IMEF-Gunny

I do have a buddy staement in regard to the scud being blown directly overhead in Bahrain, the corporal was within 15 feet of me and was peppered with shrapnel from the explosion as well. The newspaper article in question was from the local newspaper in Danville, Illinois. One of the gentlemen from our weapons company references seeing that scud blown out of the sky as being one of his outstanding memories from the Gulf. Fortunately for him, he was a bit further away than the line company was. We were almost directly underneath of the missile when hit. Research by VA from unit logs and records placed me in the area of the scud attack on Bahrain at the time of that attack, buddy statement from my fellow Marine also supported my statement. Also, the friendly fire incident, as well as a Marine that was crushed to death by the deuce. The only things, to my knowledge, that could not be verified via unit logs were my boughts with illness in country. The Corpsmen did need keep adequate records for those events. I have a NOD in on those issues on another GW claim. Compounding my challenges on that claim was the fact that I saw a doctor from childhood to 2007. I changed doctors in 2007. In 2014, per Indiana law, my past doctor destroyed all of my medical records. I did not have copies of any of those. I was rated 30% on my stomach issues after a C&P, but denied everything else because the C&P doc said I denied having any of my other contentions. I am currently in treatment, both therapy and medication by VA. I have tried to attend Vet Center gpoup sessions as well with a fellow Marine, but have scheduling issues right now because of work.

Thank you. I know that I jumped the gun sending a letter to refute. I have serious anxiety issues, especially with VA. I have yet to make it thru a VA appointment without breaking down....but, I'm trying. I have an IMO appointment scheduled August 18th locally. I understand that the wording of the opinion from IMO is critical. What brought me to seek help was memory really, after I almost killed my family last year, otherwise, I'd still be dealing as I always had. Thank you for your help, all of you.

This was a very informative read!

The difficulty here is the following, My MEPS physical doesn't note any pre-existing mental health condition. That determination was made during bootcamp, based on a confession in the "Last Chance truth Room" prior to swearing in....which is what sparked the DI's to send me to medical. I spent about 5 minutes talking to a Corpsman (not a psychologist/psychiatrist), then the commander (MSC, not a PHD psychology/psychiatry) for the med unit, looked over the notes from corpsman and wrote "Dr's Opinion..... alcohol disorder".......symptoms of depression from past, no current signs of depression currently present, fit for duty".......so would the following case even apply for "pre-existing" MDD? II. Service Connection-General Criteria Under 38 U.S.C.A. §§ 1110; 38 C.F.R. § 3.303, a veteran is entitled to disability compensation for disability resulting from personal injury or disease incurred in or aggravated by active military service. Evidence of continuity of symptomatology from the time of service until the present is required where the chronicity of a condition manifested during service either has not been established or might reasonably be questioned. 38 C.F.R. § 3.303(b); but see Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (the theory of continuity of symptomatology can be applied only in cases involving those diseases explicitly recognized as chronic under 38 C.F.R. § 3.309(a)). To establish a right to compensation for a present disability, a veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service" - the so-called "nexus" requirement." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). A Veteran is presumed to be in sound condition when examined and accepted into service, except for defects or disorders noted when examined and accepted for service or where clear and unmistakably evidence establishes that the injury or disease existed before service and was not aggravated by service. 38 U.S.C.A. § 1111; 38 C.F.R. § 3.304(b); See Cotant v. Principi, 17 Vet. App. 116 (2003); Wagner v. Principi, 370 F.3d 1989 (Fed. Cir. 2004); see also VAOPGCPREC 3-2003. A preexisting disability or disease will be considered to have been aggravated by active service when there is an increase in disability during service, unless there is clear and unmistakable evidence (obvious and manifest) that the increase in disability is due to the natural progress of the disability or disease. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306 (a), (b). Aggravation of a preexisting condition may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306(b). See Falzone v. Brown, 8 Vet. App. 398, 402 (1995) (holding that the presumption of aggravation created by section 3.306 applies only if there is an increase in severity during service); Akins v. Derwinski, 1 Vet. App. 228, 231 (1991). In Smith v. Shinseki, 24 Vet. App. 40, 45 (2010), it was clarified that the presumption applies when a Veteran has been "examined, accepted, and enrolled for service," and where that examination revealed no "defects, infirmities, or disorders." 38 U.S.C. § 1111. Plainly, the statute requires that there be an examination prior to entry into the period of service on which the claim is based. See Crowe v. Brown, 7 Vet. App. 238, 245 (1994) (holding that the presumption of sound condition "attaches only where there has been an induction examination in which the later-complained-of disability was not detected" (citing Bagby v. Derwinski, 1 Vet. App. 225, 227 (1991). Service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. If the evidence establishes a diagnosis of PTSD during service and the claimed stressor is related to that service, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the Veteran's service, the Veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. If the evidence establishes that the Veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the Veteran's service, the Veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. If a stressor claimed by a veteran is related to the Veteran's fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of PTSD and that the Veteran's symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of the Veteran's service, the Veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. "Fear of hostile military or terrorist activity" means that a veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the Veteran or others, such as from an actual or potential improvised explosive device; vehicle-imbedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon friendly military aircraft, and the Veteran's response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror. 38 C.F.R. § 3.304(f).

Yes, I have a buddy statement from a corporal that I served alongside, as well as a newspaper article where a few Marines from our unit were being interviewed a decade after the war, in it, one describes one of the scud incidents. I also have statements from employers that date from 1992 - present that were uploaded to my claim when filed. The problem, being a Gulf War vet, is people you served with often have trouble remembering things, so it can be challenging getting statements from fellow Marines. For example, we had a weapons company guy that was shot by friendly fire. I queried my company commander, as we are connected via FB, what happened to the guy. I don't know if he died, lived, etc. Company CO, doesn't even remember the incident.......it was under his command! Yes, my filing date is correct, as is my C&P date. When the VA called me to schedule, the fellow actual stated that they needed to schedule me so they could expedite my claim..... Two problems for me Berta, and it is my own doing, the C&P doctor states that I went many years without any issues. That is a false statement entirely, BUT, I never sought help until 2016. I'm not someone who asks for help. Unfortunately, for purposes of establishing a history.....that hurts me, because it leaves me with only lay statements from family, and employment records to attempt to show social/interpersonal issues.

I should also mention, the notation concerning the incident when I was 14 was brought about when, as a tender young 18 year old at MEPS, they take you into the last chance truth room.....that's when I spilled about the incident described above. They did not send me to be evaluated by a DR at MEPS. They cleared me, swore me in and off I went. It was ,maybe my third week in my training company in boot camp, they came got me, said there was a notation about possible suicidal ideation so I had to go to medical. I went, talked to a guy. I don't know if he was a psychiatrist, LCSW, therapist or what. He spoke with me for 5 minutes or so, asked me the story, ask me if I wanted to continue traing, I said yes, he noted the incident in med report and the last thing he wrote was "No current signs of depression, deemed fit for duty, return to training company".

Thank you for the help and opinions. The VA doc was new to the medical center, so all I could really find on him was he is a psychologist. My RO is Indianapolis. You, ma'am are a wealth of info and I truly appreciate all you do for Vets. Mike, I appreciate your candor and while I agree, I likely fired that off too quickly, this is the 2nd C&P that I've had that's BS.....I already scheduled an independent exam to get another opinion prior to the C&P as I anticipated this kind of horse shit! That appointment is in about two weeks. They verified that I was hammered with shrapnel, witness to injuries and deaths. Marine corp policy does not award CARs for shrapnel from missles, I believe IED's are included now, and direct fire incidents. Unfortunately, by nature of our work, we recieved a lot of indirect, but not direct fire/return to close enemy.

