Jar Head 0811

Thank you all for the help, I have thought about AA but I don't do good in groups. However, if you think it will help I will definitely give it a shot. Thank you again for the advice and guidance.

Good evening All, I am service connected for PTSD (70%) and I recently tried committing suicide by getting drunk and taking 50 Tylenol PMs (I was in a dark place at the time). My therapist wanted to have me committed, however there were no beds available. I have since quit drinking and I am in therapy and taking medications, though it doesn't seem to help. My therapist has also put me in an alcohol treatment program, though when I went and saw him it was like all my other therapy sessions. I am scheduled for a re-examination soon and I am wondering what to do and what may happen. Any and all comments are welcome and I appreciate all the help.

Good evening All, I have an update to concerning my appeal: I received a letter from my VSO stating I was awarded 80% (70%-PTSD, 10%-Knee, 10%-Back, 10%-Tinnitus). A day or so later I received "the Big Yellow Envelope", the only problem was it was inappropriately sealed and consequently I only received information concerning my knee and I assumed the the rest of my SOC had disappeared in the Burmuda Triangle. I called my VSO, explained the situation and was told the DRO "jumped the gun" on my PTSD and Sinusitis appeal, however the 80% rating was still a valid rating. So, just wondering what will happen next...Vync, BluVet and Berta, y'all have been great and your advice has been 100% percent accurate and priceless. Thank you all again so much.

The amount of information I've received and the fact that people ACTUALLY care to read my post is priceless.....Thank you all so very much...

Berta, Thank you..my VSO knows and it is my C&P exams and SMRs. Thanks again for looking over this for me.

Vync, Thanks a million, that makes a great deal of sense now..would my appeal be "placed in the bottom of the pile" or put on hold until the C&P results are submitted. I know I'm at the mercy of the DRO per se'. Also too (if I didn't mention this earlier) I received two years of mental health therapy prior to discharge and was diagnosed with PTSD at Naval Health Clinic Quantico. Thank you again.

Bluevet and Buck, Thank you both for the help...I greatly appreciate it. I have even more information. Today I spoke with my VSO and I was told since my C&P exam was in May 2014...the DRO will most likely request another exam for PTSD due to the exam being over a year old. That seems akward due to the fact it took over 2 years to get to this point and if the same time line were to hold true....the cycle would purpetuate itself. Not trying to be a "Debby Downer"...just worried.... Thank you again so much.

Vync and Bluvet, A little update to my situation : I spoke with the VA on 28 August and was informed the DRO had gathered all the necessary information from the NPRC (I don't know what exactly the needed)...I'm not sure where it goes from here...once I get an SOC...I will advise... Thank you again for all the help.

I absolutely will....Bluevet and Vync....Thank you so much for all the help....much appreciated....

Oh...and there is nothing negative in my "C" File....sorry about that

Bluevet, I never received notice for my C&P exams, called the VA, they admitted to not sending me any notice of appointments. The claim went through and as a result, everything was denied. I'm not upset about it and I know things "slip through the cracks" all the time. So did an appeal with the help of the DAV and here I am today. I don't know if the FItness Reports and awards would TRULY help (I thought I would get some guidance before I sent them). They more or less add a little more clarification to what is already on my DD214. Well thank you so much and I will definitely take your advice. Have a great night.

Vync and Bluevet, This is an appeal for an initial rating (no C&P exams on the first claim) . It was a complete mess, but thankfully the DAV was able to get me squared away. Is there a way to send documents to the DRO? I have FItness Reports (Evaluations and awards certificates) that definitely help my case. Thank you both so much.

Bluevet, Thanks for the help, I am in the DRO phase as of now...my appeal has been in the pipeline since September, 2013 and hopefully it will end soon. Thank you again. I greatly appreciate it.

Vync, Thank you so much for the guidance. I have a pretty good idea on my knee and nose; it was just my PTSD rating that seemed to be a little illusive to me. Again, thank you so much and have a great day.

