Mark D Worthen PsyD

That should get you a C&P exam for sure. I wish you all the best! Mark

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.)

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.

Great intel @Buck52 ! Nothing like having a personal contact within the bureaucracy.

Is your request for VBA-specific records that exist only in your claims file? Assuming that is the case, it might work a lot better if VBA set up a system where vets could request VBA-specific records only, e.g., Rating Decisions, Statement of the Case, etc. Might save a bunch of time and money.

From what you wrote, it sounds like the PharmD is the problem...

Licensed pharmacists (PharmD degree) employed by the VA often treat psychiatric patients, although a psychiatrist is supposed to review their work, and see the patient regularly or every once in awhile - I don't know what the standard is. But your situation does not sound right. I suggest calling the MH clinic and requesting an appt with a psychiatrist. Also try talking with the Patient Advocate (some are really effective, others not so much from what I hear.) If you still do not have an appointment with an MD soon, then call and write the Chief, Mental Health Services at your VAMC, with copies to the Chief of Staff and Medical Center Director. Btw, it's not unusual for people with Panic Disorder to become less agoraphobic with treatment over time, but it is much less common for a patient to stop having frequent panic attacks but still have the agoraphobia. Also, note the name of the diagnosis: Agoraphobia Without History of Panic Disorder. Also note that Agoraphobia Without History of Panic Disorder was a DSM-IV diagnosis that is not in DSM-5. All the Best, Mark

I apologize @Berta, I somehow missed your post. You're right, Global Assessment of Functioning (GAF) scores are no longer part of the DSM, although I still saw them mentioned by RSVRs (raters) and ALJs (BVA judges) through 2016. The GAF is a unreliable and only modestly valid measure of functional impairment. (I'm using these terms in the scientific, not legal, sense. See: Reliability and validity.) We discussed the problems with the GAF in this journal article, on page 205: Worthen, M. D. & Moering, R. G. (2011). A practical guide to conducting VA compensation and pension exams for PTSD and other mental disorders. Psychological Injury and Law, 4(3-4), 187-216. doi:10.1007/s12207-011- 9115-2 | http://bit.ly/ptsd-exams

I agree with all the great advice you received in this thread. There is a lot of debate about the changes made to the diagnostic criteria for PTSD with the publication of DSM-5 in 2013. I personally think it's a mixed bag, but one big positive I see is this addition to Criterion A A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways: ... 4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse). I see this addition as a very positive change because under DSM-IV, guys like you would have a very hard time receiving a PTSD diagnosis. It can still be a challenge, but it's better. I evaluated some of your fellow Airmen, and guys from other branches, with very similar experiences as you have had, and sure enough, the majority had PTSD or subsyndromal posttraumatic stress syndrome. I had the advantage of working at a C&P Clinic that gave us enough time to conduct thorough, evidence-based psychological evaluations, which is always important, but especially important with a new diagnostic criteria set. My hat's off to you @AirForce99. All the Best, Mark

What your VSO told you is correct. I almost always found that a combat veteran's stressor statement(s) were very helpful. In other words, particularly since I am not a veteran, it helped me more fully understand how horrible and traumatic the event(s) were. Be sure to use VA Form 21-0781 - STATEMENT IN SUPPORT OF CLAIM FOR SERVICE CONNECTION FOR POST-TRAUMATIC STRESS DISORDER (PTSD) - for your stressor statement(s). You can type or handwrite them. As long as your handwriting is legible, it's perfectly fine to do it that way. What you're writing is something exceptionally personal and painful, and what's more personal, in terms of written communication, than handwriting? There are some guides to writing to VA, such as: StateSide Legal - VA Disability - Step 3: Gather and submit evidence (general advice on writing a letter to VA - it's down near the bottom of the page). Swords to Plowshares - WRITING YOUR PTSD STRESSOR STATEMENT Nolo - How to Write a Stressor Statement for a PTSD Claim for Veterans Disability Compensation I thought I had read some good advice about a stressor letter on veterans law attorney Chris Attig's blog (http://www.veteranslawblog.org/), but I searched on his site and couldn't find it. His site is a little hard to search, so I could have missed it. Btw, the content on his site is excellent IMHO. @fiasco2g - I hope this helps. I very much admire, respect, and appreciate your service, and sacrifice, to our nation. All the Best, Mark

