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MsAsya

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About MsAsya

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  1. Thank you, you have been very helpful since I found this forum. I will log into ebenefits and see if anything has changed. Everything was still the same, that’s why I was concerned. i do have have 3 children and work for ford motor company, but have been out on medical leave for over a year. I do receive STD(short term disability) thru my employer, about 1900/mo gross, 1600 net. I don’t know if that will effect anything. But those benefits will end soon.
  2. Received an email regarding decision today from DAV, but ebenefits says pending decision approval. Does this mean that this decision could change?
  3. SECTION I: ---------- 1. Diagnostic Summary --------------------- Does the Veteran have a diagnosis of PTSD that conforms to DSM-5 criteria based on today's evaluation? [X] Yes [ ] No ICD code: F43.10 2. Current Diagnoses -------------------- a. Mental Disorder Diagnosis #1: Post-traumatic stress disorder ICD code: F43.10 Mental Disorder Diagnosis #2: Cannabis use disorder, mild ICD code: F12.10 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? [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: Cannabis use disorder accounts for persistent use despite negative consequences and large amounts of time spent using. All other symptoms are due to the PTSD. c. Does the Veteran have a diagnosed traumatic brain injury (TBI)? [ ] Yes [X] No [ ] Not shown in records reviewed 4. Occupational and social impairment ------------------------------------- a. Which of the following best summarizes the Veteran's level of occupational and social impairment with regards to all mental diagnoses? (Check only one) [X] Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation b. For the indicated occupational and social impairment, is it possible to differentiate which impairment is caused by each mental disorder? [ ] Yes [X] No [ ] Not Applicable (N/A) If no, provide reason: Veteran has not had meaningful sobriety from cannabis in some time so it is not possible to determine the level of impairment caused by her PTSD alone. c. If a diagnosis of TBI exists, is it possible to differentiate which occupational and social impairment indicated above is caused by the TBI? [ ] Yes [ ] No [X] Not Applicable (N/A) family mental health (pre-military, military, and post-military): Veteran first received counseling services as a child, related to DCFS involvement. She reported a history of suicidal ideation and self-destructive behavior around age 7-8. One inpatient hospitalization at this time. Still with suicidal ideation, "I really hate being here," estimated once per day. Has engaged in reckless behavior, like fast driving. Cites children as deterrent. Also fears not succeeding and being chronically disabled. History of self-injurious behavior (cutting and burning) 4-5 years ago. Cries daily. Limited enjoyment of activities. Able to care for children. Unclear how much assistance she receives from family me mbers. "I feel like a bad mom." Does not have many friends. Prefers to be alone. Currently attending therapy once per week. Cannot discuss trauma because she becomes too distressed. "I constantly remember or think about ways I could have gotten away or done things differently. I feel like a weak person. I can't protect myself. How can I protect my children?" Taking medications Seroquel and Lamictal along with sleep aid (Trazodone). Medications not helpful. No adverse side effects. Misses 2 doses per week. Sleep disrupted by dreams of "being trapped." Weight fluctuates along with eating. Prefers not to sleep. Wants to stay alert to surroundings. Occasionally sees "shadows." d. Relevant legal and behavioral history (pre-military, military, and post-military): Juvenile legal involvement for stealing and truancy. History of fighting as a juvenile. e. Relevant substance abuse history (pre-military, military, and post-military): 1-2 grams cannabis daily. Able to be sober 1-2 years while looking for a job or while pregnant. No problems related to use. History of alcohol use, which she stopped due to father's history of alcoholism. f. Other, if any: No response provided. 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: 2 rapes by fellow service members 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? [ ] Yes [X] No Is the stressor related to personal assault, e.g. military sexual trauma? [X] Yes [ ] No If yes, please describe the markers that may substantiate the stressor. Unplanned pregnancy documented 9/4/2008. Delivery 5/4/2009. Disclosure of MST to multiple providers, including non-VA providers. Veteran's statement in support of claim dated 8/11/2018. 