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: CH PTSD b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): PARKINSON'S, HIGH TRYGLYCERIDE. HEARING LOSS.
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) [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 [ ] 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): STRESSOR NOTE.
Evidence Comments: TALKED WITH HIS WIFE MELINDA. SHE STATES THAT GRADUALLY HAS BECOME MORE IRRITABLE, LOOSES HIS TEMPER VERY EASILY, SNAPPS AT HIS KIDS, ARGUMENT. AT NIGHT HE IS RESTLESS IN BED, YELLING AND STARTS SWINGING HIS HANDS AND FEW TIME HE HIT HER IN THE SLEEP. WHEN HE IS OFF MEDS, HE IS MORE WITHDRAWN, LESS ACITVE PHYSICALLY AND MORE IRRITABLE.
2. History ---------- a. Relevant Social/Marital/Family history (pre-military, military, and post-military)
THIS VET ARRIVED HERE FROM SIGNAL MOUNTAIN, TN, DRIVEN HERE BY HIS WIFE.HE WAS BORN IN FRANCE, HIS FATHER WAS IN ARMY. RAISED IN JASPER, TN. HE WAS RAISED BY BOTH PARENTS. HE HAS ONE BROTHER AND ONE SISTER.NO HX OF ANY KIND OF ABUSE.HE IS MARRIED FOR 31 YRS, ONLY MARRAIGE. THEY HAVE 3 CHILDREN. HE JOINED THE AIR FORCE IN 1985 AND DCED IN 2008 WHEN HE WAS DXED WITH PARKINSON'S. HE HAD 6 TO 7 YRS OF ACTIVE AIRFORCE, STATIONED IN KUWAIT AND IRAQ. HE WAS DCED FROM AIRFORCE RESERVE IN 2008. HIS RANK AT DCED WAS MASTER SERGEANT.
b. Relevant Occupational and Educational history (pre-military, military, and post-military): COMPLETED HIGH SHCOLL IN JASPER. HAS BACHELOR IN ORGANIZATIONAL MANAGEMENT.HE WORKED FOR TVA IN NUCLEAR PLANT AND DID ROOT COUSE ANALYSIT. HE WORKED LAST SEPTEMBER 2016 BECAUSE OF PARKINSON's.
c. Relevant Mental Health history, to include prescribed medications and family mental health (pre-military, military, and post-military): HE DID NOT RECEIVE ANY MH CARE BEFORE HE JOINED THE AIRFORCE, NONE WHILE IN AIRFORCE BUT AFTER DCED FROM AIRFORCE, HAD TO SEEK HELP AT CHATTANOOGA CLINIC.HE WAS THEN DEPRESSED, HIS MOTHER PASSED AWAY, COULD NOT HANDLE THE LOSS, HAD TO GIVE UP WORKING AND FELT HOPLESS AND HELPLESS.HE FELT LOW ELF ESTEEM.HE WAS THEN PRESCRIBED AND NOW HE IS STILL FOLLOWED BY PSYCHIATRIST AT CHATTANOOGA CLINIC.HE STILL FEELS DEPRESSED, SOME ARGUMENT WITH HIS WIFE.HE FREQUENTLY CRIES, FEELS HOPLESS AND SOME TIME GOES THROUGH MOOD SWING BUT DENIES ANY MANIC EPISODES.HE KEEP UP WAKING UP AT NIGHT, FIGHTS IN HIS SLEEP, FEW TIME HE HIT HIS WIFE IN SLEEP AND HAS HEPPENDED FREQUENTLY, FEELS GUILTY ABOUT.HIS WIFE TELLS HIM HE CRIES IN HIS SLEEP AND SCEAMING BUT HE DOES NOT REMEMBER DOING THESE. REPORTS THAT HE AVOIDS CROWD, FEELS MORE SAFE AT HOME. IF HE IS IN UNFAMILIAR SITUATION, DOES GET UNCOMFORTABLE.HE GETS FRIGHETEN IF THERE IS LOUD NOISE.VERY LIMITED SOCIAL LIFE, ONLY TIME GOES OUT WHEN HE ATTENDS THE CHURCH.
d. Relevant Legal and Behavioral history (pre-military, military, and post-military): NONE
e. Relevant Substance abuse history (pre-military, military, and post-military): NONE
f. Other, if any: HIS OWN PHSICAL CONDITION AND LEAD TO GIVING UP JOB AND ROLE REVERSAL WHEN HIS WIFE HAS TO WORK AND HE HAS TO STAY HOME.