I know that I'm just pissing in the wind here, but I attached this letter to ebennies after reading the C&P examiner's report. It won't do a damn bit of good, but, for what it's worth....made me feel better! So, I was diagnosed for, being treated by local VAMC for PTSD. Currently take Zoloft, Prazosin & Bupropion.....Zoloft helps. Filed a PTSD claim, stressors verified, C&P exam was attended. C&P doc says I meet none of the criteria basically for PTSD based on his exam/testing and that I have major depressive disorder. His opinion is it is "less likely than not (Less than 50%)" related to service, as it was pre-existing and I was "relatively symptom free" for decades. What evidence he used for that statement remains to be a mystery. Anyway....here's the letter....thoughts? RE: C&P Examiner’s Notes Dated 7/14/2017 I am writing in regard to the C&P examiner’s notes from 7/14/2017. In reviewing the notes from the exam, it is clear that much of the information/opinions entered seem to be skewed from facts/evidence presented to fit a certain diagnosis, misconstrued or some items left out entirely. The report seems to be formed around the idea that a "pre-existing" condition (based on two minor incidents as a young teenager) is the cause of Major Depressive Disorder, which in turn is the cause of my current issues, but that my time spent in a combat zone at the age of 19 has little or no bearing on my current mental health. "38 C.F.R. § 4.125(b) Diagnosis of mental disorders. If the diagnosis of a mental disorder is changed, the rating agency shall determine whether the new diagnosis represents progression of the prior diagnosis, correction of an error in the prior diagnosis, or development of a new and separate condition. If it is not clear from the available records what the change of diagnosis represents, the rating agency shall return the report to the examiner for a determination." I would start by pointing out that the doctors opinion is stated as the following: b. The condition claimed was less likely than not (less than 50% probability) incurred in or caused by the claimed in-service injury, event or illness. c. Rationale: The primary rationale for this opinion is the presence of symptoms similar to his current symptoms prior to joining the military (see Mental Health history, Substance Abuse history). As stated in a December 1, 1989 Mental Health note "referral for eval of EPTE SA in 1987 of putting His head through a glass window while drunk. States he was in a state of depression at the time." and goes on "Significant hx of feeling dression with suicidal ideation both sober and intoxicated. Has stopped himself from killing himself with gun but can not verbalize why he stopped." Similarly, veteran's history is inconsistent with his service being the Major precipitant of his current distress. While veteran identifies distress upon his return and a June 1, 2017 buddy statement by his mother, indicates distress after deployment (see partial statement below), his history indicates he experiences marked distress before the deployment and was relatively symptom free until 3 to 5 years ago. Such a history is inconsistent with that expected of the deployment being the primary truama. The two isolated incidents he references are as follows: 1.) At the age of 14 years old, I was invited by a friend of mine to go to St Francisville Illinois to visit two teenage girls who were babysitting. We went to see the girls and being teenage boys, we wanted to impress the girls. The people that owned the home had a party the night before. There was a box filled with alcohol and we bragged to the girls how we were experienced party guys. I poured a glass of rum, not having any experience with alcohol outside of the occasional Busch Light beer my friends and I would sneak on a weekend, as all the boys did, I gulped down approximately 20 ounces of the rum. I had no knowledge that hard alcohol affected a person differently than a beer would. I woke up on my bed, in my house. I had blacked out and had no memory after the rum. I was awaken by a very upset mother who smacked me, which she had never done in my 14 years. I smacked my head into my bedroom window. This would later be called "a suicide attempt" by hospital staff. It wasn’t at all. I was taken to the ER with a .27 BAC and later released. In an effort to avoid legal issues, I was made to attend mandatory drug and alcohol counceling, which is a requirement for alcohol related offenses such as minor consuming in Knox County. 2.) When I was approximately 16 years of age, I was riding to school with a group of friends. One of the boys had stolen a bottle of Wild Turkey from his dad’s liquor cabinet. We were all taking sips from the bottle. A teacher had driven by us on the way to school and saw me tilt the alcohol bottle. First period of class, I was taken to the office and given a breathalyzer. The test showed alcohol in my system, so I was suspended from school for 5 days. My mother grounded me for several weeks. I was kept from my friends, my girlfriend, etc. This is the incident I confessed to in the "truth room" at MEPS, where I considered suicide because I was so distraught from being grounded. I agreed to attend a couple of AA meetings with my step dad’s mother in an effort to avoid legal trouble. I quickly discovered that I had nothing in common with the people at these meetings. I had no further issues after this incident. So, it is this doctor’s opinion, and we are led to believe that two incidents, mentioned here in detail, that took place at the ages of 14 and 16 years of age, as a young teenager, in the company of peers experimenting with alcohol are "more likely than not" the cause of 26 years of mental health issues, but that 6 months in a combat theater being bombed by shrapnel, witnessing death, having a friend killed in theater, being surrounded by Arabs that are actively trying to kill you, sleeping an hour at a time per night and patrolling hostile areas is "less likely than not" the cause of my issues. The doctor goes on to mention that I spent decades "relatively symptom free", although there is no evidence to support that statement, actually quite the contrary is true. The doctor also fails to mention or consider that before and after these two incidents, up until the age of 20 years, I had no further incidents similar to those he quotes as signs of significant history of depression and/or alcohol abuse. I maintained healthy, happy friendships and family relations until 1991, post war, when all of that changed. As further evidence, he cuts & pastes portions from my Mother’s statement to VA. If you compare the C&P to the original statement from my mother, dated June 1, 2017, you will notice that he neglected to include the beginning and the last part of the statement. He only presents the text that he feels supports his opinion. A trend that is repeated throughout the report. Further into the document, he expresses the opinion that, based on the MMPI, that my emotional distress is relatively low; However, his findings in regard to social impairment, symptoms of major depressive disorder, violence, mood, suicidal ideation, memory and cognition contradict this opinion sharply. The MMPI also shows no indication of dishonesty, as it shouldn’t, I was honest. Veteran's responses indicate significant thought dysfunction. Significant persecutory ideation such as believing that others seek to harm him or her. Is suspicious of and alienated from others. Experiences interpersonal difficulties as a result of suspiciousness. Lacks insight. Blames others for his or her difficulties. He alludes to alcohol disorder and/or abuse as a contributor; although, pre-combat, I had only two isolated incidents experimenting with peers at the ages of 14 and 16 years. My post-war alcohol use was dramatically increased in the first few years after returning home. His notes appear to paint a picture of "significant history " of pre-service substance abuse based on pre-service use? He does not address the idea/possibility that alcohol was a "self medicating" tool after deployment. In light of his previous alcohol history and possible denial (see Substance Abuse history), the possibility of an additional Alcohol Use disorder should be considered if more history of abuse becomes salient. He also states later in the report, the following statement in regard to 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 Which, even based on the information/opinion he provides, however skewed or misrepresented it may be, seems mild for a veteran with Major Depression, suicidal ideation, problems at every job, no friendships, family relationships, etc. He goes on to mention that marital difficulties may account for present issues as well. He references my first marriage after deployment as I stated "I got married for the wrong reason". The doctor however does not seek out that that reason was because I was overcome with feelings of anxiety and fear from the Gulf War. I felt as though, I almost died many, many times and therefore needed to have a wife, have kids, buy a house, start a life. My marriage failed due to anger issues, interpersonal issues, anxiety and the fact that the girl I married was the first girl I dated post war. The girl was of low moral character, as I described to him. He mentions in his notes the following, but represents it as normalcy, leaving out the fact that I avoid crowds because I do not trust people, especially Arabs. I avoid crowds because it raises my anxiety and makes me extremely nervous. Especially in light of all of the extremist attacks that take place today. He also references my carrying a gun, especially in Indy, but fails to expound on the fact that I carry that gun/ammo at different levels of readiness based on threat assessment. In Vincennes, I may carry only one spare magazine. In somewhere as dangerous as indy, I generally carry a minimum of 60-90 rounds. Veteran sees himself as a home body who prefers to avoid crowds. He does run family errands without incident, for example, he went to the grocery store yesterday by himself, "one of my kids was sickly, got prescriptions, went okay I guess." Similarly, he went out to dinner last night, "it went all right;" however, this was first time eatingout, "in a long time." The VA doctor also states the following in regard to friendships/social relationships: Initially, veteran denies having any friends; however, when pressed For details he describes several on-going relationships. He has a neighbor, "navy veteran, occasionally go over and talk." His "best friend" in high school, "is married to my sister." He has a friend that he served with who comes by his house regularly, the last time, "3, 4 weeks ago." Veteran reports that he enjoys preparing meals for his family on the grill but denies any other pleasurable activities in his life. This statement skews fact to make it appear that I, in fact, do maintain "several" close relationships; However, it fails to acknowledge that the neighbor lives directly across from me, he is a navy vet who has rather severe hearing loss from flight deck work. We speak occasionally when we are both out in the yard. We do not have any type of ongoing social interaction and conversations are generally about, weather, military service, etc and are brief. He alludes to my "best friend" in high school who is married to my sister. He fails or neglects to mention that I have not spent time with that friend since 2007. Also, that my sister hasn’t spoke to me in atleast a year. I have no ongoing relationship with either. Lastly, he mentions a friend that I served with that comes by my house regularly. That "friend" is a person I went to highschool with. He served with 2/7 in Desert Storm as a machine gunner. He has been to my house two times in the last 26 years, both of those in the past 3 months, both were to speak about disabilities and VA. He has leukemia, severe memory issues, PTSD and a chronic cough that he has been denied service connection for. I am trying to help him with his claim denials. So, this is definitely presented much differently than it really is. The doctor also references the fact that I do not react to stressor discussion, but react more to conversation about anger, depression. I would point out that stressors were mentioned and/or asked about briefly one time. Most of the interview was guided toward how I’m affected socially/family, not why. I was actively crying when discussing the following death of a friend in Desert Storm: Prior to being mobilized, I had an older Harley Davidson motorcycle that had charging issues. The bike had to be push started. A friend of mine helped me start the bike for like 20 minutes of pushing together. That friend was Jeff Reel. Jeff was about 10 or so days from deploying to theater. He was a couple years older than I and was very anxious/ nervous about going to war. He said he "just wanted to make it home". I re-assured him that he would be okay, he’d make it and had a long life ahead of him. In 1991, sometime around my birthday, I received a letter from my grandmother, in it, she informed me that Jeff was killed in Saudi Arabia. He did not make it home. The doctor, seemingly agitated, ask me "so, is it the letter you’re upset about or the scuds"? I answered both. That was the only conversation and/or mention of stressors by the VA doc throughout the entire 3 hour exam. Also, as you’ll note, there was no mention of Jeff’s death in his report. Later in the exam, the doctor notes that I "seek out stimuli" related to combat theater, terrorism, military service. As evidence, he lists facebook and my trying to re-join the military. He neglects to mention that the reason I wanted to re-enlist was to contribute to the fight against radical islam by killing as many Jihadis as humanly possible with 76th Infantry Division.I was told that being treated for PTSD, I cannot join. I did not say anything about being too old. I can still join based on age/ years of service. I do not seek out stimuli on facebook. I have no friends. Facebook is my only interaction with peers. My therapist , Rhonda Bray at the VAMC, is of the opinion that the last 3 years have been markedly more difficult because of social media and the fact that terrorism reporting is always present, therefore raising my anxiety, anger much higher than in the past. Also, I would point out that he questions Rhonda Bray’s diagnosis, but did not inquire as to how she arrived at a PTSD diagnosis, and also, the only notes from my sessions with behavioral health at the Vincennes VAMC he cut/pasted were the initial intake, where I was guarded in fear of losing my handgun licesnse and the only positive report that Rhonda wrote, directly after I started Zoloft and was experiencing a "euphoric" like start, which is obviously not representative of the last decade. Again, these seemed to be hand-picked to fit the narrative. A March 3, 2017 Behavioral Medicine note reports remarkable progress, "reports that he is doing much better. 'I wanted to call you the other day and thank you, I really didn't think I could feel normal again.'" The note went on, "Vet is happy that he has been able to enjoy life, hestated his wife has really noticed a difference. Vet stated he hadn't cried in three weeks. Vet has had no suicidal ideations. Vet states he feels his memory may be a little better." The note finishes, "Vet stated he and his wife have been going out one night per week and he has been enjoying that." Veteran confirms this initial success which he attributes to Zoloft. He feels that his symptoms are still improved but that the initial period of "almost euphoria" have left. Veteran has been diagnosed with PTSD by his providers; however, the basis of this diagnosis is unclear. Veteran's January 6, 2017 Initial Psychiatry Consult does not report apparent intrusive symptoms of PTSD. As described there, "HISTORY OF PRESENT ILLNESS: Vet reports he Cries whenever he comes to the VA, Vet states he also cries sometimes at Home for no reason. Vet reports problems sleeping, states he is up five times per night. Vet does check locks every night, he contributes it to having small children, not to being hypervigilant. Vet reports road rage. Vet states he doesn't feel depressed, Vet denies suicidal or homicidal ideations. Vet does not wish to take any medications. Vet states he will think about buying Melatonin over the counter to try for sleep. Vet is agreeable to discussing with his wife and made f/u appointment with this writer for one month. Vet provided with information for the Vet Center. Vet reports poor short term memory, Vet states that he makes lists on his phone, Vet is worried that he will not be able to 'remember anything when I am 50.'" . I would also mention that he rates Panic as "None". I described having episodes of panic regularly when he asked me, and especially when I am at work and we have to donn SCBA’s, similar to a gas mask in MOP4. He asked me what the panic was like and I described to him my heart pounding/racing and I sweat, especially my palms. He neglected to put that in his report and instead listed it as none. In closing, I cannot believe that any rational human being could weigh the evidence, view this C&P report and conclude that two minor incidents as a young teen experimenting with alcohol as teens do is far more likely to have caused a lifetime of mental health, social issues barring the fact that the evidence contradicts that in every way, but believes that 6 months in a combat theater is far less likely to have caused or , at a minimum aggravated any possible pre-existing condition. I feel that this C&P is, not at all, a valid depiction of my last 26 years and hope that whoever is reading it for rating purposes can clearly discern that. Sincerely,

