[What the examiner put.]

What do you guys think it will be? He left out things that I said. I reported that I have panic attacks everyday and he said weekly or less. WTF?   

 

 

Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination    Request?    [X] Yes  [ ] No   
                                   SECTION I:                                   ---------    1. Diagnostic Summary    --------------------    Does the Veteran now have or has he/she ever been diagnosed with PTSD?    [X] Yes  [ ] No       ICD Code: F43.8
    2. Current Diagnoses    -------------------    a. Mental Disorder Diagnosis #1: Other Specified Trauma- and Stressor-Related       Disorder         ICD Code: F43.8         Comments, if any: The frequency and intensity of the veteran's current         symptoms meet the DSM-5 criteria for a diagnosis of Other Specified         Trauma- and Stressor-Related Disorder which is consistent with previous         diagnoses from a Review Posttraumatic Stress Disorder DBQ dated December         12, 2016 and a Mental Disorders DBQ dated August 25, 2017.         
       Mental Disorder Diagnosis #2: Unspecified Schizophrenia Spectrum and Other          Psychotic Disorder         ICD Code: F29         Comments, if any: The veteran has a history psychotic symptoms including         paranoid thoughts and auditory hallucinations. His symptoms are         exacerbated by stress. He reported that he benefits from treatment with         Risperdone.
    b. Medical diagnoses relevant to the understanding or management of the       Mental Health Disorder (to include TBI): Chronic back pain; Chronic knee       pain
    3. Differentiation of symptoms    -----------------------------    a. Does the Veteran have more than one mental disorder diagnosed?
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       [X] Yes  [ ] No           b. Is it possible to differentiate what symptom(s) is/are attributable to       each diagnosis?       [X] Yes  [ ] No  [ ] Not applicable (N/A)                  If yes, list which symptoms are attributable to each diagnosis and           discuss whether there is any clinical association between these           diagnoses: The veteran's symptoms of Other Specified Trauma- and           Stressor-Related Disorder include intrusive memories, recurring           dreams, avoidance behaviors, and anxious hyperarousal.
           His symptoms of Unspecified Schizophrenia Spectrum and Other Psychotic           Disorder include paranoid ideation, distrust of others, bland affect,           and apathy.               c. Does the Veteran have a diagnosed traumatic brain injury (TBI)?       [ ] Yes  [ ] No  [X] 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 reduced reliability and           productivity
    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?       [X] Yes  [ ] No  [ ] No other mental disorder has been diagnosed                  If yes, list which portion of the indicated level of occupational and           social impairment is attributable to each diagnosis: In relation to           his diagnosis of Other Trauma- and Stressor-Related Disorder, the           veteran has difficulty concentrating on occupational tasks because he           is distracted by intrusive memories.  He has recurring nightmares           which disturb his sleep resulting in daytime fatigue. His anxiety is           triggered by certain stimuli which remind him of his deployments. He           has difficulty in public places, such as supermarkets, due to his           hypervigilance.
           As result of his diagnosis of Unspecified Schizophrenia Spectrum and           Other Psychotic Disorder, the veteran is distrustful and suspicious of           others which makes it difficult for him to form and maintain           interpersonal relationships. He is easily provoked when he feels           threatened and he has had verbal outbursts towards which has affected           his occupational functioning.
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               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] VA e-folder (VBMS or Virtual VA)    [X] CPRS
