100 PERCENT or NOT???

[Bluntly]

Quick back drop I've filed for increase for ptsd Oct. 2017 and had my exam the following month. Awarded 70 percent with retro pay included, right after i filed for IU in Dec. 2017 and they just gave me another ptsd C&P exam(Feb. 17, 2018). 

3 months apart from each other for the same exam i thought was kind of strange. But none the less I would like any feed back on whether this new exam remains at 70 percent???(My gut feeling is saying 100).....

SECTION I:
                                   ----------
    1. Diagnostic Summary
    ---------------------
    Does the Veteran now have or has he/she ever been diagnosed with PTSD?
    [X] Yes  [ ] No
       ICD Code: F43.10

    2. Current Diagnoses
    --------------------
    a. Mental Disorder Diagnosis #1: Posttraumatic  Stress Disorder
         ICD Code: F43.10
         Comments, if any: 
         The Veteran reported that he continues to experience trauma disorder
         symptoms consistent with identified criteria for PTSD including having
         witnessed/endured a series of traumatic events while serving two
         deployments to Iraq (2006) and 2008), chronic severe intrusive 
ideations
         involving these traumas, avoidance of stimuli associated with traumatic
         events, negative alterations in cognitions and mood, and significant
         emotional arousal on a daily basis.  He reported that these
         self-identified index military traumas, including his having been
         wounded by an IED causing damage to his head, neck, and left leg;
         witnessing other Marines become wounded, observing the bodies of dead
         Iraqis, and fearing for his life on a regular basis secondary to
         frequent attacks on his base and IEDs while on mounted patrol fearing
         that the vehicles he rode in would be destroyed by an IED and he would
         be killed in action.  These symptoms reportedly cause him significant
         impairment in most areas of his functioning on an almost daily basis.
         Current PTSD-related symptoms reported by the veteran include severe
         anxiety, suspiciousness, chronic middle insomnia, mild memory 
impairment
         particularly immediate memory functioning, intrusive recollections of
         military service based traumas, recurrent nightmares of index military
         traumas, avoidance of activities, person, and places that resemble
         aspects of identified traumatic experiences, diminished interest in
         participation in  most daily activities, feeling detached/estranged 
from
         family and friends, frequent irritability resulting in occasional
         displays of verbal aggression, frequent hypervigilance, and chronic
         difficulty initiating and maintaining certain interpersonal
         relationships.  He reported that the frequency and severity of
         PTSD-related symptoms continue to increase in frequency and severity 
and
         do result in significant impairment in his daily functioning on more
         days than not at present. Veteran provided self-assessment of severity
         of current symptoms consistent with PTSD as "getting worse and since I
         am not working I have time to think about things that I saw in the
         military" and that it is his subjective opinion that he has experienced
         a generally mild increase in specific symptoms consistent with 
diagnosed
         PTSD during the 3-month interim between the date of the prior Review
         PTSD C&P examination completed by Dr. XXXX and the date of this
         Review PTSD examination both of which was completed at the Corporal
         XXXX VAMC. He reported that the frequency and severity of
         PTSD-related symptoms have continued to increase in terms of frequency
         and severity since his military discharge during 2009 and currently
         cause significant impairment his daily functioning on more days than
         not.  Veteran provided self-assessment of severity of current symptoms
         consistent with PTSD as "under okay control usually but if something
         makes me think of something I saw in Iraq or that I am back in Iraq
         again things gets worse".  He noted having experienced continued
         increases in level of hypervigilance at home and in the community as
         well as increased frequency of distressing ideations and nightmares of
         index traumas Veteran is currently awarded 70% disability rating by the
         VA Regional Office and Insurance Center in light of reported functional
         impairment caused by chronic PTSD symptoms.
         

    b. Medical diagnoses relevant to the understanding or management of the
       Mental Health Disorder (to include TBI): Service-connected for migraine
       headaches, flat feet, limited motion of  left arm, and limited motion of
       left ankle.

    3. Differentiation of symptoms
    ------------------------------
    a. Does the Veteran have more than one mental disorder diagnosed?
       [ ] Yes  [X] No
       
    c. Does the Veteran have a diagnosed traumatic brain injury (TBI)?
       [ ] Yes  [ ] No  [X] Not shown in records reviewed
       
           Comments, if any: No formal asessment for the presence of symptoms
           consistent with a diagnosis of traumatic brain injury had been
           completed based on a review of the Veteran's clinical files.
           