Good Afternoon All, I had my C&P exams for PTSD, osteoarthritis (right knee) and sinusitis. I will try to give the good, the bad and the ugly in my situation: -Operational Experience: OEF (Garmsir, 2008). 24 MEU. Cannon Cocker. Conducted combat patrols (was fired upon by the enemy, did not return fire due to non-combatants in the area). Indirect fire on the enemy resulting in 98 enemy casualties. We had 2 KIA in our battalion. Saw a child that had JUST been raped by a family member. Operation Unified Response. Boots on the ground. Conducting security operations for Hattian citizens coming back from US Navy Hospital ships. Saw some very horrific things. Received campaign medals and Navy and Marine Corps Achievement Medals for both operations (no “V” or CAR for OEF. Received HSM for Haiti). Three other various deployments. -Treatment in Service: PTSD: 2 years of treatment prior to discharge, diagnosed at Naval Hospital Quantico, Behavioral Health Treatment for knee throughout service diagnosed with osteoarthritis (right knee) in service. Sinusitis treatment to include surgery (septoplasty and turbinoplasty). Diagnosed with sinusitis in service. -VA claims process thus far. Veteran’s Service Organization: DAV PTSD, sinusitis and osteoarthritis on appeal, currently with DRO. Stressor: Seeing small boy being raped in Afghanistan. DRO had to gather records from the Marine Corps Archives (I am assuming to verify my stressor). 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: Posttraumatic Stress Disorder ICD code: 309.81 Mental Disorder Diagnosis #2: Major Depressive Disorder, Recurrent, Severe ICD code: 296.33 Comments, if any: The diagnosis of major depressive disorder should be considered an inferred claim. 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: PTSD and depression are often co-occurring disorders with a great deal of shared symptomology. In general, the Veteran's PTSD accounts for his intrusive trauma memories, nightmares, flashbacks, avoidance behaviors, emotional numbness, hypervigilance, hyperarousal, and related anxiety. His depression likely accounts for his chronic sad mood, feelings of worthlessness, tearfulness, lack of libido, self-criticalness, and change in appetite. The following symptoms are found in both depression and PTSD and cannot be reliably distinguished without resorting to mere speculation: loss of interest in previously enjoyed activities, social isolation/withdrawal, sleeping disturbance (and associated fatigue), irritability, difficulty concentrating, distractibility, negative belief systems, restlessness, and feelings of guilt. 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 reduced reliability and productivity 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: The extent to which symptoms of each psychiatric disorder are independently responsible for occupational and social impairment is impossible to delineate without resorting to mere speculation. 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 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 [X] Military post-deployment questionnaire [ ] Department of Defense Form 214 Separation Documents [ ] Veterans Health Administration medical records (VA treatment records) [ ] Civilian medical records [X] 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 [ ] No 2. History a. Relevant Social/Marital/Family history (pre-military, military, and post-military): Pre-military: was kind of a shy child, taking a while to warm up to people. Was able to trust others. Raised by grandparents because his mom was young, parents divorced when he was 5. No siblings. His childhood was good, lived in a small town as a child and then moved to Seattle to live with Dad when 13. No abuse in childhood. Military: He didn't stay in the same unit so moved around it was difficult to keep friendships. He still talks to some of his military friends. Only lets people in so far with the exception of his wife. Has trouble trusting people. His wife stated that his overall attitude towards people was: "Get them before they get me." and that this was with everything including her. First marriage lasted for 8 years they did not have children. She cheated on him. "I was not the best husband." He was distant. No contact with her. Married second time in 2003, they have two children. He stated that the marital relationship was "not bad", she reported "it has its moments". In the beginning it was very good, first four years. She stated that "my husband went to Afghanistan and didn’t come back." Not the same at all, not the same with wife and kids. Before he would get mad at normal things now he blows up over everything. Was drinking everyday for about 3 years after he got back and got a DUI. He still drinks and states that