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: 2001, AT AIRFORCE BASE IN QUATAR, WAS GOING TO DO PURCHASE WITH HIS PRCHASING AGENT, PERSON PULLS UP AT GATE AND PULLS OUT AK 47, START SHOOTING, HE WAS ONLY THIRD CAR FROM GATE., THIS PERSON WAS SHOTTO DEATH
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? [X] Yes [ ] No
If yes, please describe the markers that may substantiate the stressor. MIDDLE OF ATTACK.
b. Stressor #2: WHEN HE WAS STATIONED IN SAUDI DURING DESERT STORM, THERE WAS GR 1 TORNADO NEAR THE BASE, BRITISH PILOT HAD TO EJECT HIM SELF FROM
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? [ ] Yes [X] No
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 s tressor. WITNESSING BRITISH PILOT EJECTING FROM AIRPLANE WHEN THERE WAS GR 1 TORNADO AT BASE.
4. PTSD Diagnostic Criteria Please check criteria used for establishing the current PTSD diagnosis. 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 #7 - Other symptoms. The diagnostic criteria for PTSD, referred to as Criterion A-H, are from the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5).
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) [X] Witnessing, in person, the traumatic event(s) as they occurred to others
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).
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] 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] 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.
Criterion I: Which stressor(s) contributed to the Veteran's PTSD diagnosis?: [X] Stressor #1 [X] Stressor #2
5. 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 adapting to stressful circumstances, including work or a worklike setting [X] Inability to establish and maintain effective relationships
6. Behavioral Observations -------------------------- ALERT,ORIENTEDX3,COOPERATIVE, CASUALLY DRESSED, POOR EYE CONTACT, CONSTANTLY MOVING IN THE CHAIR, VERY FIDGITY. AFFECT IS CONSTRICTED, DECREASED INTENSITY, ANXIOUS MOOD. RATE OF SPEECH NORMAL, GOAL DIRECTED. NO AH/VH OR ANY PERCEPTUAL DISTURBANCES. NOT SUICIDAL OR HOMICIDAL. NO COGNITIVE DEFICIT.
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 -------------------------------------------------- THIS VET DID EXPERINECE TRAMATIC STRESSORS AND HAS EXPERIENCED SXS OF PTSD WITH CO MORBID DEPRESSION AND UNDERGOING MH RX AT CHATTANOOGA CLINIC. NOTE: VA may request additional medical information, including additional examinations if necessary to complete VA's review of the Veteran's application. ****************************************************************************
Question
SMS Payne
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: CH PTSD b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): PARKINSON'S, HIGH TRYGLYCERIDE. HEARING LOSS.
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) [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 [ ] 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): STRESSOR NOTE.
Evidence Comments: TALKED WITH HIS WIFE MELINDA. SHE STATES THAT GRADUALLY HAS BECOME MORE IRRITABLE, LOOSES HIS TEMPER VERY EASILY, SNAPPS AT HIS KIDS, ARGUMENT. AT NIGHT HE IS RESTLESS IN BED, YELLING AND STARTS SWINGING HIS HANDS AND FEW TIME HE HIT HER IN THE SLEEP. WHEN HE IS OFF MEDS, HE IS MORE WITHDRAWN, LESS ACITVE PHYSICALLY AND MORE IRRITABLE.
2. History ---------- a. Relevant Social/Marital/Family history (pre-military, military, and post-military)
THIS VET ARRIVED HERE FROM SIGNAL MOUNTAIN, TN, DRIVEN HERE BY HIS WIFE.HE WAS BORN IN FRANCE, HIS FATHER WAS IN ARMY. RAISED IN JASPER, TN. HE WAS RAISED BY BOTH PARENTS. HE HAS ONE BROTHER AND ONE SISTER.NO HX OF ANY KIND OF ABUSE.HE IS MARRIED FOR 31 YRS, ONLY MARRAIGE. THEY HAVE 3 CHILDREN. HE JOINED THE AIR FORCE IN 1985 AND DCED IN 2008 WHEN HE WAS DXED WITH PARKINSON'S. HE HAD 6 TO 7 YRS OF ACTIVE AIRFORCE, STATIONED IN KUWAIT AND IRAQ. HE WAS DCED FROM AIRFORCE RESERVE IN 2008. HIS RANK AT DCED WAS MASTER SERGEANT.
b. Relevant Occupational and Educational history (pre-military, military, and post-military): COMPLETED HIGH SHCOLL IN JASPER. HAS BACHELOR IN ORGANIZATIONAL MANAGEMENT.HE WORKED FOR TVA IN NUCLEAR PLANT AND DID ROOT COUSE ANALYSIT. HE WORKED LAST SEPTEMBER 2016 BECAUSE OF PARKINSON's.
