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Mark D Worthen PsyD

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Posts posted by Mark D Worthen PsyD

  1. It is definitely confusing! 

    I suggest that in almost all instances you communicate via U.S. Postal Service mail, sending all correspondence via Certified Mail, Return Receipt requested:

    Certified Mail - Prove you sent it. See when it was delivered or that a delivery attempt was made, and get the signature of the person who accepts the mailing when combined with Return Receipt. $3.55

    Return Receipt - Get an electronic or hardcopy delivery record showing the recipient’s signature. $2.85 for mail receipt. $1.70 for email receipt.

    Detailed info on this USPS web page - Insurance & Extra Services: Add Proof of Mailing, Delivery Confirmation, & More

    ----

    I think you know this, but just in case ...

    If your husband was discharged between 16 Oct 1992 and 31 Dec 2013, the records are supposed to be at:

    Department of Veterans Affairs
    Records Management Center (VARMC)
    4300 Goodfellow Blvd., Bldg# 104
    St. Louis, MO 63120
    Telephone: 1-800-827-1000

    If he was discharged after 1 Jan 2014, the records should be at:

    AMEDD Record Processing Center
    3370 Nacogdoches Road, Suite 116
    San Antonio, TX 78217

    All the best,

    Mark

  2. Information from a non-VA clinician (physician, psychologist, audiologist, etc.) supporting a veteran's disability claim can be divided into two types:

    (1) A report of diagnosis, treatment, prognosis, progress notes, etc. from a treating clinician, without an opinion regarding causation (nexus). For PTSD and other mental disorder claims, which is what I know best, medical records from treating clinicians are very important. VBA—and a VA examiner—should have access to your VHA (Veterans Health Administration) medical records.

    They should also have access to your STRs (service treatment records, also known as SMRs or service medical records), but it's worth making sure that they have all relevant records from your military service.

    Neither VBA nor the C&P examiner will have access to Vet Center treatment records unless you have asked your Vet Center to send records to VBA.

    You must also request that VBA obtain medical records from private clinicians that you saw while in service or afterward. You can also obtain the records yourself and send them to VBA. 

    In most instances, your treating clinicians do not need to complete a DBQ, unless they wish to do so, and provided they understand all the laws regarding service connected disability compensation. Providing an expert witness opinion (which is what a "nexus letter" or IPE/IME is) constitutes a "dual-role conflict" (an ethical concern) for most mental health clinicians, which is why most treating psychologists and psychiatrists won't complete a DBQ to support a veteran's claim. (A few treating MH clinicians will complete a DBQ or write a letter with an opinion, so there's nothing wrong with asking, but be prepared for a "no" because it can be ethically risky for treating clinicians to submit expert witness opinions.)

    (2) If you pay for an IPE (independent psychological exam) or IME (independent medical exam) to support your original claim or for an appeal, then completing a DBQ is a good thing to do for most examiners, to make sure they address all the relevant issues. If the examiner possesses extensive experience, he or she might write a report without using a DBQ but they will still include all the relevant information in that report. 

    There are several subsections of the M21-1 Adjudication Procedures Manual that are helpful to review, although for appeals I highly recommend retaining the services of a veterans law attorney or VA-accredited claims agent since understanding the law is very important for appeals to the Board of Veterans Appeals and beyond.

    Some of the subsections you might want to review are: 

    • III.iv.3.A.3.b.  Use and Acceptance of DBQs for VA Examination and Opinion Purposes
    • III.iv.3.D.2.e.  Discontinuance of Publicly Available DBQs
    • III.iv.3.D.2.f.  Authenticity of DBQs
    • III.iv.3.D.2.q.  Accepting a Fee-Based Examiner’s Report

    You can access the M21-1 Adjudication Procedures Manual at https://www.knowva.ebenefits.va.gov/ under "Compensation".

    All the best,

    Mark

  3. Were you diagnosed with a thyroid condition in service? If not, did you display hypothyroidism symptoms during your military service, in addition to the weight issue? 

    If you have all your military medical records ("STRs" or service treatment records), ask a Registered Nurse, physician, or other knowledgeable medical professional to review your labs for any indicators of hypothyroidism (or any thyroid problem). 

