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Bluebonnie

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  1. Hello Berta,

    Can you please give me some clarity as to what is going on with my claim please? It was for PTSD/personal trauma and I just received my decision but I don't understand why it was denied and what exactly they need to Grant it. I'm confused. Exam I thought was favorable except THE examiner didn't give an actual diagnose for PTSD but for other related stress disorder, however my va treating doctor inially diagnose was for PTSD, MDD GAD PANIC SOCIAL PHOBIA AND RECENTLY ADDED BEREAVEMENT. What's missing?IMG_20190401_205458_1.thumb.jpg.4de763db1f0f34227c09ab959999989b.jpg15541706148261170943643.thumb.jpg.48e239b0f6d49db4a87fc8f56a9db533.jpg

    Also my c and p exam.

    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: Other Specified Trauma- and Stressor-Related
    Disorder
    ICD code: F43.8
    Comments, if any:
    Veteran does NOT meet full DSM 5 diagnostic criteria for PTSD.
    While the veteran did experience a Criterion A trauma event
    (physical assault by significant other), her other significant
    stressor in the service does NOT meet Criterion A (sexual
    harassment), though the latter appears to have had a more long-term
    impact on her functioning. She does NOT endorse, exhibit, and there
    is no record of her experiencing core symptoms (arousal) that are
    essential to a PTSD diagnosis based on the Criterion A stressor
    (her arousal is far more closely related to her reported sexual
    harassment). However, the veteran DOES meet DSM 5 diagnostic
    criteria for Other Specified Trauma- and Stressor-Related Disorder.
    It is AT LEAST AS LIKELY AS NOT that the Other Specified Traumaand Stressor-Related Disorder is the result of an in-service
    stressor related event.
    Mental Disorder Diagnosis #2: Panic Disorder w/Agorophobia
    ICD code: F41.0
    Comments, if any:
    Veteran also meets full DSM 5 diagnostic criteria for Panic
    Disorder, with agorophobia. It is AT LEAST AS LIKELY AS NOT that
    the veteran's Panic Disorder is SECONDARY TO her Other Specified
    Trauma- and Stressor-Related Disorder.
    Mental Disorder Diagnosis #3: Unspecified Depressive Disorder
    ICD code: F32.9 

    Comments, if any:
    Veteran also meets full DSM 5 diagnostic criteria for Unspecified
    Depressive Disorder. It is AT LEAST AS LIKELY AS NOT that the
    veteran's Unspecified Depressive Disorder is SECONDARY TO her Other
    Specified Trauma- and Stressor-Related Disorder.
    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:
    PTSD Symptoms: 
    * Sleep disturbance due to nightmares 
    * Recurring/intrusive thoughts about his/her trauma(s). 
    * Arousal symptoms, including hypervigilance, exaggerated startle
    response; irritability/angry outbursts; difficulty remembering
    specifics related to the trauma event(s); 
    * Avoidance symptoms of avoiding reminders of the trauma(s);
    having strong reactions when aspects of the trauma(s) are
    encountered/experienced.
    * Negative alterations in cognitions and mood associated with the
    traumatic event(s)
    Symptoms associated with veteran's depressive disorder include:
    * depressed mood most of the day, nearly every day
    * markedly diminished interest in or pleasure in all, or almost
    all, activities most of the day, nearly every day
    * significant weight loss when not dieting or weight gain (not related to physiological condition) or decrease or increase in
    appetite nearly every day
    * insomnia or hypersomnia nearly every day
    * psychomotor agitation or retardation nearly every day
    (observable to others)
    * fatigue or loss of energy nearly every day
    * feelings of worthlessness or excessive or inappropriate guilt
    nearly every day
    * diminished ability to think or concentrate, or indecisiveness,
    nearly every day
    * recurrent thoughts of death (not just fear of dying), recurrent
    suicidal ideation or suicidality
    OVERLAPPING SYMPTOMS OF PTSD/MDD, include, but is not
    limited to:
    sleep problems (related to onset and maintenance);
    fatigue;
    concentration difficulties; difficulties experiencing
    positive
    emotions; feeling isolated or disconnected from others;
    loss of
    interest in previously enjoyable activities; having
    strong negative
    beliefs about oneself, the world, others. As well as
    feelings of
    worthlessness or excessive or inappropriate guilt nearly
    every day.
    Symptoms associated with veteran's panic disorder include:
    * palpitations, pounding heart, or accelerated heart rate
    * excessive perspiration/sweating
    * trembling or shaking
    * sensation of shortness of breath or smothering
    * feelings of choking
    * chest pain or discomfort
    * nausea or abdominal distress
    * feeling dizzy, unsteady, light-headed, or faint  chills or heat sensations
    * derealization (feelings of unreality) or depersonalization
    (being detached from one-self)
    * fear of losing control or "going crazy"
    * fear of dying
    * persistent fear or worry about additional panic attacks or their
    consequences
    * significant maladaptive change in behavior related to the
    attacks
    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 deficiencies in most areas,
    such as work, school, family relations, judgment, thinking and/or mood
    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:
    It is not feasible to parse out the veteran's level of
    occupational/social impairment (a global assessment of impairment)
    into diagnostic categories as the conditions have a significant,
    bidirectional impact on one another with significant overlap in
    symptoms.
    NOTE: The overall functional impairment of this veteran is best
    conceptualized via the chosen statement above in Section 1, Item 4a
    ("occupational and social impairment...") and NOT the symptoms
    checklist at the conclusion of this report (see section 2, Item 3 -
    "Symptoms") as symptom endorsement alone do not capture the
    frequency or severity of their presence.