4. PTSD Diagnostic Criteria --------------------------- Note: 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 to associated with the traumatic event(s), beginning after the traumatic event(s) occurred: [X] Intense or prolonged psychological distress at exposure internal or external cues that symbolize or resemble an aspect of the traumatic event(s). Criterion Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic events(s) occurred, as evidenced by one or both of the following: [X] Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with traumatic event(s). "I Criterion 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) 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] Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others. [X] Markedly diminished interest or participation in significant activities. [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] Reckless or self-destructive behavior. [X] Hypervigilance. [X] Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep). Criterion F: [X] Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month. Criterion G: [X] The disturbance causes 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. Criterion I: Which stressor(s) contributed to the Veteran's PTSD diagnosis?: [X] Stressor #1 5. Symptoms ----------- For VA rating purposes, check all symptoms that actively apply to the Veteran's diagnoses: [X] Depressed mood [X] Anxiety [X] Suspiciousness [X] Chronic sleep impairment [X] Flattened affect [X] Disturbances of motivation and mood [X] Suicidal ideation 6. Behavioral Observations -------------------------- The Veteran arrived on time and alone for her appointment, and sat calmly in the waiting room until her name was called. She responded promptly, and walked steadily and without assistance. No psychomotor abnormalities, such as tics or tremor, were observed. The Veteran displayed fair eye contact and adequate grooming, and was generally cooperative with the evaluation. Her speech was spontaneous and fluent, with soft volume and slowed rate. She provided short responses to questions. The Veteran described her mood as "depressed." Affect was distressed, tearful, and congruent with her stated mood. Thought process was linear and organized. Associations were coherent. Thought content was without delusions or homicidal ideation. Veteran reported passive suicidal ideation without intent or plan. She has no firearms at home and cited deterrents for suicide. She planned to meet with her psychiatrist after her C&P appointment and was not considered an imminent risk of self harm. The Veteran reported atypcial hallucinations of music and shadows. She did not appear to be responding to internal stimuli during the evaluation. The Veteran was alert and oriented. Attention was intact via conversation. Intellect was estimated as average. Insight and judgment were thought to be intact. 7. Other symptoms ----------------- Does the Veteran have any other symptoms attributable to PTSD (and other mental disorders) that are not listed above? [ ] Yes [X] No 8. Competency ------------- Is the Veteran capable of managing his or her financial affairs? [X] Yes [ ] No 9. Remarks, (including any testing results) if any MEDICAL OPINION SUMMARY ----------------------- RESTATEMENT OF REQUESTED OPINION: a. Opinion from general remarks: Military Sexual Trauma (MST) b. Indicate type of exam for which opinion has been requested: Psych-PTSD Initial TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR DIRECT SERVICE CONNECTION ] a. The condition claimed was at least as likely as not (50% or greater probability) incurred in or caused by the claimed in-service injury, event or illness. c. Rationale: The Veteran meets minimum diagnostic criteria for post-traumatic stress disorder. The current level of severity is moderate. Veteran reported ongoing symptoms despite medications and therapy. It is at least as likely as not that the Veteran's PTSD is due to her reported military sexual trauma (MST). It is patently impossible to determine whether or not the veteran's claimed experiences of MST are factual based only upon the evidence provided in her claims file. To be clear, the veteran has reported that these incidents occurred and there is nothing contained in her service treatment records that contradicts her report. There is evidence to support her claim starting with the diagnosis of pregnancy on 9/4/2008. This examiner can see no reason to doubt the veracity of the MST events that she has reported. The veteran's ongoing mental health symptoms are consistent with symptoms often reported by individuals who have a history of sexual assault, which serves to further substantiate the claimed events. In light of the evidence reviewed today, and the veteran's self-report, it is the opinion of this examiner that it is at least as likely as not that the MST events reported above did in fact occur. The Veteran's diagnosis of cannabis use disorder is a separate diagnosis and is not secondary to the PTSD. The mental disorders of PTSD and cannabis use disorder affect the Veteran's occupational functioning in terms of her ability to get along with others and maintain concentration. No formal cognitive assessment was performed today, nor has any been documented in records. Veteran did not display any overt cognitive deficits. She reported she is largely independent for activities of daily living, including caring for her three children. She is able to drive a car.
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