    I am not a physician. These are simply ideas based on my knowledge of the VA disability program in general. 

    Both of my brothers have hypothyroidism so I know it's no fun, to say the least! Both of them did eventually start to feel better when, as you discussed, their docs were able to fine-tune the Synthroid (levothyroxine)  dosage. I hope you get to feeling better quickly!

    ~ Mark

  4. That looks like very sound advice, dajoker12.

    I have not yet seen scientific evidence that PTSD causes obstructive sleep apnea (I have read all the articles you posted), but:

    (1) scientific evidence and legal evidence are not the same; and

    (2) it could be that there is such a causal relationship but research has simply not identified it yet. 

    There is also the question of aggravation, as you (dajoker12) discuss in your post. I think aggravation is more likely than causation. There has not been much research on the aggravation question, but a sleep medicine physician might (and I know some do) conclude that there can be such a relationship, i.e., that PTSD aggravates (exacerbates) Obstructive Sleep Apnea.

    I wrote an article (blog post) a while back about mental disorders that are secondary to service-connected medical disorders and I emphasized the importance of specifically asking VBA to consider secondary service connection, and I offered some suggested language for veterans service officers. In my experience, sometimes VBA did not ask a C&P examiner to consider the aggravation question and the examiner did not think of it either (even though they should). Consequently, veterans who might have received disability benefits for a secondary condition did not. That's why I believe it's important to clearly and specifically ask VBA to consider secondary service connection when you file the claim.

    I adjusted the wording of suggested language for veterans service officers to consider to fit the current topic, i.e., the PTSD ==> Obstructive Sleep Apnea relationship. 

    This is a claim for obstructive sleep apnea that is proximately due to, or aggravated by, the veteran's service-connected posttraumatic stress disorder (PTSD). Please note that the veteran asks the Veteran Benefits Administration to:

    1) First consider if the veteran's obstructive sleep apnea is proximately due to, or a result of, the veteran's service-connected PTSD.

    2) If not, the veteran then asks VBA to consider if the veteran's service-connected PTSD has aggravated (increased the severity of) the veteran's obstructive sleep apnea beyond its normal course or progression. Allen v. Brown, 7 Vet. App. 439 (1995); Aggravation of nonservice-connected disabilities, 38 C.F.R. § 3.310(b).


    Note that you should ask a veterans service officer, VA-accredited claims agent, or veterans law attorney about how to phrase questions since they know more about the topic than I do. What I wrote above is simply a suggestion to consider. 

    ~ Mark

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  5. Just to make sure I understand correctly, you are currently receiving disability compensation for PTSD at the 70% level. Is that correct? 

    If so, I am wondering if the letter asking you for more details on your stressors might be a mistake. Verifying stressors is something that happens before a veteran is service connected for PTSD. Once you are service connected why would they go back to the service connection question?

    It's like them saying, "You are service connected for PTSD, so we want to confirm that you have PTSD." As Spock would say, "that does not compute." 

    • Thanks 1
  6. People that exploit veterans directly or indirectly deserve harsh punishment. 

    Theresa - I love what you told the reporter: “Your service to your country shouldn’t be shilled by some carnival barker on the corner.”

    Amen.

    ~ Mark

    P.S. I used to do a lot of forensic psych evaluations in North Carolina (criminal cases) so I'm pretty familiar with the judicial system there and how to obtain (publicly-available) information. The perp in this case, Daniel D. James was on the docket for 1 Apr 2019 as the article indicated. For these initial arraignment hearings there usually isn't much info, and that's true for his case. It does list his file number though, which makes it a little easier to research down the road when he finally agrees to a plea bargain (presumably - he'd be stupid to plead his case before a jury). He's charged with a felony, Obtaining Property Under False Pretense, and a misdemeanor, violating a solicitation ordinance. His file number is  19CR 204599. The Public Defender's office is representing him.

    Here's a link to the docket printout: DISTRICT Court Calendar: 04/01/19, AM Session in court Room 0301 for DISTRICT_CRIMINAL_COURT_ (PDF) or text version. He is #15 on the docket.

