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IMEF-Gunny

PTSD C&P - Denial coming How should I proceed?

Question

So, I was diagnosed with PTSD at my VAMC, attend therapy there, take Zoloft, Prazosin & Bupropion. I filed a claim, they verified stressors, sent all my records, buddy statements. I just attended my C&P, doc says no PTSD, granted I stressed how I'm currently affected and should have went into greater detail on stressors....but I was so fuc*ing anxious/nervous. Doc basically said Major Depressive Disorder, present pre-USMC as indicated in my STR's and alluded to alcohol issues...less likely than not therefor due to military service. His basis was that I had problems in 1991, was essentially problem free for decades and then they started 3-5 years ago....so, not related to service. Problem is NO WHERE is that supported. My buddy statements from spouse, family, employers ALL show issues with depression, anxiety, anger, write ups, etc from 1992 - today....so, there is no basis for his statement that I went decades symptom free. Question is, PTSD denial is imminent of course, but can I ask/attempt to get SC for Major Depressive disorder instead? Here is my C&P......and following, my letter to VA in regard to my disagreement with the C&P examiners assumption.............my anxiety right now is redlined......any help/advice is greatly appreciated and Neeeed!

LOCAL TITLE: C&P Examination

STANDARD TITLE: C & P EXAMINATION NOTE

DATE OF NOTE: JUL 14, 2017@08:00 ENTRY DATE: JUL 17, 2017@08:51:04

AUTHOR: LONG,WILLIAM R EXP COSIGNER:

URGENCY: STATUS: COMPLETED

Medical Opinion

Disability Benefits Questionnaire

Name of patient/Veteran:  Michael

ACE and Evidence Review

-----------------------

Indicate method used to obtain medical information to complete this

document:

[X] In-person examination

Evidence Review

---------------

Evidence reviewed (check all that apply):

[X] CPRS

[X] Other (please identify other evidence reviewed):

JLV (Joint Legacy Viewer)

 CONFIDENTIAL Page 4 of 27

MEDICAL OPINION SUMMARY

-----------------------

RESTATEMENT OF REQUESTED OPINION:

a. Opinion from general remarks: DBQ PSYCH PTSD Initial

____________________________________________________________________________

The following contentions need to be examined:

PTSD (post traumatic stress disorder) (related to: PTSD - Non-Combat)

Active duty service dates:

Branch: Marine Corps

RAD: 04/29/1991

DBQ PSYCH PTSD Initial:

Please review the Veteran's electronic folder in VBMS and state that it

was

reviewed in your report.

The Veteran is claiming service connection for PTSD (post traumatic stress

disorder) (related to: PTSD - Non-Combat) due to the claimed stressor of

fear/hostile environment. Please examine the Veteran for a chronic

disability related to his or her claimed condition and indicate the current

level of severity.

If more than one mental disorder is diagnosed please comment on their

relationship to one another and, if possible, please state which symptoms

are attributed to each disorder.

If your examination determines that the Veteran does not have diagnosis of

PTSD and you diagnose another mental disorder, please provide an opinion as

to whether it is at least as likely as not that the Veteran's diagnosed

mental disorder is a result of an in-service stressor related event.

b. Indicate type of exam for which opinion has been requested: DBQ PTSD

Initial

 CONFIDENTIAL Page 5 of 27

TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR DIRECT SERVICE

CONNECTION ]

b. The condition claimed was less likely than not (less than 50%

probability) incurred in or caused by the claimed in-service injury, event

or

illness.

c. Rationale: The primary rationale for this opinion is the presence of

symptoms similar to his current symptoms prior to joining the military (see

Mental Health history, Substance Abuse history). As stated in a December 1,

1989 Mental Health note "referral for eval of EPTE SA in 1987 of putting

his

head through a glass window while drunk. States he was in a state of

depression at the time." and goes on "Significant hx of feeling

dression with

suicidal ideation both sober and intoxicated. Has stopped himself from

killing himself with gun but can not verbalize why he stopped."

Similarly, veteran's history is inconsistent with his service being the

major

precipitant of his current distress. While veteran identifies distress upon

his return and a June 1, 2017 buddy statement by his mother, indicates

distress after deployment (see partial statement below), his history

indicates he experiences marked distress before the deployment and was

relatively symptom free until 3 to 5 years ago. Such a history is

inconsistent with that expected of the deployment being the primary truama.

June 1, 2017 buddy statement by his mother, states, "After returning

from the

war in Desert Storm he seemed reserved, no longer having a close

relationship

with friends or family. He seemed more intense with any perceived conflict.

It seems like he builds walls to keep some people at bay, keeping his

feelings inside, and exhibiting a saddened mood for the most part, but

explosive when he becomes agitated. He was not the same young man that left

for Desert Srorm. He lost a tremendous amount of weight after returning

home

and seemed to rely on alcohol more when he would have especially dark moods.

Mike seemed distraught and saddened."

*************************************************************************

****************************************************************************

Initial Post Traumatic Stress Disorder (PTSD)

Disability Benefits Questionnaire

* Internal VA or DoD Use Only *

 CONFIDENTIAL Page 6 of 27

Name of patient/Veteran: Michael

SECTION I:

----------

1. Diagnostic Summary

---------------------

Does the Veteran have a diagnosis of PTSD that conforms to DSM-5 criteria

based on today's evaluation?

[ ] Yes [X] No

2. Current Diagnoses

--------------------

a. Mental Disorder Diagnosis #1: Major Depressive Disorder

Comments, if any:

Veteran's symptoms are:

over-reactive, blaming irritability (see Behavioral Observations,

Irritability)

diminished pleasure (see Family history)

psychomotor agitation (see Occupational history, see Behavioral

Observations,

aggressive behavior)

concentration difficulties (see Remarks section, concentration

difficulty, PTSD

symptom checklist

recurrent thoughts of death (repeatedly holding a gun with

consideration of suicide)

While veteran is very intensely involved in his sense of being

wronged (see discussion of intrusive thoughts, PTSD symptom

checklist, Remarks section), his overall emotional distress is

relatively low (see MMPI-2-RF). Assessment of social/occupational

functional diffiuculties are based on his marital difficulties

(see

Family history) and interpersonal anger (see Occupational

history).

Veteran experiences himself as having PTSD; however, he does not

report intrusive or avoidance symptoms of PTSD (see Remarks

section).

Buddy statements as available are consistent with major depression

and do not indicate significant intrusive symptoms of PTSD. As

stated in a June 28, 2017 buddy statement by Tim Pulliam,

supervisor, "During his time at JCI (Johnson Controls), Mr.

