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Jaydog

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Posts posted by Jaydog

  1. Yeah, I believe so. I am going to go through the RAMP guidelines and see if there is anything in there that states by opting into RAMP changes an effective date....maybe it was in the small print and we just didn't pay attention.  I have always been under the impression that opting into RAMP that the only thing different would be the speed of the appeal....we will see, but I plan to file a timely appeal to the board and not choose and of the other options. I need a legal mind to determine this not someone's interpretation of the law....I'll keep you updated as to how its going in the process of appealing a RAMP effective date.

  2. I received the decision in the mail. It states that the effective date they used was the date I was diagnosed PTSD. I need to appeal this to. Its my understanding I was seeking compensation for and acquired psychiatric condition and would encompass all issues not just one. I originally filed my appeal in sept 2015  because i received an unfavorable decision. In the first exame the psychiatrist stated i have multiple mental disorders, but said I did not meet the full criteria for PTSD. Then they stated that a diagnosis of PTSD can only be done by a board certified psychiatrist. I have notes of PTSD in my notes for a long time. Some by nurse practitioner or psychiatrist. I believe they are just hoping I will go away, but they should know by now I just don't and continue to seek the benefits I am owed and deserve.

  3. Thanks Firedog974. I checked Ebenefits today and My PTSD RAMP Appeal Was approved @ 70 % and 90% overall....My god it feels good. I did notice the effective date is wrong on it, but the main hurdle was getting service connected and will work on the effective date. Good luck to all having claims on appeal. Its a long wait and very stressful.

  4.  

    My Appeal Just moved another step.... It's getting closer, but it has been here in this phase before and went all the way back to gathering evidence.... I have to say this is pretty nerve racking..... In some way having at gathering evidence game me some comfort know they are still working on it. Now its game time do or die and whether all this time spent worrying and going over in my mind if I said something or didn't do enough to help my claim along... I am sure most of you have had those feelings. I have been waiting since 2014 after the denial. Its spent almost a year in RAMP and before that 4 years in appeal status with no movement....I am so ready to move past this. There are 2 outcomes. Approval or Denial. If denial I can still appeal to the board, but I just want it to be done, but I will continue to fight for the benefits that I deserve..... I will post more as updates are made...

     

    Current Status: Pending Decision Approval

     
  5. Update, I still have not received my Envelope in the mail on how they came up with the decision they made and that was decided on 3 Jan 2019. My RAMP appeal did get split into 2 different ones. Before they split the RAMP appeals they sent me a letter stating they made an error when i first applied back in 2014. The error was about DTA ( Duty to Assist ) and they stated they corrected the error and sending it to the rating activities for further processing under RAMP. I have not heard anything or received anything in the mail. Its almost been a year now. I am assuming they are waiting to mail me the documents until the other RAMP appeal is done, but I just don't know...I will keep updating as more info comes along, but as anyone else have this experience yet ?

  6. Update on my RAMP Claim. Looks like it went back a few steps. It went from Review Of Evidence and then today it went to Gathering Evidence. In a Matter of a week it went from Prep for Decision all the way back to Gathering Evidence. I understand That Ebenefits Is not accurate. Case in point before they decided My other RAMP claim It was at Review of evidence and had a completion date in April, But the next day it was complete, So I don't put much stock in the information it displays. The one thing I can tell by the movement is that it is being actively worked on . Since I opted In to RAMP in March of 2018 and its still there gives me hope it will be Favorable. I know they say this is quicker and supposed to get a decision in I believe it supposed to be 125 Days, but going into this I knew that was not going to be the case. I have been waiting since Sept 2015 in appeal status with no movement. I see progress and I am happy about that. Updates to follow...

  7. I received an update... They completed one of the claims I received a rating on some, but i am a little confused on one on the PTSD ( in remission ). They did not service connect me for PTSD and that in Remission wording is confusing me.... I still have the one claim open I posted in an above post and will repost at the bottom...

    posttraumatic stress disorder with depression and anxiety with alcohol use disorder (in remission)

    Not Service Connected-PTSD 

    right wrist sprain-Not Service Connected

    chronic sprain of muscles/tendons of supination and pronation of right forearm/elbow 10% Service Connected

    07/11/2016

    chronic sprain of muscles/tendons of supination and pronation of left forearm/elbow 10% Service Connected

    07/11/2016

    left shoulder strain with rotator cuff tear 20% Service Connected 08/12/2012

    left wrist sprain 10% Service Connected 07/11/2016

     