he does this to stop the continuous loop of horror in his head. She does not feel as close or connected to him, doesn't talk about what happened while he was deployed or how he feels. b. Relevant Occupational and Educational history (pre-military, military, and post-military): Pre-military: he stated that towards the beginning of school was below average but toward the end was above average. No attention or learning problems in childhood. Played soccer and swam. Military: Graduated from HS early and joined the Marines at 18. The veteran served in the Marine Corps from August 17, 1994 to May 31, 2013. Jobs in the military: started in amphibious assault then went to artillery. Has had 5 deployments with 4 combat operations, 1) Operation Southern Watch - Kuwait (2 months); 2) Operation Silent Lance - Serbia (70 days); 3) OEF - (8 months); 4) OEF - (classified); 5 Operation disaster relief in Haiti (10 days). No difficulties on the job in the military. He retired early because of downsizing. Post-military: work for the county does public service. It requires Him to have a lot of interactions with people. He goes from being very angry to being very happy and this happens daily. The anger builds like a bubble and then pops. Difficulty with co workers, I want to believe that it is not their fault. Co-workers are frustrating and irritating, it is hard for me to function and smile. Not sure how much longer he will be able to work there, He has been written up several times at work for his behavior, he gets asked to leave the office, he has been told he acts crazy. Working since August of 2013, he snaps at people, sometimes he will think that is really stupid and have to apologize. He feels that he could be able to work alone. Currently in school full-time for criminal intelligence degree. He is in a traditional classroom and is doing okay. c. Relevant Mental Health history, to include prescribed medications and family mental health (pre-military, military, and post-military): Pre-military: no psychiatric diagnosis or treatement. Military: While at Quantico he was diagnosed with PTSD November 2010 after returning from a deployment to Haiti, Jordan and Oman. He was followed from that time by psychiatrist and social work. He was tried on multiple medications for, celexa, zoloft, ambien. Since 2010 he had been diagnosed with Depression, Chronic PTSD, Anxiety NOS. and alcohol abuse. Has had TBI testing (last incident 2010) have had irregular imaging. Still has problems with attention and memory. Post-military: He stated "I just lost himself. I don't even know who I am anymore. All of this consumes me" Symptoms started in 2008 but he is not sure. Depression, anxiety, panic once a week. Sleep: maybe 3 hours of sleep a night, "I beat the shit out of my wife", sweats, bought a bigger bed trying to help, thrashes around, having nightmares, sleep talking, Irritable, angry outbursts, easily starteled. Auditory hallucinations, weird things, like a high pitched squeak, squealing every so often driving down the road. This has just started. It is unclear whether this is related to auditory dysfunction or a hallucination. Has visual anomalies, seeing movement out of the corner of his eye. If he sees trash on the side of the road he has to swerve around it. NO problem driving small distances but can't drive a long distance or "will lose my mind." Suicidal and homicidal ideation denied. Ritualistic behavior before bed, "have to get clothes ready they have to be in certain spot, if they are not in the right spot I go ape shit." If he can't do it it is very stressful he has to do it. "I am not me anymore. It happened after Afghanistan, like I don't have A soul, like I am hollow every day." He has certain rituals during morning and during the day. If he doesn't do these things he would be completely lost. He doesn't know how he is going to function the rest of his life. "I am a xxxxxxx horrible husband and father." He reported that he feels close to his children. He stated that his yougest daughter who is 10 "keeps me together." d. Relevant Legal and Behavioral history (pre-military, military, and post-military): Had a DWI in October 10, 2010 which is why he had to start seeing psychiatrist until he retired. Is not seeing a psychiatrist now or therapist. Had the conviction set aside, his wife did all the work. This was rough on both of them. Trouble with drinking began in Marine Corps. Now he is not drinking much at all, his wife stated one or two, once a week. Went a couple of years without drinking. No substance use e. Relevant Substance abuse history (pre-military, military, and post-military): See legal history No current problem with alcohol or substance use. f. Other, if any: No response provided. 