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JWMN89

C&P for PTSD/MDD - Would like opinion on results

Question

I received my C&P over the weekend.  My exam was nearly three hours and I think the report is accurate and fair and represents how things are.  I was as honest as I could be with the examiner and despite being nervous to the point of an anxiety attack about it the day before calmed down a bit and was OK during the visit.  The doctor did a good job asking questions and made me feel at ease which is saying something.  The report ended up being 18 pages which surprised me. 

I had PMd the results to a handful of people here on HADIT and a couple recommended I post it for more input.  I was hesitant to do so but decided my desire for more information is more important than my paranoia of posting it.  I'd really like to get the opinions of some senior HADIT posters like Berta and others.  I'm thinking this is a good C&P for my claim but would like a more seasoned opinion than my own completely inexperienced one.  I've posted the opinion and rationale below.  .

Thank you.  JW.

___________________________________

 

5. Symptoms 

For VA rating purposes, check all symptoms that actively apply to the Veteran's diagnoses:
[X] Depressed mood
[X] Anxiety
[X] Chronic sleep impairment
[X] Mild memory loss, such as forgetting names, directions or recent events
[X] Disturbances of motivation and mood
[X] Difficulty in establishing and maintaining effective work and social relationships
[X] Suicidal ideation

REQUESTED OPINION:

Based on information from the clinical interview, review of records (C-file and VA medical records), and psychological assessment measures, It is my opinion that the veteran meets DSM-5 diagnostic criteria for (1) Post-Traumatic Stress Disorder (PTSD) due to childhood sexual trauma with delayed onset, and (2) Major Depressive Disorder (MDD), Recurrent, with Mood-Congruent Psychotic Features secondary to PTSD. While his PTSD and MDD were less likely than not to have been caused by an in-service stressor, both conditions were more likely than not incurred in service (i.e., delayed onset with clinically significant symptom presentation beginning while on active duty).

PSYCHOLOGICAL ASSESSMENT / OBJECTIVE TESTING:

Objective psychological assessment measures administered: -- Personality Assessment Inventory (PAI): valid profile without any evidence to suggest inattention, inconsistency, or negative/positive impression management; primary code type - DEP/ARD (97T/85T) * Summary/interpretation of results: Briefly, the veteran's responses on the PAI were suggestive of significant tension, unhappiness, and pessimism, with various stressors (past and/or present) contributing to low mood and self-esteem. Individuals with similar profiles often see themselves as ineffectual and powerless to change the direction of their lives and feel uncertain about goals, priorities, and what the future may hold. In addition to depression, the veteran endorsed significant distress on measures of suicidal thoughts, traumatic stress, and social discomfort or detachment. His profile was most consistent with major depression, and while some traumatic stress concerns were indicated, he did not endorse the full range of concerns typically seen among individuals with PTSD.

RATIONALE FOR OPINION:

1. The veteran's symptoms meet DSM-5 diagnostic criteria for PTSD due to childhood sexual trauma. The veteran's history of childhood sexual abuse is well-documented across multiple sources and during the current evaluation, he endorsed the full range of trauma-related symptoms meeting criteria for a diagnosis of PTSD. He was first diagnosed with PTSD while on active duty in xxxx by a DOD psychiatrist and mental health records (private and VA) dating back to xxxx also show that multiple mental Health providers have diagnosed and treated PTSD. Although the veteran experienced some symptoms immediately following the assault (bed wetting, night terrors), these symptoms largely resolved by the time he was in middle school due to reported "traumatic amnesia." His only residual symptoms throughout the remainder of middle school and high school were associated with a chronic mistrust of others and related social detachment. His enlistment exam was silent for any relevant concerns, as were STRs from the time of his enlistment in xxxx until the first disclosure of the assault and associated symptoms in xxxx and xxxx. Thus, there is no evidence to suggest that the veteran was experiencing clinically significant symptoms of PTSD prior to his enlistment and thus the question of aggravation is moot. Records clearly document onset of symptoms while the veteran was on active duty and indicate chronic trauma-related symptoms and impairments since then.