Great advice re: filing for IU! Of course, if @Osccore9 receives a 100% rating it will be a moot point, but if it's 70% and working is not a reality at this time, then an IU claim would for sure be the thing to do. I also agree with @Gastone that, while it certainly might have been true in the past (I've heard so many very credible horror stories from countless veterans), in the 5+ years I worked for VA as a C&P examiner, I saw the vast majority of RSVRs (Raters) make conscientious decisions, even going out of there way (while under a lot of pressure to increase production) to make sure they had explored every avenue for service-connection. VBA has the highest percentage of veteran-employees (other than DoD, of course) of any agency in the federal government (50%). Although the majority of non-veterans like myself really give a s**t about you guys too, I think it does say something that they hire so many vets. By the way, going back to Osccore9's C&P exam report, the examiner did a much more thorough job researching, describing, and explaining several pertinent behavioral markers than usual. She (I think it was a she) also has clearly educated herself extensively regarding the long-term sequelae (effects) of sexual trauma. That's really nice to see, especially given how many mediocre (at best) exam reports that contractors and VA staff produce.

This is one reason why veterans should be granted electronic (Internet) access to their claims file on VBMS. VSOs have access. Contract examiners have access. The IME companies (QTC, VES, etc.) have access. C&P clinics have access. Why not the vet? Is this need on the agenda of any of the influential veterans service organizations?

That is an excellent point. Many, many vets do not know that they need to request Vet Center records separately from any other VA medical records. I recently wrote a long detailed page on how to request veterans military records and medical records, and I put the Vet Center info in red with arrows pointing at it because it is so often overlooked! http://ptsdexams.com/veterans-military-records/#vet-center-records All the best, Mark

My understanding is that de novo reviews by a Decision Review Officer (DRO) take place much faster than an appeal to the Board of Veterans Appeals. Is that correct?

That might have been true in the past, but since the advent of the DBQs, the Raters focus on the items checked off on the 'Symptoms' list (Section II, Number 5 of the Initial PTSD DBQ). The reason for this focus is that those symptoms come directly, verbatim, from the General Rating Formula for Mental Disorders. I cannot remember the last time I saw a rating consistent with the summary statement of social and occupational impairment (Section I, Number 4a) when the symptoms endorsed corresponded with a significantly higher rating. Plus, Raters now use an automated Evaluation Builder, which uses the items in the Symptoms List to determine the rating. I attached a copy of the General Rating Formula for Mental Disorders. Mark General Rating Formula for Mental Disorders.docx

At least 70%, and probably 100% based on the items checked in Section II, Number 5 ("Symptoms"), which correspond directly with the General Rating Formula for Mental Disorders. My heart goes out to you for the horrible sexual assault you endured. I am glad you will receive the assistance and (presumably) the compensation you deserve. All the Best, Mark

Thank you so much @Andyman73. Although PTSD garners most of the attention these days, the fact remains that almost as many veterans receive SC for other mental disorders. [The proportion is 59% PTSD and 41% other mental disorders.] If you haven't already, definitely tell your VA doc what you want and need and how you feel. The more direct you are with your psychologist or psychiatrist, the more you will get out of it. All the Best, Mark

VBA routinely asks C&P examiners to examine for both IU factors and current symptom severity & functional impairment (which is what the disability is rating is based on). So it's standard policy, nothing you did wrong. Personally I think that if the veteran does not ask for an increased rating, then VA should ask the examiner to address IU only. That would save everybody some time, and save the taxpayers some cash too. But, alas, VA did not ask for my opinion on the matter. [Although when I worked for VA I gave them all sorts of unsolicited opinions about how things should be done! ... I suspect the big wigs are glad I left. ;^] ~~~ Yes, definitely call the C&P Clinic (or contract company) to see if it's appropriate and safe to have the C&P exams! You might want to ask your OB/GYN about it too. ~~~ What did you want to know about the IU process? ~~~ I hope you and your baby are peachy keen throughout the birth process and afterwards, and that you and yours enjoy your new precious miracle. :O) All the Best, Mark