McGuire's interaction with co-workers and management was

often

strained due to personality conflicts, angry outbursts and a

general anti-social nature on his part." And as stated in a

May 1,

2017 buddy statement by Christina McGuire, wife "Mike has

struggled

 CONFIDENTIAL Page 7 of 27

with anxiety, anger/mood issues and depression off and on

throughout most of the time that we have been together. The last

3-5 years has been much more pronounced." The statement goes

on,

"In the past, when Mike would struggle with

depression/anxiety,

especially when he focused too much on military talks, discussions

with vet buddies, he would sometimes self-medicate with alcohol.

Those incidents, although they didn't occur often, would usually

result in erratic, angry behavior and sometimes emotional

breakdowns or incidents of rage. Mike has broken household items

and even his hand during such a case because of this, whiche

caused

him to be off work for months and have surgery and

rehabilitation."

In light of his previous alcohol history and possible denial (see

Substance Abuse history), the possibility of an additional Alcohol

Use disorder should be considered if more history of abuse becomes

salient.

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?

[ ] Yes [X] No

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 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

 CONFIDENTIAL Page 8 of 27

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] CPRS

[X] Other (please identify other evidence reviewed):

JLV (Joint Legacy Viewer)

2. History

----------

a. Relevant Social/Marital/Family history (pre-military, military, and

post-military):

Veteran was raised, "70% of time" by his maternal

grandparents. His

parents, "got married very young, I was a surprise so to

speak." They

divorced when he was age 8. He was very close to his grandparents,

particularly his grandmother, "grandmother never drank, never

cursed,

never drove a car, do anything for you, definition of unconditional

love, I was her favorite." When he was 10, his mother remarried

and

continues to be with his stepfather to this date. He has a full

sister, 5 years younger than him and a half brother by his father and

a

half sister by his mother.

Veteran describes a distant relationship with all of his family.

Regarding his mother he reports, "we get along, we love each

other,"

but "I don't see her much." He last saw her, "3 or

4 months ago, ran

into each other in a store." He last saw his biological father

"6

months ago, again just publicly, I think he and I get along okay."

He

has not seen any of his siblings in more than a year.

He reports that his father abused alcohol when he was younger and that

CONFIDENTIAL Page 9 of 27

he had an uncle, "got a DUI at one time." He concludes,

"my paternal

grandmother drank quite a bit."

FAMILY PSYCHIATRIC HISTORY: The Veteran reported no known family

history of serious mental illness or suicide attempts.

Veteran denied history of sexual abuse, physical abuse, or domestic

violence.

Veteran did not describe any psychiatric difficulties with activities

of daily living.

Veteran denies belonging to a church or any organized social group.

Veteran was first married from 1992 to 1995. He sees the marriage as

a

mistake, "I got married for wrong reasons," and that the

marriage

dissolved due to his, "anger issues." He has 2 children from

the first

marriage, a son, 23, "got Asperger's, he has a lot of

problems besides

just the Asperger's, lives in a group home." He last saw the

this son

at Christmas of 2016. He has a daughter, 21, "okay

relationship," he

saw her "a couple months ago, they went with us hiking."

Veteran met his current wife in 1996 and they married in 1999. He

does

not know if the marriage will last, "divorce has come up, last

time

about 2 weeks ago." During stressful times they both talk about

divorce, "seemed pretty mutual." He was unable to identify

the source

of the distress beyond vague statements, "life, finances, kids,

work."

Last night they had an argument. He and his wife stayed in a hotel to

avoid an early morning drive to this appointment, "she got upset

with

me because I didn't want to do anything, didn't want to take

a horse

and carriage ride." He notes, "I know she wanted to have

sex," which

he felt was very insensitive to his anxiety and distress, "that

upset

me, seemed ridiculous that she would be upset, we didn't do

something

fun." She expressed anger, "you act like you're

old."

CONFIDENTIAL Page 10 of 27

The couple has 5 children, 4 sons, 18, 15, 5, and 1, and a daughter,

10. He reports all the children "are okay, all smart, athletic

kids."

Veteran sees himself as a home body who prefers to avoid crowds. He

does run family errands without incident, for example, he went to the

grocery store yesterday by himself, "one of my kids was sickly,

got

prescriptions, went okay I guess." Similarly, he went out to

dinner

last night, "it went all right;" however, this was first time

eating

out, "in a long time."

Initially, veteran denies having any friends; however, when pressed

for

details he describes several on-going relationships. He has a

neighbor, "navy veteran, occasionally go over and talk." His

"best

friend" in high school, "is married to my sister." He

has a friend

that he served with who comes by his house regularly, the last time,

"3, 4 weeks ago." Veteran reports that he enjoys preparing

meals for

his family on the grill but denies any other pleasurable activities in

his life.

b. Relevant Occupational and Educational history (pre-military, military,

and

post-military):

Veteran is a high school graduate. History of learning disability,

special education, or being held back a grade was denied. Veteran

reports only one suspension from school at age 14, "drank too

much

alcohol in the morning before school," he was suspended and placed

in a

mandatory alcohol treatment program. He describes high school as

otherwise, "pretty good, played football, had girlfriends most of

the

time, went through school with 2 of my best friends." He

obtained,

"B's and C's mostly." He obtained an

Associate's in Robtotics in 1998.

Currently, veteran has worked the last 10 years in a "waste water

treatment plant." He reports the job is going "mostly okay,

technically I'm proficient." He has been counseled about his

behavior

on the job. The behavioral difficulties were described in an April

 CONFIDENTIAL Page 11 of 27

19,

2017 buddy statement by Steven Atteberry, Foreman, as "complaint

was

that he displayed 'Angry, intimidating and condescending'

behaviors

that disrupted the workplace." The complaint lead to, "a

written

warning and a 1 year probation in September, 2015." He works 10

hour

daytime shifts Monday through Thursday. He reports missing 5 days

over

the last year for, "personal ailments."

Veteran reports being fired only one time in 1999, "on the first

day of

the job," when they discovered he was red/green color blind,

"they

skipped a certain portion of the interview, told me I had to

leave."

He left a job in the early 2000's without notice, "it was a

clean room,

stuck in a clean room for 12 hours [in a clean suit for 12 hours], I

hated it."

His longest period of unemployment was for a year and half after his

divorce. He had no explanation for the period of unemployment beyond,

"I lost job that I had, basically a welder, for Johnson

controls." He

had this job for 3 and half years, it was his first job after leaving

the military.

