tylerb333

PTSD) Disability Benefits Questionnaire Name of patient/Veteran: Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination Request? [X] Yes [ ] No SECTION I: ---------- 1. Diagnostic Summary --------------------- Does the Veteran now have or has he/she ever been diagnosed with PTSD? [X] Yes [ ] No ICD Code: F43.10 2. Current Diagnoses -------------------- a. Mental Disorder Diagnosis #1: Antisocial personality disorder ICD Code: F60.2 Mental Disorder Diagnosis #2: Opioid use disorder ICD Code: F11.20 Mental Disorder Diagnosis #3: PTSD ICD Code: F43.10 b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): Deferred to medical 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: Antisocial personality disorder is responsible for contentious interpersonal relationships including threats, aggression, assault; failure to accept responsibility; violation of social norms and law; impulsive decisions and behaviors; and affective instability. In the symptom list below antisocial personality disorder is responsible for impaired judgment, disturbance of motivation and mood, difficulty establishing and maintaining effective social/work relationships, difficulty adapting to stressful circumstances, and impaired impulse control. Opioid use disorder has been in institutional remission June 2018, and is not at this time contributing to the symptom picture. Substance use is well known to have deleterious effects on mood, cognition, and behavior. When active, however, these symptoms likely take a predominant role. PTSD is responsible for the remaining symptoms below, which include depressed mood, chronic sleep impairment, and flat affect. 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 occupational and social impairment, is it possible to differentiate which impairment is caused by each mental disorder? [X] Yes [ ] No [ ] Not Applicable (N/A) If yes, list which occupational and social impairment is attributable to each diagnosis: As noted above regarding symptoms, Antisocial personality disorder is primary and PTSD is secondary. c. If a diagnosis of TBI exists, is it possible to differentiate which occupational and social impairment indicated above is caused by the TBI? [ ] Yes [ ] No [X] Not Applicable (N/A) SECTION II: ----------- Clinical Findings: ------------------ 1. Evidence Review ------------------ Evidence reviewed (check all that apply): [X] VA e-folder [X] CPRS 2. Recent History (since prior exam) ------------------------------------ a. Relevant social/marital/family history: The veteran last completed a PTSD review DBQ 06/20/17, and he reported that since that exam he has moved from Columbus to Marysville. The veteran currently is in residential programming at Chillicothe VA, hoping for placement in the DOM. The veteran denied his family situation since last exam. Socially, the veteran said he is getting along well with other residents here. His girlfriend and mother visited him here. He said he is made some acquaintances in the programming as well as a couple friends. b. Relevant occupational and educational history: The veteran denied changes in education since last exam. He has completed a GED and some college, and has a license to work with fuel and chemicals for shipping. The veteran denied employment since May 2017. He worked in landscaping prior and occasionally for his mother after that. His mother's business is sales of retail and bank machines. He said his mother arranged his hours to suit him. c. Relevant mental health history, to include prescribed medications and family mental health: The veteran denied pre-military and military mental health treatment. Specifically, he denied a history of hospitalization, suicide attempt, outpatient therapy, and prescription of psychotropic medications prior to about 2001. CPRS and VBMS were reviewed with the following relevant mental health entries. 06/20/17: PTSD review DBQ. MSE: Mood and affect depressed, otherwise normal. Examiner opined significant impairment. 06/14/18: Medical certificate. The veteran requested admission due to depression, suicidal ideation, overdose attempt on Seroquel and alcohol last evening, and hearing voices telling him to kill himself every day. UDS was positive for oxycodone, Suboxone, and cannabinoids. DX: Cocaine dependence; alcohol abuse; cannabis dependence; opioid dependence; PTSD. 06/19/18: Medical certificate. Veteran seen for change in programming. MSE: Normal except for dysphoric affect. d. Relevant legal and behavioral histor y: The veteran denied arrest since last exam, however, he has 3 years and 3 months left on parole. As a juvenile, the veteran was arrested for trespassing, DUI, domestic dispute. He denied being remanded to juvenile detention. During military, the veteran was arrested for underage consumption. He also received NJPs for being late to work (up to 10 hours), possession of pornography, disrespect to a commanding officer, and drinking while on duty. After service, the veteran has been arrested for domestic violence 2, aggravated robbery 3, and theft. He served 10 years in ODRC. While in prison, the veteran reported that he ran the inmate "store" providing drugs, contraband items, and running gambling schemes. He received over 50 tickets for institutional rules violations while in prison. He was released in September 2016. e. Relevant substance abuse history: The veteran reported that historically he has rarely used alcohol, perhaps 1-2 times per month and none since June 2018. The veteran denied use of illicit drugs since June 2018. In the period immediately prior he primarily used narcotics and heroin. f. Other, if any: Nothing further. 