    This is the 2nd Appeal in RAMP
     
    This is the status of the other claim in which they split my original appeal into 2 The strange part is that 2 of the contentions are the same as the one above just different dates. I'm pretty confused on why this was done
     

    Status of Your Claim

    REVIEW OF EVIDENCE
    • Submitted: 04/17/2018 (Appeal)
    • Estimated Completion: 01/09/2019 - 03/12/2019
    •  
    • Disabilities Claimed: Posttraumatic stress disorder (PTSD) and anxiety with alcohol use disorder
  8. I hope I get a Decision Before the new year. I also Noticed That the spelling is wrong and also it states an ( Increase ) for left elbow condition, but I was never service connected for it also it says left wrist sprain----------- ( REOPEN ). Never opened it, so don't understand that. Most of the contentions say ( NEW ), but there are some wording differences between the 1st Appeal and the 2nd Appeal. Just wanted to share this update...

    This Is the first Appeal in RAMP

    Status of Your Claim

    PREPARATION FOR NOTIFICATION

    • Submitted: 03/13/2018 (Appeal)
    • Estimated Completion: 12/27/2018 - 12/28/2018
    •  
    • Disabilities Claimed: Left elbow condition (Increase), Chronic sprain of muscles/tendons of supination & pronation of right forearm (New), Right elbow condition (New), Left wrist sprain (Reopen), Chronic sprin of muscles/tendons of supination & pronation of left forearm (New), Right wrist sprain (New), Depression to include alcohol abuse (New), Bipolat disorder (New), Posttraumatic stress disorder (PTSD) with depression and anxiety with alcohol use disorder (New), Left shoulder strain (New), Right shoulder rotator cuff tear (New), Lumbosacral strain claimed as back condition (New), Cervical intervertebral disc syndrome (New)
    This is the 2nd Appeal in RAMP
     
    This is the status of the other claim in which they split my original appeal into 2 The strange part is that 2 of the contentions are the same as the one above just different dates. I'm pretty confused on why this was done
     

    Status of Your Claim

    REVIEW OF EVIDENCE
    • Submitted: 04/17/2018 (Appeal)
    • Estimated Completion: 01/09/2019 - 03/12/2019
    •  
    • Disabilities Claimed: Posttraumatic stress disorder (PTSD) and anxiety with alcohol use disorder (New), Depression to include alcohol abuse (New)
  9. Good Day to you too,

    Yes i do have an estimated decision date of 3 march 2019 and mine has been in PDA for a few months actually. It just moved to Prep For Notification with an estimated date of completion 27 Dec - 28 Dec. This info just came in today. I have had mine move back and forth many times before, so I try not to guess any more...The one thing that did happen is they split my appeal into 2 different ones with different dates.... We will see what happens because I have Been In RAMP since March 2018.... 

  10. No new updates yet, but some of the contentions listed were condensed into different wording and like In the previous post they split my 1 appeal under RAMP into 2 appeals under RAMP 1 with 2 contentions and one with about 6. ..both with different dates...I have not called to figure out why because um sure calling will not give me the answer I'm looking for....

  11. So far nothing has changed. I know the letter stated they found an error with their DTA.... The only thing that changed was that they split the RAMP claim into 2 different ones with different submitted dates and different completion times. One of the claims only has 2 Contentions in it and the other has them all....I am a little confused as to why they did that. I have not called to ask why because I don't believe I will get an answer as to why they did it. 1 claim is in " Review Of Evidence " and the other is in " Prep For Notification "....I have been in RAMP since March. I don't think they will meet their promise to complete the appeal in the time they imposed on themselves, but at least there is movement and they are actually working on it. I hold out hope that that it will be favorable since it taking so long and I did not get declined right away, but only time will tell.... I will keep posting with new updates as the post....

  12. Thanks for the reply on this issue. I asked V.E.S. and they said I can go down to my R.O. and they can give it to me. At least that's what they said. I have not tried yet, but I will next week..

    I Noticed on Ebenefits that they split my Appeals in to 2 Different ones today. One was for psychiatric conditions and the others were ailments I have claimed.....They both say prep for decision and both have different appeal dates which is odd. One is in march and the other is in April.... Maybe they split them and they are going to decision one and the other they will continue working on, but I just don't know. I hope its a favorable decision and I get to post some good news soon....Thanks for all your support from everyone on here....

