lindy0331

Thanks Navy, and good luck on your increase.

Thanks HVEQ. I've been in a VA domiciliary since March for mental health treatment.

Thanks for the comment Berta. No, I haven't applied for SSDI.

Hi all. I'm new to the forum and this is my first post, hope it's in the right spot. I am a former Marine who is currently 40% SC for a spinal injury. I finally had my C&P for my PTSD and this is the note the examiner wrote. I'd appreciate any insight into the note, and how any potential award would combine with my existing 40%. Thanks. LOCAL TITLE: C&P EXAM STANDARD TITLE: C & P EXAMINATION NOTE DATE OF NOTE: JUL 14, 2014@08:00 ENTRY DATE: JUL 14, 2014@09:32:44 AUTHOR: XXX EXP COSIGNER: URGENCY: STATUS: COMPLETED Initial Post Traumatic Stress Disorder (PTSD) Disability Benefits Questionnaire * Internal VA or DoD Use Only * Name of patient/Veteran: XXX, JAMES L SECTION I: ---------- 1. Diagnostic Summary --------------------- Does the Veteran have a diagnosis of PTSD that conforms to DMS-5 criteria based on today's evaluation? [X] Yes [ ] No ICD code: 309.81 2. Current Diagnoses -------------------- a. Mental Disorder Diagnosis #1: PTSD CHRONIC SEVERE ICD code: 309.81 Mental Disorder Diagnosis #2: MDD RECURRENT SEVERE WITH PSYCHOTIC FEATURES ICD code: 296.34 b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): NONE 3. Differentiation of symptoms ------------------------------ a. Does the Veteran have more than one mental disorder diagnosed? [X] Yes [ ] No b. Is it possible to differentiate what symptom(s) is/are attributable to each diagnosis? [ ] Yes [X] No [ ] Not applicable (N/A) If no, provide reason that it is not possible to differentiate what portion of each symptom is attributable to each diagnosis: This veteran's MDD is in response to and caused by his PTSD. c. Does the Veteran have a diagnosed traumatic brain injury (TBI)? [X] Yes [ ] No [ ] Not shown in records reviewed d. Is it possible to differentiate what symptom(s) is/are attributable to each diagnosis? [ ] Yes [X] No [ ] Not applicable (N/A) If no, provide reason that it is not possible to differentiate what portion of each symptom is attributable to each diagnosis: SYMPTOM OVERLAP 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] Total occupational and social impairment 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 [X] No [ ] No other mental disorder has been diagnosed If no, provide reason that it is not possible to differentiate what portion of the indicated level of occupational and social impairment is attributable to each diagnosis: This veteran's MDD is in response to and caused by his PTSD. 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 [X] No [ ] No diagnosis of TBI If no, provide reason that it is not possible to differentiate what portion of the indicated level of occupational and social impairment is attributable to each diagnosis: SYMPTOM OVERLAP SECTION II: ----------- Clinical Findings: ------------------ 1. Evidence review ------------------ In order to provide an accurate medical opinion, the Veteran's claims folder must be reviewed. a. Medical record review: ------------------------- Was the Veteran's VA e-folder (VBMS or Virtual VA) reviewed? [X] Yes [ ] No Was the Veteran's VA claims file reviewed? [X] Yes [ ] No If yes, list any records that were reviewed but were not included in the Veteran's VA claims file: C-FILE/VBMS/VIRTUAL-VA; CPRS If no, check all records reviewed: [ ] Military service treatment records [ ] Military service personnel records [ ] Military enlistment examination [ ] Military separation examination [ ] Military post-deployment questionnaire [ ] Department of Defense Form 214 Separation Documents [ ] Veterans Health Administration medical records (VA treatment records) [ ] Civilian medical records [ ] Interviews with collateral witnesses (family and others who have known the Veteran before and after military service) [ ] No records were reviewed [ ] Other: b. Was pertinent information from collateral sources reviewed? [ ] Yes [X] No 2. History ---------- a. Relevant Social/Marital/Family history (pre-military, military, and post-military): This veteran reports being raised in an abusive family. Pre-Military, he describes an active social life and engaging in many pleasurable leisure time activities. Post-Military, the veteran describes: Avoidance of People and Places, Social Isolation, Restricted Affect, Anhedonia, Episodes of Uncontrolled Anger and Rage, Depressed Mood, and Feelings of Worthlessness and Guilt. He reports few friends, limited leisure time activity, and a very limited social life. He is currently homeless, living in a VA domicile. b. Relevant Occupational and Educational history (pre-military, military, and post-military): This veteran last worked in IT in 2012. He reports losing more than 6 positions due to his psychiatric symptoms. He reports that the following symptoms have had a detrimental impact upon his ability to function in the workplace: Episodic Auditory Hallucinations, Flashbacks, Episodes of Anxiety and Panic, Social Isolation, Chronically Disturbed Sleep, Episodes of Uncontrolled Anger and Rage, Difficulty Concentrating, Obsessive Hypervigilance, Exaggerated Startle Response, and Depressed Mood. c. Relevant Mental Health history, to include prescribed medications and family mental health (pre-military, military, and postmilitary): This veteran reports working in psychotherapy which he finds palliative. He reports taking medication at this time for these symptoms which he finds palliative. He reports the following psychological symptoms: Episodic Auditory Hallucinations, Flashbacks, Nightmares, Episodes of Anxiety and Panic, Avoidance of People and Places, Social Isolation, Restrict ed Affect, Anhedonia, Sense of Foreshortened Future, Chronically Disturbed Sleep, Episodes of Uncontrolled Anger and Rage, Difficulty Concentrating, Obsessive Hypervigilance, Exaggerated Startle Response, Depressed Mood, Fatigue, Psychomotor Sequelae, Passive Suicidal Ideation, Feelings of Worthlessness and Guilt, Suppressed Appetite, and Avoiding Thinking of Traumatic Events. d. Relevant Legal and Behavioral history (pre-military, military, and post-military): This veteran reports behavioral and/or legal difficulties prior to and on leaving the military associated with the above noted psychiatric symptoms. e. Relevant Substance abuse history (pre-military, military, and post-military): This veteran reports heavy alcohol and or substance use prior to and on leaving military service in an attempt to manage the effects of the psychiatric symptoms noted above. f. Other, if any: No response provided. 