Here is my recent C&P results for anxiety secondary to SC IBS and Fibromyalgia. Thoughts or opinions on SC rating?
LOCAL TITLE: PSYCH C&P EXAM MA
STANDARD TITLE: C & P EXAMINATION NOTE
(other than PTSD and Eating Disorders)
Disability Benefits Questionnaire
Name of patient/Veteran: Is this DBQ being completed in conjunction with a VA 21-2507,
[X] Yes [ ] No
a. Does the Veteran now have or has he/she ever been diagnosed
with a mental
[X] Yes [ ] No
If the Veteran currently has one or more mental disorders
that conform to
DSM-5 criteria, provide all diagnoses:
Mental Disorder Diagnosis #1: Anxiety Disorder due to another
condition (IBS, fibromyalgia)
b. Medical diagnoses relevant to the understanding or management
Mental Health Disorder (to include TBI):
No response provided.
2. Differentiation of symptoms
a. Does the Veteran have more than one mental disorder
[ ] Yes [X] No
c. Does the Veteran have a diagnosed traumatic brain injury
[ ] Yes [ ] No [X] Not shown in records reviewed
3. 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?
one)[X] Occupational and social impairment with reduced
reliability and productivity
b. For the indicated level of occupational and social
impairment, is it
possible to differentiate what portion of the occupational
impairment indicated above is caused by each mental disorder?
[ ] Yes [ ] No [X] No other mental disorder has been
c. If a diagnosis of TBI exists, is it possible to differentiate
what portion of the occupational and social impairment indicated above is
caused by the TBI?
No response provided.
1. Evidence Review
Evidence reviewed (check all that apply):
[X] VA e-folder (VBMS or Virtual VA)
a. Relevant Social/Marital/Family history (pre-military,
PRE-MILITARY SOCIAL/MARITAL/FAMILY HISTORY:
Please see previous C&P exams
POST - MILITARY SOCIAL/MARITAL/FAMILY HISTORY:
E. Social Functioning:
The veteran is currently married to second wife since 1999
Current relationship description: "my wife is a great
support. We get along okay, I pretend to give a shit about a lot of things.
I don't have emotional connections with others. My wife can leave
tomorrow and take the kids and I won't give a shit. I mean I love them but I
don't I don't have the emotional connection. We have not slept in same
bed in 7/8 years because she says I shake so my in bed. I sweat a lot
Children: 7 children (23 through 1.5). 5 still live
in the home.
Oldest daughter thinks her father is distant from her. He
Believes relationship with others children is good. He is supportive
Older son is autistic and lives in a home.
He has one grandson (1 year old)
Friends and Hobbies: no friends. talks to two military
Structure of day: work structures his day. When he is not
working "I tries to stay busy but winter time is boring and gives me
more time to think"
b. Relevant Occupational and Educational history (pre-military,
PRE-MILITARY OCCUPATIONAL and EDUCATIONAL HISTORY:
See previous C&P
POST-MILITARY OCCUPATIONAL and EDUCATIONAL HISTORY:
Occupation: refinery- maintenance coordinator; 11 years
Has the veteran lost time from work due to mental health
issues? He missed about 5 or 6 days a year due to anxiety. However,
when at work he is missing time from work because of anxiety- for the
days he must put on SCBA (similar to the MACH 4) this is highly anxiety
provoking. He noted about 20 hours a week he is anxious, about 10 of
those hours he is not as efficient, reliability due to the anxiety.
Difficulties at work? Anxiety. Dangerous work, needing to
don SCBA (similar to MACH 4) Causes difficulties? See above
Are these difficulties mild/moderate/severe: ranges mild to
Severe Efficiency/reliability/productivity at work: usually good
except for those 10 hours a week
Quality of interactions with supervisor/coworkers: poorly.
2016 almost lost job because a woman at work stated she was
So intimidated by him she could not bring herself to come to
work. "I have to be very careful the way I act, what I say. I
walk on eggshells. I am very blunt, very honest and other people
don't like it. I don't relate to them. I think differently than them"
Does your problems only occur during times of significant
c. Relevant Mental Health history, to include prescribed
medications and family mental health (pre-military, military, and post-
PRE-MILITARY MENTAL HEALTH HISTORY:
See prior C&P
Active Outpatient Medications (including Supplies):
Active Outpatient Medications
1) ARIPIPRAZOLE 20MG TAB TAKE ONE-HALF TABLET BY MOUTH
ONCE A DAY
2) HCTZ 12.5/LISINOPRIL 20MG TAB TAKE 1 TABLET BY MOUTH
EVERY MORNING FOR HEART OR BLOOD PRESSURE
3) PRAVASTATIN NA 20MG TAB TAKE ONE-HALF TABLET BY MOUTH
EVERY EVENING TO LOWER CHOLESTEROL (REPORT ANY
MUSCLE PAIN OR WEAKNESS)
4) SERTRALINE HCL 100MG TAB TAKE ONE AND ONE-HALF
TABLETS BY MOUTH EVERY MORNING FOR MOOD
3) Testicular hypofunction
6) Sleep disorder
8) History of noncompliance with medication regimen
9) Posttraumatic stress disorder
10) Erectile dysfunction
11) Irritable bowel syndrome
POST-MILITARY MENTAL HEALTH HISTORY: History of
His history of psychiatric care has included:
PSYCHOTROPIC MEDICATIONS: sertraline
a. Side effects of medication: none noted
PSYCHIATRIC INPATIENT TREATMENTS: none
PSYCHIATRIC OUTPATIENT CARE:
symptoms and medication monitoring: Ronda Bray, nurse
practitioner since 1.6.2017
Suicidal Thoughts, intentions, plans or intent
Presence of SI: rarely (once every three or four months)
SUICIDE RISK ASSESSMENT COMPLETED
Veteran aware of 1-800 number yes
Card handed to veteran no
Homicidal thoughts, intentions, plans, intent
Presence of HI: No
How do you see your symptoms affecting your daily living?