    c. If a diagnosis of TBI exists, is it possible to differentiate which
    occupational and social impairment indicated above is caused by the TBI?
    [ ] Yes [ ] No [X] Not Applicable (N/A)
    SECTION II:
    -----------
    Clinical Findings:
    ------------------
    1. Evidence Review
    ------------------
    Evidence reviewed (check all that apply):
    [X] VA e-folder
    [X] CPRS
    [X] Other (please identify other evidence reviewed):
    Veteran's electronic C-File (through VBMS) and CPRS medical records
    were reviewed. Particular attention was directed to 
    previous C&P examination 

    dated: n/a
    prior mental health notes: CPRS 

    VBMS documents including, but not limited to: buddy/lay statement

    DD-214; STRs (negative for psych, depression, anxiety)
    VA Form 21-0781 
    VA Form 21-526EZ
    No collateral information was available in C-file and no collaterals
    joined veteran to C&P evaluation. 
    Evidence Comments:
    DBQ PSYCH PTSD Initial:

    Please review the Veteran's electronic folder in VBMS and state that it was 
    reviewed in your report. MEDICAL OPINION REQUEST
    TYPE OF MEDICAL OPINION REQUESTED: Direct service connection
    OPINION: Direct service connection
    Does the Veteran have a diagnosis of (a) post traumatic Stressor disorder 
    that is at least as likely as not (50 percent or greater probability) 
    incurred in or caused by (the) personal trauma during service?
    Rationale must be provided in the appropriate section.
    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.

    Additional remarks for the examiner:
    Tab B (Stressor Statement in VBMS) Stessor Statement VAF 21-0781 
    Tab C (Stressor Statement in VBMS) Stessor Statement VAF 21-0781

    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: sexual harrasment (mainly verbal with some physical
    posturing)
    Does this stressor meet Criterion A (i.e., is it adequate to support
    the diagnosis of PTSD)?
    [ ] Yes [X] No
    Is the stressor related to the Veteran's fear of hostile military or
    terrorist activity?
    [ ] Yes [X] No
    If no, explain:
    sexual harrassment
    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.
    MST event

    b. Stressor #2: physical assault while pregnant by significant other (which
    prompted her military discharge)
    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
    If no, explain:
    personal assault
    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.
    see above
    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
    associated with the traumatic event(s), beginning after the traumatic event(s) occurred:
    [X] No criterion in this section met.
    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 the
    traumatic event(s).
    [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 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] Persistent negative emotional state (e.g., fear, horror,
    anger, guilt, or shame).
    [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] Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical
    aggression toward people or objects.
    [X] Reckless or self-destructive behavior.
    [X] Hypervigilance.
    [X] Exaggerated startle response.
    [X] Problems with concentration.
    [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 #2
    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] Panic attacks more than once a week
    [X] Near-continuous panic or depression affecting the ability to function
    independently, appropriately and effectively
    [X] Chronic sleep impairment
    [X] Disturbances of motivation and mood
    [X] Difficulty in adapting to stressful circumstances, including work or a
    worklike setting
    [X] Inability to establish and maintain effective relationships
    [X] Suicidal ideation
    [X] Neglect of personal appearance and hygiene
    [X] Intermittent inability to perform activities of daily living,
    including maintenance of minimal personal hygiene.