Also, keep in mind that he only mentions a few stressors in his notes here. The only one of significance of many is the SCUD shrapnel that we were peppered with.

So, I was diagnosed with PTSD at my VAMC, attend therapy there, take Zoloft, Prazosin & Bupropion. I filed a claim, they verified stressors, sent all my records, buddy statements. I just attended my C&P, doc says no PTSD, granted I stressed how I'm currently affected and should have went into greater detail on stressors....but I was so fuc*ing anxious/nervous. Doc basically said Major Depressive Disorder, present pre-USMC as indicated in my STR's and alluded to alcohol issues...less likely than not therefor due to military service. His basis was that I had problems in 1991, was essentially problem free for decades and then they started 3-5 years ago....so, not related to service. Problem is NO WHERE is that supported. My buddy statements from spouse, family, employers ALL show issues with depression, anxiety, anger, write ups, etc from 1992 - today....so, there is no basis for his statement that I went decades symptom free. Question is, PTSD denial is imminent of course, but can I ask/attempt to get SC for Major Depressive disorder instead? Here is my C&P......and following, my letter to VA in regard to my disagreement with the C&P examiners assumption.............my anxiety right now is redlined......any help/advice is greatly appreciated and Neeeed! LOCAL TITLE: C&P Examination STANDARD TITLE: C & P EXAMINATION NOTE DATE OF NOTE: JUL 14, 2017@08:00 ENTRY DATE: JUL 17, 2017@08:51:04 AUTHOR: LONG,WILLIAM R EXP COSIGNER: URGENCY: STATUS: COMPLETED Medical Opinion Disability Benefits Questionnaire Name of patient/Veteran: Michael ACE and Evidence Review ----------------------- Indicate method used to obtain medical information to complete this document: [X] In-person examination Evidence Review --------------- Evidence reviewed (check all that apply): [X] CPRS [X] Other (please identify other evidence reviewed): JLV (Joint Legacy Viewer) CONFIDENTIAL Page 4 of 27 MEDICAL OPINION SUMMARY ----------------------- RESTATEMENT OF REQUESTED OPINION: a. Opinion from general remarks: DBQ PSYCH PTSD Initial ____________________________________________________________________________ The following contentions need to be examined: PTSD (post traumatic stress disorder) (related to: PTSD - Non-Combat) Active duty service dates: Branch: Marine Corps RAD: 04/29/1991 DBQ PSYCH PTSD Initial: Please review the Veteran's electronic folder in VBMS and state that it was reviewed in your report. The Veteran is claiming service connection for PTSD (post traumatic stress disorder) (related to: PTSD - Non-Combat) due to the claimed stressor of fear/hostile environment. Please examine the Veteran for a chronic disability related to his or her claimed condition and indicate the current level of severity. If more than one mental disorder is diagnosed please comment on their relationship to one another and, if possible, please state which symptoms are attributed to each disorder. If your examination determines that the Veteran does not have diagnosis of PTSD and you diagnose another mental disorder, please provide an opinion as to whether it is at least as likely as not that the Veteran's diagnosed mental disorder is a result of an in-service stressor related event. b. Indicate type of exam for which opinion has been requested: DBQ PTSD Initial CONFIDENTIAL Page 5 of 27 TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR DIRECT SERVICE CONNECTION ] b. The condition claimed was less likely than not (less than 50% probability) incurred in or caused by the claimed in-service injury, event or illness. c. Rationale: The primary rationale for this opinion is the presence of symptoms similar to his current symptoms prior to joining the military (see Mental Health history, Substance Abuse history). As stated in a December 1, 1989 Mental Health note "referral for eval of EPTE SA in 1987 of putting his head through a glass window while drunk. States he was in a state of depression at the time." and goes on "Significant hx of feeling dression with suicidal ideation both sober and intoxicated. Has stopped himself from killing himself with gun but can not verbalize why he stopped." Similarly, veteran's history is inconsistent with his service being the major precipitant of his current distress. While veteran identifies distress upon his return and a June 1, 2017 buddy statement by his mother, indicates distress after deployment (see partial statement below), his history indicates he experiences marked distress before the deployment and was relatively symptom free until 3 to 5 years ago. Such a history is inconsistent with that expected of the deployment being the primary truama. June 1, 2017 buddy statement by his mother, states, "After returning from the war in Desert Storm he seemed reserved, no longer having a close relationship with friends or family. He seemed more intense with any perceived conflict. It seems like he builds walls to keep some people at bay, keeping his feelings inside, and exhibiting a saddened mood for the most part, but explosive when he becomes agitated. He was not the same young man that left for Desert Srorm. He lost a tremendous amount of weight after returning home and seemed to rely on alcohol more when he would have especially dark moods. Mike seemed distraught and saddened." ************************************************************************* **************************************************************************** Initial Post Traumatic Stress Disorder (PTSD) Disability Benefits Questionnaire * Internal VA or DoD Use Only * CONFIDENTIAL Page 6 of 27 Name of patient/Veteran: Michael SECTION I: ---------- 1. Diagnostic Summary --------------------- Does the Veteran have a diagnosis of PTSD that conforms to DSM-5 criteria based on today's evaluation? [ ] Yes [X] No 2. Current Diagnoses -------------------- a. Mental Disorder Diagnosis #1: Major Depressive Disorder Comments, if any: Veteran's symptoms are: over-reactive, blaming irritability (see Behavioral Observations, Irritability) diminished pleasure (see Family history) psychomotor agitation (see Occupational history, see Behavioral Observations, aggressive behavior) concentration difficulties (see Remarks section, concentration difficulty, PTSD symptom checklist recurrent thoughts of death (repeatedly holding a gun with consideration of suicide) While veteran is very intensely involved in his sense of being wronged (see discussion of intrusive thoughts, PTSD symptom checklist, Remarks section), his overall emotional distress is relatively low (see MMPI-2-RF). Assessment of social/occupational functional diffiuculties are based on his marital difficulties (see Family history) and interpersonal anger (see Occupational history). Veteran experiences himself as having PTSD; however, he does not report intrusive or avoidance symptoms of PTSD (see Remarks section). Buddy statements as available are consistent with major depression and do not indicate significant intrusive symptoms of PTSD. As stated in a June 28, 2017 buddy statement by Tim Pulliam, supervisor, "During his time at JCI (Johnson Controls), Mr. McGuire's interaction with co-workers and management was often strained due to personality conflicts, angry outbursts and a general anti-social nature on his part." And as stated in a May 1, 2017 buddy statement by Christina McGuire, wife "Mike has struggled CONFIDENTIAL Page 7 of 27 with anxiety, anger/mood issues and depression off and on throughout most of the time that we have been together. The last 3-5 years has been much more pronounced." The statement goes on, "In the past, when Mike would struggle with depression/anxiety, especially when he focused too much on military talks, discussions with vet buddies, he would sometimes self-medicate with alcohol. Those incidents, although they didn't occur often, would usually result in erratic, angry behavior and sometimes emotional breakdowns or incidents of rage. Mike has broken household items and even his hand during such a case because of this, whiche caused him to be off work for months and have surgery and rehabilitation." In light of his previous alcohol history and possible denial (see Substance Abuse history), the possibility of an additional Alcohol Use disorder should be considered if more history of abuse becomes salient. b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): No response provided. 3. Differentiation of symptoms ------------------------------ a. Does the Veteran have more than one mental disorder diagnosed? [ ] Yes [X] No 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 level of occupational and social impairment, is it possible to differentiate what portion of the occupational and social impairment indicated above is caused by each mental disorder? [ ] Yes [ ] No [X] No other mental disorder has been diagnosed CONFIDENTIAL Page 8 of 27 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? [ ] Yes [ ] No [X] No diagnosis of TBI SECTION II: ----------- Clinical Findings: ------------------ 1. Evidence Review ------------------ Evidence reviewed (check all that apply): [X] CPRS [X] Other (please identify other evidence reviewed): JLV (Joint Legacy Viewer) 2. History ---------- a. Relevant Social/Marital/Family history (pre-military, military, and post-military): Veteran was raised, "70% of time" by his maternal grandparents. His parents, "got married very young, I was a surprise so to speak." They divorced when he was age 8. He was very close to his grandparents, particularly his grandmother, "grandmother never drank, never cursed, never drove a car, do anything for you, definition of unconditional love, I was her favorite." When he was 10, his mother remarried and continues to be with his stepfather to this date. He has a full sister, 5 years younger than him and a half brother by his father and a half sister by his mother. Veteran describes a distant relationship with all of his family. Regarding his mother he reports, "we get along, we love each other," but "I don't see her much." He last saw her, "3 or 4 months ago, ran into each other in a store." He last saw his biological father "6 months ago, again just publicly, I think he and I get along okay." He has not seen any of his siblings in more than a year. He reports that his father abused alcohol when he was younger and that CONFIDENTIAL Page 9 of 27 he had an uncle, "got a DUI at one time." He concludes, "my paternal grandmother drank quite a bit." FAMILY PSYCHIATRIC HISTORY: The Veteran reported no known family history of serious mental illness or suicide attempts. Veteran denied history of sexual abuse, physical abuse, or domestic violence. Veteran did not describe any psychiatric difficulties with activities of daily living. Veteran denies belonging to a church or any organized social group. Veteran was first married from 1992 to 1995. He sees the marriage as a mistake, "I got married for wrong reasons," and that the marriage dissolved due to his, "anger issues." He has 2 children from the first marriage, a son, 23, "got Asperger's, he has a lot of problems besides just the Asperger's, lives in a group home." He last saw the this son at Christmas of 2016. He has a daughter, 21, "okay relationship," he saw her "a couple months ago, they went with us hiking." Veteran met his current wife in 1996 and they married in 1999. He does not know if the marriage will last, "divorce has come up, last time about 2 weeks ago." During stressful times they both talk about divorce, "seemed pretty mutual." He was unable to identify the source of the distress beyond vague statements, "life, finances, kids, work." Last night they had an argument. He and his wife stayed in a hotel to avoid an early morning drive to this appointment, "she got upset with me because I didn't want to do anything, didn't want to take a horse and carriage ride." He notes, "I know she wanted to have sex," which he felt was very insensitive to his anxiety and distress, "that upset me, seemed ridiculous that she would be upset, we didn't do something fun." She expressed anger, "you act like you're old." CONFIDENTIAL Page 10 of 27 The couple has 5 children, 4 sons, 18, 15, 5, and 1, and a daughter, 10. He reports all the children "are okay, all smart, athletic kids." Veteran sees himself as a home body who prefers to avoid crowds. He does run family errands without incident, for example, he went to the grocery store yesterday by himself, "one of my kids was sickly, got prescriptions, went okay I guess." Similarly, he went out to dinner last night, "it went all right;" however, this was first time eating out, "in a long time." Initially, veteran denies