Mark D Worthen PsyD

This descriptor is at the 30% level, from the General Rating Formula for Mental Disorders (38 C.F.R. § 4.130): [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 However, these items, from Section II, Number 3 of the Mental Disorders DBQ, are at generally higher levels: 30% [X] Depressed mood [X] Anxiety [X] Suspiciousness [X] Chronic sleep impairment 50% [X] Disturbances of motivation and mood [X] Difficulty in establishing and maintaining effective work and social relationships 70% [X] Difficulty in adapting to stressful circumstances, including work or a worklike setting [X] Inability to establish and maintain effective relationships [X] Neglect of personal appearance and hygiene [X] Intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene You can find the signs, descriptions of functional impairment, and symptoms associated with each disability rating level in the General Rating Formula for Mental Disorders. I attached a Word doc, whcih contains the Rating Formula. Of course, the RVSR (VBA 'rater') determines your disability rating, but as I understand it, if they assign a rating lower than 70%, in your case, then they need to provide a rationale. It partly depends on your medical records, particularly mental health treatment records, but if they are not dramatically different, in terms of the symptoms and associated problems noted, then I would anticipate an increased disability rating for depression. I noticed that she (the C&P psychologist) did not say anything about IU (Individual Unemployability). If the VBA requested information about employability on VA FORM 2507 (the referral form VBA uses to request a C&P from a VA medical center or contractor), then VBA will probably send your exam report back as insufficient and instruct the examiner to answer their question(s) about employability. Her diagnosis for ICD-10 code F32.9 is wrong. She listed Depressive Disorder NOS (Not Otherwise Specified), which is a DSM-IV diagnosis. VA instructed C&P psychologists to use DSM-5 beginning on 1 December 2013. The ICD-10 code F32.9 is for Major Depressive Disorder, Single Episode, Unspecified. Although the C&P psychologist's report is not a good one, it looks like the end result will be positive for you. Thank you for your service and sacrifice for our country @dolfanbls. All the Best, Mark General Rating Formula for Mental Disorders.docx

I list the following resources on my website (PTSDexams.com). The first two links are articles (posts) I wrote, published on my site: Advice for Veterans – VA PTSD Compensation and Pension Exam – Advice for veterans who have filed a VA disability benefits claim for posttraumatic stress disorder (PTSD), and have been scheduled for a Compensation and Pension examination (C&P exam). Advice for Veterans – PTSD Military Sexual Trauma (MST) C&P Exams – Suggestions for MST survivors to file a successful claim for VA disability compensation benefits, although much of the information applies to veterans disability benefits claims in general. What to Expect at Your C&P Exam – Well-written article for veterans that explains what you can expect at your C&P exam and how to prepare. What to Expect at Your C&P Exam (Video) – A 5-minute video produced by the Department of Veterans Affairs that describes what veterans can expect at their C&P exam. Exam Tips from a Veterans Law Attorney – Check out lawyer Chris Attig’s 10 Tips to Help You Keep the C&P Exam in Perspective. He offers excellent advice from a legal perspective, which is entirely consistent with the suggestions I provide from a psychologist’s perspective.

Hi Rita, I recently wrote a blog post with detailed suggestions for filing a PTSD due to MST claim, including several links to additional online resources: Advice for Veterans – PTSD Military Sexual Trauma (MST) C&P Exams Feel free to ask any questions about the information in that post, either in a response (comment) to the post, or here on HadIt.com :O) The good news is that, as @GuaymasJim said, you can indeed receive disability benefits for PTSD/MST even the horrible crime against you occurred many years ago. All the Best, Mark

My understanding is that eating disorders are considered to be a separate disability from all other mental disorders. See this post: Extremely unlikely. I hope it goes well for you. :O) All the Best, Mark

VBA service connected you for TBI, but then said you do not have TBI?

In the VBA Decision Letter you received, they provide reasons for denying a claim. What reasons did they give you for denying your PTSD claim?