Branch: Marines

Dates of Service: November, 1990 to April, 1991

Discharge Type: HONORABLE

Rank on Discharge: E3

Veteran was deployed to Bahrain and Saudi Arabia during his active

service as above.

c. Relevant Mental Health history, to include prescribed medications and

family mental health (pre-military, military, and post-military):

MENTAL HEALTH TREATMENT AFTER MILITARY: Veteran denies formal mental

health treatment before approaching the St Louis VA in January of this

year. Prior to that he did approach a primary care provider "in

1994

maybe, I was having a lot of troubles at work." The "company

doctor

prescribed me Buspar, couldn't take it, threw my equilibrium off,

never

went back."

 CONFIDENTIAL Page 12 of 27

He has been seen regularly through the VA since January with a

diagnosis of PTSD.

A March 3, 2017 Behavioral Medicine note reports remarkable progress,

"reports that he is doing much better. 'I wanted to call you

the other

day and thank you, I really didn't think I could feel normal

again.'"

The note went on, "Vet is happy that he has been able to enjoy

life, he

stated his wife has really noticed a difference. Vet stated he

hadn't

cried in three weeks. Vet has had no suicidal ideations. Vet states

he feels his memory may be a little better." The note finishes,

"Vet

stated he and his wife have been going out one night per week and he

has been enjoying that." Veteran confirms this initial success

which

he attributes to Zoloft. He feels that his symptoms are still

improved

but that the initial period of "almost euphoria" have left.

Veteran has been diagnosed with PTSD by his providers; however, the

basis of this diagnosis is unclear. Veteran's January 6, 2017

Initial

Psychiatry Consult does not report apparent intrusive symptoms of

PTSD.

As described there, "HISTORY OF PRESENT ILLNESS: Vet reports he

cries

whenever he comes to the VA, Vet states he also cries sometimes at

home

for no reason. Vet reports problems sleeping, states he is up five

times per night. Vet does check locks every night, he contributes it

to

having small children, not to being hypervigilant. Vet reports road

rage. Vet states he doesn't feel depressed, Vet denies suicidal

or

homicidal ideations. Vet does not wish to take any medications. Vet

states he will think about buying Melatonin over the counter to try

for

sleep. Vet is agreeable to discussing with his wife and made f/u

appointment with this writer for one month. Vet provided with

information for the Vet Center. Vet reports poor short term memory,

Vet

states that he makes lists on his phone, Vet is worried that he will

not be able to 'remember anything when I am 50.'" He

was initially

referred to behavioral health by his primary care providers with a

diagnosis of Major Depression and concerns about his crying and sleep

difficulties (see August 5, 2016 Clinic note). Treatment notes do

discuss "nightmares" but not in a way that meets criteria as

an

 CONFIDENTIAL Page 13 of 27

intrusive symptom. For example, the March 3, 2017 Behavioral Medicine

note states, "Vet reports that he believes he has nightmares,

although

he doesn't remember them. Vet states he sleeps well some nights

and

others not as good. Vet and wife have not slept in the same bed for

over 6 years."

Current medications include:

Jun 14, 2017 SERTRALINE HCL 100MG TAB ACTIVE Mar 04, 2018 STL

MENTAL HEALTH TREATMENT DURING MILITARY: Veteran denies mental health

treatment in the military. He was evaluated by Mental Health,

"when I

got to boot camp," because he reported prior treatment for

alcohol

abuse. A December 1, 1989 Mental Health note apparently documents

this

visit, "18 y/o ... referral for eval of EPTE SA in 1987 of putting

his

head through a glass window while drunk. States he was in a state of

depression at the time. Secondary to 'his situations.'"

The note

continues, "has gone through ETOH tx including AA." Based on

the

change in writing style, a second author adds to the same note,

"Significant hx of feeling dression with suicidal ideation both

sober

and intoxicated. Has stopped himself from killing himself with gun

but

can not verbalize why he stopped. Treatment received for alcohol was

mandatory outpt group education following drunk and disorderly at

school." The note concludes, "Impression: I. Alcohol Abuse

by

history."

MENTAL HEALTH TREATMENT PRIOR TO THE MILITARY: See above

PSYCHIATRIC HOSPITALIZATIONS: None

SUBSTANCE ABUSE RELATED HOSPITALIZATIONS: Veteran reports a third

significant incident related to alcohol in addition to those described

in the December 1, 1989 Mental Health note. He reports the incident

was shortly after his school suspension. He and his friends came

across, "big box of bottles, vodka, rum, poured a big glass of

it." He

drank it all, "more or less showing off, [he became unconscious

and]

ended up hospital, .27 BAL." He was kept overnight and released.

 CONFIDENTIAL Page 14 of 27

d. Relevant Legal and Behavioral history (pre-military, military, and

post-military):

HISTORY OF TROUBLE AS YOUTH: Veteran denies contact with the police

other than, "incident there at school, when I got suspended."

MILITARY DISCIPLINARY PROBLEMS (ARTICLE 15/NJP/CAPTAIN?S MAST/COURT

MARTIALS): None

LIST ALL NON-MILITARY LEGAL OFFENSES AND LEGAL CONSEQUENCES: Veteran

reports being arrested, "right after my divorce, for invasion of

privacy, I went to my ex-wife's apartment," when there was

a,

"restraining order against me." He denies other arrests.

e. Relevant Substance abuse history (pre-military, military, and

post-military):

CAFFEINE: cup of coffee in the morning

ALCOHOL: Veteran report limited current consumption of alcohol,

consuming only a single serving on 2 separate occasions during the

last

week and not consuming over 5 servings at one time in over a year.

He reports his heaviest period of use was 1992 to 1996. He reports

drinking, "too much, maybe 3 days a week," 5 or 6 servings on

a typical

day. His January 6, 2017 Psychiatry Consults suggests greater use

during that period, "Vet stated that he drank anything he could,

whiskey, beer."

The May 1, 2017 buddy statement by Christina McGuire, his wife

suggests

that veteran's current difficulties with alcohol may be greater

than

that reported above. As stated there, ""In the past, when

Mike would

struggle with depression/anxiety, especially when he focused too much

on military talks, discussions with vet buddies, he would sometimes

self-medicate with alcohol. Those incidents, although they

didn't

occur often, would usually result in erratic, angry behavior and

sometimes emotional breakdowns or incidents of rage. Mike has broken

household items and even his hand during such a case because of this,

whiche caused him to be off work for months and have surgery and

rehabilitation [2013]." The statement continues, "Mike has

made a

tremendous effort to avoid alcohol when he wrestles with anxiety and

depression."

ILLICIT DRUG USE: Veteran reports only experimental use of marijuana

as a child.