3. PTSD Diagnostic Criteria --------------------------- Please check criteria used for establishing the current PTSD diagnosis. The diagnostic criteria for PTSD, are from the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5). The stressful event can be due to combat, personal trauma, other life threatening situations (non- combat related stressors). Do NOT mark symptoms below that are clearly not attributable to the Criterion A stressor/PTSD. Instead, overlapping symptoms clearly attributable to other things should be noted under #6 - "Other symptoms". Criterion A: Exposure to actual or threatened a) death, b) serious injury, c) sexual violence, in one or more of the following ways: [X] Directly experiencing the traumatic event(s) Criterion B: Presence of (one or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred: [X] Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). [X] Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s). 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). Criterion D: Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: [X] Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., "I am bad,: "No one can be trusted,: "The world is completely dangerous,: "My whole nervous system is permanently ruined"). [X] Markedly diminished interest or participation in significant activities. Criterion E: Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: [X] Hypervigilance. [X] Exaggerated startle response. [X] Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep). Criterion F: [X] The duration of the symptoms described above in Criteria B, C, and D are more than 1 month. Criterion G: [X] The PTSD symptoms described above cause 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. 4. Symptoms ----------- For VA rating purposes, check all symptoms that actively apply to the Veteran's diagnoses: [X] Depressed mood [X] Chronic sleep impairment [X] Flattened affect [X] Impaired judgment [X] Disturbances of motivation and mood [X] Difficulty in establishing and maintaining effective work and social relationships [X] Difficulty in adapting to stressful circumstances, including work or a worklike setting [X] Impaired impulse control, such as unprovoked irritability with periods of violence 5. Behavioral observations -------------------------- The veteran presented as guarded. We were able to establish adequate rapport through time. He initiated conversation and elaborated on topics, often to highlight the frequency and severity of symptoms. He was easily re-directed, however. He was cooperative in that he answered all questions asked. The veteran's mood was neutral and stable. His affect was mildly flat and mildly irritable, with limited mobility in range and intensity. The veteran seldom smiled and laughed, and seldom responded to humor. He was not tearful. There was no hopelessness and helplessness evident in his comments. There was no objective evidence of facial flushing, vigilance, arousal, tremor, perspiration, or muscle tension. Speech, thought processes, orientation, attention, and memory all were within expectations. Psychomotor was remarkable for bouncing a leg. Given vocabulary, and educational, employment, and military history, I estimate his IQ in the average range. The veteran denied recent changes in sleep, noting he experiences nightmares about 70% of the time. He appeared alert and rested and did not report functional loss due to sleep problems. He said his appetite is unchanged with some weight increase with abstinence from drugs. Thought content was negative for objective signs of psychosis and the veteran denied same. He also denied suicidal and homicidal ideation, but added "They call it passive SI. I'm getting better at telling people about it." Given several opportunities, the veteran reported current symptoms of: Nightmares; not liking to think about the military event; staying away from crowds; inability to interact with people; increased stress with work; blaming himself for the event happening; being aware of his surroundings; isolating from others; not sleeping well; drug use. The veteran reported abilities indicating that he retains considerable cognitive capacity (physical capacity is not assessed here). When home, he enjoys gardening, growing roses, and mowing his sisters grass. He told that he can drive independently. The veteran said he can perform personal care independently. The veteran told that he can use a calendar, clock, calculator, telephone, and computer. He reported that he can manage money, appointments, and medications, as well as shop and pay bills. For enjoyment he watches TV on his laptop, works out, watches OSU football, and does some light reading. He had good social skills on exam. Socially, the veteran said he is getting along well with other residents here. His girlfriend and mother visited him here. He said he is made some acquaintances in the programming as well as a couple friends. 