DIAGNOSIS Per DSM-5, the diagnostic manual published by the American Psychiatric Association, Borderline Personality Disorder (BPD) is: The key part for your situation is "beginning in early adulthood". By definition, symptoms that began after the multiple tragic losses you suffered cannot be BPD because you were well into adulthood by that time. Also, note this paragraph from the NAMI website: Did your psychotherapist (the social worker) talk with your previous doctors and therapists, or at least read their notes? Did you complete any medical or psychological testing/evaluations? Did she interview a friend or family member or two? BE ASSERTIVE - TAKE CARE OF YOURSELF Have you talked with your therapist about your concerns? That's usually the best first step. If she listens carefully and responds empathically, and rethinks the diagnosis, then it could turn out to be a good learning experience for her, and therapeutic for you. Or, maybe you have some BPD characteristics (I tend to doubt it, but it's best to consider the possibilities). If that is the case and she explains why she thinks you have some BPD characteristics, and how she can help you (and you can help yourself), then that too would probably be therapeutic. Keep in mind that BPD, or some BPD traits without having the full-blown disorder, does not make the individual a 'bad' person, or 'crazy', or anything along those lines. BPD usually results from significant emotional, sexual, and/or physical abuse during childhood or adolescence, and represents the child's best attempts to try to cope with an overwhelmingly painful, difficult, no-win environment. People can develop borderline-like symptoms in adulthood, although that is much less common (and they would not be diagnosed with BPD because of the diagnostic criteria I mentioned earlier). If your therapist does not seem to understand why this new diagnosis bothers you, and she does not respond with warmth and empathy, I would suggest asking for a second opinion from a psychologist or psychiatrist with a lot of experience helping people with PTSD due to sexual trauma. And ask for a new psychotherapist--you have that right. All the Best, Mark

Hmmm. That's a pretty glaring error for the examiner to make IMHO. I agree with @Gastone that you might not need to retain legal counsel, and that waiting to see what VBA says is probably your best course of action. And definitely find a new service officer! You need someone you can count on. The National Association of County Veterans Service Officers provides an easy-to-use Find a Service Officer Tool on their website.Also ask vets in your area if they have a good service officer that you might be able to see. I don't know. I've never filled out that DBQ. - Seriously though, I have no idea what the "internal VA only" part means--I've not seen anything like that before. Yes, they should. I would imagine the exam will be returned as "insufficient", with questions for the examiner. You know, something like, "WTF?! Were you on crack when you wrote this?!" All the Best @Prettypantha, ~ Mark

Btw, I consulted Mr. Google to make sure I was wording things correctly - I searched for "presumption of soundness" - and one of the first results was from a veterans law attorney's blog. Check out what this lawyer did for the vet he represented. I do not know this attorney or his firm, I just thought it was pretty cool that they tracked down a surgeon and nurse who treated the veteran almost 50 years ago. ~ Mark

I agree that there is no need for the veteran to bring up problems they had prior to military service. At the same time, the C&P psychologist might ask some questions about a veteran's "developmental history." As others have wisely advised, just answer such questions matter-of-factly. Don't be vague or evasive, but you don't have to go into a lot of detail. I know that some C&P examiners seem to go out of their way to pin a vet's current problems on an (allegedly) pre-existing mental disorder. I have seen such C&P exam reports. Occasionally, the examiner is accurate, but more often than not it's clear they went on a fishing expedition, which is infuriating to me, so I can only imagine how frustrating and demoralizing it must be for a veteran who receives such a bad exam. Fortunately, I have seen less of those types of biased exams in recent years. But, as TALON said, it can happen. If VBA denies a claim based on an allegedly pre-existing mental disorder, and the vet believes it's a mistake, then definitely ask for a reconsideration or appeal the decision. Also as TALON said, service members are presumed to be fit for duty, or one might say, "of sound mind and body", when they are accepted into service. This "presumption of soundness" means that if VA later says, "Wait, no, he really wasn't of sound mind and body", then VA must present "clear and unmistakable evidence" proving that the veteran's current mental disorder (or other medical disorder/injury) pre-existed service, and was not aggravated by service. That's a high burden to prove, although sometimes it takes a judge to ask the hard questions and to conclude that VA's 'evidence' is not clear and unmistakable. In the mental health realm I have seen VBA issuing fewer denials based on pre-existing mental disorders over time, although it certainly still happens. The most common problems I've seen are the usually ludicrous, but unfortunately ubiquitous, personality disorder diagnoses made by Army, Navy, or Air Force docs. My advice to interns and new C&P psychologists has been to be highly skeptical of such diagnoses, i.e., assume they are inaccurate unless the military psychologist or psychiatrist presented a compelling case for the diagnosis in MEB/PEB proceedings or otherwise. Such compelling evidence is very uncommon in my experience.