    4. Occupational and social impairment
    -------------------------------------
    a. Which of the following best summarizes the Veteran's level of 
occupational
       and social impairment with regards to all mental diagnoses? (Check only
       one)
       
       [X] Occupational and social impairment with reduced reliability and
           productivity

    b. For the indicated level of occupational and social impairment, is it
       possible to differentiate what portion of the occupational and social
       impairment indicated above is caused by each mental disorder?
       [ ] Yes  [ ] No  [X] No other mental disorder has been diagnosed
       
    c. If a diagnosis of TBI exists, is it possible to differentiate what 
portion
       of the occupational and social impairment indicated above is caused by 
the
       TBI?
       [ ] Yes  [ ] No  [X] No diagnosis of TBI
       
                                   SECTION II:
                                   -----------
                               Clinical Findings:
                               ------------------
    1. Evidence Review
    ------------------
    Evidence reviewed (check all that apply):
    
    [X] VA e-folder (VBMS or Virtual VA)
    [X] CPRS


    2. Recent History (since prior exam)
    ------------------------------------
    a. Relevant Social/Marital/Family history:
          Veteran served in the US Marine Corps (USMC) and his period of active
          duty began during June 2005 and ended 4 years later during June 2009.
          He completed his course of basic training at the Parris Island USMC
          Base in South Carolina.  He the completed infantry school at the North
          Carolina.  His primary military specialty was a 0311 Rifleman.  He was
          deployed twice, Iraq (2006-07) and Iraq (2008).  He suffered injuries
          to his head and neck as the result of an IED blast during initial
          deployment as a turret gunner.  He stated that there was a bright 
flash
          as the IED exploded and suffered a laceration othis head and bried 
loss
          of consciousness.  He denied having been the
 focus of any significant
          action of military discipline.  He was assessed a Page 11 violation 
and
          was charged with failure to supervise a fellow Marine under his 
command
          and that other Marine accidentally discharged his weapon which
          fortunately did not result in personal injury or property damage.  He
          believes that it was that incident that prevented him from achieving
          the rank of Sergeant.  He was awarded an Honorable Discharge at the
          rank of Corporal (E-4) during June 2009.   

          Veteran reported that he has not experienced any significant changes 
in
          his social, marital, or family history during the 3-month interim
          between the last Review PTSD C&P examination and the date of this
          examination.  Veteran continues to reside with his mother near 
Xxxx,
          XX and reports a successful relationship with his mother.   He has an
          emotionally detached relationship with his father currently and that
          has been the status of their relationship for the past few years.
          Veteran noted that his relationship has been slightly more amicable
          during the past year or so.  He has close relationships with his
          siblings (2 sisters and 1brother) and interacts with them one monthly
          on average.  Reported having enjoyed close relationships with all his
          family members prior to military service and over time the intimacy of
          those relationships diminished to differing degrees.  He noted "I 
would
          like to be closer to my brother but he changed after he was in a car
          accident and is hard to get along to get along with".  

          Veteran reported that he is divorced and had been for 6 years.  He
          reported that the marriage ended primarily because of irreconcilable
          differences including his displaying anxiety, isolation, and frequent
          hypervigilance.  He has 1 daughter and whom he enjoys a very close,
          rewarding relationship.  He described his relationship with his
          girlfriend in positive terms and described her as his primary source 
of
          social support.  Veteran reported that he has been married only once
          and has only one child.  
          
          
    b. Relevant Occupational and Educational history:
          Veteran reported that he has not experienced any significant change in
          his occupational or social functioning since the date of the prior
          Review PTSD C&P examination.  He remains unemployed.  His last period
          of employment ended during 2011 when he resigned from his employment 
as
          a mechanic at New Jersey Transit in the regional rail division of that
          organization.  He reported having left that position because he did 
not
          find the work tasks stimulating and rewarding. As he had during the
          interview associated with the prior Review PTSD C&P examination during
          November 2017 he perceived that job as "working was killing me, it w
          aborning, and I didn't think it was getting me anywhere.  I felt like 
I
          was wasting my life being there".   