6. Other symptoms ----------------- Does the Veteran have any other symptoms attributable to PTSD (and other mental disorders) that are not listed above? [ ] Yes [X] No 7. Competency ------------- Is the Veteran capable of managing his or her financial affairs? [X] Yes [ ] No 8. Remarks, (including any testing results) if any: --------------------------------------------------- ****This forensic report is a legal document intended for the sole use of VBA in determining the veteran's eligibility for compensation and pension. This examination is very different from other psychological examinations, such as for treatment, with considerably different criteria and, thus, often with considerably different diagnoses and outcomes. As such, great caution is needed in interpreting this information and use of this report outside its intended purpose by VHA personnel, VSO, and/or the veteran is STRONGLY discouraged. This examination does not constitute a rating decision. Rating decisions are made solely by the Regional Office after all available data have been reviewed and verified. Note that "The examiner should not express an opinion regarding the merits of any claim or the percentage evaluation that should be assigned for a disability. Determination of service connection and disability ratings for VA benefits is exclusively a function of VBA" (VHA Directive 1046). Thus, any questions or concerns regarding rating decisions should be directed to the Regional Office or an Appeals Board.**** The veteran was seen today for this PTSD Review exam. I verbally provided the usual informed consent regarding: this being a VBA assessment, not treatment; the report becomes a legal document; the forensic role of VBA; the potential outcomes of a review exam; and limits to confidentiality. A written copy of Informed Consent was offered. Throughout the interview the veteran inserted nearly every symptom of PTSD listed in the DSM 5. He noted often that these symptoms are severe and prevent him from interacting with people and working with others. This was not particularly consistent with mental status and functional data. Some patterns of thought developed throughout the interview, such as when the veteran noted that when people try to enforce rules or consequences for his behavior he makes threats and blames them for causing him to use substances. He noted that all his criminal behavior and drug use is due to the military assault, even though he also reported that alcohol and drug use began at an early age, as did arrest. For example, the veteran said that the traumatic event in service caused and or heightened his drug use in response, but he also commented that "I figured out when I was younger that using drugs and alcohol makes problems like that go away." The veteran noted that he was found to have steroids in his jacket while at Bay Pines. He subsequently was discharged from the program. He then interpreted that as "people make me fail. That (being discharged from Bay Pines) put me in a bad place and made me attempt suicide. They deny my individual unemployability because they say I'll get better with treatment, then the treatment kicks me out and I'm worse now." This behavior and thinking is quite consistent with personality disorder. The veteran was diagnosed with PTSD in prior C&P exams, the diagnosis has been carried forward by treatment providers, and by his report continues with sufficient symptoms for the diagnosis. Thus the diagnosis of PTSD continues, as likely as not due to events in military service. Antisocial personality disorder was present well before military service, so it is less likely as not caused by military events, and there is no evidence that this disorder was exaggerated by military events. Also, alcohol and illicit drug use clearly was present prior to enrollment in military, so it is less likely as not caused by military service. There is no evidence that the veteran's substance use was due to events in military service nor has it progressed beyond the normal course for this disorder. Put another way, even if the military event had not occurred it is likely that the resulting pattern of substance use would have been present. Moreover, while there is some equivalence in the literature about the direction of causality when both mental disorder and substance use are present, DSM 5 does not acknowledge any substance use disorder as "due to mental illness," yet there are numerous "substance-induced" mental disorders. INDIVIDUAL UNEMPLOYABILITY The veteran retains considerable residual mental function (physical limitations, if any, are not assessed nor considered here). The veteran can perform personal care independently. He has a driver's license and drives independently. The veteran can use a calendar, clock, calculator, telephone, and computer. He can manage money, appointments, and medications, as well as pay bills. There is no mental disorder that prevents him from attending to, learning, and persisting to complete simple and complex tasks. There is no cognitive dysfunction that would prevent same. His performance on mental status in attention, concentration, memory, abstraction, and thought processes were within expectations for age. The veteran reported limited socialization. Yet, he dated, married, and maintains a current relationship (after divorcing). He maintains some contact with family. Moreover, the veteran was a quite bright, capable, pleasant, cooperative gentleman on exam, and his social skills here were excellent. He reported isolating at home, not liking to be around people, and having difficult relationships through time. The veteran is not a member of any clubs/organizations. Indeed, personality disorder is predictive of contentious interpersonal relationships and the affective instability and impulsive decisionmaking/behavior of the personality disorder may interfere with motivation and concentration.

