Just had my C&P last week. And, I've been trying to figure out if I will get the compensation benefits and at what percentage?..I was hoping some of my service family could help me with..Appreciate any input you guys or girls can give me. Thanks!! Initial Post Traumatic Stress Disorder (PTSD) Disability Benefits Questionnaire * Internal VA or DoD Use Only * Name of patient/Veteran: Taylor, David G. 0507 SECTION I: ---------- 1. Diagnostic Summary --------------------- Does the Veteran have a diagnosis of PTSD that conforms to DSM-5 criteria based on today's evaluation? [X] Yes [ ] No ICD code: 309.89 2. Current Diagnoses -------------------- a. Mental Disorder Diagnosis #1: Other Trauma- and Stressor- Related Disorder ICD code: F43.8 Comments, if any: This is the DSM-5 diagnosis which applies when symptoms characteristic of a trauma- and stressor-related disorder cause clinically significant distress or impairment, but do not meet the full criteria for any other specific disorders within this category. In Mr. Taylor's case, criteria are met for categories A. (stressor), B. (intrusive symptoms), and C. (avoidance symptoms), but not catagories D. (Negative alterations in cognition and mood) and E. (Marked alterations in arousal and reactivity). Mental Disorder Diagnosis #2: Unspecified Depressive Disorder ICD code: F32.9 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: Mr. Taylor's Other Specified Trauma- and Stressor- Related Disorder includes situational symptoms which are activated by situations like thunderstorms. These symptoms are reported to include intrusive thoughts/fears/memories and accompanying states of anxiety. Mr. Taylor makes efforts to avoid encountering triggering stimuli. The Unspecified Depressive Disorder includes symptoms of sad and depressed moods, decreased energy and motivation, interpersonal withdrawal, feelings of hopelessness, and anxious distress. 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 occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation 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? [X] Yes [ ] No [ ] No other mental disorder has been diagnosed If yes, list which portion of the indicated level of occupational and social impairment is attributable to each diagnosis: The symptoms related to Mr. Taylor's Other Specified Trauma- and Stressor- Related Disorder are situationally circumscribed and seem to be mild or transient in nature. Symptoms of the Unspecified Depressive Disorder are more pervasive, resulting in occasionally diminished social and occupational functioning. 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 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): Mr. Taylor was born and raised in Buffalo, NY. Family consisted of his mother and a brother five years older. Mr. Taylor's father was not involved in his upbringing. Growing up, "We weren't rich... single mom... towards (my) teenaged years she got addicted to some things... got pretty bad... brother was older, so I was kind of there by myself a lot." "I had a godfather that kind of watched me when my mom was working... He was there, which is more than what I could say about my dad..." Father had 15 children- "You can see why he wasn't around... came around to high school graduation... boot camp graduation... I forgave him... just the type of person he is... I have all these other siblings... call me when they need some money... Only time I talk to them is when I go visit... got a little sister who will call me once in a blue moon..." Relationship with his brother- "We're working on it... He was a little abusive... beating me up... one time I had to come at him with a knife... I was always doing the chores... wasn't really the best brother to have... Think he was probably a littl e jealous... He always had problems in school... I was kind of the smart one... He apologized to me... We're working on it..." First marriage- 1995-1997. From that relationship, "I had a daughter and a son (both are currently in Buffalo), same mom..." "My daughter, she's 20... pregnant now... with a man that's older than I am... I think it's because I wasn't there... looking for a father figure (Mr. Taylor is visibly, audibly sad, no longer making eye contact)... My daughter, that's awreck... She's staying over there with the guy... He's trying to control her... I talked to her about stuff, but kind of late, like 16, 17... Her mom and her got into it and her mom said she had to go... but too young to go... I just want to be there for her when she needs someone... If I was there, it could have been a little different..." "My son, I'm still working on him... I think he's a little mad... thinks I abandoned him... wasn't my choice... couldn't financially help him... I flew him down a couple summers ago... apologized to him for not being there... told him my thoughts... I got to be honest with myself, I could have done more for him..." "I was married (second) for about seven, eight years... two kids in that marriage... I was unfaithful, but she kind of forgave me... but I think that was more a way to get out.. I don't think I was really.. I get in so many situations I'm not comfortable... I'm not maybe the marriage type... getting married for no reason... I just left..." Current marriage of three years- "Terrible... I don't know if it's me... reason I'm here is maybe 50%... I think I moved too fast once again... When I left my first marriage, I was supposed to work on myself... I think it was more just having somebody there... She's kind of verbally abusive, and I think I allow it because... I can take a lot..." "I don't want to be a third time loser... but I think I need to be by myself... same thing over and over..." "She (current wife) thinks I'm just around now because it's comfortable... If I could afford to move, I'd have been gone... That's true... I bit off more than I could chew.... worst thing that could have happened to