  7. Congratulations SwiftSig! I admire your hard work, willingness to ask for help (which takes guts in my book), and discipline to do your part, like organizing everything per your service officer's suggestion. Not an easy task when you are, after all, having to cope with several disabilities and the added stress of the arduous claims process. 

    And it is heartening to hear that 83% of the VA examiners you saw did their homework and treated you with the respect you deserve. Of course, 83% means there's room for improvement, but really that's not too bad for a huge bureaucracy like the VA, and considering that being a C&P examiner is one of the more difficult jobs at VHA. 

    ~ Mark

    P.S. Lest anyone think I am an apologist for the VA, you should know (and many of you already know) that I am not shy about criticizing the Department of Veterans Affairs. Case in point is a 97-page "white paper", Psych C&P Exams Are Unfair to Veterans, which I submitted to the federal Advisory Committee on Disability Compensation and posted online for anyone to read (or scan, it is a bit dense ;-). 

    • Like 1
  8. 2 hours ago, Unique11128 said:

    Dr. Valette is an expert in MST claims. He will look at your c file for markers related to Mst/ PTSD. He is in Colorado but does do phone interviews for Va claims.

    This isn't a crucial point as I'm sure Dr. Valette is up to date on VBA regulations and policies. But just as an FYI for everyone, see this part of the M21-1:

    M21-1 Adjudicative Procedures Manual, III.iv.3.D.2.c. Telehealth and Telemental Health Examinations 
    ...
    A mental health DBQ submitted by a private provider and based on a telephone interview with a Veteran is not acceptable or actionable for rating purposes under any circumstances. VHA has determined that, in order to assess a Veteran’s mental health via telemental protocol, examiners must be able to see clearly, and fully appreciate all non-verbal cues, mannerisms, and manifestations displayed by the Veteran in a manner on par with an in-person examination.

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  9. Bluebonnie - I feel sad and angry (toward VA) reading your denial letter. You have serious, painful psychological disorders caused by sexual assault which occurred when you were serving our country. A VA psychologist even said so! But because your painful, debilitating symptom do not match with the precise diagnostic criteria for the one-and-only diagnosis that counts, oh gosh sorry you're horrific experience and resulting years and years of suffering don't count.

    The problem here is not the VA examiner, or the VBA rater, or any of the front-line VA staff who work in the disability claims arena. Most of them like and respect veterans, want to help veterans if they legally can, and many of them are veterans.

    The problem is VA upper management who apparently did not consult with sexual assault experts, and did not read the scientific literature on this topic. If they had, they would know that sexual assault, particularly when compared to combat trauma (where PTSD is far and away the most common diagnosis), causes a variety of psychological maladies (disorders).

    VA could have done it right in 2010 when they added 38 C.F.R. § 3.304(f)(5) and they have had 8 + years since then to update the regulation so that any mental disorder caused (or aggravated) by MST is compensable. 

    ---

    I agree with others who have recommended an Independent Psychological Exam (IPE) or Independent Medical Exam (if it is a psychiatrist). I don't know Dr. Valette but if other vets recommend him, that sounds like a good plan to me!

    There are definitely legitimate ways to respond to this denial from the psychology perspective. Plus, there are probably legal issues to consider, so I highly recommending retaining an attorney. Of course, all professionals have to earn a living so you need to pay them, but you can pay veterans law attorneys based on a contingency agreement where they receive 20% (or thereabouts) of your back pay if you win your case. 

  10. Have you had your C&P exam for PTSD yet? 

    Folks with ADHD, which is a disorder with an onset during childhood (although it can continue into adulthood), are probably more likely to develop PTSD. 

    I can certainly see PTSD aggravating pre-existing ADHD beyond its normal course and progression. From a VA disability benefits perspective, this is the most important relationship between the disorders. If an examiner concludes, and VBA agrees, that PTSD exacerbated your ADHD, and that this exacerbation (aggravation) led to even more social & occupational impairment than the PTSD alone would cause, the combined effects of PTSD and ADHD are compensable.