I agree 100% Andyman73. We are definitely on the same page.

I don't make a habit of disagreeing with Marines, as I value my life and limbs , but I would suggest caution about focusing only on your worst day ever. I understand where you're coming from Andyman73, as there are some biased, prejudiced, disrespectful C&P psychologists or psychiatrists who tend to discount or minimize a veteran's symptoms and associated functional impairment. IMHO those types should immediately get the boot, and it really pisses me off that they are even allowed near a DBQ. On the other hand, if you get a decent examiner, you don't want him or her to think you're exaggerating. Of course, if they ask you to "describe one of your worst days", definitely do so--tell it like it is. Otherwise, it is usually best to answer the examiner's questions as asked. This will usually mean describing both your history of depression, which will include the worst times, and your current symptoms. Keeping a daily symptom diary can really help with providing vivid descriptions of your symptoms and how they limit your life. I write about such a diary on my blog (URL in my signature, below), along with a lot of other advice for PTSD and mental disorder C&P exams. (There is no advertising on my blog, and I do not sell anything.) All the Best, Mark

I would check with your veterans service officer, but if VBA requested a Mental Disorders C&P exam, that means they will issue a disability determination regarding depression, so it does not seem like you would need to file a Mental Disorders claim. Again, check with your service officer as there may be details or intricacies in your case that would dictate a difference course of action. Your goal of establishing SC, even if it is only 0%, is smart. Hopefully you will not suffer from depressive illness in the future. But as the old saying goes, "An ounce of prevention is worth a pound of cure." All the Best, Mark

I'm not a gynecologist, but I agree that as written the examiner's Opinion and Rationale do not seem to make sense. I wonder if the examiner checked the wrong box on the DBQ? The Opinion part is basically a 'Yes or No' checkbox, i.e., the examiner does not actually type, "The condition claimed was less likely than not...". The examiner does type the rationale, which is what makes me wonder if she checked the wrong box for the Opinion. Did the examiner answer the question about female sexual arousal disorder? I did not see it, but I could have missed it. Looks like the VSR (VBA employee who prepares the 2507--the request for exam) did a good job highlighting the pages of your service medical records (SMRs, also known as service treatment records or STRs). I wonder if requesting a reconsideration--and pointing out the possibility of a simply clerical error, i.e., checking the wrong box on the DBQ--would be the best course of action. What does your veterans service officer think?

Symptoms. In general, the RVSR ('Rater') must justify, with a well-written rationale, why they assigned a lower disability rating than the rating reflected in the symptoms the examiner endorsed on the DBQ. In your case, the examiner endorsed four symptoms at the 30% level; two at 50%; and four at 70%. Therefore, if the RVSR assigns a 50% disability rating (unlikely), he or she would need to explain why, given that you have four symptoms representative of a 70% rating. There are exceptions to this general rule, which an experienced VBA staffer, veterans service officer, or veterans law attorney can explain better than I could, but in my experience those exceptions are rare. As you said, hopefully you will receive your Rating Decision soon and you can breathe a sigh of relief. All the Best, Mark

Thanks man! Much appreciated. Nice. Looks like a smart, well-written opinion with rationale. Good doc for your fellow veterans to know about for an IME (Independent Medical Examination). All the Best, Mark

No problem at all. Although I earned a Doctor of Psychology (PsyD) degree, when it comes right down to it, I see myself as just another guy. Like most folks, it's a man's (or woman's) character that means the most. Having said that, I do appreciate your courtesy and kind words. And I wish you the absolute best in your healing and in receiving the benefits you have earned! ~ Mark

It's not easy to find, but there is a BVA Customer Service page, which contains the following info: Note that the "Ask a Question" link takes you to a generic form on the VA's Inquiry Routing & Information System (IRIS). So it is really important to include your full name, file number, and specific request on the form. Also, here are the categories you want to select from the drop-down menu in the Topic, Sub-topic, and Inquiry Type section:

No, it would not be pyramiding. It would be a 'secondary' disorder, which is a “…disability which is proximately due to or the result of a service-connected disease or injury…” (38 C.F.R § 3.310). In terms of evidence, I would definitely talk with a Veterans Service Officer about it. There are a couple of options: You could file a claim for OSA (Obstructive Sleep Apnea) secondary to PTSD, and then go to the C&P exam and see what happens. --> If this is not successful, you could then try the next option and ask for a reconsideration. You could pay for an Independent Medical Examination (IME) and then file the claim. --> Downside here is that you might be successful with the first option, and you would not have needed to spend the money on an IME. You could ask your sleep medicine doctor and/or psychiatrist for a 'nexus letter'. --> Unless the doctor knows what's involved and how to write it (which takes a lot of time, btw), this is not likely to succeed. I know that many veterans have received SC for sleep apnea secondary to PTSD. However, there is not any scientific evidence at this time that shows a causal link (nexus) between PTSD and OSA. Vets usually get SC because the C&P examiner does not read the scientific literature and they simply give an opinion. The VBA must accept such opinions as valid unless there is some obvious error. If you do file a claim, be sure to request not only SC based on OSA being "proximately due to or the result of" PTSD, but also SC based on OSA being aggravated by PTSD. I wrote about this point in a blog post regarding secondary mental disorder claims, although the same principle applies to a PTSD-->OSA claim. There is not yet any definitive research regarding PTSD exacerbating OSA, but it seems to be a more plausible connection than direct causation. All the Best, Mark P.S. Central Sleep Apnea is a different animal--I am referring only to OSA. I would never give an opinion regarding PTSD-->CSA secondary claim because there is so little known about the possible relationship, but some physicians, e.g., neurologists, psychiatrists, and others, are more comfortable with such claims because they have more knowledge about possible physiological processes that could theoretically lead a person with PTSD to develop CSA (or PTSD aggravating CSA). Thus, the couple of times I was scheduled for a C&P exam regarding a PTSD-->CSA claim, I would have the exam transferred to an MD. P.P.S. I highly recommend working with a Veterans Service Officer for a PTSD-->OSA claim.

C&P exam reports, or 'nexus letters' are more probative, i.e., carry more weight, if the report or letter... cites relevant medical research literature provides a cogent rationale, i.e., clearly explains why the condition was or was not incurred during military service makes it clear that the examiner reviewed all the ‘evidence of record’ (“all procurable and assembled data”) — military records, treatment records, statements by the veteran or others, etc. conforms to expectations the Court of Appeals for Veterans Claims (CAVC) set for an examiner’s expert witness testimony (the exam report), as enunciated by the Nieves decision:1 (1) The testimony is based upon sufficient facts or data; (2) the testimony is the product of reliable principles and methods; and (3) the expert witness has applied the principles and methods reliably to the facts of the case. All the Best, Mark P.S. Note that the federal courts, including the CAVC, use traditional legal terminology, whereas the VA has created its own terminology. Here is a ‘translation guide’: Testimony = C&P examiner’s report. Expert Witness = C&P examiner. Expert Witness Opinion = Conclusions or opinions reached by the examiner that help to answer a legal question, e.g., diagnoses and the etiology of those diagnoses. Footnote 1. Nieves-Rodriguez v. Peake, 22 Vet.App. 295 (2009)

I agree with you, although it's always good to run questions like this by your Veterans Service Officer since he or she is most familiar with all the details of your situation. Mark Note: Nothing I write here should be construed as representing the views or policies of the U.S. Department of Veterans Affairs or the federal government. I contribute here as a private citizen who cares about the men and women who risk their lives to protect the rest of us.

That probably means the psychiatrist checked off a box in his report (using the DBQ form) saying he thought you were not competent to manage your financial affairs. If VBA concludes that you are not competent to manage your financial affairs, they will assign a fiduciary who will receive your compensation funds and dole it out for you. Also, your right to own a firearm will be revoked. See the one-page Word doc I attached to this post for more info. If you believe you are capable of managing your own finances, I suggest that you: 1) Talk with your Veterans Service Officer about the issue; 2) Ask your treating psychologist or physician (or both) to write a brief letter stating they have not seen any evidence that you cannot manage your own finances - they may or may not be able to write such a letter - don't be offended if they say they can't; and 3) Also ask a family member and/or friend--someone who knows you well--to write a letter indicating that they have seen you manage your finances well, with an example or two of your ability. Mail or fax the letters to one of VBA's two centralized mail processing centers for disability compensation claims--which one depends on where you live--click here to see the chart on the VA website. If you fax your request, wait to receive a confirmation fax from them. The confirmation will be faxed to you immediately after they receive your fax. If you mail your request, do so in a way that gives you proof that it was received, e.g., U.S. Postal Service Signature Confirmation, or a similar service via FedEx or UPS. All the Best, Mark Veteran Financial Incompetency and the Brady Act _Info-for-Veterans.docx Note: Nothing I write here should be construed as representing the views or policies of the U.S. Department of Veterans Affairs or the federal government. I contribute here as a private citizen who cares about the men and women who risk their lives to protect the rest of us.