"I can't go anywhere, I can't relax, I am always worried about the
bathroom, if I am going to have an accident. I stay away from everyone. I am
Any remission from symptoms? Veteran says no
Stressors: Health, Family, Significant other, MH problems
causing more MH problems
Impairment in thought: none
Spontaneous Reporting of Symptoms: "I never know when I
have to go to the bathroom. I must carry close with me. You can't go
anywhere or do anything. I have had incidents in public, work, home. I
never have a good time. I don't like to go out. Its horrifying. It
effects intimacy with my wife."
End of Spontaneous Report:
Anxiety: jittery, worry, jumpy, mind races, unable to shut
Down thoughts. Inter turmoil. He paces and fidgets. Used to
drink but no longer. Does not like crowds, noise, being out, being
Sometimes heart races, hands sweat other times it is
feeling of uneasy.
He noted when he is home he "gets a break" from the
He likes to grill and that helps him relax.
He noted the IBS accidents : "its anywhere, anytime, there
is no method, it can be morning, noon or night. I can go (to the
bathroom) several times a day, I can go once a day" He noted incontinence of
bowel at least once every two weeks.
He noted IBS can "go away" for a week and he then obtains a
false sense of security that he is better. Unfortunately then IBS
Mild anxiety: fidgety, overly watchful
Moderate anxiety; somewhere in the middle of the two
Severe anxiety: pacing "like crazy" he cannot sit still.
Hands sweating, increased heart rate. His body aches.
More anxiety he has the more he is eating, more sleep
Problems He feels on most days he is moderately anxious. He notes he
spends equal amount of time in mild and severe anxiety
He does not endorse symptoms of Generalized Anxiety
Consequence of anxiety: he cannot relax, he cannot enjoy
being around family, Big public stuff is worse.
Fibromyalgia: body aches all the time, interrupts sleep. "I
don't think it increases my anxiety but fibro effects everything. You
know every day is going to be a shitty day"
He has 7 children. 2 from his first marriage (wife adopted
his oldest two children).
Poor impulse control when feels disrespected, unsafe. Last
Physical altercation 3 months ago. Beat the heck out of a man who
was threatening him and was trying to get violent with the veteran. He has
been in very violent altercations (stabbed three times). Medications
help to mellow him out. Themes that will incite violence is when he is
threatened, disrespected (but this will incite angry but not
necessarily physical violence).
He carries a firearm when not working. He noted he has bene
carrying a firearm since age 18.
Anxiety makes it difficult for him to recall information.
d. Relevant Legal and Behavioral history (pre-military, military, and
POST MILITARY LEGAL HISTORY:
Veteran denied any legal entanglements since discharge/last
e. Relevant Substance abuse history (pre-military, military, and
PRE-MILITARY SUBSTANCE USAGE HISTORY:
See past C&P exam
POST MILITARY SUBSTANCE USAGE HISTORY:
Substance abuse problems/treatment: denied "I might have
one glass of wine a week. I just don't drink" Use or abusing illicit drugs: denied
Use and abuse of prescription drugs: Denied
f. Other, if any:
No response provided.
For VA rating purposes, check all symptoms that actively apply
[X] Chronic sleep impairment
[X] Mild memory loss, such as forgetting names, directions or recent
[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] Suicidal ideation
4. Behavioral observations
Confidentiality and lack of discussed and veteran voiced
Veteran's response to interview: "I wish you were my therapist:
Cognition- Attention & Concentration: Sufficient
Memory- (ST & LT) average for recent events of last few hours or
days; average for remote events of past year.
Abstraction- able to think abstractly
Insight into illness- both intellectual and emotional
Orientation: Time, place and person
Judgement: poor when feeling threatened
Is the thought content consistent with reality? yes
Clothing Appropriate to age, season, setting and occasion? yes
Clean, neat, tidy,? yes
Hygiene and grooming: clean
Eye Contact: WNL
Abnormal movements: none noted
Mood and affect
Appropriateness of affect: Appropriate to situation.
Range of affect: flat
Stability of affect: Stable.
Attitude toward examiner during encounter: Frank.
Specific mood or feelings observed or reported: anxious
Rate of speech: WNL
Flow of speech: wnl
Intensity of volume: soft.
Quantity: offers information
Other disorders or symptoms and the extent they interfere with
substance abuse disorders: none current
somatoform disorders: no
personality disorders: no
5. Other symptoms
Does the Veteran have any other symptoms attributable to mental
that are not listed above?
[ ] Yes [X] No
Is the Veteran capable of managing his or her financial affairs?
[X] Yes [ ] No
7. Remarks (including any testing results), if any:
Explained to veteran:
examiner has no decision making capacity regarding the veteran's
rating; the examiner will be asking numerous questions, some of which
will provoke emotional response; the veteran was asked to please understand the examiner is not make any personaljudgments regarding the veteran but due to the vast
amount of questions some might feel they are being judged and the veteran is
encouraged to understand this is not the case it is simply a matter of
gathering information for the examination the veteran requested;
the veteran was informed the examiner is not native of this
geographical area thus mannerisms are different and no offense is meant if the
examiner appears to be abrupt or blunt; Veteran was informed of these things at the onset of the interview; the veteran voiced understanding of the above statements: yes
Did veteran bring documents to interview: no
Interview started: early on time
Testing deemed necessary: no
Anxiety Disorder due to another medical condition (IBS,
fibromyalgia) is at least as likely as not due to or caused by IBS and fibromyalgia.