There appears to be a problem with your attachment. When I clicked on the link I got this error message: Sorry, there is a problem We could not locate the item you are trying to view. Error code: 2S328/1

Then even less likely that they will do anything related to you current 70% rating for PTSD, i.e., I would be shocked if they don't just keep it the same. Your claim is mainly about TDIU anyway, so, as you know, that will be the focus. Btw, I very much respect and honor you for your service to our nation. My kids get to grow up in a free country because of brave men like you. Mark

Thank you @Berta! Yes, the VA policy regarding Initial PTSD C&P exams is not well-justified. For example, why can non-VA psychologists or psychiatrists conduct an Initial Mental Disorder C&P exam, but not an Initial PTSD exam? I agree that an IMO/IME can definitely help with regard to claims for an increased disability rating, and Individual Unemployability, if applicable. And I wholeheartedly agree about everyone being over-focused on PTSD. Of course, it's completely understandable with all the VA's emphasis on the disorder, and our society's and media's extensive coverage of PTSD. That's mostly a good thing, btw, i.e., increasing awareness. But it has led some vets to (understandably) think they have PTSD, when they actually have another mental disorder, usually depression and/or anxiety disorders, or they have subsyndromal posttraumatic stress + depression and/or anxiety. When I had vets present to me for an Initial PTSD exam, and they did not have PTSD, but I thought they did have a service-related mental disorder, I would write up the report as such, and provide two 'medical opinions' with detailed rationales: 1) The veteran does not have PTSD. 2a) But the veteran does have [other mental disorder] which was incurred during his or her military service. 2b) But the veteran does have [other mental disorder] which is proximately due to, or the result of, his or her currently service-connected [medical condition]. When I wrote reports like that I was technically not following the rules because C&P examiners are not supposed to "provide opinions that VBA did not ask for" (there are some exceptions). The rationale for the rule is that the veteran should file a new claim for the other mental disorder, and by doing so his or her claim could be fully developed by VBA. That rationale does make sense in some cases, and there were times I did not give the second opinion for various reasons, but I would say something in the report about the possibility of a service-related mental disorder, and, of course, I would tell the vet to file the new claim! Otherwise, when I did provide two opinions with rationales, which is what I did most of the time, I never had one returned to me by VBA, and the vets always received service connection for the mental disorder. Fortunately the VBA Regional Office that adjudicated most of the cases I worked on (Winston-Salem, NC) was a good one with many Raters who would go the extra mile to make it work within the regs. I did get dinged a couple of times by VHA (as opposed to VBA) for "giving unsolicited opinions." I just ignored those little memos. All the Best, Mark P.S. I put 'medical opinion' in single quotes because, except for VA-related cases, I would not use the term 'medical' in that context since I am a psychologist, not a physician. But that is what the VA calls C&P examiner's opinions, whether the examiner is a physician, psychologist, audiologist, or nurse practitioner.

You could submit a Statement in Support of Claim (VA FORM  21-4138) and list the progress notes from your neurologist and primary care physician that document four or more prostrating migraine headaches per month. Give the date and title of the progress note and the doctor's name. Assuming you receive treatment at the VA that's all VBA needs to review those notes. ~~~ Keep in mind that there is always a (small) chance that when you request TDIU and/or a rating increase that you could end up with a disability rating decrease. VBA almost never does that right away--they usually say "we're keeping it the same be we'll have you come back for a routine future exam", or they notify you of a proposal to decrease (less common). For example, your PTSD C&P exam report rings all the bells for a 50% disability rating. ~~~ All the Best, Mark [Disclaimer: I am not a veterans service officer, claims agent, or attorney. I am simply sharing my impressions based on my experience as a C&P examiner. I recommend that you always consult with a veterans service officer, claims agent, or veterans law attorney about any VA disability compensation questions you might have.]