 CONFIDENTIAL Page 15 of 27

f. Other, if any:

The following is cut and pasted from JLV (Joint Legacy Viewer):

PROBLEM LIST

Mar 03, 2017 POST-TRAUMATIC STRESS DISORDER, CHRONIC F43.12 ACTIVE

STL

Dec 05, 2016 NICOTINE DEPENDENCE, CIGARETTES, WITH UNSPECIFIED

NICOTINE-INDUCED

Dec 05, 2016 PATIENT'S OTHER NONCOMPLIANCE WITH MEDICATION

REGIMEN Z91.14 ACTIVE

Sep 08, 2016 ESSENTIAL (PRIMARY) HYPERTENSION I10. ACTIVE STL

Sep 08, 2016 HYPERLIPIDEMIA, UNSPECIFIED E78.5 ACTIVE STL

Sep 08, 2016 TESTICULAR HYPOFUNCTION E29.1 ACTIVE STL

Sep 08, 2016 NICOTINE DEPENDENCE, CIGARETTES,

UNCOMPLICATED F17.210 ACTIVE STL

Sep 08, 2016 ABDOMINAL DISTENSION (GASEOUS) R14.0 ACTIVE STL

Sep 08, 2016 SLEEP DISORDER, UNSPECIFIED G47.9 ACTIVE STL

MEDICATION LIST

Jun 14, 2017 ATORVASTATIN CALCIUM 80MG TAB ACTIVE Sep 01, 2017

STL

Jun 14, 2017 SERTRALINE HCL 100MG TAB ACTIVE Mar 04, 2018 STL

Feb 02, 2017 HCTZ 12.5/LISINOPRIL 20MG TAB ACTIVE Feb 03, 2018

STL

Aug 31, 2016 NICOTINE 21MG/24HR PATCH EXPIRED Sep 30, 2016

STL

Aug 31, 2016 HCTZ 12.5/LISINOPRIL 20MG TAB DISCONTINUED Nov 04,

2016

STL

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: multiple SCUD attacks including debris coming to his

position

in an ammo dump

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

 CONFIDENTIAL Page 16 of 27

Is the stressor related to personal assault, e.g. military sexual

trauma?

[ ] Yes [X] No

b. Stressor #2: just avoiding friendly fire

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: Saudi nationals pointing weapons in his direction

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

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)

Criterion B: Presence of (one or more) of the following intrusion

symptoms

associated with the traumatic event(s), beginning after the

 CONFIDENTIAL Page 17 of 27

traumatic event(s) occurred:

[X] No criterion in this section met.

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] No criterion in this section met.

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] No criterion in this section met.

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] No criterion in this section met.

Criterion F:

[X] No criterion in this section met.

Criterion G:

[X] No criterion in this section met.

Criterion H:

No response provided.

Criterion I: Which stressor(s) contributed to the Veteran's PTSD

diagnosis?:

No response provided.

5. Symptoms

-----------

For VA rating purposes, check all symptoms that actively apply to the

Veteran's diagnoses:

[X] Anxiety

6. Behavioral Observations

 CONFIDENTIAL Page 18 of 27

--------------------------

******MENTAL STATUS******

Hallucinations: None reported

Orientation: Veteran expressed understanding of the reason for the

interview

and was oriented to person, place, and time.

Memory: Veteran recalled 3 of 3 items after a period of intervening tasks.

Executive Function: Veteran was able to produce a clock face with the

correct time, follow a 3 step command, and explain an abstract proverb.

Suicidal Ideation: Veteran had tears in his eyes as he described suicidal

ideation/behavior. Three months ago, "I went to my cousin's house,

set by

their pond, tried to clear my mind, set a gun in my lap." He sees his

"wife

and kids," as the only thing that stopped him from committing suicide.

Veteran reports similar behavior, holding a gun in consideration of killing

himself for many years. (See Mental Health history of suicidal

ideation/behavior beginning prior to his military service). Veteran reports

his suicidal ideation has decreased since he began taking psychotropic

medication, that it was much more frequent for the last 3 years, and that it

was an only occasional difficulty between approximately 1997 and 2005.

Impulse Control: Good. Veteran denies engaging in any reckless/impulsive

behaviors (i.e., impulsive violence, reckless driving, extravagant spending,

excessive gambling, and impulsive sex).

QUERY FOR SYMPTOMS OF MANIA: Veteran denies Inflated self-esteem or

grandiosity, Decreased need for sleep, Being more talkative or pressure to

keep talking, Flight of ideas or subjective experience of racing thoughts,

Distractibility, Increase in goal-directed activity, or Excessive

involvement

in pleasurable activities that have a high potential for painful

consequences.

Sleep: Veteran reports typically going to bed at 10 or 10:30 pm and getting

out of bed at 5:30 am on weekdays and 7:30 on weekends. He denies difficult

obtaining or reobtaining sleep but that he awakes repeatedly during the

night. He notes, "it has improved since they put me on Zoloft, before

Zoloft

it was absolutely horrendous, up any where from 6 to 20 times a night."

He

reports awaking 5 or fewer times at the current time. When he awakes he is

bothered by, "horible shoulder and arm cramps," which he has to

"stretch

out," before returning to sleep.

He and his wife "haven't slept together for 7 8 years," due to

his frequent

awakenings and "shaking" in bed.

Panic Attacks: None.

Irritability: Veteran again became tearful as he discussed his

 CONFIDENTIAL Page 19 of 27

"rage." He

reports last becoming enraged "a couple months ago, I love animals, not

proud

of saying this, have a puppy, trying to get him to go outide, ran from me, I

smacked his ass, he ran under a table, just infuriated me, whacked him

again,

the more I hit him, the more he cried, yelping and hollering."

He lost his temper earlier this week, "didn't start out angry,

ended up that

way." He was, "on my way home form work, guy pulled out behind me,

right on

my bumper." The incident escalated, "I tapped my brake, try to get

him to

back off, [the other driver began] honking his horn, flashing his lights, I

pull over, he pulled over." He believed the man was going to attack

him, "he

dropped his shoulder," so the veteran, "hit him, I hit him 3 times,

he hit

the ground." The veteran, "made sure he was turned on his side,

make sure he

didn't choke on blood, and I left," with the man laying there.

He reports becoming angry, raising his voice, more than daily and becoming

angry to the point of wanting to strike something, "once a week."

A

significantly reduced level since beginning on medication.