    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
    --------------------------------------------------
    As part of this C&P evaluation, veteran was administered the PTSD
    Checklist - DSM 5 (PCL-5) & Beck Depression Inventory - Second Edition
    (BDI-II). 
    The PTSD Checklist - DSM 5 is a 20-item self-report instrument for
    measuring the severity of criteria for posttraumatic stress disorder. Ms.(......)
    PCL score of 68 is above the recommended score that is typically
    indicative of PTSD symptomatology (31-33 based on Bovin et al., 2015,
    Psych Assessment; maximum score of 80). No previous administration(s) of
    this instrument were located in the veteran's records. The PCL is
    considered a screening measure and does NOT include validity scales. As
    such, it is susceptible to positive and negative impression management.
    The Beck Depression Inventory - Second Edition (BDI-II) is a 21-item
    self-report instrument for measuring the severity of depression in adults
    and adolescents aged 13 years and older. Ms. (........) BDI-II score of 46 is
    indicative of severe depressive symptoms being endorsed at the present
    time. No previous administration(s) of this instrument were located in the
    veteran's records. The BDI-2 is considered a screening measure and does
    NOT include validity scales. As such, it is susceptible to positive and negative impressions.

  2. Hello Unique11128, Who is Dr Brett valette and do you think he will be able to do something about this? Also can you explain to me what they are saying in layman's term please?
  3. Can someone please explain to me what exactly are they saying as to why they denied my claim for PTSD and what is needed to Grant it? Also what should I do next because I have no idea, I'm so confused!
  4. Update So my claim was deferred for additional development, which I don't understand what they mean. If I had all the required caluza elements, what can I possible do now to get it moving along? Does anyone know what I should do at this point?
  5. So they don't have enough to deny it but they don't have enough to grant/rate? What more could they want? Are they going to tell me? I mean they could have just flat out denied me right? Do they usually do after a deferred, I mean I heard they like to delay and deny.
  6. Update My claim status changed to deferred with a new completion date. Can someone tell exactly what that is and why would they deferre it? Do you think maybe it was because of my c and p exam wasn't clear enough? I thought overall it was a thorough report other than the box left uncheck in criterion B and the pyramid diagnosis situation.
  7. Thank all of you for the responses. I am really wishing for the best, even though I feel like they sometimes try to find any reason to just deny us. I will update as soon as I know something.
  8. I thought it says I don't meet the criteria rating PTSD? I'm confused. If the rater reads?
  9. Thank you...I sure hope everything is alright. Now that I have posted it more clearly I was wondering if you could look at criterion B and tell me why he stated (no criterion met)? Will this affect my claim even though I was diagnosed with Other Specified Trauma- and Stressor-Related Disorder and not PTSD? Also, why did my status change so quickly after my c and p exam. It was at gathering evidence and changed to pending decision approval all in a matter of four days after my exam. Do you have any idea why?
  10. --------------------- 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: Other Specified Trauma- and Stressor-Related Disorder ICD code: F43.8 Comments, if any: Veteran does NOT meet full DSM 5 diagnostic criteria for PTSD. While the veteran did experience a Criterion A trauma event (physical assault by significant other), her other significant stressor in the service does NOT meet Criterion A (sexual harassment), though the latter appears to have had a more long-term impact on her functioning. She does NOT endorse, exhibit, and there is no record of her experiencing core symptoms (arousal) that are essential to a PTSD diagnosis based on the Criterion A stressor (her arousal is far more closely related to her reported sexual harassment). However, the veteran DOES meet DSM 5 diagnostic criteria for Other Specified Trauma- and Stressor-Related Disorder. It is AT LEAST AS LIKELY AS NOT that the Other Specified Trauma and Stressor-Related Disorder is the result of an in-service stressor related event. Mental Disorder Diagnosis #2: Panic Disorder w/Agorophobia ICD code: F41.0 Comments, if any: Veteran also meets full DSM 5 diagnostic criteria for Panic Disorder, with agorophobia. It is AT LEAST AS LIKELY AS NOT that the veteran's Panic Disorder is SECONDARY TO her Other Specified Trauma- and Stressor-Related Disorder. Mental Disorder Diagnosis #3: Unspecified Depressive Disorder ICD code: F32.9 Comments, if any: Veteran also meets full DSM 5 diagnostic criteria for Unspecified Depressive Disorder. It is AT LEAST AS LIKELY AS NOT that the veteran's Unspecified Depressive Disorder is SECONDARY TO her Other Specified Trauma- and Stressor-Related Disorder. 