  11. In addition to the excellent advice you've received from your fellow vets, I'll briefly share from an examiner's perspective.

    I learned from my friends who are veterans and from the many veterans I evaluated over the years that the "rules of the game" change dramatically when services members leave the military and enter the world of being a veteran.

    In the military, seeing the doc for anything that's serious or chronic will likely hurt your career and you'll go from "Awesome member of the team" to "Potential liability". 

    Then, when you enter the world of being a veteran all of a sudden everyone is exclaims, "What?! You haven't sought treatment? You gotta do that man."  I don't mean in any way to discount the advice you've received here--I totally agree with it. I'm simply highlighting the stark contrast between life in the military vs. life as a veteran. 

    My main point is that decent C&P examiners know that there are many possible reasons why a veteran hasn't sought treatment before. 

    When and if it seems appropriate (trust your gut) tell your examiners in a brief, matter-of-fact way (like you did here) why you put off treatment for so long. Don't belabor the point. 

    Finally, as others have said, when you go for treatment appointments, try to put your disability claim out of your head. Ask yourself, "If I didn't have a pending claim, what would I say? How would I act?"

    I've had severe allergies since I was a teenager and they're awful. People who don't have them really don't understand (unless they're medical folks.) But over the years my doctors have found treatments that work for me and now the allergies are a nuisance, but tolerable. Allergies are just one of the ailments you're dealing with, but my point is that treatment is often quite helpful.

    All the best,

    Mark

    • Like 1
    • Thanks 1
  12. As a C&P examiner, I took letters from spouses seriously. And, if a vet was accompanied by his or her spouse and asked me to speak with him or her, I would always do so as it often helped me to better understand the frequency, intensity, and duration of mental disorder symptoms and associated functional impairment. 

    Unfortunately, VA does not require examiners to interview family members, and there are not any specific requirements for examiners about how to regard letters from family members. 

    Nonetheless, letters from "lay witnesses" could help, even help a lot, and they're unlikely to hurt a veteran's claim.

    Veterans law attorney Chris Attig recommends submitting lay witness statements as a "Declaration", which he explains in a blog post. Note that Mr. Attig calls it a "sworn declaration" whereas other legal websites, and the relevant U.S. Code, call it either an "unsworn declaration" or simply a "declaration". In my experience reading Mr. Attig's blog over the years, he offers well-written, important, accurate information for veterans and their representatives. I don't know Chris Attig personally, but I respect him and value his opinion.

    Although they don't mention using a Declaration, the law firm Chisholm, Chisholm, & Kilpatrick has a good article, accompanied by a question & answer video titled, How to Use Lay Evidence for VA Disability Claims.

    There's an easy-to-understand, informative article on the Martindale (legal publisher) website that discusses Declarations in general,  i.e, the article is not specific to veterans law: When to Swear and When to Declare: Affidavit or Declaration? by Matthew J. Bakota (21 May 2012).

    Finally, here is the statute itself: 28 U.S. Code § 1746 - Unsworn declarations under penalty of per­jury. I'm not an attorney, but it looks pretty straightforward. If it were me I would write exactly what the law specifies at the bottom of a family member's letter, and ask them to date and sign it:

    Quote

    “I declare under penalty of perjury that the foregoing is true and correct. Executed on (date). (Signature)”. - copied from 28 U.S. Code § 1746.

    Note this part: "... under penalty of perjury ...." Chris Attig offers important advice in the blog post I mentioned above:

    Quote

     

    Just be aware: by using this form you are saying that you are making the statements “under pain of perjury”.  That means that if the VA can show you lied in this document on a material fact, you could be charged with perjury (that’s a crime, folks).

     

    I hope all your exams go well SwiftSig!

    ~ Mark

    • Thanks 2
  13. My guess would be that yours is not a difficult claim to adjudicate so they were able to get it (almost) finished faster than expected. Based on the info you shared, there's no way they'll reduce your rating. 

    Regarding the term "moderate to severe", it's important to put it in perspective. 90% to 95% of the country is not suffering from two serious debilitating mental disorders at the same time.