  13. Well today I went to my C & P exam through VES..... I will have to say the exam was better than the last one I had. The main difference was that the examiner. The last C & P I had for PTSD was done by a VA Examiner. I believe she was more interested in trying to catch me in a lie. She did not believe me and the questions she was asking and how she was saying it was demeaning. All I can say is this was better, but I just don't know what the outcome will be. Of course I always think the worst about these things and second guess myself on the answers I provided and wonder if I said enough about how my behavior and how I am feeling... the examiner pretty much went off the DBQ according to the questions they were asking me.... Making sure my dates and times were correct and the timeline was correct. He was more Detailed oriented for sure.....I wish I knew how to get a copy of the report when its available to read it, but for now I just wait and see what happens... Ill keep you all posted and Thank you all  

  14. Thank you all for the feed back.....Well I won't make anything up that's for sure plus they can verify my statements from the last exam I had. My story never changes its just the DR who interprets them and offers an opinion. I just hope I get someone who is sympathetic to what happened to me and not judge and take me serious. I did not feel that way during the last exam. I almost felt I was being interrogated by her and just looking for holes in my story...I just fear its another repeat of almost 5 years ago.... In my head I keep running scenarios that could happen.....I read my previous exam maybe 10 times maybe more looking for inaccuracy. I broke it done sentence by sentence to fully understand what the last examiner said or intended to say..... driving my self loony over this  

  15. I originally filed my claim 24 August 2014 and the denial came about 15 Sept. 2015. I filed a NOD right away contesting the results. In march of 2018 I got a notice to opt in the the new RAMP program which I did without hesitation. I figured why not i have already been waiting this long and what else could happen. Ill be the guinea pig to see how this works. I have nothing to loose. So a week ago I got a Call from V.E.S. scheduling a new C&P Exam for next week on a Saturday. Needless to say I was quite surprised about this development. I am happy this process is moving forward and I hope the results are positive. Im a little nervous about the exam as well. I will update the progress of this process as it develops..... 

  16. I thought maybe as well, but it still shows the appeals. 1 from 2013 and 1 from 2015. Maybe they merged my one I just did a NOD on. I will just have to wait and see what happens

     

     

     

    If a new claim is submitted while an existing claim is pending, any new information will be consolidated with the pending claim. The new claim will then be marked as Complete and moved to Historical Claims with no further action required.

    SubmittedTypeStatusUpdatesActions
    10/01/2015CompensationGathering Of Evidence
    • Requested Documents are Past Due
    • Development Letter Sent

    Upload Documents

    View Documents

     

     

     

    This section shows status updates for your Open Appeals.

    Latest ProgressStatusDescriptionReceived
    12/28/2015Appeal Pending - Notice of DisagreementVA has received your Notice of Disagreement. You will be receiving a communication from VA in the near future describing the next steps of your appeal.Date not available
    09/16/2013Appeal Pending - Notice of DisagreementVA has received your Notice of Disagreement. You will be receiving a communication from VA in the near future describing the next steps of your appeal.Date not available
  17. I just had a disability added to my pending disabilities its vbms/appeal. I do have an appeal out and an open claim for my other contentions. Just looking to see if anyone knows why it does this or anyone else have the same thing going on or does it mean they are going to work on my appeal at the same time as my other contentions.

     

    Pending Disabilities

    DisabilitySubmittedTypeActions
    Vbms/appeal12/07/2015NEWView Pending Claim
    Shoulder Condition Right 10/01/2015SECView Pending Claim
    Neck Strain 10/01/2015SECView Pending Claim
    Back Condition 10/01/2015SECView Pending Claim
    Left Shoulder Strain10/01/2015INCView Pending Claim
  18. I just received a copy of my C & P exam. It only took 20 days. I will post an edited copy of it and any feedback would be great also I noticed an error about the dates. I will Highlight the error. Now how would I go about getting that fixed ?

    ---------------------------------------------------------------------------------------------------------------------------------------------------------------