having any friends; however, when pressed for details he describes several on-going relationships. He has a neighbor, "navy veteran, occasionally go over and talk." His "best friend" in high school, "is married to my sister." He has a friend that he served with who comes by his house regularly, the last time, "3, 4 weeks ago." Veteran reports that he enjoys preparing meals for his family on the grill but denies any other pleasurable activities in his life. b. Relevant Occupational and Educational history (pre-military, military, and post-military): Veteran is a high school graduate. History of learning disability, special education, or being held back a grade was denied. Veteran reports only one suspension from school at age 14, "drank too much alcohol in the morning before school," he was suspended and placed in a mandatory alcohol treatment program. He describes high school as otherwise, "pretty good, played football, had girlfriends most of the time, went through school with 2 of my best friends." He obtained, "B's and C's mostly." He obtained an Associate's in Robtotics in 1998. Currently, veteran has worked the last 10 years in a "waste water treatment plant." He reports the job is going "mostly okay, technically I'm proficient." He has been counseled about his behavior on the job. The behavioral difficulties were described in an April CONFIDENTIAL Page 11 of 27 19, 2017 buddy statement by Steven Atteberry, Foreman, as "complaint was that he displayed 'Angry, intimidating and condescending' behaviors that disrupted the workplace." The complaint lead to, "a written warning and a 1 year probation in September, 2015." He works 10 hour daytime shifts Monday through Thursday. He reports missing 5 days over the last year for, "personal ailments." Veteran reports being fired only one time in 1999, "on the first day of the job," when they discovered he was red/green color blind, "they skipped a certain portion of the interview, told me I had to leave." He left a job in the early 2000's without notice, "it was a clean room, stuck in a clean room for 12 hours [in a clean suit for 12 hours], I hated it." His longest period of unemployment was for a year and half after his divorce. He had no explanation for the period of unemployment beyond, "I lost job that I had, basically a welder, for Johnson controls." He had this job for 3 and half years, it was his first job after leaving the military. Branch: Marines Dates of Service: November, 1990 to April, 1991 Discharge Type: HONORABLE Rank on Discharge: E3 Veteran was deployed to Bahrain and Saudi Arabia during his active service as above. c. Relevant Mental Health history, to include prescribed medications and family mental health (pre-military, military, and post-military): MENTAL HEALTH TREATMENT AFTER MILITARY: Veteran denies formal mental health treatment before approaching the St Louis VA in January of this year. Prior to that he did approach a primary care provider "in 1994 maybe, I was having a lot of troubles at work." The "company doctor prescribed me Buspar, couldn't take it, threw my equilibrium off, never went back." CONFIDENTIAL Page 12 of 27 He has been seen regularly through the VA since January with a diagnosis of PTSD. A March 3, 2017 Behavioral Medicine note reports remarkable progress, "reports that he is doing much better. 'I wanted to call you the other day and thank you, I really didn't think I could feel normal again.'" The note went on, "Vet is happy that he has been able to enjoy life, he stated his wife has really noticed a difference. Vet stated he hadn't cried in three weeks. Vet has had no suicidal ideations. Vet states he feels his memory may be a little better." The note finishes, "Vet stated he and his wife have been going out one night per week and he has been enjoying that." Veteran confirms this initial success which he attributes to Zoloft. He feels that his symptoms are still improved but that the initial period of "almost euphoria" have left. Veteran has been diagnosed with PTSD by his providers; however, the basis of this diagnosis is unclear. Veteran's January 6, 2017 Initial Psychiatry Consult does not report apparent intrusive symptoms of PTSD. As described there, "HISTORY OF PRESENT ILLNESS: Vet reports he cries whenever he comes to the VA, Vet states he also cries sometimes at home for no reason. Vet reports problems sleeping, states he is up five times per night. Vet does check locks every night, he contributes it to having small children, not to being hypervigilant. Vet reports road rage. Vet states he doesn't feel depressed, Vet denies suicidal or homicidal ideations. Vet does not wish to take any medications. Vet states he will think about buying Melatonin over the counter to try for sleep. Vet is agreeable to discussing with his wife and made f/u appointment with this writer for one month. Vet provided with information for the Vet Center. Vet reports poor short term memory, Vet states that he makes lists on his phone, Vet is worried that he will not be able to 'remember anything when I am 50.'" He was initially referred to behavioral health by his primary care providers with a diagnosis of Major Depression and concerns about his crying and sleep difficulties (see August 5, 2016 Clinic note). Treatment notes do discuss "nightmares" but not in a way that meets criteria as an CONFIDENTIAL Page 13 of 27 intrusive symptom. For example, the March 3, 2017 Behavioral Medicine note states, "Vet reports that he believes he has nightmares, although he doesn't remember them. Vet states he sleeps well some nights and others not as good. Vet and wife have not slept in the same bed for over 6 years." Current medications include: Jun 14, 2017 SERTRALINE HCL 100MG TAB ACTIVE Mar 04, 2018 STL MENTAL HEALTH TREATMENT DURING MILITARY: Veteran denies mental health treatment in the military. He was evaluated by Mental Health, "when I got to boot camp," because he reported prior treatment for alcohol abuse. A December 1, 1989 Mental Health note apparently documents this visit, "18 y/o ... referral for eval of EPTE SA in 1987 of putting his head through a glass window while drunk. States he was in a state of depression at the time. Secondary to 'his situations.'" The note continues, "has gone through ETOH tx including AA." Based on the change in writing style, a second author adds to the same note, "Significant hx of feeling dression with suicidal ideation both sober and intoxicated. Has stopped himself from killing himself with gun but can not verbalize why he stopped. Treatment received for alcohol was mandatory outpt group education following drunk and disorderly at school." The note concludes, "Impression: I. Alcohol Abuse by history." MENTAL HEALTH TREATMENT PRIOR TO THE MILITARY: See above PSYCHIATRIC HOSPITALIZATIONS: None SUBSTANCE ABUSE RELATED HOSPITALIZATIONS: Veteran reports a third significant incident related to alcohol in addition to those described in the December 1, 1989 Mental Health note. He reports the incident was shortly after his school suspension. He and his friends came across, "big box of bottles, vodka, rum, poured a big glass of it." He drank it all, "more or less showing off, [he became unconscious and] ended up hospital, .27 BAL." He was kept overnight and released. CONFIDENTIAL Page 14 of 27 d. Relevant Legal and Behavioral history (pre-military, military, and post-military): HISTORY OF TROUBLE AS YOUTH: Veteran denies contact with the police other than, "incident there at school, when I got suspended." MILITARY DISCIPLINARY PROBLEMS (ARTICLE 15/NJP/CAPTAIN?S MAST/COURT MARTIALS): None LIST ALL NON-MILITARY LEGAL OFFENSES AND LEGAL CONSEQUENCES: Veteran reports being arrested, "right after my divorce, for invasion of privacy, I went to my ex-wife's apartment," when there was a, "restraining order against me." He denies other arrests. e. Relevant Substance abuse history (pre-military, military, and post-military): CAFFEINE: cup of coffee in the morning ALCOHOL: Veteran report limited current consumption of alcohol, consuming only a single serving on 2 separate occasions during the last week and not consuming over 5 servings at one time in over a year. He reports his heaviest period of use was 1992 to 1996. He reports drinking, "too much, maybe 3 days a week," 5 or 6 servings on a typical day. His January 6, 2017 Psychiatry Consults suggests greater use during that period, "Vet stated that he drank anything he could, whiskey, beer." The May 1, 2017 buddy statement by Christina McGuire, his wife suggests that veteran's current difficulties with alcohol may be greater than that reported above. As stated there, ""In the past, when Mike would struggle with depression/anxiety, especially when he focused too much on military talks, discussions with vet buddies, he would sometimes self-medicate with alcohol. Those incidents, although they didn't occur often, would usually result in erratic, angry behavior and sometimes emotional breakdowns or incidents of rage. Mike has broken household items and even his hand during such a case because of this, whiche caused him to be off work for months and have surgery and rehabilitation [2013]." The statement continues, "Mike has made a tremendous effort to avoid alcohol when he wrestles with anxiety and depression." ILLICIT DRUG USE: Veteran reports only experimental use of marijuana as a child. CONFIDENTIAL Page 15 of 27 f. Other, if any: The following is cut and pasted from JLV (Joint Legacy Viewer): PROBLEM LIST Mar 03, 2017 POST-TRAUMATIC STRESS DISORDER, CHRONIC F43.12 ACTIVE STL Dec 05, 2016 NICOTINE DEPENDENCE, CIGARETTES, WITH UNSPECIFIED NICOTINE-INDUCED Dec 05, 2016 PATIENT'S OTHER NONCOMPLIANCE WITH MEDICATION REGIMEN Z91.14 ACTIVE Sep 08, 2016 ESSENTIAL (PRIMARY) HYPERTENSION I10. ACTIVE STL Sep 08, 2016 HYPERLIPIDEMIA, UNSPECIFIED E78.5 ACTIVE STL Sep 08, 2016 TESTICULAR HYPOFUNCTION E29.1 ACTIVE STL Sep 08, 2016 NICOTINE DEPENDENCE, CIGARETTES, UNCOMPLICATED F17.210 ACTIVE STL Sep 08, 2016 ABDOMINAL DISTENSION (GASEOUS) R14.0 ACTIVE STL Sep 08, 2016 SLEEP DISORDER, UNSPECIFIED G47.9 ACTIVE STL MEDICATION LIST Jun 14, 2017 ATORVASTATIN CALCIUM 80MG TAB ACTIVE Sep 01, 2017 STL Jun 14, 2017 SERTRALINE HCL 100MG TAB ACTIVE Mar 04, 2018 STL Feb 02, 2017 HCTZ 12.5/LISINOPRIL 20MG TAB ACTIVE Feb 03, 2018 STL Aug 31, 2016 NICOTINE 21MG/24HR PATCH EXPIRED Sep 30, 2016 STL Aug 31, 2016 HCTZ 12.5/LISINOPRIL 20MG TAB DISCONTINUED Nov 04, 2016 STL 3. Stressors ------------ Describe one or more specific stressor event(s) the Veteran considers traumatic (may be pre-military, military, or post-military): a. Stressor #1: multiple SCUD attacks including debris coming to his position in an ammo dump Does this stressor meet Criterion A (i.e., is it adequate to support the diagnosis of PTSD)? [X] Yes [ ] No Is the stressor related to the Veteran's fear of hostile military or terrorist activity? [X] Yes [ ] No CONFIDENTIAL Page 16 of 27 Is the stressor related to personal assault, e.g. military sexual trauma? [ ] Yes [X] No b. Stressor #2: just avoiding friendly fire Does this stressor meet Criterion A (i.e., is it adequate to support the diagnosis of PTSD)? [X] Yes [ ] No Is the stressor related to the Veteran's fear of hostile military or terrorist activity? [X] Yes [ ] No Is the stressor related to personal assault, e.g. military sexual trauma? [ ] Yes [X] No c. Stressor #3: Saudi nationals pointing weapons in his direction Does this stressor meet Criterion A (i.e., is it adequate to support the diagnosis of PTSD)? [X] Yes [ ] No Is the stressor related to the Veteran's fear of hostile military or terrorist activity? [X] Yes [ ] No Is the stressor related to personal assault, e.g. military sexual trauma? [ ] Yes [X] No 4. PTSD Diagnostic Criteria --------------------------- Please check criteria used for establishing the current PTSD diagnosis. 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 #7 - Other symptoms. The diagnostic criteria for PTSD, referred to as Criterion A-H, are from the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5). 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 CONFIDENTIAL Page 17 of 27 traumatic event(s) occurred: [X] No criterion in this section met. 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] No criterion in this section met. 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] No criterion in this section met. 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] No criterion in this section met. Criterion F: [X] No criterion in this section met. Criterion G: [X] No criterion in this section met. Criterion H: No response provided. Criterion I: Which stressor(s) contributed to the Veteran's PTSD diagnosis?: No response provided. 