    2. Recent History (since prior exam)    -----------------------------------    a. Relevant Social/Marital/Family history:          DESCRIPTION OF MARITAL, FAMILY, AND SOCIAL RELATIONSHIPS: Mr. Stone was          married in April 2016. His wife is employed as a clerk at the Post          Office. He has a seven-year-old stepson and a six-month-old daughter.          He reported that both of the children are in good general health and          his stepson is doing well in school. He stated that he gets along well          with his stepson. The veteran and his wife go out to eat occasionally.          Most of the time he stays at home because he is anxious in public          places.  His wife socializes with friends from work but the veteran          avoids going to social events.  He communicates with one friend on          social media, otherwise, he has not maintained friendships.  The          veteran's father is deceased. His mother lives in Texas and she calls          to see how the baby is doing. He has not traveled to Texas to visit her          recently.  His sister lives in Lexington, KY and he talks to her on the          holidays. He did not identify any hobbies or past time activities that          interest him. He stated that he used to enjoy playing soccer but he          lost interest.              b. Relevant Occupational and Educational history:          MILITARY HISTORY          ---------------          DATE(S) OF SERVICE: December 12, 2005 to October 11, 2011          BRANCH OF SERVICE: Navy           HIGHEST RANK OBTAINED: E4           TYPE OF DISCHARGE: Honorable           RANK AT DISCHARGE: E4
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          MILITARY OCCUPATIONAL SPECIALTY: HM Field Medical Service Technician          DECORATIONS AND MEDALS AWARDED: Combat Action Ribbon; First Good          Conduct Medal; National Defense Service Medal; Afghanistan Campaign          Medal; Iraq Campaign Medal; Global War on Terrorism Service Medal; Sea          Service Deployment Ribbon; NATO Medal; Rifle Marksmanship Ribbon          DID THE VETERAN HAVE COMBAT EXPERIENCE: Yes          LOCATION AND DATE OF COMBAT EXPERIENCE: Iraq from August 2009 to          October 2009; Afghanistan from December 2010 to July 2011.
          EDUCATION:  The veteran obtained a bachelor's degree in business from          Mid way University. He has completed courses towards and master's degree          in health care administration.            EMPLOYMENT:  The veteran has been employed as an outpatient surgery          technician at the Lexington VAMC since October 2015. His duties          included setting up for procedures, getting vital signs from patients,          assisting physicians, and cleaning up after procedures.  He reported          that he recently had an angry outburst towards a coworker.  He was          subsequently reassigned to the sterilization room where he operates the          sterilization equipment and he has less interactions with coworkers.                         c. Relevant Mental Health history, to include prescribed medications and       family mental health:          PSYCHIATRIC HOSPITALIZATIONS: The veteran received psychiatric          treatment on an inpatient basis at the Lexington VAMC from January 19,          2014 to January 23, 2014. His attending psychiatrist was Dr. Courtney          Markham-Abedi. He was admitted with depressed mood, anxiety, and          thoughts of suicide. He reported psychotic symptoms which included          auditory hallucinations, delusional thoughts, and disorganized          behaviors. He reported hearing voices of people giving him directions          while driving and he expressed fears that people are following him or          talking about him. Prior to this admission, he had been taking his          psychiatric medications inconsistently and he was abusing marijuana and          synthetic marijuana.
          The veteran has been provided with out-patient mental health treatment          at the Lexington VAMC from March 2016 to the present. He attends          individual and group psychotherapy sessions with his treating          psychologist, Dr. Craig Cabezas.            CURRENT TREATMENT(S): Anti-depressant          SPECIFY MEDICATION: Bupropion 150 mg. per day; Risperidone 1 mg., one          and on-half tablets twice per day          MEDICATION SIDE EFFECT(S): He reported problems with dizziness and          nausea          GROUP THERAPY: Yes          INDIVIDUAL PSYCHOTHERAPY: Yes          EFFECTIVENESS OF THERAPY: Fair          COMMENT ON EFFECTIVENESS OF THERAPY: He reported that treatment with