    Here's Dr. Mark's off-the-cuff, unscientific, for-illustrative-purposes only, 11-point "severity scale" that I just typed out as a "thought experiment" to give you a sense of where "moderate to severe" fits on the continuum.

    Rating - Description

    0 - No symptoms, no history of disorder.

    2 - Mild symptoms but frequency, intensity, & duration insufficient for DSM-5 diagnosis of disorder.

    4 - Mild symptoms that satisfy DSM-5 diagnosis for the disorder. Experiencing symptoms more often and with more intensity - harder for him to say "it's just a bad week" or similar. Wife said he seems dejected, less energy, motivation flags. He'll bounce back for days or even a week or two but that's becoming less often. Calling in sick to work more often. Supervisor said management has commented on his declined productivity.

    6 - Moderate symptoms that cause noticeable and significant social and occupational impairment; frequent distress, dispirited; interpersonal relationships strained, even with her children; school functioning has clearly declined. Got a "C" in one course and two Incomplete grades. Decided to hold off on continuing college coursework, even though she is close to earning all credits for bachelor's degree.

    8 - Moderate to Severe - frequent painful symptoms much of the time despite assiduously seeking treatment and following his doctors' advice; significant social & occupational dysfunction; probably will need to seek medical leave, reduce work hours, or may end up not being able to work. Psychiatrist has discussed options for "treatment-resistant depression", e.g., ECT (electroconvulsive therapy); the new ketamine-like medication; Lithium; Abilify; etc.; psychologist recommended VA's 6-week residential treatment program for PTSD in Sheridan, WY.

    10 - Severe - very frequent, soul-crushing painful symptoms most of the time despite assiduously seeking treatment and following his doctors' advice; substantial suffering is obvious; significant social impairment, and no longer able to work, at least for the next several months or longer.

    [The above is not an official, unofficial, actual, or real mental health scale. It's just a way to put symptom severity and functional impairment in perspective for illustrative purposes only.]

    • Like 2
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  14. Quote

    They also stated in the decision letter that only a Board certified psychiatrist can diagnose PTSD .

    If that is literally what they wrote, with nothing about other mental health professionals, it's flat out wrong. Most VBA staff would never write such nonsense. Maybe he or she was brand new? (Not that being new is an excuse.)

  15. On 3/28/2019 at 6:35 PM, Soliz said:

    I received a combined rating of 60%-10 for tinnitus and 50 for PTSD.  I had a few things deferred.  I am a bit of shock right now and thankful.  I appreciate everyone that took the time to help!  Hope you get this update 

    I am glad it worked out for you! 

    - Mark

  16. Wow, this is a great thread. Nothing like the voices of experience to get a good sense of what's available in terms of an IMO/IME/Nexus Opinion. 

    I don't know any of the physicians personally, but similar to what y'all have written, I have been impressed with Drs. Bash and Anise with regard to their breadth and depth of knowledge and ability to communicate effectively in writing. I have also enjoyed listening to Dr. Bash on the HadIt radio hour. 

    I don't know as much about Dr. Ellis but I have read numerous positive reports here and on other forums. I have never read anything negative. 

    Setting one's fees as an expert witness (which is how the federal courts refer to doctors like Ellis, Bash, & Anise) is interesting. I suspect a lot of it has to do with the stage of one's career, overall financial situation, and staff resources. If you're still in the midst of your career and you've got kids in college or grad/med school, then you should run your practice like a good small business and make some money. If you're approaching retirement and are financially secure then you might charge less as a community service. 

    I am guessing, but Dr. Bash is probably following sound business principles for consultants of all kinds: If you have done good work, built up a solid reputation, and are swamped with referrals, you should raise your rates until you have a manageable number of referrals. Basic supply and demand in a free market economy (capitalism). 

    Some people complain about such professionals, saying they are "too expensive". My usual response to such judgments is something like: "Well, if you want an economic system based on the principle, from each according to his ability, to each according to his needs, such a system has been proposed."

    • Like 1
  17. On 2/27/2019 at 3:40 PM, Soliz said:

    does this sentence make it an automatic 10% or could the listed symptoms make the rating higher?

    symptoms listed are anxiety, suspiciousness, chronic sleep impairment, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances (including work or a worklike setting

     

    Usually the endorsed symptoms make the rating higher.