    LOCAL TITLE: C&P PTSD
    STANDARD TITLE: MENTAL HEALTH C & P EXAMINATION CONSULT
    DATE OF NOTE: JUL 08, 2015@10:00 ENTRY DATE: JUL 29, 2015@18:07:05
    AUTHOR: XXXXXXXXXx EXP COSIGNER:
    URGENCY: STATUS: COMPLETED
    Initial Post Traumatic Stress Disorder (PTSD)
    Disability Benefits Questionnaire
    * Internal VA or DoD Use Only *
    Name of patient/Veteran:xxxxxxx
    SECTION I:
    ----------
    1. Diagnostic Summary
    ---------------------
    Does the Veteran have a diagnosis of PTSD that conforms to DSM-5 criteria
    based on today's evaluation?
    CONFIDENTIAL Page 5 of 54
    [ ] Yes [X] No
    If no diagnosis of PTSD, check all that apply:
    [X] Veteran's symptoms do not meet the diagnostic criteria for PTSD under DSM-5 criteria
    [X] Veteran has another Mental Disorder diagnosis. Continue to complete this Questionnaire and/or the Eating Disorder Questionnaire:
    2. Current Diagnoses
    --------------------
    a. Mental Disorder Diagnosis #1: Major Depressive Disorder, Recurrent, Moderate ICD code: 292.32
    Comments, if any:
    Although Veteran has been treated for Bipolar II disorder, his
    long hours of work are more conceputalized as avoidance rather than
    hyperproductivity during those hours at work. Veteran does express
    chronic irritability toward self and others. He denied other
    hypomanic behaviors that met criteria for Bipolar II disorder at
    the present time.
    Mental Disorder Diagnosis #2: Other Specified Anxiety Disorder
    ICD code: 300.09
    Comments, if any:
    Subthreshold for features of Social Anxiety Disorder and Other
    Stressor Related Disorder. Please see "remarks" section below for further detail.
    b. Medical diagnoses relevant to the understanding or management of the
    Mental Health Disorder (to include TBI): N/A
    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:
    Pervasive feelings of shame, negative view of self, passive
    suicidal ideation without intent, anhedonia, isolation, anergia,
    absent libido are more accounted for by Major Depressive Disorder.
    Avoidance of social contact and relationships were reportedly
    related to negative views of self, and negative self-appraisal.
    Anxiety symptoms were reportedly largely related to interpersonal
    relationships.
    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 due to mild or transient symptoms
    which decrease work efficiency and ability to perform occupational
    tasks only during periods of significant stress, or; symptoms controlled by medication
    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
    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
    ------------------
    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:
    [X] Military service treatment records
    [X] Military service personnel records
    [ ] Military enlistment examination
    [ ] Military separation examination
    [ ] Military post-deployment questionnaire
    [X] Department of Defense Form 214 Separation Documents
    [X] Veterans Health Administration medical records (VA treatmentrecords)
    [X] 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):
    was born and raised in northern California, although
    relocated frequently as his father served in the U.S. Coast Guard. He
    is the 3rd of 2 brothers and 2 sisters and grew up in an intact family.
    Veteran denied social or behavioral problems during development, was
    social and made friends, and denied any history of childhood physical,
    sexual, or emotional abuse or any exposure to violence in the home. He
    enlisted in the military at age 18, serving from 1994-1996 when he was
    discharged due to failed alcohol rehabilitation; discharge status was
    honorable. Mr. xxxx reported continued problems related to alcohol
    use and worked sporadic jobs after discharge. In 2005, he married his 1st
    wife and had two children who are now 11 and 10 years old. He and
    ex-wife divorced in 2006, and he last had any contact with his
    children approximately 1.5 years ago. He married again in 2011 and has 1 child
    age 3 y/o. He and his wife moved to xxxxxxx approximately 2 years
    ago for a job transfer for him to manage a dealership in xxxxx. He
    reported challenges with his wife, as he stated being emotionally shut
    down with her, about which he feels very guilty. He denied any intimate
    partner violence in his current marriage.
    b. Relevant Occupational and Educational history (pre-military, military, and post-military):
    xxxxxx completed high school and attended some college. While in the
    military, he worked as a mechanic and after discharge, worked in
    various jobs. Most recently he has been working as a sales manager at a
    car dealership in xxxxxxx, and stated that he works approximately 13
    hours per day, 6 days a week, "to avoid going home." He reported
    feeling that his work provides a place for him to focus on tasks,
    though he acknowledged that it is not service of productivity as much
    as it serves his avoidance.
    c. Relevant Mental Health history, to include prescribed medications and
    family mental health (pre-military, military, and post-military):
    xxxxxxx denied any mental health treatment prior to the military,
    although VA progress notes indicate that he reported onset of
    depressive symptoms at age 13 (see notes MH-Medication Management by
    , MD on 5/1/08 and MH Biopsychosocial signed by J Leif
    on 6/26/08). During the military, after his DUI and
    continued alcohol use, he reported to be referred to an Alcohol and
    Drug Program "for a few weeks" that included some group and individual
    sessions, though he reported not receiving much benefit. After the
    military, xxxxxxxx was hospitalized once in 2005 for suicide attempt
    by drug overdose and multiple times in 2006 for suicidal ideation in