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          antidepressant medication has helped to improve his mood and          psychotherapy is helping to improve his coping skills.                         d. Relevant Legal and Behavioral history:          The veteran had no disciplinary infractions during his military          service. He reported no history of civilian legal charges.              e. Relevant Substance abuse history:          The veteran described his alcohol use as occasional. He stated that he          will drink at home and he does not go out and drink anywhere and the          last time he had a beer was two weeks ago.  He denied any problems          related to alcohol use and he was never referred for treatment for          alcohol abuse.  He has a history of occasional marijuana use and he          stated that it has helped to reduce his anxiety.  He stated that he          failed a random drug screen at work, due to recent cannabis use, and he          is afraid that he may lose his job.              f. Other, if any:          The veteran has a history of chronic back pain and knee pain.  He is          provided with primary medical care by Dr. Wisam Owais at the Lexington          VAMC.  His current medications include the following:           1)  BUPROPION HCL 150MG 12HR SR TAB TAKE ONE TABLET DAILY FOR MOOD OR          SMOKING CESSATION          2)  BUSPIRONE HCL 10MG TAB TAKE ONE TABLET EVERY MORNING AND TAKE          ONE-HALF TABLET AT NOON AND TAKE ONE TABLET AT BEDTIME FOR ANXIETY          3)  HYDROXYZINE HCL 25MG TAB TAKE 1 TABLET (25MG) EVERY MORNING AND          TAKE 1 TO 2 TABLETS (25-50MG) AT BEDTIME FOR ANXIETY          4)  RISPERIDONE 1MG TAB TAKE ONE AND ONE-HALF TABLETS TWICE A DAY FOR          MOOD          5)  CARBAMAZEPINE 200MG TAB TAKE TWO TABLETS TWICE A DAY FOR MOOD                        3. PTSD Diagnostic Criteria    --------------------------
    Please check criteria used for establishing the current PTSD diagnosis. The    diagnostic criteria for PTSD, are from the Diagnostic and Statistical Manual    of Mental Disorders, 5th edition (DSM-5).  The stressful event can be due to    combat, personal trauma, other life threatening situations (non-combat    related stressors).  Do NOT mark symptoms below that are clearly not    attributable to the Criterion A stressor/PTSD.  Instead, overlapping symptoms    clearly attributable to other things should be noted under #6 - "Other    symptoms".           Criterion A: Exposure to actual or threatened a) death, b) serious injury,                    c) sexual violence, in one or more of the following ways:                                       [X] Directly experiencing the traumatic event(s)
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                   [X] Witnessing, in person, the traumatic event(s) as they                       occurred to others
       Criterion B: Presence of (one or more) of the following intrusion symptoms                    associated with the traumatic event(s), beginning after the                    traumatic event(s) occurred:                                       [X] Recurrent, involuntary, and intrusive distressing memories                       of the traumatic event(s).                   [X] Recurrent distressing dreams in which the content and/or                       affect of the dream are related to the traumatic event(s).
       Criterion C: Persistent avoidance of stimuli associated with the traumatic                    event(s), beginning after the traumatic events(s) occurred,                    as evidenced by one or both of the following:                                       [X] Avoidance of or efforts to avoid external reminders                       (people, places, conversations, activities, objects,                       situations) that arouse distressing memories, thoughts, or                       feelings about or closely associated with the traumatic                       event(s).
       Criterion D: Negative alterations in cognitions and mood associated with                    the traumatic event(s), beginning or worsening after the                    traumatic event(s) occurred, as evidenced by two (or more) of                    the following:                                       [X] Persistent and exaggerated negative beliefs or                       expectations about oneself, others, or the world (e.g., "I                       am bad,: "No one can be trusted,: "The world is completely                       dangerous,: "My whole nervous system is permanently                       ruined").                   [X] Feelings of detachment or estrangement from others.