Veteran's sees his anger as part of an intense hate of Islam. He sees

this

as out of character for him, "not a person who believes in hate,

don't let my

kids even use the word, don't care black, white, gay, straight,

Mexican." He

notes that both his wife and his therapist associate this with his overuse

of

Facebook, "only social interaction I have is through Facebook, so much

of

Facebook is about terrorism and Islam, I f**king hate Islam." He

attempted

to rejoin the military a year ago, to address what he perceives as the

problem of Islam but notes, "they won't take me, too old."

Homicidal Ideation: Unknown. When asked about homicidal ideation, veteran

asked if his responses would be confidential. The examiner reiterated that

information is confidential to the VA system, that it was unlikely that

action would be necessary, but that indications of significant threat to

self

or others would need to be addressed. At that point, veteran responded,

"I

would say no."

History of Violent Behaviors: Veteran reports his previous involvement with

 CONFIDENTIAL Page 20 of 27

violence was "5 years ago or so, friend of mine had been drinking [in

veteran's home], I tried to take his keys." The man responded,

"he demanded

his keys back." The veteran told him you have 2 choices, "stay

here or I can

knock you the f**k out, he opted for plan B, exactly what I did [knock him

out]." The friendship continued for 2 years after the incident.

7. Other symptoms

-----------------

Does the Veteran have any other symptoms attributable to PTSD (and other

mental disorders) that are not listed above?

[X] Yes [ ] No

If yes, describe:

Veteran reports difficulty controlling his anger (See Behavioral

Observations, Irritability).

8. Competency

-------------

Is the Veteran capable of managing his or her financial affairs?

[X] Yes [ ] No

9. Remarks, (including any testing results) if any

--------------------------------------------------

Prior to beginning the C&P exam, this examiner informed the veteran

about

the purpose of this interview being for disability benefits, limits of

confidentiality, (e.g., risk of harm to self/others), risks of

participation in interview (e.g. stress, anxiety), access to records, how

results will be communicated to the Regional Office, and the fact that

the

Regional Office is responsible for making decisions regarding

service-connection and disability ratings. ?Veteran expressed willingness

to continue with the evaluation. The interview was conducted from 7:40

to

10:15 am.

Diagnoses obtained in this evaluation were based on the criteria

contained

in the DSM5.

Veteran is 46 years old. Veteran was referred by the Muskone Regional

Office for a PTSD Initial C&P Evaluation.

At the end of this exam, the veteran was asked whether there were other

symptoms of possible mental disorder that had not been covered in the

exam

 CONFIDENTIAL Page 21 of 27

Unless otherwise stated, all historical information in this DBQ is based

on the veteran's statements during the examination.

***REVIEW OF CRITERIA FOR DIAGNOSIS OF PTSD

Below are questions (based on the diagnostic criteria for PTSD) and

veteran responses. Items were rated positive if they reached clinical

levels. The ratings below represent the assessment of the examiner after

completion of a structured interview. Following the items are the

veterans comments in regards to the questions, which are provided for the

benefit of other mental health examiners, who may be interested in

understanding the veterans specific response patterns. Please note that

the veteran responses alone are not sufficient for diagnostic purposes.

Items have high face validity (obvious items asking about symptoms) and

can be influenced by the subject?s motivations. A total score was not

calculated, rather item responses were used to assess whether DSM

diagnostic criteria were met.

Veteran reports 0 of 5 re-experiencing symptoms, 0 of 2 avoidance

symptoms, 0 of 7 negative mood/cognition symptoms, and 0 of 6

hyperarousal

symptoms at a Moderate level or higher, these symptom counts do not meet

DSM-5 or DSM-IV criteria for PTSD. Hyperarousal and negative

mood/cognition symptoms that may be present are likely the result of

other

factors besides PTSD.

Incident: Veteran reports multiple traumatic experiences on deployment

including multiple SCUD attacks, an incident where he just avoided

friendly fire, and Saudi nationals pointing weapons in his direction.

One

of the SCUD attacks resulted in debris coming to his position in an ammo

dump, a potentially deadly situation. A June 16, 2017 buddy statement by

Chris Powell, part of his unit in Bahrain confirms some of these traumas,

"The SCUD missle that was shot down by Patriots above out position

actually struck our line positions with shrapnel, which was amplified in

terms of seriousness by the fact that we were close proximity to an ammo

dump at the time."

Notes on affect: No change during discussion of traumatic events.

Veteran was much more distressed (tearful) as he discussed his anger and

feelings of being out of control.

B: REEXPERIENCING

1. disturbing memories -> rated as negative

This rating is based on: Veteran reports negative, more than daily,

distressing thoughts; however, he does not describe intrusive memories of

trauma. He describes thoughts more consistent with Major Depression.

Specifically, he describes a preoccupation with, "why I didn't

die over

there, I don't know how I made it, there's so many different

 CONFIDENTIAL Page 22 of 27

incidents

where I should of died and I didn't."

2. disturbing dreams -> rated as negative

This rating is based on: Veteran denies memories of nightmares. "I

don't

remember my dreams." He does reports a disturbed sleep and a belief

that

he is having dreams, "my wife says I shake in my sleep, wake up

sweaty."

3. flashbacks -> rated as negative

This rating is based on: Veteran responded "not really, no," to

descriptions of flashbacks and dissociative experiences.

4. feeling upset -> rated as negative

This rating is based on: Veteran again describes anger and depression but

not connected to prior trauma. He focuses on his use of Facebook,

"my

wife tries to get me to stay away from the social media stuff, I get in

trouble if I start to much the military stuff." He describes an

obsession

with it, "it is a part of who I am, if I don't allow myself to

feel some

of that struggle, then it's like I'm not acknowledging part of

me."

5. physical reactions -> rated as negative

This rating is based on: Denied

C: AVOIDANCE:

1. avoiding thoughts -> rated as negative

This rating is based on: Veteran describes an obsessive focus on his

thoughts, see above, rather than avoidance.

2. avoiding activities -> rated as negative

This rating is based on: Veteran does report some avoidance, "I

don't

watch any of that [movies, documentaries], you probably know more about

Desert Storm than I do, don't have any interest in it."

However, he does

not describe active avoidance. In addition, he describes actively

seeking

out stimuli (see Facebook discussion above, see desire to join the

military, Behavioral Observations).

D: NEGATIVE MOOD/COGNITION

1. trouble remembering -> rated as attributed to Major Depression

This rating is based on: Veteran is very preoccupied with how his

deployment damaged him and other veterans, "seems like we are all

damaged

to some degree." He sees the fact that he remembers some things

from

deployment that others have forgotten and the others remember things that

he has forgotten as evidence of this "damage." He notes one of

his fellow

Marines, "doesn't remember either of [incidents noted above],

 CONFIDENTIAL Page 23 of 27

but

remembers the marine that got run over." He sees this as endemic to

veterans, "contacted my old commanding officer, doesn't even

remember the

incident, what happened to weapons company guy." He concludes

"everybody

remembers different pieces."