    the context of alcohol use. He was treated in the community at xxxxx
    xxxxxxxxxxxx CDDP and outpatient treatment. VA medical records
    indicate sporadic and minimal engagement, first presenting to VANCHCS in 1999 (2
    visits), 2003 (1 visit); he engaged in medication management visits
    2008-2013 for the treatment of depression by xxxxxxxx at VANCHCS.
    He relocated to xxxxxxx in 2013 and started being treated by
    xxxxxxxxxxxxxxx, NP on 10/16/2013 for bipolar II disorder. His current
    psychiatric medication regimen includes quetiapine 50 mg, gabapentin
    100 mg, sertraline 100 mg, and buspar 5 mg. On 8/6/2014, he disclosed
    to xxxxxxx and his treatment was adjusted to
    include PTSD 2/2 MST. This disclosure precipitated his submitted
    statement for service connection for PTSD due to MST dated 8/21/2014,
    after 1st denial of claim for depression/anxiety on 8/23/2013 and his
    notice of disagreement on 9/10/2013. He attended a screening and 1
    group appointment for men with MST support, but has not received
    psychotherapy for mental health problems since the mid-1990s
    when he was being treated for alcohol abuse and attending AA. He
    reported to continue to be abstinent from alcohol
    d. Relevant Legal and Behavioral history (pre-military, military, and post-military):
    Prior to the military, Veteran went to juvenile hall for being drunk in
    public. During the military, Veteran denied any demotions or Article15s.
    Veteran was arrested in 1995 for domestic violence against his wife ( The date is wrong it was 2004 ) He denied current problems with behavioral violence or legal issues.
    e. Relevant Substance abuse history (pre-military, military, and post-military):
    Mr. xxxx reported use of alcohol 1x when 15 y/o and was arrested for
    being drunk in public. He denied drinking again until he was in the
    service and began drinking heaviily while in the service. He reported
    having one "wet reckless" detainment as he was driving wet but under
    the BAC limit, and received 1 DUI in 1996. He reported drinking heavily
    "off and on" from 1996 - 2008. He reported attending AA and has a
    sponsor; last drink was reportedly July 15, 2008. He reported being in
    contact with his sponsor by phone. He denied current use of nicotine,
    marijuana, cocaine, opiates, hallucinogens or other illicit substances.
    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: Edited
    Does this stressor meet Criterion A (i.e., is it adequate to support the diagnosis of PTSD)?
    [ ] Yes [X] 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.
    It is at least as likely as not that the stressor occurred.
    Veteran attributes increase in quantity and frequency of drinking
    and disturbed self-image after this incident, although that is
    unclear, as he reportedly had been drinking even prior to this
    incident. Veteran stated in his statement of disagreement with
    denial of claim for depression/anxiety on 9/10/2013: "I will not
    say it was one single event that happened during my time in
    service. It was a series of experiences that happened during my
    service... I still have a very hard time when ever I hear
    helicopters and smell diesel fuel exhaust." When queried in
    the exam interview about the "series of experiences" that
    he found to be distressing, he reported that antagonistic harassment by
    superiors related to alcohol rehabilitation contributed to his
    distress. The intrusive reminders of diesel exhaust and
    helicopters are not consistent with the MST and the experience
    of antagonism by his superiors do not meet criterion A for PTSD.
    Clinical symptoms appear to be more consistent with major
    depressive disorder with strong anxiety features contributing to
    avoidance. Please see "Remarks" below for further results from
    the examination.
    4. PTSD Diagnostic Criteria
    ---------------------------
    No response provided
    5. Symptoms
    -----------
    For VA rating purposes, check all symptoms that actively apply to the
    Veteran's diagnoses:
    [X] Depressed mood
    [X] Anxiety
    [X] Difficulty in establishing and maintaining effective work and social
    relationships
    [X] Suicidal ideation
    6. Behavioral Observations
    --------------------------
    Appearance and Behavior: A&Ox4, appeared stated age, casually
    dressed/groomed, avoidant eye contact, clammy palms consistent with
    presentation of anxiety, cooperative with interview, polite, did not require redirection.
    Motor Activity:
    No PMA/PMR, no abnormal movements
    Speech: regular rate and rhythm, normal prosody and tone
    Mood: Anxious, dysphoric
    Affect: congruent with content, restricted range of affect
    Thought Process: linear, goal oriented
    Thought Content: the patient reported passive suicidal/homicidal ideation,
    but denies intent. No evidence of psychosis, mania, or other formal thought disorder.
    Perception: No evidence of auditory/visual hallucinations.
    Insight/Judgment: limited/limited; intact/intact
    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
    --------------------------------------------------
    xxxxxxxxx was examined via clinical interview and the gold-standard
    Clinician-Administered PTSD Scale (CAPS-5), and self-report measures via
    Minnesota Multiphasic Personality Inventory (2nd edition; MMPI-II),
    Millon Clinical Multiaxial Inventory (3rd edition; MCMI-III), Beck Depression
    Inventory (2nd edition; BDI-II), Alcohol Use Disorders Identification
    Test (AUDIT), and Life Events Checklist (LEC). In addition to this examiner,
    with the patient's verbal consent, another licensed psychologist
    observed the
  19. I just received a copy of my C & P exam. It only took 20 days. I will post an edited copy of it and any feedback would be great.