2. The veteran's current mental health symptoms also meet DSM-5 diagnostic criteria for Major Depressive Disorder (MDD), Recurrent, with Mood-Congruent Psychotic Features, secondary to underlying PTSD. His current depressive symptoms are a continuation of those first diagnosed in service as Dysthymic Disorder, and the veteran has been treated for MDD by multiple mental health providers (private and VA) since at least xxxx. As indicated above (Rationale #1), there is no evidence to suggest Clinically significant symptoms of depression prior to military service, and he was first diagnosed with a depressive disorder while psychiatrically hospitalized in service (xxxx). Subsequent records indicate chronic problems with depression since his discharge from active duty.

3. The veteran's history is suggestive of some underlying Personality features which are likely contributing to some of his on-going concerns (e.g., schizoid and avoidant features). Although he was diagnosed with a personality disorder in service, there is insufficient evidence to warrant a personality disorder diagnosis at present, as some of his on-going symptoms can be attributed to underlying PTSD (e.g., mistrust of others, social/interpersonal detachment, avoidance of intimate relationships).

4. The veteran showed no signs of significant exaggeration/feigning or minimization of mental health symptoms on objective testing, during the interview, or when comparing his self-report to the evidence in the record. As such, information from this evaluation is believed to be an accurate reflection of the veteran's current mental health concerns and relevant background.

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This was not what I expected....and not the entire C & P report, but as you said it was quite lengthy.

Did the VA ever deny a PTSD/MDD claim from you in the past?

The examiner ruled out the childhood trauma this way:

"Thus, there is no evidence to suggest that the veteran was experiencing clinically significant symptoms of PTSD prior to his enlistment and thus the question of aggravation is moot. Records clearly document onset of symptoms while the veteran was on active duty and indicate chronic trauma-related symptoms and impairments since then."

I cannot see what stressor (s) the examiner considered, as there is much more to the report but apparently it was all explained well enough for VA to make the award.

This brief partial exam is one of the most unusual C & P exams I have ever read for PTSD. It also reveals that a VA C & P MH doctor took considerable time to develop their opinion.

That does not happen much at all these days. 
 

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Berta,

Yes the original report was 18 pages.  I thought the doctor did an excellent job  and the report was very accurate.  I didn't post the whole thing because it's full of very personal information and I'm a bit paranoid.  The doctor was exactly correct though in her assumptions.  There were two stressors that occurred in service leading to a flashback and memories emerging so there was enough for them I guess.  I was pleased it went well as it took nearly three hours for the appointment.

JW

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This brief partial exam is one of the most unusual C & P exams I have ever read for PTSD. It also reveals that a VA C & P MH doctor took considerable time to develop their opinion.

 

Berta,

To clarify this was part of the 18 page report (the ending) it's not a separate report itself.

JW

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Yes, I understand that. And it is best not to even post very personal info here.

I have had  many times (for 2 decades) to remind friends and neighbors to call me first before dropping in because, due to the HIPPA law, I cannot let anyone in if a C & P exam or even other posts are visible on my PC. I just greet them outside, and I dont care if it is 20 below zero-and I tell them I cannot let them in due to the HIPPA Law.

I live in an isolated area and another reason is that this is a long way for many to come, only to find I might not even be home....if they didnt call me first.

(Of course I could just click out of the web site but why should I ,because of a  drop in person who thinks I have nothing better to do, then entertain them.)

If I get a heads up phone call, then I will gladly try to spend time with them.

I dont think we ever talk about HIPPA here. I used to print off C & Ps if they required a lot of thought,and would burn them in my wood stove as soon as I posted a response here. I dont even do that anymore.

Everyone's medical records are private but fortunately we need to see them sometimes ,so that we can give the best help.And they are posting with the veteran's or survivor/dependents permission, by the simple act of posting them here with name, address, C file etc etc redacted. I wont even let in one of my closest friends , a VA employee for decades, if he shows up with no phone call first, if hadit is visible on my PC .

I could move my PC to another room but why should I- it is funny in a way---this is a very isolated farm community but the fact that I am usually always home, means I seem to be available for gossip or other crap.

A girl friend of mine was a medical transcriber for years , doing her work at home. She too has a farm like I do, on another isolated hill, and had the same problem I had. 

well enough of that griping on my part.......you did very well with your claim and I regret that you went through so much.......I hope the award letter comes soon!  The cash might even be in the mail or bank before the award letter shows up.

 

 

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