This is a reply to @Cliche Magnet's post - PTSD's long term effects. Did you win a decision? For some reason I was not able to reply the usual way (I could not type into the box). Incurrence and Continuity When did you discharge from military service, and when did you first seek mental health treatment? If you began to manifest symptoms of a psych disorder during service, and you sought treatment soon after discharge, and you have suffered from that same (or similar) disorder since that time, i.e., you have shown continuity of symptoms, then it is possible that VBA could find that the disorder was incurred during your military service and you are entitled to VA disability benefits. [See: 38 C.F.R. §3.303(a) and (b)]. This principle would apply whether or not your diagnosis is PTSD. In other words, if you manifested some posttraumatic stress symptoms, but not enough to satisfy the DSM-5 diagnostic criteria for the disorder, but all your psych symptoms considered collectively, for example, posttraumatic stress symptoms + depression sx + anxiety sx, do meet diagnostic criteria for another mental disorder, then that mental disorder could be service-connected, Service connection for a psych disorder under these incurrence and continuity principles poses some challenges, but I evaluated several veterans over the years who received disability compensation for such conditions. Usually the biggest challenge is that the veteran did not seek treatment until many years after discharge. In those cases, one of the fundamental questions the C&P examiner and the VBA adjudicator have to consider is, "If he had a mental disorder that caused functional disability for all those years, why didn't he seek help?" Of course, there are some very legitimate answers to that question, e.g., socialization causing men to avoid seeking help due to the narrow, rigid masculine role identity our society has historically imposed on boys and men; plus an ethos in the military to eschew mental health treatment because others will likely perceive it as a sign of weakness and incompetence. As an aside, I should mention that if a veteran suffers from psychoses during or shortly after military service, and he or she still has disabling symptoms from the same or similar psychotic disorder, then service connection is covered under a different regulation concerning chronic conditions. [See: C.F.R. 38 §3.307 and §3.309(a)]. PTSD If you have PTSD due to watching your friend burn to death, and your friend's tragic demise is documented, and your presence on the scene can also be demonstrated via documentation and/or lay testimony, then yes, the PTSD can be service connected. And in that case, a letter from your commander and others would be helpful. You could certainly seek an IME (I use the term, IPE, since I am a psychologist ;-), and that is something I do in my private practice, but frankly it costs $1000 or more and you can get a C&P exam for free. If the C&P exam ends up being inadequate and VBA denies service connection, then an IME/IPE would make more sense. Of course, that's just my opinion. You should also see what other knowledgeable people think. Dual Role Conflict In general, treating psychologists should not write 'nexus letters' or complete DBQs because doing so constitutes a dual role conflict. A C&P exam is a forensic mental health evaluation, where the 'client' is VBA, the 'referral questions' are directly related to legal issues, and the goal is to conduct an independent, objective, unbiased evaluation. In terms of the C&P psychologist, he or she is an expert witness, providing expert witness testimony in a federal legal proceeding. Psychotherapy is a treatment/helping relationship, where you are the client, the referral questions relate to helping you, and the objective is to help you achieve your recovery goals. In terms of the treating psychologist, he or she is providing a healthcare service. As you can see, the professional relationship between the psychologist and the veteran in these two scenarios are very different. In situations like the one you mentioned, i.e., asking a treating psychologist to write a nexus letter, it's helpful to know that such treating psychologists must be very careful about being in two very different roles at the same time with the same person. Usually it is not a good idea. (See: American Psychological Association's (APA) Ethical Principles of Psychologists and Code of Conduct, Ethical Standards 3.06 and 3.07. All the Best, Mark

Maybe the examiner realized afterwards that she did not do an adequate job, felt guilty, and is trying to make it up to you? Complete speculation on my part, but that's the first thing the came to my mind. I agree with @broncovet that it's best to wait and see what she wrote, and what VBA decides. Re: getting a copy of your exam report, I just did a bunch of research on how veterans can obtain copy of their military and VA records. The part about getting VA medical records is here: http://www.ptsdexams.com/veterans-military-records/#va-medical-records All the Best, Mark

I keep getting an error message when I try to change my forum signature: Too many links and Signature spans too many lines I tried several different combinations of line length, links or no links, etc., but nothing worked, not even a single plain text character. I cleared cache and temp files, but that didn't help either. Any ideas? Thanks! Mark