It should not be a problem because of the presumption of soundness doctrine. Thus, the burden of proof is on VA to prove, with clear and unmistakable evidence, that you suffered from PTSD prior to your military service, and that military service did not aggravate the pre-existing PTSD. If your entrance physical does not say anything about mental health problems, and if you were never diagnosed with PTSD prior to service, it is not easy for VA to provide "clear and unmistakable" evidence that can refute the presumption of soundness. Even if the C&P psychiatrist (I'm assuming this was a C&P exam) says you had PTSD before service, unless he wrote a detailed and compelling rationale for that opinion, VBA may very well not accept his opinion as "clear and unmistakable" evidence. If they do, I would definitely appeal. Unless your stepfather's spankings were particularly harsh and abusive, or accompanied by threats, intimidation, and verbal terrorizing, it would be unusual for such an experience to cause PTSD. Keep us posted. ~ Mark Note: Nothing I write here should be construed as representing the views or policies of the U.S. Department of Veterans Affairs or the federal government. I contribute here as a private citizen who cares about the men and women who risk their lives to protect the rest of us.

VBA is required to request your SSD records, but it wouldn't hurt to submit the letter. A C&P exam, if you did not file for an increase, is probably a "routine future exam" - the regulations require VBA to do those about 5 years after an initial exam. AS pete992 said, your POA could have filed a claim on your behalf although they shouldn't do that without asking you. If that is the reason, you can withdraw the claim. All the Best, Mark Note: Nothing I write here should be construed as representing the views or policies of the U.S. Department of Veterans Affairs or the federal government. I contribute here as a private citizen who cares about the men and women who risk their lives to protect the rest of us.

Most veterans rated 100% for PTSD are not able to work, but you are not prohibited from working. If you received Total Disability due to Individual Unemployability (TDIU), by definition you are not able to work. In other words, you receive IU benefits based on your inability to work. This article (also a podcast), on TheMilitaryWallet.com, provides a good explanation of "VA math", including a table you can consult to figure out your total disability rating: Podcast 004: Funny Math – VA Disability Ratings. When 30 + 20 Doesn’t Always Equal 50. You can also use online disability calculators to compute your total disability rating. I think the easiest one to us is Calculating Combined Disability, provided by the Vietnam Veterans of America - Arizona Council. But there is also the VA Disability Rating Calculator, by MicroHealth, and HadIt.com's Service Connected Disabilities Calculator. NOLO has a good article on their site, How the VA Rates a Service-Connected Mental Disability. You can also consult the official General Rating Formula for Mental Disorders (38 C.F.R.§ 4.130) in the Code of Federal Regulations. Regarding filing a claim for an increase and the C&P exam that VBA will probably require as part of that process, here are some resources: Advice for Veterans – VA PTSD Compensation and Pension Exam – Advice for veterans who have filed a VA disability benefits claim for posttraumatic stress disorder (PTSD), and have been scheduled for a Compensation and Pension examination (C&P exam). [Open disclosure: That one is on my blog.] Veterans Benefits for PTSD – Wikipedia article with details on VA benefits for veterans suffering from PTSD. Comprehensive but succinct. What to Expect at Your C&P Exam – Well-written article for veterans that explains what you can expect at your C&P exam and how to prepare on Swords to Plowshares. What to Expect at Your C&P Exam (Video) – A 5-minute video produced by the Department of Veterans Affairs that describes what veterans can expect at their C&P exam. Of course, the most important thing is that you receive all the help and support that you need. Are you receiving treatment for PTSD? Contact the Veterans Crisis Line for immediate help: Call 1-800-273-8255 and Press 1, or chat, or text with a professional counselor. It does sound like you are having significant difficulties related to PTSD, based on what you wrote, so filing for an increase makes sense. I wish you all the best, Mark Note: Nothing I write here should be construed as representing the views or policies of the U.S. Department of Veterans Affairs or the federal government. I contribute here as a private citizen who cares about the men and women who risk their lives to protect the rest of us.