3. Stressors a. Stressor #1: I saw a boy 9 to 10 years old get raped by one of his family member and not being able to do anything about it. Happened in afghanistan. 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] Near-continuous panic or depression affecting the ability to function independently, appropriately and effectively [X] Chronic sleep impairment [X] Mild memory loss, such as forgetting names, directions or recent events [X] Difficulty in understanding complex commands [X] Disturbances of motivation and mood [X] Difficulty in adapting to stressful circumstances, including work or A worklike setting [X] Inability to establish and maintain effective relationships [X] Obsessional rituals which interfere with routine activities [X] Impaired impulse control, such as unprovoked irritability with Periods of violence 6. Behavioral Observations The veteran and his wife arrived on time for his scheduled evaluation. He Was appropriately dressed and groomed. Gait appeared normal, with no gross motor deficits observed. He was alert and attentive. He shows no significant impairment of communication. Thought processes were normal and goal-directed, with no signs of hallucinations or delusions. Eye contact was appropriate. He is able to maintain his personal hygiene and perform other activities of daily living independently. He endorses obsessive, ruminative thoughts as well as mild compulsive behaviors. Suicidal and homicidal ideation were denied. Remote and recent memory was grossly intact. Affectively, he was noticeably anxious and labile throughout the examination; affect and mood were congruent. His speech was logical and goal-directed, rate was at times pressured, rhythm and flow were within normal limits. Throughout the interview and assessment the veteran was fully compliant and cooperative. 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 Testing battery was completed including: Insomnia Severity Index (ISI), Beck Depression Inventory-II (BDI-II), Beck Hopelessness Scale (BHS), Beck Anxiety Inventory (BAI), Posttraumatic Stress Disorder Checklist-Military Version for the DSM-IV (PCL-M), the Mississippi Scale (MISS) and the Combat Exposure Scale (CES). The ISI is a self-report measure which provides a global measure of perceived insomnia severity. The first item includes 3 scored responses, and items 2-5 provide a total of 4 additional responses, for a total of 7 scored items for the questionnaire. Question 6 is not scored, but rather provides a subjective assessment of daytime symptoms which allows one to determine if the respondent meets full diagnostic criteria for an insomnia diagnosis, which requires a deficit in daytime functioning. Each of the scored items are rated on a 5-point Likert scale for a total score ranging from 0-28. The ISI has adequate psychometric properties, has been validated against diary and polysomnographic measures of sleep, and has been shown sensitive to therapeutic changes in a pilot study for veterans with PTSD. Veteran scored 26/28 on the ISI which indicates a severe level of insomnia. The daytime affects of poor sleep that were endorsed by veteran included: daytime fatigue (tired, exhausted, washed out, sleepy), difficulty functioning (performance impairment at work/daily chores, difficulty concentrating, memory problems), mood problems (irritable, tense, nervous, groggy, depressed, anxious, grouchy, hostile, angry, confused), and physical symptoms (muscle aches/pain, light-headed, headache, nausea, heartburn, muscle tension). The Beck Depression Inventory (BDI-II) was administered to determine the degree to which specific depressive symptoms are experienced by the Veteran. Scores on the BDI-II range from 0 to 63, with higher scores indicating more severe depression. Today, the veteran scored a 45 on the BDI-II which indicates a severe level of depression. The interpretation Of the BDI-II is based on normative data and is consistent with self report of severe depressive symptoms and behavioral observation during the clinical interview. The Beck Anxiety Inventory (BAI) is a 21 item self-report measure used to assess anxiety symptom severity as well as to assist in the diagnosis of anxiety. The veteran is asked to rate each item on a scale from 0 to 3 with 0 being "Not at all" and 3 being "Severely" to indicate the degree to which they have been bothered by symptoms of anxiety during the past week including today. Each of the 21 items is then added to provide a total score, with higher scores indicating greater anxiety. Today, the veteran scored a 30 on the BAI which indicates a severe level of anxiety. The interpretation of the BAI is based on normative data and is consistent with self report and behavioral observations of anxiety symptoms during the clinical