Can I site law in a letter submitted as evidence? The veteran was diagnosed with PTSD in prior C&P exams, the diagnosis has been carried forward by treatment providers, and by his report continues with sufficient symptoms for the diagnosis. Thus the diagnosis of PTSD continues, as likely as not due to events in military service. Antisocial personality disorder was present well before military service, so it is less likely as not caused by military events, and there is no evidence that this disorder was exaggerated by military events. Also, alcohol and illicit drug use clearly was present prior to enrollment in military, so it is less likely as not caused by military service. There is no evidence that the veteran's substance use was due to events in military service nor has it progressed beyond the normal course for this disorder. Put another way, even if the military event had not occurred it is likely that the resulting pattern of substance use would have been present. Moreover, while there is some equivalence in the literature about the direction of causality when both mental disorder and substance use are present, DSM 5 does not acknowledge any substance use disorder as "due to mental illness," yet there are numerous "substance-induced" mental disorders. LAW: pay attention to examples not to use....and c an p doc uses likely, less likely as not....

Yes I'm 70 percent with secondary substance use disorder. I have a total rating of 80 percent. The soc said I was able to follow direction, etc. And I would likely get better with treatment.

this was the clarfacation the BVA asked for, and the subsequent opinion: The veteran's use of opiates, cannabis, and alcohol began prior to service, thus current/recent use/abuse is not caused by an in-service related event. Given the veteran's consistent diagnosis and treatment of PTSD, and the frequency of relapse of substance use, it is as least as likely as not that his substance use (to include opioid use disorder) is aggravated beyond its natural progression by his PTSD symptoms. (this is in my favor) Per 3/15/2017 initial PTSD exam the veteran was diagnosed with PTSD, alcohol use disorder, cannabis use disorder, and opioid use disorder, all of which were in early remission. The 3/15/2017 medical opinion, the examiner opined that the veteran's opioid use disorder, and substance use in general, was made worse by his MST. The 6/20/2017 review PTSD examination indicates that symptoms present at that time were due to PTSD and not substance use as he had been abstinent from drug use with the exception of his opioid maintenance therapy. The veteran is service connected for the combination of PTSD and substance use disorders however per 11/20/2017 medical opinion regarding unemployability, the examiner noted that the veteran was service-connected only for PTSD and not substance use which is incorrect. Per rating decisions 3/27/2017 and 10/11/2017, the veteran was service connected for "PTSD with secondary alcohol use disorder, cannabis use disorder, and opioid use disorder." They are separate disorders, and not all symptoms are present all of the time. The examiner commented specifically on the veteran's PTSD symptoms and separated the veteran's substance abuse disorder symptoms. The veteran's substance use predated his military service;(sic) thus it was not caused by his reported assault. It was, however, likely aggravated by the residuals of his assault as described in treatment notes which indicate that with worsening PTSD symptoms, the veteran has reported relapsing on substances, particularly heroin. (again, in my favor)

except, I was denied. You think I'd win in ramp? Ive got additional evidence...I've been hospitalized three times,. Once, in a lockdown ward/

Denial...really? The veteran's use of opiates, cannabis, and alcohol began prior to service, thus current/recent use/abuse is not caused by an in-service related event. Given the veteran's consistent diagnosis and treatment of PTSD, and the frequency of relapse of substance use, it is as least as likely as not that his substance use (to include opioid use disorder) is aggravated beyond its natural progression by his PTSD symptoms. Per 3/15/2017 initial PTSD exam the veteran was diagnosed with PTSD, alcohol use disorder, cannabis use disorder, and opioid use disorder, all of which were in early remission. The 3/15/2017 medical opinion, the examiner opined that the veteran's opioid use disorder, and substance use in general, was made worse by his MST. The 6/20/2017 review PTSD examination indicates that symptoms present at that time were due to PTSD and not substance use as he had been abstinent from drug use with the exception of his opioid maintenance therapy. The veteran is service connected for the combination of PTSD and substance use disorders however per 11/20/2017 medical opinion regarding unemployability, the examiner noted that the veteran was service-connected only for PTSD and not substance use which is incorrect. Per rating decisions 3/27/2017 and 10/11/2017, the veteran was service connected for "PTSD with secondary alcohol use disorder, cannabis use disorder, and opioid use disorder." They are separate disorders, and not all symptoms are present all of the time. The examiner commented specifically on the veteran's PTSD symptoms and separated the veteran's substance abuse disorder symptoms. The veteran's substance use predated his military service, thus it was not caused by his reported assault. It was, however, likely aggravated by the residuals of his assault as described in treatment notes which indicate that with worsening PTSD symptoms, the veteran has reported relapsing on substances, particularly heroin.

is this in my favor? The veteran's use of opiates, cannabis, and alcohol began prior to service, thus current/recent use/abuse is not caused by an in-service related event. Given the veteran's consistent diagnosis and treatment of PTSD, and the frequency of relapse of substance use, it is as least as likely as not that his substance use (to include opioid use disorder) is aggravated beyond its natural progression by his PTSD symptoms.

