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Let me know what you guys think and maybe a guess at the rating. Thanks! 05/13/2011 ADDENDUM STATUS: COMPLETED Initial Posttraumatic Stress Disorder (PTSD) Examination This examination does not constitute adisability rating decision. Disability rating decisions are made solely by theVBA Regional Office after all available data have been reviewed and verified.Questions or concerns regarding disability rating decisions should be directedto the VBA Regional Office and/or an appeals board. THE VETERAN'S C-FILE WAS REVIEWED. 1. Diagnosis --------------- a. Does the Veteran have a diagnosis of PTSD that conforms toDSM-IV criteria? [X] Yes [ ] No Name of diagnosing facility or clinician: VA c. If there is a diagnosis ofPTSD, does the Veteran also have any other Axis-I-IV diagnoses? [X] Yes [ ] No Additional mental health disorder diagnosis #1: Cognitive Disorder NOS(Provisional) Name of diagnosing facility or clinician: VA Indicate the Axis category: [X] Axis I [ ] Axis II Describe its relationship to PTSD: Unclear. 2. Medical History ---------------------- See C-file. 3. DiagnosticCriteria ------------------------- The diagnostic criteria for PTSD, referred to as Criteria A-F, are fromthe Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV). Criterion A: The person has beenexposed to a traumatic event in which both of the following have been present: [X] The person has experienced,witnessed, or been confronted with an event or events that involve actual orthreatened death or serious injury, or a threat to the physical integrity ofoneself or others. [X] The person's response involvedintense fear, helplessness, or horror. Note: in children, it may be expressedinstead by disorganized or agitated behavior. Criterion B: The traumatic event is persistently re-experienced in atleast one of the following ways: [X] Recurrent and intrusive distressingrecollections of the event, including images, thoughts, or perceptions. Note:in young children, repetitive play may occur in which themes or aspects of thetrauma are expressed. [X] Recurrent distressing dreams of theevent. Note: in children, there may be frightening dreams without recognizablecontent [X] Acting or feeling as if thetraumatic event were recurring (includes a sense of reliving the experience,illusions, hallucinations, and dissociative flashback episodes, including thosethat occur upon awakening or when intoxicated). Note: in children,trauma-specific reenactment may occur. [X] Intense psychological distress atexposure to internal or external cues that symbolize or resemble an aspect ofthe traumatic event. [X] Physiologic reactivity uponexposure to internal or external cues that symbolize or resemble an aspect ofthe traumatic event Criterion C: Persistent avoidance of stimuli associated with the traumaand numbing of general responsiveness (not present before the trauma), asindicated by at least three of the following: [X] Efforts to avoid thoughts,feelings, or conversations associated with the trauma [X] Efforts to avoid activities,places, or people that arouse recollections of the trauma [X] Inability to recall an importantaspect of the trauma [X] Markedly diminished interest orparticipation in significant activities [X] Feeling of detachment orestrangement from others [X] Restricted range of affect (e.g.,unable to have loving feelings) [X] Sense of foreshortened future(e.g., does not expect to have a career, marriage, children, or a normal lifespan) Criterion D: Persistent symptoms of increasing arousal (not presentbefore the trauma), indicated by at least two of the following: [X] Difficulty falling or stayingasleep [X] Irritability or outbursts of anger [X] Difficulty concentrating [X] Hyper-vigilance [X] Exaggerated startle response Criterion E: [X] The duration of the symptoms described above in Criteria B, C,and D is more than 1 month. Criterion F: [X] The symptoms described above in Criteria B, C, and D causeclinically significant distress or impairment in social, occupational, or otherimportant areas of functioning. 4. Evidence Review ------------------------ Was the Veteran's VA claims file reviewed? [X] Yes [ ] No If yes, list any records, that were reviewed but were not included inthe Veteran's VA claims file: N/A. 5. Stressors --------------- a. Stressor(s): Hostile military orterrorist activity. Describe circumstance of stressor(s): Military war zone activity. Are the Veteran's symptoms related to this stressor(s) [X] Yes [ ] No Does this stressor(s) meet Criterion A (i.e., is it adequate to supportthe diagnosis of PTSD)? [X] Yes [ ] No Is the stressor(s) related to the Veteran's fear of hostile military orterrorist activity? [X] Yes [ ] No 6. Symptoms: ----------------- For each level below, check all symptoms that apply. Level I Does the Veteran have any symptoms from the list below? [X] Yes [ ] No If yes, check all that apply: [X] Depressed mood [X] Anxiety [X] Suspiciousness [X] Panic attacks that occur weekly or less often [X] Chronic sleep impairment [X] Mild memory loss, such as forgetting names, directions or recent events Level II Does the Veteran have any symptoms from the list below? [X] Yes [ ] No If yes, check all that apply: [X] Flattened affect [X] Circumstantial, circumlocutory or stereotyped speech [X] Panic attacks more than once a week [X] Impairment of short- and long-term memory, for example, retention of only highly learned material, while forgetting to complete tasks [X] Disturbances of motivation and mood [X] Difficulty in establishing and maintaining effective work and social relationships Level III Does the Veteran have any symptoms from the list below? [X] Yes [ ] No If yes, check all that apply: [X] Suicidal ideation [X] Obsessional rituals which interfere with routine activities [X] Speech intermittently illogical, obscure, or irrelevant [X] Impaired impulse control, such as unprovoked irritability with periods of violence [X] Difficulty in adapting to stressful circumstances, including work or a worklike setting [X] Inability to establish and maintain effective relationships Level IV Does the Veteran have any Level IV symptoms? [ ] Yes [X] No 7. Other symptoms ----------------- Does the Veteran have any other symptoms attributable to PTSD (and other mental disorders that are not listed above? [] Yes [X] No 8. Differentiation of symptoms ------------------------------ Are you able to differentiate what portion of the symptom complex above is caused by each diagnosis? [ ] Yes [X] No 9. Functional Impairment ------------------------- Occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. 10. Current Global Assessment of Functioning (GAF) Score: 41 ----------------------------------------------------------------------- 11. Competency ------------- Is the Veteran capable of managing his or her financial affairs? [X] Yes [ ] No 12. Diagnostic testing --------------------- Has any mental health testing been performed? [ ] Yes [X] No 13. Functional impact --------------------- Does the Veteran's PTSD (and other mental disorders) impact his or her ability to work? [X] Yes [ ] No If yes, describe impact, providing one or more examples: See above for details. The Veteran was given a draft of the above exam to review prior to its signature and asked to provide feedback to the examiner regarding its accuracy and completeness. The Veteran was then given the completed and signed examination for his or her records. Signed by: /es/ -------- PSYCHOLOGIST 5/13/2011