I have to type this all by hand so if I skip something that might be important ask and I will try and find it for you. Thanks for the help.
Does the Veteran have a diagnosis of PTSD that conforms to DSM-IV criteria based on today's evaluation? YES
2. Current Diagnoses
a. Diagnosis #1: PTSD
b. Axis III - medical diagnosis: ( to include TBI)
c. Axis IV- Psychosocial and Environmental Problems:
exposure to personal assaults, inadequate income
d. Axis V - Current global assessment of functioning (GAF) score: 60
3. Differentiations of symptoms
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a. Does the veteran have more than one mental disorder diagnosed?
[X] no
4. Occupational and social impairment
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a. Which of the following best summarizes the Veteran's level of occupational and social impairment in regards to all mental
diagnoses?
[X} Occupational and social impairment with occasional decease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self care and conversation
Does this stressor meet Criterion A (i.e., is it adequate to support the diagnosis of PTSD)? YES
Is the stressor related to the Veteran's fear of hostile military or terrorist activity? No
4. PTSD Diagnostic Criteria
a.
Criterion A:
<X> The Veteran experienced, witnessed, or was confronted with an event that involved actual or threateded death or serious injury, or a threat to the physical integrity of self or others.
<X> The Veteran's response involved intense fear, helplessness or horror.
Criterion B:
<X> Recurrent and distressing recollections of the event, including images, thoughts, or perceptions
<X> Recurrent distressing dreams of the event
<X> Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event
<X> physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event
Criterion C:
<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> Markedly diminished interest or participation in significant activities
<X> Feeling of detachment or estrangement from others
<X> Restricted range of affect (e.g., unable to have loving feelings)
<X> Sense of foreshortened future
Criterion D:
<X> Difficulty falling or staying asleep
<X> Irritability or outbursts of anger
<X> Difficulty concentrating
<X> Hypervigilance
Criterion E:
<X> The duration fo the symptoms described above in Criteria B, C, and D is more than 1 month
Criterion F:
<X> The PTSD symptoms described above cause clinically significant distress or impairment in social, occupational, or other important areas of functioning
b. Which stressor(s) contributed to the Veterans PTSD diagnosis?:
<X> Stressor #1
5. Symptoms
<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
<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> Suicidal ideation
6. Other symptoms: NO
7. Competency
Is Veteran capable of managing his or her financial affairs? YES