    In the General Rating Formula for Mental Disorders (38 C.F.R. § 4.130) the endorsed symptoms are associated with the following disability impairment levels (ratings):

    anxiety, suspiciousness, chronic sleep impairment > 30%

    difficulty in establishing and maintaining effective work and social relationships > 50%

    difficulty adapting to stressful circumstances (including work or a worklike setting) > 70%

    The VBA RSVR ("rater") considers all reliable evidence, although the endorsed symptoms carry more weight, all other things being equal, probably because they come directly from the guidelines for rating mental disorder disabilities (the General Formula).

  18. Complex PTSD usually results from sustained, awful childhood abuse - sexual, physical, or mental/emotional - often all three. I've diagnosed Complex PTSD several times, usually with female MST survivors.

    A crucial point for C&P psychologists:

    1. Either opine that military sexual trauma aggravated the pre-existing mental disorder beyond its normal course and progression; or 
    2. explain how adult trauma can, in a sense, "reawaken" dormant or subthreshold trauma-related symptomatology.

    It's rare these days for VBA to claim a disorder pre-dated military service, but the last thing I want is someone with horrible PTSD to receive a denial. 

  19. I tried to connect my social media accounts--Twitter, Google+, and LinkedIn--but for each of them I received an error message, like this:

    You need to pass the "client_id" parameter 

    Missing required parameter: client_id 

    Is there something I need to do on my end that I'm too dense to figure out? 🤖

    Thanks!

    P.S. Teresa - Thank you for regularly publishing your newsletter. I haven't worked the past two years while I received medical treatment, and I wasn't keeping up with veterans disability news as much as in the past. But as my recovery progressed (all better now thank goodness!), I started to get back up to date and your newsletters (which I did read regularly) reminded me to get back on the forum so that I can share info when it might help and so I can continue to learn from you all. 🤠

  20. The odds are exceptionally low that it would change anything. A few facts to know:

    * If VA used ICD-11, a vet could theoretically be diagnosed with Complex PTSD due to childhood trauma and due to combat trauma.

    * Complex PTSD is an ICD-11 diagnosis, but the VA uses DSM-5/ICD-10-CM, which does not have Complex PTSD as a diagnosis.

    * I'm neither a veterans law attorney, nor an expert on the regulations, but I think you fall under 38 C.F.R. § 3.951(b), which states in part:

    "A disability which has been continuously rated at or above any evaluation of disability for 20 or more years for compensation purposes under laws administered by the Department of Veterans Affairs will not be reduced to less than such evaluation except upon a showing that such rating was based on fraud."

    See also M21-1 III.iv.8.C.1.a. Protected Evaluations for Compensation Purposes Under 38 CFR 3.951(b).

    And see M21-1 IV.ii.2.F.5.b. Discontinuance of Monitoring for Changes in Employability Status. Here's a quote:

    "Monitoring changes in employability status is not required when the Veteran ... as an IU rating that has been in effect for 20 or more continuous years ..."

    All the best,

    Mark

  21. If he hasn't had an Agent Orange Registry Health Exam for Veterans, it's a good thing to do for medical (treatment) reasons. It is completely separate from the disability compensation process, but the doctor can alert the veteran to conditions that might be related to Agent Orange exposure, for which he could then receive treatment. (If he does not have an earned income, and for other reasons, he is probably eligible for free medical treatment at the VA.)

  22. 17 minutes ago, 63Charlie said:

    I submitted a Freedom Of Information Request first through normal channels.

    Waited a month and nothing.

    Emailed the Secretary..... mentioned my doctor needed the C-File to prepare his IMO.

    and...SHAZAM!!

    IMHO Secretary Bob is the real deal - he really gives a f**k. 

    He is trying to drastically change the entrenched, fear-based, authoritarian management style that emanates from 810 Varmint Ave. (Can you tell whose blog I read?)

    Of course the Entrenched are resisting tooth and nail. I hope whomever is Prez come next January will reappoint him, although that doesn't happen often.

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