted to work inside of 
a
       bank due to his felony record. The veteran reported that he was "working"
       during his 10 years in prison selling drugs. He denied having any
       difficulties while in prison. The veteran is capable of following
       instructions and performing simple tasks. He is able to concentrate on a
       simple task and respond appropriately to coworkers and supervisors.  

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This statement could be a problem "The veteran reported that he was "working"
       during his 10 years in prison selling drugs. According to the previous C&P exam, he is
       not able to work many hours due to not being permitted to work inside of 
       a bank due to his felony record
.

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My boss is going to write a supportung statement claiming that that just isnt true.  I have full time work available, 40 hours a week, buy due to my back ailment and ptsd symptom as well as meetings, groups, therapy and physical therapy i am not able to work full time

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2 minutes ago, tylerb333 said:

My boss is going to write a supportung statement claiming that that just isnt true.  I have full time work available, 40 hours a week, buy due to my back ailment and ptsd symptom as well as meetings, groups, therapy and physical therapy i am not able to work full time

Don't post everything on an open forum for everyone to see, keep somethings to your self just 

a word of advice but Good luck

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