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: PTSD Symptoms: * Sleep disturbance due to nightmares * Recurring/intrusive thoughts about his/her trauma(s). * Arousal symptoms, including hypervigilance, exaggerated startle response; irritability/angry outbursts; difficulty remembering specifics related to the trauma event(s); * Avoidance symptoms of avoiding reminders of the trauma(s); having strong reactions when aspects of the trauma(s) are encountered/experienced. * Negative alterations in cognitions and mood associated with the traumatic event(s) Symptoms associated with veteran's depressive disorder include: * depressed mood most of the day, nearly every day * markedly diminished interest in or pleasure in all, or almost all, activities most of the day, nearly every day * significant weight loss when not dieting or weight gain (not related to physiological condition) or decrease or increase in appetite nearly every day * insomnia or hypersomnia nearly every day * psychomotor agitation or retardation nearly every day (observable to others) * fatigue or loss of energy nearly every day * feelings of worthlessness or excessive or inappropriate guilt nearly every day * diminished ability to think or concentrate, or indecisiveness, nearly every day * recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation or suicidality OVERLAPPING SYMPTOMS OF PTSD/MDD, include, but is not limited to: sleep problems (related to onset and maintenance); fatigue; concentration difficulties; difficulties experiencing positive emotions; feeling isolated or disconnected from others; loss of interest in previously enjoyable activities; having strong negative beliefs about oneself, the world, others. As well as feelings of worthlessness or excessive or inappropriate guilt nearly every day. Symptoms associated with veteran's panic disorder include: * palpitations, pounding heart, or accelerated heart rate * excessive perspiration/sweating * trembling or shaking * sensation of shortness of breath or smothering * feelings of choking * chest pain or discomfort * nausea or abdominal distress * feeling dizzy, unsteady, light-headed, or faint chills or heat sensations * derealization (feelings of unreality) or depersonalization (being detached from one-self) * fear of losing control or "going crazy" * fear of dying * persistent fear or worry about additional panic attacks or their consequences * significant maladaptive change in behavior related to the attacks 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 deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood 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: It is not feasible to parse out the veteran's level of occupational/social impairment (a global assessment of impairment) into diagnostic categories as the conditions have a significant, bidirectional impact on one another with significant overlap in symptoms. NOTE: The overall functional impairment of this veteran is best conceptualized via the chosen statement above in Section 1, Item 4a ("occupational and social impairment...") and NOT the symptoms checklist at the conclusion of this report (see section 2, Item 3 - "Symptoms") as symptom endorsement alone do not capture the frequency or severity of their presence. c. If a diagnosis of TBI exists, is it possible to differentiate which occupational and social impairment indicated above is caused by the TBI? [ ] Yes [ ] No [X] Not Applicable (N/A) SECTION II: ----------- Clinical Findings: ------------------ 1. Evidence Review ------------------ Evidence reviewed (check all that apply): [X] VA e-folder [X] CPRS [X] Other (please identify other evidence reviewed): Veteran's electronic C-File (through VBMS) and CPRS medical records were reviewed. Particular attention was directed to previous C&P examination ] dated: n/a prior mental health notes: CPRS VBMS documents including, but not limited to: buddy/lay statement DD-214; STRs (negative for psych, depression, anxiety) VA Form 21-0781 VA Form 21-526EZ No collateral information was available in C-file and no collaterals joined veteran to C&P evaluation. Evidence Comments: DBQ PSYCH PTSD Initial: Please review the Veteran's electronic folder in VBMS and state that it was reviewed in your report. MEDICAL OPINION REQUEST TYPE OF MEDICAL OPINION REQUESTED: Direct service connection OPINION: Direct service connection Does the Veteran have a diagnosis of (a) post traumatic Stressor disorder that is at least as likely as not (50 percent or greater probability) incurred in or caused by (the) personal trauma during service? Rationale must be provided in the appropriate section. 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. Additional remarks for the examiner: Tab B (Stressor Statement in VBMS) Stessor Statement VAF 21-0781 Tab C (Stressor Statement in VBMS) Stessor Statement VAF 21-0781 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: sexual harrasment (mainly verbal with some physical posturing) Does this stressor meet Criterion A (i.e., is it adequate to support the diagnosis of PTSD)? [ ] Yes [X] No Is the stressor related to the Veteran's fear of hostile military or terrorist activity? [ ] Yes [X] No If no, explain: sexual harrassment 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. MST event b. Stressor #2: physical assault while pregnant by significant other (which prompted her military discharge) 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 If no, explain: personal assault 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. see above 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 associated with the traumatic event(s), beginning after the traumatic event(s) occurred: [X] No criterion in this section met. 