    ---------------------------------------------------------------------------------------------------------------------------------------------------------------

    LOCAL TITLE: C&P PTSD
    STANDARD TITLE: MENTAL HEALTH C & P EXAMINATION CONSULT
    DATE OF NOTE: JUL 08, 2015@10:00 ENTRY DATE: JUL 29, 2015@18:07:05
    AUTHOR: XXXXXXXXXx EXP COSIGNER:
    URGENCY: STATUS: COMPLETED
    Initial Post Traumatic Stress Disorder (PTSD)
    Disability Benefits Questionnaire
    * Internal VA or DoD Use Only *
    Name of patient/Veteran:xxxxxxx
    SECTION I:
    ----------
    1. Diagnostic Summary
    ---------------------
    Does the Veteran have a diagnosis of PTSD that conforms to DSM-5 criteria
    based on today's evaluation?
    CONFIDENTIAL Page 5 of 54
    [ ] Yes [X] No
    If no diagnosis of PTSD, check all that apply:
    [X] Veteran's symptoms do not meet the diagnostic criteria for PTSD under DSM-5 criteria
    [X] Veteran has another Mental Disorder diagnosis. Continue to complete this Questionnaire and/or the Eating Disorder Questionnaire:
    2. Current Diagnoses
    --------------------
    a. Mental Disorder Diagnosis #1: Major Depressive Disorder, Recurrent, Moderate ICD code: 292.32
    Comments, if any:
    Although Veteran has been treated for Bipolar II disorder, his
    long hours of work are more conceputalized as avoidance rather than
    hyperproductivity during those hours at work. Veteran does express
    chronic irritability toward self and others. He denied other
    hypomanic behaviors that met criteria for Bipolar II disorder at
    the present time.
    Mental Disorder Diagnosis #2: Other Specified Anxiety Disorder
    ICD code: 300.09
    Comments, if any:
    Subthreshold for features of Social Anxiety Disorder and Other
    Stressor Related Disorder. Please see "remarks" section below for further detail.
    b. Medical diagnoses relevant to the understanding or management of the
    Mental Health Disorder (to include TBI): N/A
    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:
    Pervasive feelings of shame, negative view of self, passive
    suicidal ideation without intent, anhedonia, isolation, anergia,
    absent libido are more accounted for by Major Depressive Disorder.
    Avoidance of social contact and relationships were reportedly
    related to negative views of self, and negative self-appraisal.
    Anxiety symptoms were reportedly largely related to interpersonal
    relationships.
    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 due to mild or transient symptoms
    which decrease work efficiency and ability to perform occupational
    tasks only during periods of significant stress, or; symptoms controlled by medication
    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
    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
    ------------------
    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:
    [X] Military service treatment records
    [X] Military service personnel records
    [ ] Military enlistment examination
    [ ] Military separation examination
    [ ] Military post-deployment questionnaire
    [X] Department of Defense Form 214 Separation Documents
    [X] Veterans Health Administration medical records (VA treatmentrecords)
    [X] 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):
    was born and raised in northern California, although
    relocated frequently as his father served in the U.S. Coast Guard. He
    is the 3rd of 2 brothers and 2 sisters and grew up in an intact family.
    Veteran denied social or behavioral problems during development, was
    social and made friends, and denied any history of childhood physical,
    sexual, or emotional abuse or any exposure to violence in the home. He
    enlisted in the military at age 18, serving from 1994-1996 when he was
    discharged due to failed alcohol rehabilitation; discharge status was
    honorable. Mr. xxxx reported continued problems related to alcohol
    use and worked sporadic jobs after discharge. In 2005, he married his 1st
    wife and had two children who are now 11 and 10 years old. He and
    ex-wife divorced in 2006, and he last had any contact with his
    children approximately 1.5 years ago. He married again in 2011 and has 1 child
    age 3 y/o. He and his wife moved to xxxxxxx approximately 2 years
    ago for a job transfer for him to manage a dealership in xxxxx. He
    reported challenges with his wife, as he stated being emotionally shut
    down with her, about which he feels very guilty. He denied any intimate
    partner violence in his current marriage.
    b. Relevant Occupational and Educational history (pre-military, military, and post-military):
    xxxxxx completed high school and attended some college. While in the
    military, he worked as a mechanic and after discharge, worked in
    various jobs. Most recently he has been working as a sales manager at a