If a c and p examiner checked the box stating it was an in-person exam, and it was not. Is this good enough for appeal for remand or reversal?

The last C and P examiner said this: The veteran's use of opiates, cannabis, and alcohol began prior to service, thus current/recent use/abuse is not caused by an in-service related event. Given the veteran's consistent diagnosis and treatment of PTSD, and the frequency of relapse of substance use, it is as least as likely as not that his substance use (to include opioid use disorder) is aggravated beyond its natural progression by his PTSD symptoms. The examiner was mistaken when they said I had used opiates prior to service. That is factually untrue. I had tried marijuana and alcohol, what teenager hasn't. Additionally, I had gotten waivers prior to enlisting for marijuana. Also, the examiner checked the box stating it was an in-person exam. It was not.

Note Title: SUICIDE BEHAVIOR REPORT Location: Chillicothe OH VAMC Signed By: HINES,JEENEE M Co-signed By: HINES,JEENEE M Date/Time Signed: 18 Jun 2018 @ 1007 ------------------------------------------------------------------------- LOCAL TITLE: SUICIDE BEHAVIOR REPORT STANDARD TITLE: SUICIDE RISK ASSESSMENT NOTE DATE OF NOTE: JUN 18, 2018@10:03 ENTRY DATE: JUN 18, 2018@10:04:06 AUTHOR: HINES,JEENEE M EXP COSIGNER: URGENCY: STATUS: COMPLETED DOB: JUL 22,1980 (37) -- Date/Time of event: Jun 13,2018@22:00 (Time is approximate) Location of event: Off station Patient status at time of event: Outpatient Outcome of event: remained outpt, hospitalized: indicate where in the box below voluntarily came to UC day after -- Source of information: Written, Patient self-report Name & Phone # of source: veteran -- Patient's stated: Level of INTENT of this event was: High Staff assessment: Level of INTENT of this event was: High Staff assessment: Level of LETHALITY of this event was: Low Last Pain Score Before Event: 6 Did the patient have access to firearms? Unknown Description of event: struggling with depression and positive for suicidal ideation, made an attempt at overdose on quetiapine and alcohol Past 10 Clinic Visits: 06/17/2018 12:40 CHI MH INPT PSY 21-45MIN UNSCHEDULED 06/16/2018 14:31 CHI MH INPT PSY 21-45MIN UNSCHEDULED 06/15/2018 13:00 CHI RECREATION GROUP 2 UNSCHEDULED 06/15/2018 12:46 CHI PHARM INPT MH UNSCHEDULED 06/15/2018 09:03 CHI MH INPT PSY 21-45MIN UNSCHEDULED 06/15/2018 09:00 CHI TCM CARE MANAGEMENT R UNSCHEDULED 06/14/2018 12:37 CHI MH URGENT CARE 8-4 1 01/03/2018 15:30 CHI TELE MHRRTP UNSCHEDULED 12/20/2017 15:55 CHI PRRTP NP UNSCHEDULED 12/20/2017 13:30 CHI PM&RS PHYSICIAN INPAT CANCELLED BY CLINIC -- Patient is currently receiving treatment in the following areas: Ambulatory Care Primary Care Provider: COPC Case Manager/Therapist: COPC Name of Provider prescribing psychiatric medications:COPC Active problems - Computerized Problem List is the source for the following: 1. Cocaine dependence (SNOMED CT 31956009) 2. AA - Alcohol abuse (SNOMED CT 15167005) 3. Cannabis dependence (SNOMED CT 85005007) 4. Low back pain (SNOMED CT 279039007) 5. Chronic post-traumatic stress disorder 6. Opioid dependence -- BRIEF PLAN/DISPOSITION: Developed crisis management plan, Medication management, Refer for Mental Health treatment, Assure followup appointment is made /es/ JEENEE M HINES, LISW-S CLINICAL SOCIAL WORKER Signed: 06/18/2018 10:07 From the service...even then I had work, social, and legal problems.

Here is a fascinating one as well. I always heard this was the golden ticket...

The aforementioned C and P examiner was a nightmare! There are horror stories about this woman. She acted like the benefits were coming out of her pocket. My initial C and P examiner's opinion was closer to the truth.