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 the traumatic event(s). [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 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] Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame). [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] Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects. [X] Reckless or self-destructive behavior. [X] Hypervigilance. [X] Exaggerated startle response. [X] Problems with concentration. [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 #2 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] Panic attacks more than once a week [X] Near-continuous panic or depression affecting the ability to function independently, appropriately and effectively [X] Chronic sleep impairment [X] Disturbances of motivation and mood [X] Difficulty in adapting to stressful circumstances, including work or a worklike setting [X] Inability to establish and maintain effective relationships [X] Suicidal ideation [X] Neglect of personal appearance and hygiene [X] Intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene. 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 -------------------------------------------------- As part of this C&P evaluation, veteran was administered the PTSD Checklist - DSM 5 (PCL-5) & Beck Depression Inventory - Second Edition (BDI-II). The PTSD Checklist - DSM 5 is a 20-item self-report instrument for measuring the severity of criteria for posttraumatic stress disorder. Ms.(......) PCL score of 68 is above the recommended score that is typically indicative of PTSD symptomatology (31-33 based on Bovin et al., 2015, Psych Assessment; maximum score of 80). No previous administration(s) of this instrument were located in the veteran's records. The PCL is considered a screening measure and does NOT include validity scales. As such, it is susceptible to positive and negative impression management. The Beck Depression Inventory - Second Edition (BDI-II) is a 21-item self-report instrument for measuring the severity of depression in adults and adolescents aged 13 years and older. Ms. (........) BDI-II score of 46 is indicative of severe depressive symptoms being endorsed at the present time. No previous administration(s) of this instrument were located in the veteran's records. The BDI-2 is considered a screening measure and does NOT include validity scales. As such, it is susceptible to positive and negative impressions. Timeline C and p exam done Monday 12/31/2018 Results ready/claim status change to prep for decision on Thursday 01/03/2019 Friday 01/04/2019 pending decision approval
  11. Don't know why the lines are on there when I tried to post this.sry
  12. 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: Other Specified Trauma- and Stressor-Related Disorder ICD code: F43.8 Comments, if any: Veteran does NOT meet full DSM 5 diagnostic criteria for PTSD. While the veteran did experience a Criterion A trauma event (physical assault by significant other), her other significant stressor in the service does NOT meet Criterion A (sexual harassment), though the latter appears to have had a more long-term impact on her functioning. She does NOT endorse, exhibit, and there is no record of her experiencing core symptoms (arousal) that are essential to a PTSD diagnosis based on the Criterion A stressor (her arousal is far more closely related to her reported sexual harassment). However, the veteran DOES meet DSM 5 diagnostic criteria for Other Specified Trauma- and Stressor-Related Disorder. It is AT LEAST AS LIKELY AS NOT that the Other Specified Traumaand Stressor-Related Disorder is the result of an in-service stressor related event. Mental Disorder Diagnosis #2: Panic Disorder w/Agorophobia ICD code: F41.0 Comments, if any: Veteran also meets full DSM 5 diagnostic criteria for Panic Disorder, with agorophobia. It is AT LEAST AS LIKELY AS NOT that the veteran's Panic Disorder is SECONDARY TO her Other Specified Trauma- and Stressor-Related Disorder. Mental Disorder Diagnosis #3: Unspecified Depressive Disorder ICD code: F32.9 Comments, if any: Veteran also meets full DSM 5 diagnostic criteria for Unspecified Depressive Disorder. It is AT LEAST AS LIKELY AS NOT that the veteran's Unspecified Depressive Disorder is SECONDARY TO her Other Specified Trauma- and Stressor-Related Disorder. 