me... wrong relationship for me... I need to go, but I don't know how..." "My second kids... When they come over my house... feeling guilty because I left them... If I was there, they'd be living a little bit better... a little bit of order... I try to make sure when they come and see me that everything is good... got clothes... do things with them..." His current wife gets mad because they don't have more responsibilities when they visit. Friends- "I have friends... wife kind of chased them off... Now I'm embarrassed to even go... They know... certain changes... She throws temper tantrums... doesn't really have no respect for nobody..." b. Relevant Occupational and Educational history (pre-military, military, and post-military): School- "Very well... honor roll... played basketball." Pre-service work at McDonald's. Marine Corps- 1995-1999- Administrative Clerk- No deployments. Honorable discharge. "The reason why I got in... I had a daughter on the way when I was in high school... early entry program... didn't work out so well... She (wife) broke up... She was gonna go to school and come back... didn't hear from her for a while... back with her old boyfriend... caused my issues in the service... I told my commanding officer I needed to go home... try to save my marriage... I came back and they shipped me to another office... Headquarters Battalion... They were more focused on the job than some young guy focused on trying to save his marriage..." After the Marines, "A lot of call-center the first couple years... kind of moved down here because there wasn't a lot of good jobs where I'm from... I got laid off about a year ago... help desk... Carolinas' Associated General Contractors... about seven or eight years..." Currently, "I'm working at Lending Tree in Ballantyne now... going good... I'm always able to separate (work life)... from my personal life..." c. Relevant Mental Health history, to include prescribed medications and family mental health (pre-military, military, and post-military): Mr. Taylor says he took anger management classes during the service, following an altercation with his wife. No indication of any other mental health problems observed in STR, nor in military separation exam- June 8, 1999. Denies any mental health services before or after the military. d. Relevant Legal and Behavioral history (pre-military, military, and post-military): During the service, "I got some anger management classes... Me and my ex-wife had got into it.. she kind of hit me first.. reactionary thing... I hit her back... I did get arrested for that think with my first wife... got restrictions for a week or two... money taken away..." Other disciplinary action, "Here and there... I'm not good at relationships I don't think... kind of got in trouble sleeping around with a... married woman... some other rules things... over-sleeping because I was drunk maybe a couple times..." Thinks he had two or three Article 15s. "I did get caught shop-lifting... When I was young... didn't have money to buy things... (in the service) video game card... got like 30 days restriction... like $400 in pay... maybe why I never got promoted beyond E-3... Most of the things happened during the first two years... kind of settled down after that." e. Relevant Substance abuse history (pre-military, military, and post-military): Alcohol- "Usually I'm just a social drinker... lately... kind of depressed... things ain't working out like they should have... expected more of myself... I might make two or three (drinks), maybe three, four times a week..." Sometimes more. No history of alcohol treatment. No history of illicit substances. f. Other, if any: Sleep- "I guess it depends... lately either I can sleep good, real deep... or I have... since I applied for this... sleep more off and on because I'm thinking about it... some periods I might have like restless leg syndrome... wife tells me... in and out of it..." "I try to work out now... try to help me sleep a little better... This bad relationship I'm in though, don't help me with my sleep..." Mr. Taylor says he gets "a good five" hours of sleep, "Then I toss and turn... had a surgery on my thumb... bulging disc in my neck... muscle relaxers... help me go to sleep..." Depression- "I've been depressed for a while... kind of live with it... I do have thoughts of maybe, you know..." Denies suicidal intent or plan. Wouldn't act on it because of his children. "I think I'm just hard on myself... The women, I don't really have emotional attachment with... my kids, I love my kids... feel like I've failed them... guilt... probably don't do what I need to do to handle it right..." Talks about his son acting out, being disrespectful to his mother, with Mr. Taylor feeling guilty/responsible for it. "If I was there, I know that wouldn't be going on." "My confidence in myself... kind of mumbling... I lost it somehow... It's embarrassing... Everything pretty much... I think my mom had more hope for me... kind of let myself and my kids down... especially my older kids..." Anger, "I can keep it in check, cause if I don't keep it in check, I don't know where it will go... That's the reason I don't discipline my kids... one time I did it... ended up (going too hard)... that's why I don't..." Anxiety, "I think I'm... I can tell by how my nails look, how I'm doing lately... I swear it has something to do with losing my hair... I kind of go in kind of a shell too... There's kind of a compulsive thing I do... I always got a remote in my hand... constantly going back and forth (does some numerical patterns with buttons/symmetry). "If it's raining... lightning... If I see that (memory of reported stressor)... even in the car... Even though when the lightning struck, we weren't near a tree... lightning hit the ground... I always had a wariness of... lightning... staying where I'm at, or make sure if I'm getting anywhere, I don't see no puddles of water... or passing by trees or metal... I know it happens... I was right there... I'm staying there until it at least slows down..." "Ever since I started coming here, I keep replaying it in my mind... wonder if it has anything to do with what's going on..." 