5. Symptoms ----------- For VA rating purposes, check all symptoms that actively apply to the Veteran's diagnoses: [X] Anxiety 6. Behavioral Observations CONFIDENTIAL Page 18 of 27 -------------------------- ******MENTAL STATUS****** Hallucinations: None reported Orientation: Veteran expressed understanding of the reason for the interview and was oriented to person, place, and time. Memory: Veteran recalled 3 of 3 items after a period of intervening tasks. Executive Function: Veteran was able to produce a clock face with the correct time, follow a 3 step command, and explain an abstract proverb. Suicidal Ideation: Veteran had tears in his eyes as he described suicidal ideation/behavior. Three months ago, "I went to my cousin's house, set by their pond, tried to clear my mind, set a gun in my lap." He sees his "wife and kids," as the only thing that stopped him from committing suicide. Veteran reports similar behavior, holding a gun in consideration of killing himself for many years. (See Mental Health history of suicidal ideation/behavior beginning prior to his military service). Veteran reports his suicidal ideation has decreased since he began taking psychotropic medication, that it was much more frequent for the last 3 years, and that it was an only occasional difficulty between approximately 1997 and 2005. Impulse Control: Good. Veteran denies engaging in any reckless/impulsive behaviors (i.e., impulsive violence, reckless driving, extravagant spending, excessive gambling, and impulsive sex). QUERY FOR SYMPTOMS OF MANIA: Veteran denies Inflated self-esteem or grandiosity, Decreased need for sleep, Being more talkative or pressure to keep talking, Flight of ideas or subjective experience of racing thoughts, Distractibility, Increase in goal-directed activity, or Excessive involvement in pleasurable activities that have a high potential for painful consequences. Sleep: Veteran reports typically going to bed at 10 or 10:30 pm and getting out of bed at 5:30 am on weekdays and 7:30 on weekends. He denies difficult obtaining or reobtaining sleep but that he awakes repeatedly during the night. He notes, "it has improved since they put me on Zoloft, before Zoloft it was absolutely horrendous, up any where from 6 to 20 times a night." He reports awaking 5 or fewer times at the current time. When he awakes he is bothered by, "horible shoulder and arm cramps," which he has to "stretch out," before returning to sleep. He and his wife "haven't slept together for 7 8 years," due to his frequent awakenings and "shaking" in bed. Panic Attacks: None. Irritability: Veteran again became tearful as he discussed his CONFIDENTIAL Page 19 of 27 "rage." He reports last becoming enraged "a couple months ago, I love animals, not proud of saying this, have a puppy, trying to get him to go outide, ran from me, I smacked his ass, he ran under a table, just infuriated me, whacked him again, the more I hit him, the more he cried, yelping and hollering." He lost his temper earlier this week, "didn't start out angry, ended up that way." He was, "on my way home form work, guy pulled out behind me, right on my bumper." The incident escalated, "I tapped my brake, try to get him to back off, [the other driver began] honking his horn, flashing his lights, I pull over, he pulled over." He believed the man was going to attack him, "he dropped his shoulder," so the veteran, "hit him, I hit him 3 times, he hit the ground." The veteran, "made sure he was turned on his side, make sure he didn't choke on blood, and I left," with the man laying there. He reports becoming angry, raising his voice, more than daily and becoming angry to the point of wanting to strike something, "once a week." A significantly reduced level since beginning on medication. Veteran's sees his anger as part of an intense hate of Islam. He sees this as out of character for him, "not a person who believes in hate, don't let my kids even use the word, don't care black, white, gay, straight, Mexican." He notes that both his wife and his therapist associate this with his overuse of Facebook, "only social interaction I have is through Facebook, so much of Facebook is about terrorism and Islam, I f**king hate Islam." He attempted to rejoin the military a year ago, to address what he perceives as the problem of Islam but notes, "they won't take me, too old." Homicidal Ideation: Unknown. When asked about homicidal ideation, veteran asked if his responses would be confidential. The examiner reiterated that information is confidential to the VA system, that it was unlikely that action would be necessary, but that indications of significant threat to self or others would need to be addressed. At that point, veteran responded, "I would say no." History of Violent Behaviors: Veteran reports his previous involvement with CONFIDENTIAL Page 20 of 27 violence was "5 years ago or so, friend of mine had been drinking [in veteran's home], I tried to take his keys." The man responded, "he demanded his keys back." The veteran told him you have 2 choices, "stay here or I can knock you the f**k out, he opted for plan B, exactly what I did [knock him out]." The friendship continued for 2 years after the incident. 7. Other symptoms ----------------- Does the Veteran have any other symptoms attributable to PTSD (and other mental disorders) that are not listed above? [X] Yes [ ] No If yes, describe: Veteran reports difficulty controlling his anger (See Behavioral Observations, Irritability). 8. Competency ------------- Is the Veteran capable of managing his or her financial affairs? [X] Yes [ ] No 9. Remarks, (including any testing results) if any -------------------------------------------------- Prior to beginning the C&P exam, this examiner informed the veteran about the purpose of this interview being for disability benefits, limits of confidentiality, (e.g., risk of harm to self/others), risks of participation in interview (e.g. stress, anxiety), access to records, how results will be communicated to the Regional Office, and the fact that the Regional Office is responsible for making decisions regarding service-connection and disability ratings. ?Veteran expressed willingness to continue with the evaluation. The interview was conducted from 7:40 to 10:15 am. Diagnoses obtained in this evaluation were based on the criteria contained in the DSM5. Veteran is 46 years old. Veteran was referred by the Muskone Regional Office for a PTSD Initial C&P Evaluation. At the end of this exam, the veteran was asked whether there were other symptoms of possible mental disorder that had not been covered in the exam CONFIDENTIAL Page 21 of 27 Unless otherwise stated, all historical information in this DBQ is based on the veteran's statements during the examination. ***REVIEW OF CRITERIA FOR DIAGNOSIS OF PTSD Below are questions (based on the diagnostic criteria for PTSD) and veteran responses. Items were rated positive if they reached clinical levels. The ratings below represent the assessment of the examiner after completion of a structured interview. Following the items are the veterans comments in regards to the questions, which are provided for the benefit of other mental health examiners, who may be interested in understanding the veterans specific response patterns. Please note that the veteran responses alone are not sufficient for diagnostic purposes. Items have high face validity (obvious items asking about symptoms) and can be influenced by the subject?s motivations. A total score was not calculated, rather item responses were used to assess whether DSM diagnostic criteria were met. Veteran reports 0 of 5 re-experiencing symptoms, 0 of 2 avoidance symptoms, 0 of 7 negative mood/cognition symptoms, and 0 of 6 hyperarousal symptoms at a Moderate level or higher, these symptom counts do not meet DSM-5 or DSM-IV criteria for PTSD. Hyperarousal and negative mood/cognition symptoms that may be present are likely the result of other factors besides PTSD. Incident: Veteran reports multiple traumatic experiences on deployment including multiple SCUD attacks, an incident where he just avoided friendly fire, and Saudi nationals pointing weapons in his direction. One of the SCUD attacks resulted in debris coming to his position in an ammo dump, a potentially deadly situation. A June 16, 2017 buddy statement by Chris Powell, part of his unit in Bahrain confirms some of these traumas, "The SCUD missle that was shot down by Patriots above out position actually struck our line positions with shrapnel, which was amplified in terms of seriousness by the fact that we were close proximity to an ammo dump at the time." Notes on affect: No change during discussion of traumatic events. Veteran was much more distressed (tearful) as he discussed his anger and feelings of being out of control. B: REEXPERIENCING 1. disturbing memories -> rated as negative This rating is based on: Veteran reports negative, more than daily, distressing thoughts; however, he does not describe intrusive memories of trauma. He describes thoughts more consistent with Major Depression. Specifically, he describes a preoccupation with, "why I didn't die over there, I don't know how I made it, there's so many different CONFIDENTIAL Page 22 of 27 incidents where I should of died and I didn't." 2. disturbing dreams -> rated as negative This rating is based on: Veteran denies memories of nightmares. "I don't remember my dreams." He does reports a disturbed sleep and a belief that he is having dreams, "my wife says I shake in my sleep, wake up sweaty." 3. flashbacks -> rated as negative This rating is based on: Veteran responded "not really, no," to descriptions of flashbacks and dissociative experiences. 4. feeling upset -> rated as negative This rating is based on: Veteran again describes anger and depression but not connected to prior trauma. He focuses on his use of Facebook, "my wife tries to get me to stay away from the social media stuff, I get in trouble if I start to much the military stuff." He describes an obsession with it, "it is a part of who I am, if I don't allow myself to feel some of that struggle, then it's like I'm not acknowledging part of me." 5. physical reactions -> rated as negative This rating is based on: Denied C: AVOIDANCE: 1. avoiding thoughts -> rated as negative This rating is based on: Veteran describes an obsessive focus on his thoughts, see above, rather than avoidance. 2. avoiding activities -> rated as negative This rating is based on: Veteran does report some avoidance, "I don't watch any of that [movies, documentaries], you probably know more about Desert Storm than I do, don't have any interest in it." However, he does not describe active avoidance. In addition, he describes actively seeking out stimuli (see Facebook discussion above, see desire to join the military, Behavioral Observations). D: NEGATIVE MOOD/COGNITION 1. trouble remembering -> rated as attributed to Major Depression This rating is based on: Veteran is very preoccupied with how his deployment damaged him and other veterans, "seems like we are all damaged to some degree." He sees the fact that he remembers some things from deployment that others have forgotten and the others remember things that he has forgotten as evidence of this "damage." He notes one of his fellow Marines, "doesn't remember either of [incidents noted above], CONFIDENTIAL Page 23 of 27 but remembers the marine that got run over." He sees this as endemic to veterans, "contacted my old commanding officer, doesn't even remember the incident, what happened to weapons company guy." He concludes "everybody remembers different pieces." He describes a memory that might be unrelated to deployment as further evidence, "I remember getting on bus, remember thinking the guy driving this bus looked like Satan, big beard, big eyebrows, just evil looking," but that he doesn't, "remember where that bus went, odd to me, why would I remember what the guy looked like." 2. strong negative beliefs -> rated as attributed to Major Depression This rating is based on: Veteran reports his experiences, "taught me to not take things for granted, went 5 months without showering." 3. blaming self -> rated as negative This rating is based on: "no" 4. fear, horror, anger -> rated as attributed to Major Depression This rating is based on: Veteran reports frequent crying, crying as recently as yesterday, "I was nervous about this appointment, don't know what to expect." See description of crying below associated with concentration difficulties and original referral for mental health services. 