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: PTSD Symptoms: * Sleep disturbance due to nightmares * Recurring/intrusive thoughts about his/her trauma(s). * Arousal symptoms, including hypervigilance, exaggerated startle response; irritability/angry outbursts; difficulty remembering specifics related to the trauma event(s); * Avoidance symptoms of avoiding reminders of the trauma(s); having strong reactions when aspects of the trauma(s) are encountered/experienced. * Negative alterations in cognitions and mood associated with the traumatic event(s) Symptoms associated with veteran's depressive disorder include: * depressed mood most of the day, nearly every day * markedly diminished interest in or pleasure in all, or almost all, activities most of the day, nearly every day * significant weight loss when not dieting or weight gain (not related to physiological condition) or decrease or increase in appetite nearly every day * insomnia or hypersomnia nearly every day * psychomotor agitation or retardation nearly every day (observable to others) * fatigue or loss of energy nearly every day * feelings of worthlessness or excessive or inappropriate guilt nearly every day * diminished ability to think or concentrate, or indecisiveness, nearly every day * recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation or suicidality OVERLAPPING SYMPTOMS OF PTSD/MDD, include, but is not limited to: sleep problems (related to onset and maintenance); fatigue; concentration difficulties; difficulties experiencing positive emotions; feeling isolated or disconnected from others; loss of interest in previously enjoyable activities; having strong negative beliefs about oneself, the world, others. As well as feelings of worthlessness or excessive or inappropriate guilt nearly every day. Symptoms associated with veteran's panic disorder include: * palpitations, pounding heart, or accelerated heart rate * excessive perspiration/sweating * trembling or shaking * sensation of shortness of breath or smothering * feelings of choking * chest pain or discomfort * nausea or abdominal distress * feeling dizzy, unsteady, light-headed, or faint chills or heat sensations * derealization (feelings of unreality) or depersonalization (being detached from one-self) * fear of losing control or "going crazy" * fear of dying * persistent fear or worry about additional panic attacks or their consequences * significant maladaptive change in behavior related to the attacks 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 deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood 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: It is not feasible to parse out the veteran's level of occupational/social impairment (a global assessment of impairment) into diagnostic categories as the conditions have a significant, bidirectional impact on one another with significant overlap in symptoms. NOTE: The overall functional impairment of this veteran is best conceptualized via the chosen statement above in Section 1, Item 4a ("occupational and social impairment...") and NOT the symptoms checklist at the conclusion of this report (see section 2, Item 3 - "Symptoms") as symptom endorsement alone do not capture the frequency or severity of their presence. c. If a diagnosis of TBI exists, is it possible to differentiate which occupational and social impairment indicated above is caused by the TBI? [ ] Yes [ ] No [X] Not Applicable (N/A) SECTION II: ----------- Clinical Findings: ------------------ 1. Evidence Review ------------------ Evidence reviewed (check all that apply): [X] VA e-folder [X] CPRS [X] Other (please identify other evidence reviewed): Veteran's electronic C-File (through VBMS) and CPRS medical records were reviewed. Particular attention was directed to previous C&P examination dated: n/a prior mental health notes: CPRS VBMS documents including, but not limited to: buddy/lay statement DD-214; STRs (negative for psych, depression, anxiety) VA Form 21-0781 VA Form 21-526EZ No collateral information was available in C-file and no collaterals joined veteran to C&P evaluation. Evidence Comments: DBQ PSYCH PTSD Initial: Please review the Veteran's electronic folder in VBMS and state that it was reviewed in your report. MEDICAL OPINION REQUEST TYPE OF MEDICAL OPINION REQUESTED: Direct service connection OPINION: Direct service connection Does the Veteran have a diagnosis of (a) post traumatic Stressor disorder that is at least as likely as not (50 percent or greater probability) incurred in or caused by (the) personal trauma during service? Rationale must be provided in the appropriate section. 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. Additional remarks for the examiner: Tab B (Stressor Statement in VBMS) Stessor Statement VAF 21-0781 Tab C (Stressor Statement in VBMS) Stessor Statement VAF 21-0781 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: sexual harassment (mainly verbal with some physical posturing) Does this stressor meet Criterion A (i.e., is it adequate to support the diagnosis of PTSD)? [ ] Yes [X] No Is the stressor related to the Veteran's fear of hostile military or terrorist activity? [ ] Yes [X] No If no, explain: sexual harassment 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. MST event b. Stressor #2: physical assault while pregnant by significant other (which prompted her military discharge) 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 If no, explain: personal assault 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. see above 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 associated with the traumatic event(s), beginning after the traumatic event(s) occurred: [X] No criterion in this section met. 