I am new here and was hoping some could help me understand this. And if they think I would be approved and is so at about what percent. Thank you in advance for your time and consideration on this.
Initial Post Traumatic Stress Disorder (PTSD)
Disability Benefits Questionnaire
SECTION I:
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1. Diagnostic Summary
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Does the Veteran have a diagnosis of PTSD that conforms to DSM-5 criteria
based on today's evaluation?
[X] Yes [ ] No
ICD code: 309.81
2. Current Diagnoses
--------------------
a. Mental Disorder Diagnosis #1: Posttraumatic stress disorder
ICD code: 309.81
Mental Disorder Diagnosis #2: Unspecified depressive disorder
ICD code: 311
b. Medical diagnoses relevant to the understanding or management of the
Mental Health Disorder (to include TBI):
No response provided.
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?
[X] Yes [ ] No [ ] Not applicable (N/A)
If yes, list which symptoms are attributable to each diagnosis and
discuss whether there is any clinical association between these
diagnoses:
Symptoms of PTSD are detailed in criteria section below.
Depressive symptoms include depressed mood, loss of interest in
activities, low motivation and low energy. Depression is at least
as likely as not secondary to PTSD.
c. Does the Veteran have a diagnosed traumatic brain injury (TBI)?
[ ] Yes [X] No [ ] Not shown in records reviewed
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 deficiencies in most areas,
such as work, school, family relations, judgment, thinking and/or
mood
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:
Depression is at least as likely as not secondary to 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 [ ] No [X] No diagnosis of TBI
SECTION II:
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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 (hard copy paper C-file) reviewed?
[ ] Yes [X] No
If yes, list any records that were reviewed but were not included in the
Veteran's VA claims file:
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
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a. Relevant Social/Marital/Family history (pre-military, military, and
post-military):
f. Other, if any:
No response provided.
3. Stressors
------------
Describe one or more specific stressor event(s) the Veteran considers
traumatic (may be pre-military, military, or post-military):
a. Stressor #1: rape; detailed in mental heatlh section
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?
[ ] Yes [X] No
Is the stressor related to personal assault, e.g. military sexual
trauma?
[X] Yes [ ] No
If yes, please describe the markers that may substantiate the
stressor. detailed records of event
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 #7 - 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 (DSM-5).
Criterion A: Exposure to actual or threatened a) death, b) serious
injury, c) sexual violation, in one or more of the following ways:
[X] Directly experiencing the traumatic event(s)
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).
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.
[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] Hypervigilance.
[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.
Criterion I: Which stressor(s) contributed to the Veteran's PTSD
diagnosis?:
[X] Stressor #1
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] Flattened affect
[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] Impaired impulse control, such as unprovoked irritability with
Periods of violence
[X] Intermittent inability to perform activities of daily living,
including maintenance of minimal personal hygiene
6. Behavioral Observations
--------------------------
The veteran arrived on time to her appointment. She was casually and nicely
dressed. She was able to answer all questions asked of her. Her speech was
normal in rate and tone. Mood appeared dysphoric. Thought production was
functional. She denied any current suicidal ideation. Judgement and insight appeared adequate. Orientation was intact. She appeared credible and consistent.
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, (including any testing results) if any
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No remarks provided.