          He reported currently experiencing mild overall impairment in social
          functioning.  He has close, loving relationships with his mother and
          girlfriend.  He reported feeling grateful for the support provided him
          by his mother and girlfriend.  He has a very successful relationship
          with his daughter.  He has few friends and visits with them on "now 
and
          then".  Reported that he can tolerate most social environments but
          prefers to be at home when he can.  He generally does not attend 
social
          occasions hosted by members of his family or his friends and at those
          occasions he does attend he often remains at those occasions for an
          hour or two and interacts with select attendees based on how
          comfortable he feels interacting with them.   
          
          
    c. Relevant Mental Health history, to include prescribed medications and
       family mental health:
          Veteran reported that he has not participated in any manner of formal
          treatment of his reported chronic symptoms consistent with diagnosed
          PTSD since the date of the prior Review PTSD C&P examination 3 months
          earlier.  Reported having last participated in formal mental health
          disorder treatment during 2014.  Reported currently considering
          beginning outpatient mental health disorder treatment at the Lyons 
VAMC
          in NJ.  Veteran denied having ever been prescribed psychotropic
          medication.
          
    d. Relevant Legal and Behavioral history:
          The Veteran denied any history of significant involvement with
          representatives of the legal or criminal justice system prior to,
          during, and/or following discharge from military service.
          
    e. Relevant Substance abuse history:
          Veteran denied any history of exhibiting behavior consistent with
          identified criteria for any substance use disorder listed in the DSM-5
          Manual including alcohol, cannabis, cocaine, opiates, 
methamphetamines,
          or prescription medication.  He reported that he generally imbibes
          alcohol on an infrequent basis, has never overused cannabis or other
          common substances of abuse, and never abused prescription medication.
          Veteran reported that he is currently smoking close to a half of a 
pack
          of cigarettes daily and smoking 1 or 2 joints (cannabis) on 2 or 3 
days
          per week.
          
    f. Other, if any:
          No other mental health disorder symptoms reported by the Veteran 
during
          the examination interview or noted in his electronic clinical files.
          
    3. PTSD Diagnostic Criteria
    ---------------------------

    Please check criteria used for establishing the current PTSD diagnosis. The
    diagnostic criteria for PTSD, are from the Diagnostic and Statistical Manual
    of Mental Disorders, 5th edition (DSM-5).  The stressful event can be due to
    combat, personal trauma, other life threatening situations (non-combat
    related stressors).  Do NOT mark symptoms below that are clearly not
    attributable to the Criterion A stressor/PTSD.  Instead, overlapping 
symptoms
    clearly attributable to other things should be noted under #6 - "Other
    symptoms".
    
       Criterion A: Exposure to actual or threatened a) death, b) serious 
injury,
                    c) sexual violence, in one or more of the following ways:
                    
                   [X] Directly experiencing the traumatic event(s)
                   [X] Witnessing, in person, the traumatic event(s) as they
                       occurred to others

       Criterion B: Presence of (one or more) of the following intrusion 
symptoms
                    associated with the traumatic event(s), beginning after the
                    traumatic event(s) occurred:
                    
                   [X] Recurrent, involuntary, and intrusive distressing 
memories
                       of the traumatic event(s).
                   [X] Recurrent distressing dreams in which the content and/or
                       affect of the dream are related to the traumatic 
event(s).
                   [X] Marked physiological reactions to internal or external
                       cues that symbolize or resemble an aspect of the 
traumatic
                       event(s).

       Criterion C: Persistent avoidance of stimuli associated with the 
traumatic
                    event(s), beginning after the traumatic events(s) occurred,


                    as evidenced by one or both of the following:
                    
                   [X] Avoidance of or efforts to avoid distressing memories,
                       thoughts, or feelings about or closely associated with 
the
                       traumatic event(s).
                   [X] Avoidance of or efforts to avoid external reminders
                       (people, places, conversations, activities, objects,
                       situations) that arouse distressing memories, thoughts, 
or
                       feelings about or closely associated with the traumatic
                       event(s).

       Criterion D: Negative alterations in cognitions and mood associated with
                    the traumatic event(s), beginning or worsening after the
                    traumatic event(s) occurred, as evidenced by two (or more) 
of
                    the following:
                    
                   [X] Markedly diminished interest or participation in
                       significant activities.
                   [X] Feelings of detachment or estrangement from others.

       Criterion E: Marked alterations in arousal and reactivity associated with
                    the traumatic event(s), beginning or worsening after the
                    traumatic event(s) occurred, as evidenced by two (or more) 
of
                    the following:
                    
                   [X] Irritable behavior and angry outbursts (with little or no
                       provocation) typically expressed as verbal or physical
                       aggression toward people or objects.
                   [X] Hypervigilance.
                   [X] Problems with concentration.
                   [X] Sleep disturbance (e.g., difficulty falling or staying
                       asleep or restless sleep).

       Criterion F:
                   [X] The duration of the symptoms described above in Criteria
                       B, C, and D are more than 1 month.

       Criterion G:
                   [X] The PTSD symptoms described above cause clinically
                       significant distress or impairment in social,
                       occupational, or other important areas of functioning.