5. loss of interest -> rated as attributed to Major Depression This rating is based on: See Family history 6. feeling cut off -> rated as attributed to Major Depression This rating is based on: Veteran reports feeling cut off, "people don't understand my personality, and I don't understnad theirs, why don't I have close emotional ties to people, don't react way they do." 7. feeling emotionally numb -> rated as negative This rating is based on: Denied E: HYPERAROUSAL: 1. feeling irritable -> rated as attributed to Major Depression This rating is based on: See Behavioral Observations. 2. taking too many risks -> rated as negative This rating is based on: See Behavioral Observations. 3. hypervigilance -> rated as negative This rating is based on: Veteran denies vigilance beyond, "carry a firearm, especially when I go to Indianapolis." 4. startle response -> rated as negative CONFIDENTIAL Page 24 of 27 This rating is based on: "don't have a startle response." 5. difficulty concentrating -> rated as attributed to Major Depression This rating is based on: Veteran reports concentration difficulties which he labels as memory problems. He reports they occur, "daily, I keep a lot of notes." He describes an example, "say my wife and I have conversation about Saturday, I'll forget completely, she'll mention it, I've completely forgotten." He gives other examples, "forgotten my daugher's name, forgotten my son's name, go to the store, don't make a list, I'll forget, come in the house, forget why I'm there, what I came in for." He goes on, "sometimes, I will lose myself mid sentence, be talking to somebody, I stutter, soon as I do, can't remember the topic of the converstiaon, it just goes." He reports difficulty at work, "work in a very dangerous environment." He will forget to do, "air sampling for oxygen, hydrogen sulfide, explosive atmosphere, I have forgotten all of those mid shifts." His memory/concentration difficulties make him feel out of control. He became very tearful in the interview as he described an incident leading to his referral to mental health. He went to his primary care provider and broke down in uncontrollable crying about an "incident, we were grilling, pushed the grill into the garage, I forgot the grill was warm." The CO monitor went off, "house was filling with carbon monoxide, I would of killed anybody in the house, because I forgot." It was at that point, he decided, "I need to get help." 6. trouble sleeping -> rated as negative This rating is based on: See Behavioral Observations. ***PSYCHOLOGICAL TESTING MMPI-2-RF The Veteran was administered the Minnesota Multiphasic Personality Inventory-2 Restructured Form (MMPI-2 RF), a self-report scale that provides information about an individual's clinical symptoms and personality features as well as validity measures for the individual's CONFIDENTIAL Page 25 of 27 response pattern. Veteran's responses to the validity scales of the MMPI-2-RF indicated consistent responding and were within normal limits. As such, response biases are unlikely to have affected responses to the clinical scales on the exam. OVERALL CLINICAL INTERPRETATION: Veteran endorsed an overall low number of items indicating generalized distress. Overall clinical interpretation would indicate only a mild level of clinical distress. SOMATIC/COGNITIVE DYSFUNCTION: Reports multiple somatic complaints that may include head pain, neurological, and gastrointestinal symptoms. Reports a number of gastrointestinal complaints. Reports head pain. Reports a diffuse pattern of cognitive difficulties. EMOTIONAL DYSFUNCTION: Reports: A lack of positive emotional experiences. Significant anhedonia. Lack of interest. Is pessimistic. Is socially introverted. Is socially disengaged. Lacks energy. Displays vegetative symptoms of depression. Reports: a lack of positive emotional experiences and avoiding social situations. Lacks positive emotional experiences. Experiences significant problems with anhedonia. Complains about depression. Lacks interests. Is pessimistic. Is socially introverted. Reports being anger prone. THOUGHT DYSFUNCTION: Veteran's responses indicate significant thought dysfunction. Significant persecutory ideation such as believing that others seek to harm him or her. Is suspicious of and alienated from others. Experiences interpersonal difficulties as a result of suspiciousness. Lacks insight. Blames others for his or her difficulties. BEHAVIORAL DYSFUNCTION: Reports a significant history of antisocial behavior. Reports engaging in physically aggressive, violent behavior and losing control. Reports being interpersonally aggressive and assertive. Is overly assertive and socially dominant. Engages in instrumentally aggressive behavior. CONFIDENTIAL Page 26 of 27 INTERPERSONAL FUNCTIONING: Reports not enjoying social events and avoiding social situations, including parties and other events where crowds are likely to gather, being introverted and emotionally restricted. Has difficulty forming close relationships. Reports disliking people and being around them, preferring to be alone. NOTE: VA may request additional medical information, including additional examinations if necessary to complete VA's review of the Veteran's application. /es/ WILLIAM R. LONG CLINICAL PSYCHOLOGIST Signed: 07/17/2017 08:51 My letter to VA in regard to this examiner's findings: Thursday, July 20, 2017 RE: C&P Exam July 14th 2017 I am writing in regard to the C&P exam returned to VA July 17th, 2017. I would ask VA consider that this decision/opinion was made, in terms of service connection, based on the following statement: TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR DIRECT SERVICE CONNECTION ] b. The condition claimed was less likely than not (less than 50% probability) incurred in or caused by the claimed in-service injury, event or illness. c. Rationale: The primary rationale for this opinion is the presence of symptoms similar to his current symptoms prior to joining the military (see Mental Health history, Substance Abuse history). As stated in a December 1, 1989 Mental Health note "referral for eval of EPTE SA in 1987 of putting his head through a glass window while drunk. States he was in a state of depression at the time." and goes on "Significant hx of feeling dression with suicidal ideation both sober and intoxicated. Has stopped himself from killing himself with gun but can not verbalize why he stopped." Similarly, veteran's history is inconsistent with his service being the major precipitant of his current distress. While veteran identifies distress upon his return and a June 1, 2017 buddy statement by his mother, indicates distress after deployment (see partial statement below), his history indicates he experiences marked distress before the deployment and was relatively symptom free until 3 to 5 years ago. Such a history is inconsistent with that expected of the deployment being the primary truama. June 1, 2017 buddy statement by his mother, states, "After returning from the war in Desert Storm he seemed reserved, no longer having a close relationship with friends or family. He seemed more intense with any perceived conflict. It seems like he builds walls to keep some people at bay, keeping his feelings inside, and exhibiting a saddened mood for the most part, but explosive when he becomes agitated. He was not the same young man that left for Desert Srorm. He lost a tremendous amount of weight after returning home and seemed to rely on alcohol more when he would have especially dark moods. Mike seemed distraught and saddened." There is significant evidence in my claim from persons that I have worked with, lived with and known that contradict these conclusions. Nowhere in my claims file does anyone, including myself state that my conditions were present after returning home in 1991, absent for decades and then re-appeared 3-5 years ago. To the contrary, they have been clearly present and affected my social, family & work life to varying degrees since 1991, but have “worsened” in the last 3-5 years. Also, the Dr acknowledges my stressors are active and legitimate, but because I was reluctant to go into detail about the stressors and how they affect me and have since the time of the incident, he doesn’t find criteria for PTSD, though at the same time acknowledges my “fear and/or horror in regard to imminent threat of death/serious injury and threat of terrorist activity: Describe one or more specific stressor event(s) the Veteran considers traumatic (may be pre-military, military, or post-military): a. Stressor #1: multiple SCUD attacks including debris coming to his position in an ammo dump Does this stressor meet Criterion A (i.e., is it adequate to support the diagnosis of PTSD)? [X] Yes [ ] No Is the stressor related to the Veteran's fear of hostile military or terrorist activity? [X] Yes [ ] No MCGUIRE, MICHAEL SEAN CONFIDENTIAL Page 18 of 29 Is the stressor related to personal assault, e.g. military sexual trauma? [ ] Yes [X] No b. Stressor #2: just avoiding friendly fire Does this stressor meet Criterion A (i.e., is it adequate to support the diagnosis of PTSD)? [X] Yes [ ] No Is the stressor related to the Veteran's fear of hostile military or terrorist activity? [X] Yes [ ] No Is the stressor related to personal assault, e.g. military sexual trauma? [ ] Yes [X] No c. Stressor #3: Saudi nationals pointing weapons in his direction Does this stressor meet Criterion A (i.e., is it adequate to support the diagnosis of PTSD)? [X] Yes [ ] No Is the stressor related to the Veteran's fear of hostile military or terrorist activity? [X] Yes [ ] No Is the stressor related to personal assault, e.g. military sexual trauma? [ ] Yes [X] No 4. PTSD Diagnostic Criteria --------------------------- Please check criteria used for establishing the current PTSD diagnosis. 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 #7 - Other symptoms. The diagnostic criteria for PTSD, referred to as Criterion A-H, are from the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5). 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) He states his opinion is the following: 2. Current Diagnoses -------------------- a. Mental Disorder Diagnosis #1: Major Depressive Disorder Comments, if any: Veteran's symptoms are: over-reactive, blaming irritability (see Behavioral Observations, Irritability) diminished pleasure (see Family history) psychomotor agitation (see Occupational history, see Behavioral Observations, aggressive behavior) concentration difficulties (see Remarks section, concentration difficulty, PTSD symptom checklist recurrent thoughts of death (repeatedly holding a gun with consideration of suicide) He clearly indicates that he believes that I have major Depressive Disorder, but that he feels it is not related to military service as it was manifest prior to bootcamp; however, he wrongly assumed, through no basis in fact or evidence presented, that it was present before boot camp (pre-existing), was clearly present and by definition indicated from buddy statements, weight loss etc, pronounced and present upon return from desert storm, but it was absent for decades and then re-appeared 3-5 years ago. Again, there is no evidence, nor statements from me or anyone that alludes to my condition being absent between 1991 and today. Quite the contrary in fact. Also, He disagrees with VMAC, Rhonda Bray’s assessment and diagnosis based on the idea that following, but made no efforts to get clarification from provider as to her assessment/diagnosis. There are many things I have discussed with Mrs. Bray, that I forgot or was uncomfortable discussing with a new/stranger physician: “Veteran has been diagnosed with PTSD by his providers; however, the basis of this diagnosis is unclear.” Also, there is no mention of a significant event that was discussed in the exam concerning the death of a friend in February, 1991 Jeff Reel and the effects that had on me at the time and/or to this day. At a minimum, I would ask that VA consider these issues/discrepancies in this exam, consider my memory and level of anxiety when I am at VA, documented by Rhonda Bray, that is so severe that she has suggested conducting clinic visits on VA provided equipment from home versus physically coming to the VAMC. Also, please consider that I requested my wife be allowed into the exam room due to this anxiety and my memory issues and was refused. In closing, please also consider that, though this doctor disagreed with prior VA diagnosis of PTSD, he does support a clear diagnosis of Major Depressive Disorder, perhaps mis-diagnosed as PTSD, acknowledges it was present prior to service, but does not address whether it may have been aggrivated as a result of service in Desert Storm by one of the many stressful events that took place. Myself, as a veteran, would not be able to distinguish myself the proper claimed disability (PTSD or Major Depressive Disorder) and therefor sought help/claim for the PTSD diagnosis from VAMC. Sincerely,