interview. The Beck Hopelessness Scale (BHS) was used to measure attitudes about hopelessness, feelings about the veteran's future, loss of motivation and expectations. The BHS has been shown to predict suicidal ideation and intent. Today the veteran scored 18/20 indicating a severe level of hopelessness. The veteran denied suicidal ideation. The scores from the BHS indicated that he has negative feelings about his future, loss of motivation and negative expectations of what his future holds. The PCL-M was used to asses PTSD symptom severity as well as to assist in diagnosis. The 17 item self-report measure has three subscales following the DSM-IV criteria; re-experiencing subscale, avoidance/numbing subscale, hyperarousal subscale. The Veteran rates each item on a scale from 1 to 5 with 1 being "not at all" and 5 "extremely" to indicate the degree to which they have been bothered by the symptom over the past month. This instrument provides a total score which can range from 17 to 85. Veteran’s score indicated that he has experienced severe to Extreme symptoms of PTSD over the past month. It appears that veteran has had difficulties with re-experiencing, avoidance behaviors and hyperarousal. The total score is well above the suggested cutoff for combat veterans. Total Score (cutoff = 50, Veteran's score = 82) The Mississippi Scale (MISS) was used to assess the presence of symptoms reflecting the three main DSM-IV criteria for PTSD: re-experiencing, avoidance and numbing, and hyperarousal along with associated features such as depression and substance abuse. The 35 items are rated on a five-point scale asking respondents to rate their symptoms over time "since the event." Symptom severity can range from 35-175. The Cutoff score of 107 was suggested for combat related PTSD (Vietnam). Veteran’s score of 155 is well above the suggested cutoff. Total Score (cutoff = 107, Veteran's score = 155) The Combat Exposure Scale (CES) was used to assess wartime stressors experienced by the examinee. The 7-item self-report measure is rated on a 5-point frequency (1 = "no" or "never" to 5 = "more than 50 times"), 5-point duration (1 = "never" to 5 = "more than 6 months"), 4-point frequency (1 = "no" to 4 = "more than 12 times") or 4-point degree of loss (1 = "no one" to 4 = "more than 50%") scale. Respondents are asked to answer based on their exposure to various combat situations, such as firing rounds at the enemy and being on dangerous duty. The total CES score (ranging from 0 to 41) is calculated by using a sum of weighted scores, which can be classified into 1 of 5 categories of combat exposure ranging from "light" to "heavy." The CES was developed to be easily administered and scored. The veteran's total score is 24 indicating a moderate level of Combat exposure. Combat experiences endorsed by the veteran included: combat patrols or other dangerous duty, was under enemy fire, was surrounded by the enemy, had soldiers in his unit that were KIA, wounded or MIA, fired rounds at the enemy, saw someone hit by incoming or outgoing rounds and was in danger of being injured or killed. Based on DSM-IV and DSM-5 criteria, current interview with veteran and his wife, review of the VA and VBMS electronic record, as well as scores on the ISI, BDI-II, BAI, BHS, PCL-M, MISS and CES, the Veteran has symptoms consistent with Post Traumatic Stress Disorder and Major Depressive Disorder, Recurrent, Severe. THE DIAGNOSIS OF MAJOR DEPRESSIVE DISORDER SHOULD BE CONSIDERED AN INFERRED CLAIM (Veteran was diagnosed in service). Overall, chronic psychiatric symptoms have resulted in very severe disruptions in family, social, leisure, occupational and psychological domains of functioning. He is having great difficulty in his job which requires him to interact with co-workers and the public appropriately when there is evidence of significant irritability, low frustration tolerance, and angry outbursts. This has resulted in reprimands and being written up for inappropriate behavior in the office which threatens his job. His symptoms create an incredible burden for the veteran and his family. The veteran and his wife are unable to have any social experiences. He was diagnosed and treated in 2010 for PTSD and depression while he was in the Marines. There is no record or report of psychiatric diagnosis or treatment before the military. He is currently prescribed lexapro by a private primary care physician for PTSD and depressive symptoms which is not effective. Severe symptoms of PTSD and depression which began during his service is at least as likely as not due to the cumulative effects of daily, multiple exposures to war and fear of hostile military or terrorist activity. Any help or insight with this would be great. Thank you again.