He describes a memory that might be unrelated to deployment as further

evidence, "I remember getting on bus, remember thinking the guy

driving

this bus looked like Satan, big beard, big eyebrows, just evil

looking,"

but that he doesn't, "remember where that bus went, odd to me,

why would I

remember what the guy looked like."

2. strong negative beliefs -> rated as attributed to Major Depression

This rating is based on: Veteran reports his experiences, "taught me

to

not take things for granted, went 5 months without showering."

3. blaming self -> rated as negative

This rating is based on: "no"

4. fear, horror, anger -> rated as attributed to Major Depression

This rating is based on: Veteran reports frequent crying, crying as

recently as yesterday, "I was nervous about this appointment,

don't know

what to expect." See description of crying below associated with

concentration difficulties and original referral for mental health

services.

5. loss of interest -> rated as attributed to Major Depression

This rating is based on: See Family history

6. feeling cut off -> rated as attributed to Major Depression

This rating is based on: Veteran reports feeling cut off, "people

don't

understand my personality, and I don't understnad theirs, why

don't I have

close emotional ties to people, don't react way they do."

7. feeling emotionally numb -> rated as negative

This rating is based on: Denied

E: HYPERAROUSAL:

1. feeling irritable -> rated as attributed to Major Depression

This rating is based on: See Behavioral Observations.

2. taking too many risks -> rated as negative

This rating is based on: See Behavioral Observations.

3. hypervigilance -> rated as negative

This rating is based on: Veteran denies vigilance beyond, "carry a

firearm, especially when I go to Indianapolis."

4. startle response -> rated as negative

 CONFIDENTIAL Page 24 of 27

This rating is based on: "don't have a startle response."

5. difficulty concentrating -> rated as attributed to Major

Depression

This rating is based on: Veteran reports concentration difficulties which

he labels as memory problems. He reports they occur, "daily, I keep

a lot

of notes." He describes an example, "say my wife and I have

conversation

about Saturday, I'll forget completely, she'll mention it,

I've completely

forgotten." He gives other examples, "forgotten my

daugher's name,

forgotten my son's name, go to the store, don't make a list,

I'll forget,

come in the house, forget why I'm there, what I came in for."

He goes on,

"sometimes, I will lose myself mid sentence, be talking to somebody,

I

stutter, soon as I do, can't remember the topic of the converstiaon,

it

just goes." He reports difficulty at work, "work in a very

dangerous

environment." He will forget to do, "air sampling for oxygen,

hydrogen

sulfide, explosive atmosphere, I have forgotten all of those mid

shifts."

His memory/concentration difficulties make him feel out of control. He

became very tearful in the interview as he described an incident leading

to his referral to mental health. He went to his primary care provider

and broke down in uncontrollable crying about an "incident, we were

grilling, pushed the grill into the garage, I forgot the grill was

warm."

The CO monitor went off, "house was filling with carbon monoxide, I

would

of killed anybody in the house, because I forgot." It was at that

point,

he decided, "I need to get help."

6. trouble sleeping -> rated as negative

This rating is based on: See Behavioral Observations.

***PSYCHOLOGICAL TESTING

MMPI-2-RF

The Veteran was administered the Minnesota Multiphasic Personality

Inventory-2 Restructured Form (MMPI-2 RF), a self-report scale that

provides information about an individual's clinical symptoms and

personality features as well as validity measures for the

individual's

 CONFIDENTIAL Page 25 of 27

response pattern.

Veteran's responses to the validity scales of the MMPI-2-RF

indicated

consistent responding and were within normal limits. As such, response

biases are unlikely to have affected responses to the clinical scales on

the exam.

OVERALL CLINICAL INTERPRETATION:

Veteran endorsed an overall low number of items indicating generalized

distress. Overall clinical interpretation would indicate only a mild

level of clinical distress.

SOMATIC/COGNITIVE DYSFUNCTION:

Reports multiple somatic complaints that may include head pain,

neurological, and gastrointestinal symptoms. Reports a number of

gastrointestinal complaints. Reports head pain. Reports a diffuse

pattern of cognitive difficulties.

EMOTIONAL DYSFUNCTION:

Reports: A lack of positive emotional experiences. Significant

anhedonia.

Lack of interest. Is pessimistic. Is socially introverted. Is socially

disengaged. Lacks energy. Displays vegetative symptoms of depression.

Reports: a lack of positive emotional experiences and avoiding social

situations. Lacks positive emotional experiences. Experiences

significant problems with anhedonia. Complains about depression. Lacks

interests. Is pessimistic. Is socially introverted.

Reports being anger prone.

THOUGHT DYSFUNCTION:

Veteran's responses indicate significant thought dysfunction.

Significant

persecutory ideation such as believing that others seek to harm him or

her. Is suspicious of and alienated from others. Experiences

interpersonal difficulties as a result of suspiciousness. Lacks insight.

Blames others for his or her difficulties.

BEHAVIORAL DYSFUNCTION:

Reports a significant history of antisocial behavior. Reports engaging

in

physically aggressive, violent behavior and losing control. Reports

being

interpersonally aggressive and assertive. Is overly assertive and

socially dominant. Engages in instrumentally aggressive behavior.

CONFIDENTIAL Page 26 of 27

INTERPERSONAL FUNCTIONING:

Reports not enjoying social events and avoiding social situations,

including parties and other events where crowds are likely to gather,

being introverted and emotionally restricted. Has difficulty forming

close relationships. Reports disliking people and being around them,

preferring to be alone.

NOTE: VA may request additional medical information, including additional

examinations if necessary to complete VA's review of the Veteran's

application.

/es/ WILLIAM R. LONG

CLINICAL PSYCHOLOGIST

Signed: 07/17/2017 08:51

 

My letter to VA in regard to this examiner's findings:

Thursday, July 20, 2017

RE: C&P Exam July 14th 2017

I am writing in regard to the C&P exam returned to VA July 17th, 2017. I would ask VA consider that this decision/opinion was made, in terms of service connection, based on the following statement:

TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR DIRECT SERVICE

CONNECTION ]

b. The condition claimed was less likely than not (less than 50%

probability) incurred in or caused by the claimed in-service injury, event

or

illness.

c. Rationale: The primary rationale for this opinion is the presence of

symptoms similar to his current symptoms prior to joining the military (see

Mental Health history, Substance Abuse history). As stated in a December 1,

1989 Mental Health note "referral for eval of EPTE SA in 1987 of putting

his

head through a glass window while drunk. States he was in a state of

depression at the time." and goes on "Significant hx of feeling

dression with

suicidal ideation both sober and intoxicated. Has stopped himself from

killing himself with gun but can not verbalize why he stopped."