Completed my exam. I went down the night before so I could make sure I knew where I was going and not be late. Went to the hospital an hour early and sat in the parking lot chain smoking and trying to mellow out. Called ahead and asked, but my wife was not allowed to go into the exam with me. Exam was just shy of 3 hours long. Questions and personality test. Although I tried to maintain composure, I lost it a few times (cried). Doctor asked me if I needed to take a break at the halfway mark, I definitely needed it. A very difficult day, but after I came out of the exam I felt like I could finally breathe. I had a slight melt down hours later after getting home, but I think that was just because I spent the entire week stressed out over this exam. It wasn't as bad as I thought, but I'm not sure that I remembered many things that I should have talked about, so I guess we will see in a few days.

C&P tomorrow morning........doc is new, so I can't find him on the net to look at reviews........hospital said wife can't come into exam with me (She usually goes at my VAMC because I struggle)........trying to take Broncovets advice and focus elsewhere......but I'd be lying if I said i wasn't defcon 9 on anxiety right now!

Thanks Mike......fingers crossed. I'm definitely having a rough week anticipating this exam.....doesn't help that I had a crazy driver go batshit on me yesterday. I had to punch him in the face after he got out of control.....now I'm walking into an exam with my knuckles shredded and hoping I don't get some weird infection from his nasty ass teeth. I appreciate the input.....sometimes just good to hear someone say......"You're not totally f**ked yet".

1. I have been called by VARO early in a claim to verify or clarify contentions, so I don't believe it would be indicative of a coming approval or denial, but more simply an effort to gather needed evidence (clarification). I am assuming their records search to verify your stressors perhaps came up empty handed or didn't necesarily correlate directly with your stressor letter perhaps. 2. Unfortunately, not to be a Debbie downer, the question of how long is similar to asking "how long is rope".....tough when you have anxiety....trust me, I'm with you! But, unfortunately, it depends on evidence, records, C&P's being needed, etc. I would assume since you needed a stressor letter to be researched by VA that you do not have a CAR/CIB.....if you do, it is considered your stressor (combat action). 3. Worst case scenario, you will be scheduled a C&P.....PTSD is the only mental health issue, that I am aware of, one can file for post service that does not necesarily require "in service" treatment records as it affects can be months, years or even decades after the traumatic event. If it helps, I think if your stressor can be verified by unit logs, time/place in service, buddy statements, etc and you have a clear diagnosis from an appropriate person qualified to diagnose the condition, then you appear to have a good strong case. Just my .02......but when dealing with VA......you just never really know. I wish you the best.....hope there will be no NOD in your future!

Nobody has interacted with the Louisville RO? Hmmmm, that may be good or bad!

So, I filed an FDC claim for PTSD at the end of June 2017 with all of my STR's, Buddy statements, Stressor letters, etc. I have been scheduled for a C&P exam at the Louisville, KY RO this week. Needless to say, my anxiety is peaked out....I have a history of extreme anxiety in regard to being at VAMC....to the point my threapsit has suggested maybe doing my sessions remotely with VA supplied equipment (Like Skype). My question is, has anyone had any experience with this RO? I can find very little written in regard to the Louisville RO good, bad or indifferent. When they called me, the guy was very nice and asked when they could get me in for the exam, so they could expedite my claim for me.....hope that's a sign of their willingness to help/fairly adjucate legitimate claims. Any input in regard to this RO (past experiences, knowledge, etc) would be greatly appreciated.