    car dealership in xxxxxxx, and stated that he works approximately 13
    hours per day, 6 days a week, "to avoid going home." He reported
    feeling that his work provides a place for him to focus on tasks,
    though he acknowledged that it is not service of productivity as much
    as it serves his avoidance.
    c. Relevant Mental Health history, to include prescribed medications and
    family mental health (pre-military, military, and post-military):
    xxxxxxx denied any mental health treatment prior to the military,
    although VA progress notes indicate that he reported onset of
    depressive symptoms at age 13 (see notes MH-Medication Management by
    , MD on 5/1/08 and MH Biopsychosocial signed by J Leif
    on 6/26/08). During the military, after his DUI and
    continued alcohol use, he reported to be referred to an Alcohol and
    Drug Program "for a few weeks" that included some group and individual
    sessions, though he reported not receiving much benefit. After the
    military, xxxxxxxx was hospitalized once in 2005 for suicide attempt
    by drug overdose and multiple times in 2006 for suicidal ideation in
    the context of alcohol use. He was treated in the community at xxxxx
    xxxxxxxxxxxx CDDP and outpatient treatment. VA medical records
    indicate sporadic and minimal engagement, first presenting to VANCHCS in 1999 (2
    visits), 2003 (1 visit); he engaged in medication management visits
    2008-2013 for the treatment of depression by xxxxxxxx at VANCHCS.
    He relocated to xxxxxxx in 2013 and started being treated by
    xxxxxxxxxxxxxxx, NP on 10/16/2013 for bipolar II disorder. His current
    psychiatric medication regimen includes quetiapine 50 mg, gabapentin
    100 mg, sertraline 100 mg, and buspar 5 mg. On 8/6/2014, he disclosed
    to xxxxxxx and his treatment was adjusted to
    include PTSD 2/2 MST. This disclosure precipitated his submitted
    statement for service connection for PTSD due to MST dated 8/21/2014,
    after 1st denial of claim for depression/anxiety on 8/23/2013 and his
    notice of disagreement on 9/10/2013. He attended a screening and 1
    group appointment for men with MST support, but has not received
    psychotherapy for mental health problems since the mid-1990s
    when he was being treated for alcohol abuse and attending AA. He
    reported to continue to be abstinent from alcohol
    d. Relevant Legal and Behavioral history (pre-military, military, and post-military):
    Prior to the military, Veteran went to juvenile hall for being drunk in
    public. During the military, Veteran denied any demotions or Article
    15s. Veteran was arrested in 1995 for domestic violence against his
    wife. He denied current problems with behavioral violence or legal
    issues.
    e. Relevant Substance abuse history (pre-military, military, and post-military):
    Mr. xxxx reported use of alcohol 1x when 15 y/o and was arrested for
    being drunk in public. He denied drinking again until he was in the
    service and began drinking heaviily while in the service. He reported
    having one "wet reckless" detainment as he was driving wet but under
    the BAC limit, and received 1 DUI in 1996. He reported drinking heavily
    "off and on" from 1996 - 2008. He reported attending AA and has a
    sponsor; last drink was reportedly July 15, 2008. He reported being in
    contact with his sponsor by phone. He denied current use of nicotine,
    marijuana, cocaine, opiates, hallucinogens or other illicit substances.
    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: Edited
    Does this stressor meet Criterion A (i.e., is it adequate to support the diagnosis of PTSD)?
    [ ] Yes [X] 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.
    It is at least as likely as not that the stressor occurred.
    Veteran attributes increase in quantity and frequency of drinking
    and disturbed self-image after this incident, although that is
    unclear, as he reportedly had been drinking even prior to this
    incident. Veteran stated in his statement of disagreement with
    denial of claim for depression/anxiety on 9/10/2013: "I will not
    say it was one single event that happened during my time in
    service. It was a series of experiences that happened during my
    service... I still have a very hard time when ever I hear
    helicopters and smell diesel fuel exhaust." When queried in
    the exam interview about the "series of experiences" that
    he found to be distressing, he reported that antagonistic harassment by
    superiors related to alcohol rehabilitation contributed to his
    distress. The intrusive reminders of diesel exhaust and
    helicopters are not consistent with the MST and the experience
    of antagonism by his superiors do not meet criterion A for PTSD.
    Clinical symptoms appear to be more consistent with major