Similarly, veteran's history is inconsistent with his service being the

major

precipitant of his current distress. While veteran identifies distress upon

his return and a June 1, 2017 buddy statement by his mother, indicates

distress after deployment (see partial statement below), his history

indicates he experiences marked distress before the deployment and was

relatively symptom free until 3 to 5 years ago. Such a history is

inconsistent with that expected of the deployment being the primary truama.

June 1, 2017 buddy statement by his mother, states, "After returning

from the

war in Desert Storm he seemed reserved, no longer having a close

relationship

with friends or family. He seemed more intense with any perceived conflict.

It seems like he builds walls to keep some people at bay, keeping his

feelings inside, and exhibiting a saddened mood for the most part, but

explosive when he becomes agitated. He was not the same young man that left

for Desert Srorm. He lost a tremendous amount of weight after returning

home

and seemed to rely on alcohol more when he would have especially dark moods.

Mike seemed distraught and saddened."

There is significant evidence in my claim from persons that I have worked with, lived with and known that contradict these conclusions.

Nowhere in my claims file does anyone, including myself state that my conditions were present after returning home in 1991, absent for decades and then re-appeared 3-5 years ago. To the contrary, they have been clearly present and affected my social, family & work life to varying degrees since 1991, but have “worsened” in the last 3-5 years.

Also, the Dr acknowledges my stressors are active and legitimate, but because I was reluctant to go into detail about the stressors and how they affect me and have since the time of the incident, he doesn’t find criteria for PTSD, though at the same time acknowledges my “fear and/or horror in regard to imminent threat of death/serious injury and threat of terrorist activity:

Describe one or more specific stressor event(s) the Veteran considers

traumatic (may be pre-military, military, or post-military):

a. Stressor #1: multiple SCUD attacks including debris coming to his

position

in an ammo dump

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

MCGUIRE, MICHAEL SEAN CONFIDENTIAL Page 18 of 29

Is the stressor related to personal assault, e.g. military sexual

trauma?

[ ] Yes [X] No

b. Stressor #2: just avoiding friendly fire

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: Saudi nationals pointing weapons in his direction

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

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)

 

He states his opinion is the following:

2. Current Diagnoses

--------------------

a. Mental Disorder Diagnosis #1: Major Depressive Disorder

Comments, if any:

Veteran's symptoms are:

over-reactive, blaming irritability (see Behavioral Observations,

Irritability)

diminished pleasure (see Family history)

psychomotor agitation (see Occupational history, see Behavioral

Observations,

aggressive behavior)

concentration difficulties (see Remarks section, concentration

difficulty, PTSD

symptom checklist

recurrent thoughts of death (repeatedly holding a gun with

consideration of suicide)

He clearly indicates that he believes that I have major Depressive Disorder, but that he feels it is not related to military service as it was manifest prior to bootcamp; however, he wrongly assumed, through no basis in fact or evidence presented, that it was present before boot camp (pre-existing), was clearly present and by definition indicated from buddy statements, weight loss etc, pronounced and present upon return from desert storm, but it was absent for decades and then re-appeared 3-5 years ago. Again, there is no evidence, nor statements from me or anyone that alludes to my condition being absent between 1991 and today. Quite the contrary in fact.

Also, He disagrees with VMAC, Rhonda Bray’s assessment and diagnosis based on the idea that following, but made no efforts to get clarification from provider as to her assessment/diagnosis. There are many things I have discussed with Mrs. Bray, that I forgot or was uncomfortable discussing with a new/stranger physician:

“Veteran has been diagnosed with PTSD by his providers; however, the

basis of this diagnosis is unclear.”

Also, there is no mention of a significant event that was discussed in the exam concerning the death of a friend in February, 1991 Jeff Reel and the effects that had on me at the time and/or to this day.

 

At a minimum, I would ask that VA consider these issues/discrepancies in this exam, consider my memory and level of anxiety when I am at VA, documented by Rhonda Bray, that is so severe that she has suggested conducting clinic visits on VA provided equipment from home versus physically coming to the VAMC.

Also, please consider that I requested my wife be allowed into the exam room due to this anxiety and my memory issues and was refused.

In closing, please also consider that, though this doctor disagreed with prior VA diagnosis of PTSD, he does support a clear diagnosis of Major Depressive Disorder, perhaps mis-diagnosed as PTSD, acknowledges it was present prior to service, but does not address whether it may have been aggrivated  as a result of  service in Desert Storm by one of the many stressful events that took place. Myself, as a veteran, would not be able to distinguish myself the proper claimed disability (PTSD or Major Depressive Disorder) and therefor sought help/claim for the PTSD diagnosis from VAMC.

Sincerely,

 

 

 

Edited by IMEF-Gunny

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Also, keep in mind that he only mentions a few stressors in his notes here. The only one of significance of many is the SCUD shrapnel that we were peppered with.

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Once you get a denial letter from VARO, if you get one, we can advise you on how to proceed.  The VARO has to give a "reasons and bases" for denials, and when they deny you, I like to try to refute their reasons as much as possible.  Since you apparently  dont have a denial letter, I can not tell you how to refute these reasons.  

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The VA sent back for a medical opinion, since their doc said I was MDD pre-existing, to inquire about possible aggrivation.......here is his response. Seems denial is imminent.....bear in mind, NO WHERE in my history, records, buddy statements, etc is there evidence of being "relatively symptom free" for 25 years.....quite the contrary, the Pre-existing opinion was based on (2) minor incidents with alcohol as a teen, that was not addressed at MEPS.....but two weeks into training at bootcamp......and I saw a navy corpsman and a his superior who was not a psychologist. ........and they wonder why vets get frustrated and go ape shit......

 

b. The claimed condition, which clearly and unmistakably existed prior to

service, was not aggravated beyond its natural progression by an in-service

 

event, injury or illness.

c. Rationale: It would be speculation to determine the presence of

aggravation due to any trauma occurring during veteran's military

service.

This conclusion is based on the following: 1) Veteran has multiple

established factors increasing the likelihood of depression including

relationship difficulties, early family risk factors, and alcohol abuse.