3. Stressors ------------ a. Stressor #1: The veteran's location was the target of mortar, rocket, RPG and/or small arms fire. During these experiences the veteran was terrified for life and horrified by the aftermath of the experience. 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 b. Stressor #2: This veteran was engaged in return of fire with the enemy which was terrifying and horrifying. 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: This veteran witnessed and broke up a gang rape on a young child who was seriously harmed. He found this terrifying and horrifying. 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 criteria A stressor/PTSD. Instead, overlapping symptoms clearly attributable to other things should be noted under #6 - other symptoms. The diagnostic criteria for PTSD, referred to as Criteria A-H, are from the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DMS-5). Criterion A: Exposure to actual or threatened a) death, b) serious injury, c) sexual violatrion, in one or more of the following ways: [X] Directly experiencing the tramuatic 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] Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings). [X] Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of 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] Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs). [X] Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., "I am bad,: "No one can be trusted,: "The world is completely dangerous,: "My whole nervous system is permanently ruined"). [X] Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead to the individual to blame himself/herself or others. [X] Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame). [X] Markedly diminished interest or participation in significant activities. [X] Feelings of detachment or estrangement from others. [X] Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings.) 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] Reckless or self-destructive behavior. [X] Hypervigilance. [X] Exaggerated startle response. [X] Problems with concentration. [X] Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep). Criterion F: [X] Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month. Criterion G: [X] The disturbance causes 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. 5. Symptoms ----------- For VA rating purposes, check all symptoms that apply to the Veterans diagnoses: [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] Impairment of short- and long-term memory, for example, retention of only highly learned material, while forgetting to complete tasks [X] Flattened affect [X] Difficulty in understanding complex commands [X] Impaired judgment [X] Impaired abstract thinking [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] Inability to establish and maintain effective relationships [X] Suicidal ideation [X] Obsessional rituals which interfere with routine activities [X] Impaired impulse control, such as unprovoked irritability with periods of violence [X] Persistent delusions or hallucinations [X] Neglect of personal appearance and hygiene 6. Behavioral Observations -------------------------- No response provided 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. Competency ------------- Is the Veteran capable of managing his or her financial affairs? [X] Yes [ ] No 9. Remarks, if any ------------------ This veteran meets the criteria for DSM-IV and DSM-V Diagnoses of PTSD CHRONIC SEVERE and MDD RECURRENT SEVERE WITH PSYCHOTIC FEATURES. This veteran's MDD is in response to and caused by his PTSD. He reports the following psychological symptoms: Episodic Auditory Hallucinations, Flashbacks, Nightmares, Episodes of Anxiety and Panic, Avoidance of People and Places, Social Isolation, Restricted Affect, Anhedonia, Sense of Foreshortened Future, Chronically Disturbed Sleep, Episodes of Uncontrolled Anger and Rage, Difficulty Concentrating, Obsessive Hypervigilance, Exaggerated Startle Response, Depressed Mood, Fatigue, Psychomotor Sequelae, Passive Suicidal Ideation, Feelings of Worthlessness and Guilt, Suppressed Appetite, and Avoiding Thinking of Traumatic Events. This psychiatric condition was caused by the veteran's military experience and/or combat exposure. The reported stressors are directly related to the veteran's fear of hostile military and/or terrorist activity. This veteran's GAF score represents serious symptoms and deficits in social, work and personal functioning. (GAF: 42) Due to the level of the symptoms discussed above, and the manner in which they disrupt the veteran's ability to relate to superiors and coworkers; and the degree to which they impair the veteran's ability to accomplish tasks for which the veteran is being paid; it is at least as likely as not that this veteran would be unable to secure or maintain any kind of reasonable employment at this time. Despite having serious functional deficits, this veteran has been able to manage finances over the past year. The veteran demonstrated knowledge of financial resources and obligations, and the cognitive wherewithall to appropriately discharge financial obligations. This veteran is considered competent to continue independent financial management without the assistance of a conservator. NOTE: VA may request additional medical information, including additional examinations if necessary to complete VA's review of the Veteran's application. Thanks again for any thoughts.