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