       Criterion E: Marked alterations in arousal and reactivity associated with                    the traumatic event(s), beginning or worsening after the                    traumatic event(s) occurred, as evidenced by two (or more) of                    the following:                                       [X] Hypervigilance.                   [X] Sleep disturbance (e.g., difficulty falling or staying                       asleep or restless sleep).
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       Criterion F:                   [X] The duration of the symptoms described above in Criteria                       B, C, and D are more than 1 month.
       Criterion G:                   [X] The PTSD symptoms described above cause clinically                       significant distress or impairment in social,
                       occupational, or other important areas of functioning.
       Criterion H:                   [X] The disturbance is not attributable to the physiological                       effects of a substance (e.g., medication, alcohol) or                       another medical condition.
    4. Symptoms    ----------    For VA rating purposes, check all symptoms that actively apply to the    Veteran's diagnoses:           [X] Depressed mood       [X] Anxiety       [X] Suspiciousness       [X] Panic attacks that occur weekly or less often       [X] Chronic sleep impairment       [X] Difficulty in establishing and maintaining effective work and social           relationships
    5. Behavioral observations    -------------------------       MENTAL STATUS EXAM       ==========       GENERAL APPEARANCE: Casually dressed       PSYCHOMOTOR ACTIVITY: Unremarkable       SPEECH: Monotone         ATTITUDE TOWARD EXAMINER: Cooperative       AFFECT: Bland       MOOD: Depressed        ATTENTION: He reported that he has difficulty concentrating because his       mind wanders.         ORIENTATION: Intact       THOUGHT PROCESS: Logical       THOUGHT CONTENT: Unremarkable       DELUSIONS: None       HALLUCINATIONS: None       JUDGMENT: Understands outcome of behavior       INTELLIGENCE: Average       INSIGHT: The veteran understands his treatment recommendations.       DOES THE PATIENT HAVE SLEEP IMPAIRMENT? Yes       COMMENTS AND DESCRIPTION OF EXTENT SLEEP IMPAIRMENT INTERFERES WITH DAILY       ACTIVITY: He reported having difficulty falling asleep because of racing
STONE, WILLIAM MIKAEL CONFIDENTIAL Page 19 of 42
       thoughts. He wakes up and has difficulty falling back to sleep.  His sleep       is disturbed by nightmares most nights.  He gets about four to five hours       of broken sleep per night and he has difficulty waking up to get to work       on time.          DOES THE PATIENT HAVE OBSESSIVE/RITUALISTIC BEHAVIOR? No       DOES THE PATIENT HAVE PANIC ATTACKS? Yes       FREQUENCY, SEVERITY, DURATION AND EFFECTS ON FUNCTIONING: He reported       having panic attacks when he feels crowded or closed in        IS THERE PRESENCE OF HOMICIDAL THOUGHTS? No       IS THERE PRESENCE OF SUICIDAL THOUGHTS? No       EXTENT OF IMPULSE CONTROL: Fair       EPISODES OF VIOLENCE: No       EXAMPLES OF EFFECTS ON MOTIVATION/MOOD OR OTHER COMMENTS: He tends to be       irritable and short tempered.  He had a verbal outburst at work and was       transferred to another job.  He has had instances of road rage when he       felt someone was tailgating him. He stated that he gets irritated and       yells at home but he denied any physical violence.         ABILITY TO MAINTAIN MINIMUM PERSONAL HYGIENE? Yes       IS THERE PROBLEM WITH ACTIVITIES OF DAILY LIVING: No            COMMENTS OR ELABORATION OF ANY ITEMS IN THE MSE OR FOR ITEMS NOT COVERED       OR OTHER COMMENTS: The veteran reported depressed mood with lack of       interest and pleasure and low motivation.  He reported having thoughts       that life would be easier for his family if he was not there but he denied       any plans or intent for suicide. He stated that he does not want his       daughter to grow up without a father. He stated that he has difficulty       going outside because he feels that people are watching him and he is       hypervigilant in public places.  He will wear sunglasses and headphones if       he goes out anywhere.         MEMORY       -----       REMOTE MEMORY: Normal       RECENT MEMORY: Normal       IMMEDIATE MEMORY: Normal                  6. Other symptoms    ----------------    Does the Veteran have any other symptoms attributable to PTSD (and other    mental disorders) that are not listed above?    [ ] Yes  [X] No        7. Competency    ------------    Is the Veteran capable of managing his or her financial affairs?    [X] Yes  [ ] No        8. Remarks, (including any testing results) if any:    --------------------------------------------------       PCL-5 (Clinician Administered and Scored) 