These established factors are likely associated with significant aspects of

veteran's depression. Separating out the portion of depression

attributable

to trauma in the presence of these other larger factors would be a

questionable exercise at best. 2) The literature to establish a connection

between trauma and depression does not exist in a way that allows

application

in this situation. PTSD and Major Depression likely have some level of

concordance (having one diagnosis increases the likelihood of having the

other diagnosis); however, even this literature has not established firm

levels of concordance depending on the severity of trauma, family history,

and other risk factors not to mention the more than 25 years between the

trauma and current functioning such as exists for the veteran. In addition,

this literature is about diagnosed PTSD, not just a trauma having occurred.

Similarly, there is literature on connection between general stresses and

depression but again not in a manner that allows the assessment of a 25 year

lapse between stress and current depression. 3) Veteran's depression is

very

mild. The mildness of the depression suggests that any portion of

depression

attributable to aggravation would be very small. Smaller than the accuracy

of current psychological strategies to measure.

*************************************************************************

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"Separating out the portion of depression attributable to trauma in the presence of these other larger factors would be a questionable exercise at best."

So, the doc acknowledged that there was a portion of depression attributable to trauma...but refused to show how much. He evaded his responsibility here. If the portion can not be identified, and if the portion can not be separated, all of the symptoms will automatically be attributed to the PTSD. This is where they lose. The level of proof that the pre-existing condition was not aggravated by the new stressor is a very high level of proof.  This level has not been met, because of the doc's speculation.  

4.2 Interpretation of examination reports.

... If a diagnosis is not supported by the findings on the examination report or if the report does not contain sufficient detail, it is incumbent upon the rating board to return the report as inadequate for evaluation purposes.

4.6 Evaluation of evidence.

The element of the weight to be accorded the character of the veteran's service is but one factor entering into the considerations of the rating boards in arriving at determinations of the evaluation of disability. Every element in any way affecting the probative value to be assigned to the evidence in each individual claim must be thoroughly and conscientiously studied by each member of the rating board in the light of the established policies of the Department of Veterans Affairs to the end that decisions will be equitable and just as contemplated by the requirements of the law.

The presumption of sound condition has not been addressed. The VA has to show that the MDD was NOT resolved before you entered the service. Did they do that? I dont see it.

 The presumption of aggravation is found in 38 U.S.C. 1153, which states: “A preexisting injury or disease will be considered to have been aggravated by active military, naval, or air service, where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease.”

 

"c. Rationale: It would be speculation to determine the presence of aggravation due to any trauma occurring during veteran's military service."

It is also speculation to determine that there was no aggravation for the same reason. The fact that a stressor can be confirmed demands that there is no speculation. The examination should be set aside, ready for another C&P exam?

.

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Thank you for the input. I knew when they queried the same psychologist to expound, it would go this way. I am still trying to get an IMO and my claim went to prep for decision immediately, so, I', certain that is going to be denial, NOD and a 4 - 7 year wait!

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      * Second I then make a copy of my service medical records on a different color paper, yellow or buff something easy to read, but it will distinguish it from the original.

      * I then put my original away and work off the copy.

      * Now if you know the specific date it's fairly easy to find. 

      * If on the other hand you don't know specifically or you had symptoms leading up to it. Well this may take some detective work and so Watson the game is afoot.

      * Let's say it's Irritable Syndrome 

      * I would start page by page from page 1, if the first thing I run across an entry that supports my claim for IBS, I number it #1, I Bracket it in Red, and then on a separate piece of paper I start to compile my medical evidence log. So I would write Page 10 #1 and a brief summary of the evidence, do this has you go through all the your medical records and when you are finished you will have an index and easy way to find your evidence. 

      Study your diagnosis symptoms look them up. Check common medications for your IBS and look for the symptoms noted in your evidence that seem to point to IBS, if your doctor prescribes meds for IBS, but doesn't call it that make those a reference also.
      • 9 replies
    • How to get your questions answered on the forum
      Do not post your question in someone else's thread. If you are reading a topic that sounds similar to your question, start a new topic and post your question. When you add your question to a topic someone else started both your questions get lost in the thread. So best to start your own thread so you can follow your question and the other member can follow theirs.

      All VA Claims questions should be posted on our forums. Read the forums without registering, to post you must register it’s free. Register for a free account.

      Tips on posting on the forums.

      Post a clear title like ‘Need help preparing PTSD claim’ or “VA med center won’t schedule my surgery” instead of ‘I have a question’.


      Knowledgable people who don’t have time to read all posts may skip yours if your need isn’t clear in the title. I don’t read all posts every login and will gravitate towards those I have more info on.


      Use paragraphs instead of one huge, rambling introduction or story. Again – You want to make it easy for others to help. If your question is buried in a monster paragraph there are fewer who will investigate to dig it out.



      Leading to:

      Post clear questions and then give background info on them.



      Examples:

      A. I was previously denied for apnea – Should I refile a claim?



      I was diagnosed with apnea in service and received a CPAP machine but claim was denied in 2008. Should I refile?




      B. I may have PTSD- how can I be sure?


      I was involved in traumatic incident on base in 1974 and have had nightmares ever since, but I did not go to mental health while enlisted. How can I get help?





      This gives members a starting point to ask clarifying questions like “Can you post the Reasons for Denial from your claim?” etc.

      Note:

      Your firsts posts on the board may be delayed before they show up, as they are reviewed, this process does not take long and the review requirement will be removed usually by the 6th post, though we reserve the right to keep anyone on moderator preview.

      This process allows us to remove spam and other junk posts before they hit the board. We want to keep the focus on VA Claims and this helps us do that.
      • 2 replies
    • I have a 30% hearing loss and 10% Tinnitus rating since 5/17.  I have Meniere's Syndrome which was diagnosed by a VA facility in 2010 yet I never thought to include this in my quest for a rating.  Meniere's is very debilitating for me, but I have not made any noise about it because I could lose my license to drive.  I am thinking of applying for additional compensation as I am unable to work at any meaningful employment as I cannot communicate effectively because of my hearing and comprehension difficulties.  I don't know whether to file for a TDUI, or just ask for additional compensation.  My county Veterans service contact who helped me get my current rating has been totally useless on this when I asked her for help.  Does anyone know which forms I should use?  There are so many different directions to proceed on this that I am confused.  Any help would be appreciated.  Vietnam Vet 64-67. 
    • e-Benefits Status Messages
      e-Benefits Status Messages 

      Claims Process – Your claim can go from any step to back a step depending on the specifics of the claim, so you may go from Pending Decision Approval back to Review of Evidence. Ebenefits status is helpful but not definitive. Continue Reading
      • 0 replies
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