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: "What they said and what happened are two different things... storms... rifle range... lightning hit the surrounding tree line... I'm like... 'That's real close... don't know why we were still there.'... As we were leaving... two formations... guys (other group) right behind me... I was in the back of mine... Drill sergeant was like, 'Cover your rifles with your ponchos.'... We were doing that... All the sudden... blue light... no sound... feel this heat on the back of my neck... several of us got down... As I turn around... see several guys down on the ground... Drill instructor is running up... eyes out of his head... 'Everybody get up to the... shelter!'... This one guy... just down... all this happened in probably no more than ten seconds... That heat... and you could smell it, like electrical burn... 'til I hear the boom, then I recognized what it was... My ears was ringing... One of the guys... He had died... hit him first, and came out and hit the people closest to him... We was in boot camp... didn't tell us anything... We went to his funeral... after that, we didn't do but ten or fifteen percent of the stuff... because it was raining a lot... lightning... We didn't do it after that... He could have been alive if we'd have left ten minutes earlier..." 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 If no, explain: Mr. Taylor was witness to another man being killed by a lightning strike during training. 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 #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] 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] 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: No response provided. 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: No response provided. 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 6. Behavioral Observations -------------------------- Mr. Taylor arrived about 15 minutes early for his appointment. He was neatly and casually dressed. No abnormalities of gate or posture were noted. He was cooperative with the interview process and made good eye contact. Mr. Taylor was fully oriented. Speech was clear and coherent, quiet at times. Mood was somewhat depressed. Affective expression was mild, congruent, sad at times. Thought process was logical and goal-directed. Thought content was relevant and with adequate detail. Gross concentration and memory were adequate. Insight and judgment are in tact. There was no evidence of perceptual disturbance. There was no evidence of thought disorder or hallucinations. Mr. Taylor relates that he has thought about suicide, but denies any intent or plan. Homicidal ideation is denied. 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 -------------------------------------------------- Prior to beginning the interview, the undersigned examiner informed the veteran of the purpose of the evaluation, the role of the undersigned examiner, and the limits of confidentiality. The veteran indicated understanding of the aforementioned information. Per VA Memorandum titled Information Bulletin: Implementation Guidance for the Fifth Edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-5) use in Compensation and Pension Examinations, dated December 16, 2013, this examination was conducted using DSM-5 criteria. Of note, the DSM-5 no longer requires computation of a GAF score. Per 2507: "Please indicate in exam report the stressor(s) claimed by the veteran upon which a diagnosis of PTSD is based. **If a diagnosis other than PTSD is rendered, please state if that psychiatric condition is at least as likely as not (50 percent or greater probability) linked to the conceded stressor." Examiner's Response: Mr. Taylor does not meet DSM-5 criteria for a diagnosis of PTSD. However, he does currently meet criteria for Other Specified Trauma- and Stressor- Related Disorder. This includes situational symptoms including intrusive thoughts/fears/memories of the stressor event, with accompanying states of anxiety, which are triggered by situations like thunderstorms. Mr. Taylor makes efforts to avoid encountering triggering events. The Unspecified Depressive Disorder includes symptoms of sad and depressed moods, decreased energy and motivation, interpersonal withdrawal, feelings of hopelessness, and anxious distress. The symptoms related to Mr. Taylor's Other Specified Trauma- and Stressor- Related Disorder are situationally circumscribed and seem to be mild or transient in nature. Symptoms of the Unspecified Depressive Disorder are more pervasive, resulting in occasionally diminished social and occupational functioning. It is at least as likely as not (50 percent or greater probability) that Mr. Taylor's currently diagnosed Other Specified Trauma- and Stressor- Related Disorder is due to his having been witness to the lightning strike killing a fellow Marine during training. The reported stressor is sufficient for the potential development of a trauma- or stressor-related disorder. The symptoms of intrusive thoughts/fears/memories of the stressor, accompanying states of anxiety, and efforts to avoid triggers to memory of the stressor are meaningfully related to the stressor itself. It is less likely as not (less than 50 percent probability) that Mr. Taylor's currently diagnosed Unspecified Depressive Disorder is due to the lightning strike killing a fellow Marine during training. Mr. Taylor's problems with depression seem more likely due to historical and current difficulties with significant other relationships, difficulties and regret in his relationships with his children, and perhaps aspects of adverse circumstances during childhood.