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       Criterion A:  Deployments to Iraq and Afghanistan       In the past month, how much were you bothered by:       0 = Not at all   1 = A little bit   2 = Moderately    3 = Quite a bit    4       = Extremely       Criterion B: INTRUSION symptoms        1. Repeated, disturbing, and unwanted memories of the stressful       experience?  3  He has intrusive thoughts intermittently during the day       which distract him while he is at work.         2. Repeated, disturbing dreams of the stressful experience?  3 He reported       a recurring nightmare and he wakes up in a cold sweat.         3. Suddenly feeling or acting as if the stressful experience were actually       happening again (as if you were actually back there reliving it)?  2 He is       triggered by certain smells.          4. Feeling very upset when something reminded you of the stressful       experience? 2 He becomes anxious but is able to calm himself down.          5. Having strong physical reactions when something reminded you of the       stressful experience (for example, heart pounding, trouble breathing,       sweating)?   2 Occasional panic attacks.          Criterion C: AVOIDANCE        1. Avoiding memories, thoughts, or feelings related to the stressful       experience?  2  He avoids talking about his service but attending a peer       support group was helpful to him.        2. Avoiding external reminders of the stressful experience (for example,       people, places, conversations, activities, objects, or situations)?  2 He       avoids watching the news because he will be anxious for the rest of the       day.          Criterion D: Negative alterations in COGNITIONS AND MOOD       1. Trouble remembering important parts of the stressful experience? 0       2. Having strong negative beliefs about yourself, other people, or the       world (for example, having thoughts such as: I am bad, there is something       seriously wrong with me, no one can be trusted, the world is completely       dangerous)?  2  He has difficulty trusting others and he is less sociable.               3. Blaming yourself or someone else for stressful experience or what       happened after it?  0        4. Having strong negative feelings such as fear, horror, anger, guilt, or       shame?  2 He is guarded and fearful.          5. Loss of interest in activities that you used to enjoy?  2 He lost       interest in preferred activities such as playing soccer.  He plays video       games to pass the time       6. Feeling distant or cut off from other people?  3 He has not maintained       friendships and he does not socialize.          7. Trouble experiencing positive feelings (for example, being unable to       feel happiness or have loving feelings for people close to you)?  2 He       reported decreased pleasure in social activities.          Criterion E: Alterations in AROUSAL AND REACTIVITY        1. Irritable behavior, angry outbursts, or acting aggressively?  2 
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Verbal       outbursts.       2. Taking too many risks or doing things that could cause you harm?  1       History of impulsive spending.       3. Being "superalert" or watchful or on guard? 3  He is hypervigilant in       public places.        4. Feeling jumpy or easily startled?  2 He is startled by unexpected loud       noises.           5. Having difficulty concentrating?  2 Difficulty concentrating because       his mind wanders.         6. Trouble falling or staying asleep?  2 Four to five hours of broken       sleep per night.        PCL-5 Score:  39       Cluster B (items  1-5) :  12       Cluster C (items  6-7) :  4       Cluster D (items  8-14):  11       Cluster E (items 15-20):  12
       Interpretive Statement: PCL-5 has a total score range of 0-80, with higher       scores indicating greater PTSD symptom severity.        0-10:  no or minimal symptoms reported       11-20:  mild symptoms reported       21-40:  moderate symptoms reported       41-60:  severe symptoms reported       61-80:  very severe symptoms reporte