Yes sir.......by the way, you don't often hear that term Caluza. I have read some of Mario's misadventures......wow! The way I'm reading the combining diagnostic codes though, it appears that they can indeed combine the 7319 and 7332 and these do not qualify for seperate ratings.

I may have just found my answer......If I'm reading this correctly 7319 & 7332 could be combined under one rating. Am I correct in that assumptionbased on this clause? §4.114 Schedule of ratings—digestive system. "Ratings under diagnostic codes 7301 to 7329, inclusive, 7331, 7342, and 7345 to 7348 inclusive will not be combined with each other. A single evaluation will be assigned under the diagnostic code which reflects the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation."

So, I have an interesting situation here that I’m not entirely sure how to approach. I had a C&P exam January 2017. The doc examined my stomach for a contention of gastro-intestinal disturbance (Gulf War vet). The doc also examined my anus/sphincter for hemmoroids. In regard to intestinal/colon: (7319) 3. Signs and symptoms --------------------- Does the Veteran have any signs or symptoms attributable to any non-surgical non-infectious intestinal conditions? [X] Yes [ ] No If yes, check all that apply: [X] Alternating diarrhea and constipation If checked, describe: Has been having diarrhea and constipation [X] Abdominal distension If checked, describe: Constant bloating. 4. Symptom episodes, attacks and exacerbations ---- If checked, describe typical exacerbation or attack: Every day episodes. Indicate number of exacerbations and/or attacks in past 12 months: [ ] 0 [ ] 1 [ ] 2 [ ] 3 [ ] 4 [ ] 5 [ ] 6 [X] 7 or more I was awarded 30% SC for Gastro-intestinal disturbances . Doc also noted in his exam notes (DBQ) the following: In Regard to Rectum/Sphincter (7332) 3. Signs and Symptoms --------------------- Does the Veteran have any findings, signs or symptoms attributable to any of the diagnoses in Section 1? [X] Yes [ ] No [X] d. Impairment of rectal sphincter control If checked, indicate severity (check all that apply): [X] Leakage necessitates wearing of pad [X] Occasional involuntary bowel movements [X] Other, describe: Usually after bowel movememts leaks feces. My initial contentions were Gastro-intestinal disturbance, Sleeplessness, Short term memory loss and bi-lateral arm/ shoulder pain. After my C&P results came in, I noticed on Ebenefits that the VSR had deferred all other items and had added “Stool Incontinence” as a separate deferred disability on my claim. Turned out, the doc was supposed to examine me for all contentions on the initial C&P. It was returned to him as incomplete and he simply answered I denied sleeplessness, memory loss or bi-lateral arm/ shoulder pain (Ludicrous and untrue). I was denied on all three contentions based on his answer;However, they did not deny stool incontinence, they simply removed it! Now, stool incontinence is listed as a separate disability under conditions of the anus & sphincter. The VA doc physically examined my anus/sphincter and put the previous comments in my DBQ. He noted in that DBQ that his findings were “undiagnosed illness”. How would you approach this since they added it to my initial claim and then simply deleted it when they denied the other contentions? Also, since it is listed on the DBQ as being pretty severe and undiagnosed, should I contest it or simply file it as a new claim with the January C&P as evidence for SC? This code 7332 based on his notes would rate a seperate SC% -Occasional involuntary bowel movements, necessitating wearing of pad 30% Any advice/opinion is appreciated.

So, here's where I am as of yesterday: Filed 6/16 Gulf War Vet (Gastro-intestinal disturbances, Short term memory loss, Bi-lateral arm/shoulder pain, sleep disturbances) Recieved 2 letters (same mailing, one acknowledging my filing an FDC claim/ one acknowledging I did not opt for FDC claim, but traditional) Called VA, they said "You did not file FDC, your claim is traditional) January 2017 scheduled for first C&P exam (Unaware of which contention it was for) immediately after C&P rated 30% for IBS - VSR added stool incontinence to my claim as a disability (deffered) * My C&P examiner was an 87 year old Iranian doctor who was a family practioner working at the VAMC. He thoroughly examined my stomach issues, took xrays and check me for hemmoroids. He asked if I had hemmoroids, I said "not that I am aware of". He checked me and said I didn't have hemmoroids. He noted that I had stool incontinence requiring wearing of a pad. He asked me if I had any other issues, I said "Yes, I don't sleep well. I wake up 6-20 times per night....mostly due to shoulder/arm pain and joint stiffness. I also have very serious short term memory problems, which is my greatest concern". He said memory is mental health and asked me NO other questions. Memory loss, bi-lateral arm/shoulder pain, stool incontinence, Sleep disturbances all deffered checked VA notes - discovered that my C&P was returned to doc as incomplete, He was suppose to check all other contentions as well. Doc answered that "Veteran complained of stomach problems and about his hemmoroid, Veteran denied having any other issues". I uploaded a letter disputing the docs answer as it was not accurate at all. April 2017 called Peggy and told VA was waiting for STR's.....from Records Management center (told them RMC did not hold my records NPRC did) April 27 - uploaded STR's to ebenefits, called Peggy and they sent that info to VSR May VA still waiting on STR's from RMC - no response from RMC Called RMC - RMC says they replied 3 times, stating they did not hold those records as I left USMC in 1992 Clicked "Decide claim now" as i had nothing else to send them Yesterday - all deffered items denied "Not service connected" Waiting on BBE to file NOD. So, my question is...... A. Do I have a decent chance for getting scheduled for a new C&P if I was denied due to Doc's answer? B. Do I have a decent chance if they say, they couldn't obtain STR's? C. Do i ask for DRO review in my NOD? Any advice greatly appreciated. I have a VSO.....they've done absolutely "0" for me.....told me "it's your claim, do what you want"......so, they are out....I'm on my own. Currently rated at 30% IBS. I have another intent to file, started 8/16, I'm considering a PTSD claim. I have a buddy letter for stressor and have been diagnosed with PTSD at local VAMC, on medication. Had a mention of suicidal ideation, in my STR's, prior to Marine Corps boot camp (possible aggravated by later service(Gulf War)).

WOW.......aid and assist.......relative term apparently for that one!

So, Ebennies is a hard habit to break for a vet with anxiety....we all know that, but it NEVER updates, so I call Peggy "somewhat" frequently. Sometimes you get very polite folks who dig and look, sometimes you get a bolo! I call yesterday, right off, this guy sounds like he has the enthusiasm of a tortoise traveling through a marshmallow cream field in 130 degree heat.....I'm sure (in his defense), he has answered 1,000 questions since 8am, but he's no "people person" by 4pm! He says (with a very preturbed tone) "Shows here that you just called 2 days ago for a status update, and you want another one already?"......."I seriously doubt anything has changed in 2 days, but i'll look"......"no, nothings changed" ....."anything else"? Think he's frustrated.....try being a vet 360 days into an initial claim...a Vietnam vet who is STILL fighting for "Presumptive" conditions.........hell, who knows.....maybe he is! Alas, I digress..... - Carry on

My VAMC MH diagnosed me with PTSD after several sessions, reading my letters, files, buddy statements and interviewing my spouse. I refused that diagnosis. I am being treated (finally agreed to take medication) and it has helped me a lot. However, I have not filed a PTSD claim. I feel like, compared to a lot of my brothers out there ie; Vietnam veterans (God bless all of them), who seen, on average 20+ days of combat action per month, my actions, incidents were trivial in comparison. For 26 years I drank, occassionally cried/melted down, nearly lost every job I'd ever had, never fit in (nor want to), haven't slept a full night, had/have no friends to speak of, and have & continue to be viewed as "intense and or intimidating" by all who know or meet me. 0 family relationships outside my wife & kids, wrestle with alcohol use and I have few real emotions anymore......but I'm trying. In the last 3 years, things have intensified 100 fold.......felt like my mind was breaking. I got to where I distanced myself, even from my kids and sat on many occassions, alone drinking with a 9mm in my lap. My next step will be visiting the Vet Center, maybe, for a group session. Baby steps.......but I still will likely never file a PTSD claim.

I may, someday, file a PTSD claim, but, at the moment my focus is on the presumptive issues. I will not file for SA, as I don't believe that, if I have it at all, that it could be SC.....especially considering I've been a smoker for 35 years. I'm deaf as shit and have tinnitus to, but I've worked in factories most of my life since I got out, so.......there again, it probably was from my time (I can remember firing a saw to the point it was physically painful, thought my ears would bleed), but I can't say definitively it was SC. I have none of the audiograms my company done on me in the early 90's so........be hard to prove SC anyway at this point. Frankly, even if I have an issue, if I don't personally believe something that plagues me is SC, then I would never file a claim for it.....integrity is of the highest importance to me, as I'm sure it is to most Marines. Semper Fi

I have not filed a PTSD or SA claim. My VAMC NP prescribed me Prazosin for sleep issues (Psych NP believes I have nightmares, even though I told her I never remember my dreams) based on my spouses description of my sleep. My wife and I have not slept in the same bed or bedroom in atleast 8 years. Wife says I'm restless all night and I shake in my sleep. Before Zoloft, I was up anywhere from 6 - 20 times per night....average I'd say was 10-12. I'd always wake up with tremendous arm/shoulder pain and stiffness, to the point it was painful and took me several minutes to move them enough to go back to sleep. The only exam I've had was January 2017 for my stomach. No activity since on my claim. I did not mention the name of my VSO, because I'm guessing this individual is not representative of ALL VSO employees for the originization, but yes, it is a major hitter in the Veteran's Orginizations. I try to give benefit of the doubt and not make waves, but I may take your advice and file a complaint about the STR's via IRIS. What I don't understand is, they sent me paperwork initially acknowledging that I file an FDC claim (Which I did not) and in the same mailing sent me the exact same envelope acknowledging that I chose not to file FDC, but rather a standard filing. Question is, if had been an FDC claim, they would have accepted the Strs' that I uploaded. Right now, they're saying they cannot accept the STR's that I uploaded in April because they need STR's from records management to assure they are complete records? Weird........ Thanks for the input all! Semper Fi!