    depressive disorder with strong anxiety features contributing to
    avoidance. Please see "Remarks" below for further results from
    the examination.
    4. PTSD Diagnostic Criteria
    ---------------------------
    No response provided
    5. Symptoms
    -----------
    For VA rating purposes, check all symptoms that actively apply to the
    Veteran's diagnoses:
    [X] Depressed mood
    [X] Anxiety
    [X] Difficulty in establishing and maintaining effective work and social
    relationships
    [X] Suicidal ideation
    6. Behavioral Observations
    --------------------------
    Appearance and Behavior: A&Ox4, appeared stated age, casually
    dressed/groomed, avoidant eye contact, clammy palms consistent with
    presentation of anxiety, cooperative with interview, polite, did not require redirection.
    Motor Activity:
    No PMA/PMR, no abnormal movements
    Speech: regular rate and rhythm, normal prosody and tone
    Mood: Anxious, dysphoric
    Affect: congruent with content, restricted range of affect
    Thought Process: linear, goal oriented
    Thought Content: the patient reported passive suicidal/homicidal ideation,
    but denies intent. No evidence of psychosis, mania, or other formal thought disorder.
    Perception: No evidence of auditory/visual hallucinations.
    Insight/Judgment: limited/limited; intact/intact
    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
    --------------------------------------------------
    xxxxxxxxx was examined via clinical interview and the gold-standard
    Clinician-Administered PTSD Scale (CAPS-5), and self-report measures via
    Minnesota Multiphasic Personality Inventory (2nd edition; MMPI-II),
    Millon Clinical Multiaxial Inventory (3rd edition; MCMI-III), Beck Depression
    Inventory (2nd edition; BDI-II), Alcohol Use Disorders Identification
    Test (AUDIT), and Life Events Checklist (LEC). In addition to this examiner,
    with the patient's verbal consent, another licensed psychologist
    observed the examination for disability examination training purposes.
    On the LEC, Veteran endorsed witnessing a friend accidentally shooting
    himself in the leg and taking him to the hospital, and experiencing the
    sexual molestation during the military by another man. On the CAPS-5, xxxx
    endorsed physical sensations associated with anxiety, feelings of
    hopelessness and sadness, feelings of alienation, self-blame, shame,
    anhedonia, irritability, guardedness, and exaggerated startle response.
    He denied other symptoms of PTSD, or other symptoms could not be determined
    as directly associated with the military sexual molestation incident. His
    symptoms were most consistent with Major Depressive Disorder (BDI-II =55)
    and Other Specified Anxiety Disorder (subthreshold for Social Anxiety
    Disorder and Other Stressor-Related Disorder). Consistent with self-report
    during clinical interview, Veteran's anxiety, disturbed and negative
    self-image, guilt, irritability, and poor mood contribute to avoiding
    interaction with family at home (thus leading him to be at work for 13
    hrs/day, 6 days/week, but not necessarily reflecting hyperproductivity at
    work). His score on the AUDIT was 4, indicating no current alcohol use disorder.
    Mr. XXXX' results on the MMPI-II reflected a response pattern of
    overendorsing distress, leading to an invalid profile that should not be
    interpreted (MMPI-II F = 104; F-K = 17; FBS = 90). Similarly, his
    responses on the MCMI-III also reflected a pattern of responses that
    overly portrayed himself in a negative light(MCMI-III X BR = 100; Z BR =
    . Due to these response patterns, dissimulation and/or
    characterological factors could not be ruled out at the present time.
    Thus, while it is at least as likely as not that the MST occurred,
    Veteran's responses and report of his symptoms are not consistent with a
    PTSD diagnosis and are better accounted for by Major Depressive Disorder
    and Other Specified Anxiety Disorder (subthreshold for Social Anxiety
    Disorder and Other Stressor-Related Disorder). He does appear to have
    difficulty with social functioning apart from his current wife and child,
    and he reported avoidance of even those intimate relationships. He denied
    current impaired occupational functioning, though did report often
    expressing irritation with work colleagues. Veteran's depressive symptoms
    were reported to be related to significant negative views of self and
    guilt/shame over his past alcohol abuse and its sequelae including
    domestic violence, DUIs, impact on his military career, and current
    alienation from wife and child. It cannot be said with confidence that his
    depression or anxiety are solely attributed to the MST.
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