[decision]

Thank you for the reply. I'm a Iraq and afghan combat vet with a diagnosis of chronic ptsd and get treated at the VA. 

[decision]

I recently had a c and p exam. This is what I reported to the psych. Any idea on where I stand?

 

Medications – I am unable to function without my medications

Care for myself – my wife has to constantly remind me to do things for myself like take my medications. I need to go to the dentist bc I have a cracked tooth but I keep putting off going to the dentist bc it isn’t important to me. My wife mentioned that I am forgetful by doing things like forgetting our baby in our car constantly, unable to watch our child alone, not checking to make sure my stepson has his coat and lunch for school. My wife pointed out that im horrible at grooming myself by constantly not trimming my nose hairs or getting haircuts when I need to. She sais I have no regard for money. I leave huge tips and buy expensive things when we don’t have the money free. My wife manages our money. I no longer control it since the consequence of spending it when I shouldn’t does not affect me as it does for normal people.

 

Symptoms – I hallucinate that I hear voices constantly on a daily basis and have when I make the voices out it is hard to distinguish that they aren’t real. My wife sais I have horrible memory for remembering important things I need to do like self care and care for others and sometimes names of people I know. I mumble to myself which really annoys my wife and sometimes co-workers. My wife sais that my reasoning is horrible and communication lacks a lot. I am in a constant state of anxiety, suspicion and fear on a daily basis. Anxiety that something bad is going to happen and I don’t know what it is. Suspicion that people are out to get me. Fear that I am going to be attacked by muslims for being a veteran. I on a daily basis am hyper alert. It feels like I am failing backwards but just does not go away. I have panic attacks multiple times a day that make me sweat. I get triggered by smells of smoke reminding me of when I was in Afghanistan and have panic attacks. Body odor reminds me of the people in Afghanistan and I have panic attacks. People digging on the side of the road and driving to close to me makes me have panic attacks and I have to pull over. My panic attacks usually end with me crying and being overcome with the emotions and grief of my whole situation and how my life is. I have nightmares every night about being in Afghanistan on patrol with my marines. I see the ieds going off in front of my face. The shockwave from the ied whooshing through my body. Our patrol base where we slept being attacked with aks and rocket propelled grenades. My Marines being blown up and me having to put tourniquets and pressure dressing on them. There screaming for me their Doc. Running around the patrol base as the Taliban attack checking on the posts to make sure no one was shot and bullets hitting close to me on the ground. I have anger and am short tempered over little things that really don’t matter in the long run but in the moment I have outbursts of yelling. I have yelled at co workers and been very short in conversation because I get angry easily. I have an addictive personality and sometimes find myself drinking just for the buzz and release. Ive smoked pot to help with my anxiety but I cant do that because I have a family. Sometimes I wake up in my dream and am locked on the bed unable to move yelling for my wife but no one answers and it’s a very traumatic experience for me when that happens. I have had flashbacks at work where a smell took mer back to the moments when I was treating my marines. My anxiety gets so bad that I throw up and am unable to eat on a daily basis. My medications make me nausiouse and dizzy and makes it hard to concentrate because im in a fog. I am constantly depressed and not hopeful of my future. I constantly think my life would be better if I was just not here anymore. I am horrible with procrastinating by putting things off to the last minute or just not doing them at all.

 

Work – I yelled at some co-workers and was reassigned to a new job at the VA in Lexington. My anxiety makes it extremely hard to function doing my job. I have missed almost a month of work within the last year because my anxiety doesn’t let me leave the house. It is overwhelming. I find myself zoning out thinking of Afghanistan while at work on a daily basis making it hard to concentrate on tasks. As I mentioned earlier I was reassigned, I no longer have any patient contact and am greatly restrained in my work duties. I am now in spd. As I mentioned earlier I smoke pot and was recently drug tested. I am about to lose my job. When I do I will not be able to pay my mortgage and will lose my house. I understand that it is my fault. It is as if I have no regard for consequences at times.

 

Social – I do not like to meet new people. I don’t like talking and do not seek out new relationships. I don’t have any friends that I hang out with. I never leave my house unless I have too. I would rather avoid social interaction. My Wife sais she has to walk on egg shells around me sometimes bc my temper. I don’t have a relationship with my family. They care about me but it’s as if I don’t care about them or am indifferent.

 

Thanks for the help.