       Criterion H:
                   [X] The disturbance is not attributable to the physiological
                       effects of a substance (e.g., medication, alcohol) or
                       another medical condition.

    4. Symptoms
    -----------
    For VA rating purposes, check all symptoms that actively apply to the
    Veteran's diagnoses:
    
       [X] Anxiety
       [X] Suspiciousness
       [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] Difficulty in adapting to stressful circumstances, including work or 
a
           worklike setting
       [X] Intermittent inability to perform activities of daily living,
           including maintenance of minimal personal hygiene

    5. Behavioral observations
    --------------------------
       The results of a brief mental status examination found that the Veteran
       appeared his stated age, was adequately groomed, and casually attired.  
He
       displayed anxious affect and stated his mood in positive terms.  Veteran
       did not display any abnormal or inappropriate behavior during the
       60-minute interview.  Veteran displayed an open and cooperative attitude
       towards this examiner during the course of examination session.  His
       speech production was within normal limits in terms of pitch, pace, and
       volume. Content of his speech indicated reality-based, concise, adaptive
       ideations and no evidence of formal thought disorder or frank psychotic
       thinking was observed.  His skills in insight and judgment were assessed
       as intact, his skills in concentration and memory were found to be mildly
       impaired in areas assessed. Veteran reported that he had experienced
       suicidal ideations and attempted suicide during 2014 (drank bleach) after
       experiencing acute psychosocial stressors and was subsequently treated on
       an inpatient psychiatry unit of a local hospital. He stated that he has
       not experienced active suicidal ideations since he was discharged from
       that hospitalization.  Denied a history of experiencing homicidal
       ideations.
       
    6. Other symptoms
    -----------------
    Does the Veteran have any other symptoms attributable to PTSD (and other
    mental disorders) that are not listed above?
    [ ] Yes  [X] No
    
    7. Competency
    -------------
    Is the Veteran capable of managing his or her financial affairs?
    [X] Yes  [ ] No
    
    8. Remarks, (including any testing results) if any:
    -----------------------

Edited March 2, 2018 by Bluntly

[Buck52]

Note: Not all this exam is complete ..we don't have everything the examiner marked.

from what I can gather from this in part exam .  he should be rated 100% unless given IU , Most of or All of the boxes were check yes in the veterans favor showing 100 % rating.

if they keep the rating at 70% they may infer the IU... It will be up to this Veteran to disagree with that decision.

OK The TDIU P&T was given based on his inability to hold a job  so they must kept his rating at 70% and infer the  Extra schedulerTDIU , Which I would have disagreed with that decision, and went got myself a screening for TBI  b/c TBI AND PTSD do have overlapping symptoms and he could have or should have been diagnosed with TBI and in the rating that would put him up to the 100% plus possible SMC Probability.

my reasons for the disagrement here  when a Vet is IU or TDIU ON COMBINED RATINGS or ratings less that the 100%  Ok  he is being paid at the 100% rate but the fact is he is still considered 70% rating  and this makes it harder to reach the 100%

unless he re-post all of this exam its really hard to give a good answer.

I was wanting to know if they screen him for a Possible TBI?

 I  realize in this exam the examiner marked  NO TBI Diagnoses.

Edited June 21, 2018 by Buck52

[Buck52]

To add

Unless your in dire straits financial wise  you need to think long and hard about the disagreement. if you need the $$  then just keep things as they are ( jmo)

[broncovet]

Im skeptical that this will be increased to 100 percent.  If you read the criteria for 100 percent it states that you have "Total Occupational and social impairment".  They did not use those terms.  

As far as TDIU, if your doc says you are unable to work due to PTSD and or other sc items, then you should be good to go.  

[Bluntly]

Appreciate your response and that's part of my reason that had me skeptical. "Total Occupational and social impairment" is something they specifically didn't note, so just waiting to find out either way.

[broncovet]

"Total occupational impairment"is the term used for the criteria for 100 percent for PTSD.  However, if you are not working they may give it to you, instead of granting tdiu.  Its a judgement call made by the decision maker, and you may get a generous one.  We dont know.  I estimate about 15 to 20 percent of the raters are "generous", with the other 85 percent "deny everything".  Of course, there are also many in between this continium.  

[Inarticulate&Distorted]

I think 100% wouldnt be too off, all it would take is one bad day and Total Occupational Imparment would be there. A Rater who sees the whole picture on this Vets file would see that theres not going to be any improvement. My opinion of course. Good luck and keep us updated please.