c. Relevant Mental Health history, to include prescribed medications and family mental health (pre-military, military, and post-military): HE DID NOT RECEIVE ANY MH CARE BEFORE HE JOINED THE AIRFORCE, NONE WHILE IN AIRFORCE BUT AFTER DCED FROM AIRFORCE, HAD TO SEEK HELP AT CHATTANOOGA CLINIC.HE WAS THEN DEPRESSED, HIS MOTHER PASSED AWAY, COULD NOT HANDLE THE LOSS, HAD TO GIVE UP WORKING AND FELT HOPLESS AND HELPLESS.HE FELT LOW ELF ESTEEM.HE WAS THEN PRESCRIBED AND NOW HE IS STILL FOLLOWED BY PSYCHIATRIST AT CHATTANOOGA CLINIC.HE STILL FEELS DEPRESSED, SOME ARGUMENT WITH HIS WIFE.HE FREQUENTLY CRIES, FEELS HOPLESS AND SOME TIME GOES THROUGH MOOD SWING BUT DENIES ANY MANIC EPISODES.HE KEEP UP WAKING UP AT NIGHT, FIGHTS IN HIS SLEEP, FEW TIME HE HIT HIS WIFE IN SLEEP AND HAS HEPPENDED FREQUENTLY, FEELS GUILTY ABOUT.HIS WIFE TELLS HIM HE CRIES IN HIS SLEEP AND SCEAMING BUT HE DOES NOT REMEMBER DOING THESE. REPORTS THAT HE AVOIDS CROWD, FEELS MORE SAFE AT HOME. IF HE IS IN UNFAMILIAR SITUATION, DOES GET UNCOMFORTABLE.HE GETS FRIGHETEN IF THERE IS LOUD NOISE.VERY LIMITED SOCIAL LIFE, ONLY TIME GOES OUT WHEN HE ATTENDS THE CHURCH.
d. Relevant Legal and Behavioral history (pre-military, military, and post-military): NONE
e. Relevant Substance abuse history (pre-military, military, and post-military): NONE
f. Other, if any: HIS OWN PHSICAL CONDITION AND LEAD TO GIVING UP JOB AND ROLE REVERSAL WHEN HIS WIFE HAS TO WORK AND HE HAS TO STAY HOME.
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: 2001, AT AIRFORCE BASE IN QUATAR, WAS GOING TO DO PURCHASE WITH HIS PRCHASING AGENT, PERSON PULLS UP AT GATE AND PULLS OUT AK 47, START SHOOTING, HE WAS ONLY THIRD CAR FROM GATE., THIS PERSON WAS SHOTTO DEATH
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? [X] Yes [ ] No
If yes, please describe the markers that may substantiate the stressor. MIDDLE OF ATTACK.
b. Stressor #2: WHEN HE WAS STATIONED IN SAUDI DURING DESERT STORM, THERE WAS GR 1 TORNADO NEAR THE BASE, BRITISH PILOT HAD TO EJECT HIM SELF FROM
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? [ ] Yes [X] No
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 s tressor. WITNESSING BRITISH PILOT EJECTING FROM AIRPLANE WHEN THERE WAS GR 1 TORNADO AT BASE.
4. PTSD Diagnostic Criteria Please check criteria used for establishing the current PTSD diagnosis. 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 #7 - Other symptoms. The diagnostic criteria for PTSD, referred to as Criterion A-H, are from the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5).
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) [X] Witnessing, in person, the traumatic event(s) as they occurred to others
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).
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] 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] 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.
Criterion I: Which stressor(s) contributed to the Veteran's PTSD diagnosis?: [X] Stressor #1 [X] Stressor #2
5. 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 adapting to stressful circumstances, including work or a worklike setting [X] Inability to establish and maintain effective relationships
6. Behavioral Observations -------------------------- ALERT,ORIENTEDX3,COOPERATIVE, CASUALLY DRESSED, POOR EYE CONTACT, CONSTANTLY MOVING IN THE CHAIR, VERY FIDGITY. AFFECT IS CONSTRICTED, DECREASED INTENSITY, ANXIOUS MOOD. RATE OF SPEECH NORMAL, GOAL DIRECTED. NO AH/VH OR ANY PERCEPTUAL DISTURBANCES. NOT SUICIDAL OR HOMICIDAL. NO COGNITIVE DEFICIT.
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 -------------------------------------------------- THIS VET DID EXPERINECE TRAMATIC STRESSORS AND HAS EXPERIENCED SXS OF PTSD WITH CO MORBID DEPRESSION AND UNDERGOING MH RX AT CHATTANOOGA CLINIC. NOTE: VA may request additional medical information, including additional examinations if necessary to complete VA's review of the Veteran's application. ****************************************************************************
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