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 the traumatic event(s). [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 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] Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame). [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] Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects. [X] Reckless or self-destructive behavior. [X] Hypervigilance. [X] Exaggerated startle response. [X] Problems with concentration. [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 #2 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] Panic attacks more than once a week [X] Near-continuous panic or depression affecting the ability to function independently, appropriately and effectively [X] Chronic sleep impairment [X] Disturbances of motivation and mood [X] Difficulty in adapting to stressful circumstances, including work or a work like setting [X] Inability to establish and maintain effective relationships [X] Suicidal ideation [X] Neglect of personal appearance and hygiene [X] Intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene 6. Behavioral Oberservations( I'm skipping it) 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 -------------------------------------------------- As part of this C&P evaluation, veteran was administered the PTSD Checklist - DSM 5 (PCL-5) & Beck Depression Inventory - Second Edition (BDI-II). The PTSD Checklist - DSM 5 is a 20-item self-report instrument for measuring the severity of criteria for posttraumatic stress disorder. (My name)PCL score of 68 is above the recommended score that is typically indicative of PTSD symptomatology (31-33 based on Bovin et al., 2015, Psych Assessment; maximum score of 80). No previous administration(s) of this instrument were located in the veteran's records. The PCL is considered a screening measure and does NOT include validity scales. As such, it is susceptible to positive and negative impression management. The Beck Depression Inventory - Second Edition (BDI-II) is a 21-item self-report instrument for measuring the severity of depression in adults and adolescents aged 13 years and older. (Name) BDI-II score of 46 is indicative of severe depressive symptoms being endorsed at the present time. No previous administration(s) of this instrument were located in the veteran's records. The BDI-2 is considered a screening measure and does NOT include validity scales. As such, it is susceptible to positive and negative impressions.
  13. First, I don't understand my results of c and p exam. Can someone help me out with this. After having my c and p exam 12/31/2018 my status changed quickly to prep for decision on 01/03/2019, then the next day on 1/04/2019 it changed to pending decision approval. Does this mean that it will be denied because it's moving so quickly. Why is it changing so fast? I have a copy of my report. Also estimated completion date is 1/12/2019-01/18/2019. Seems all to quickly to me which makes it scary. 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: Other Specified Trauma- and Stressor-Related Disorder ICD code: F43.8 Comments, if any: Veteran does NOT meet full DSM 5 diagnostic criteria for PTSD. While the veteran did experience a Criterion A trauma event (physical assault by significant other), her other significant stressor in the service does NOT meet Criterion A (sexual harassment), though the latter appears to have had a more long-term impact on her functioning. She does NOT endorse, exhibit, and there is no record of her experiencing core symptoms (arousal) that are essential to a PTSD diagnosis based on the Criterion A stressor (her arousal is far more closely related to her reported sexual harassment). However, the veteran DOES meet DSM 5 diagnostic criteria for Other Specified Trauma- and Stressor-Related Disorder. It is AT LEAST AS LIKELY AS NOT that the Other Specified Traumaand Stressor-Related Disorder is the result of an in-service stressor related event. Mental Disorder Diagnosis #2: Panic Disorder w/Agorophobia ICD code: F41.0 Comments, if any: Veteran also meets full DSM 5 diagnostic criteria for Panic Disorder, with agorophobia. It is AT LEAST AS LIKELY AS NOT that the veteran's Panic Disorder is SECONDARY TO her Other Specified Trauma- and Stressor-Related Disorder. Mental Disorder Diagnosis #3: Unspecified Depressive Disorder ICD code: F32.9 Comments, if any: Veteran also meets full DSM 5 diagnostic criteria for Unspecified Depressive Disorder. It is AT LEAST AS LIKELY AS NOT that the veteran's Unspecified Depressive Disorder is SECONDARY TO her Other Specified Trauma- and Stressor-Related Disorder. 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: PTSD Symptoms: * Sleep disturbance due to nightmares * Recurring/intrusive thoughts about his/her trauma(s). * Arousal symptoms, including hypervigilance, exaggerated startle response; irritability/angry outbursts; difficulty remembering specifics related to the trauma event(s); * Avoidance symptoms of avoiding reminders of the trauma(s); having strong reactions when aspects of the trauma(s) are encountered/experienced. * Negative alterations in cognitions and mood associated with the traumatic event(s) Symptoms associated with veteran's depressive disorder include: * depressed mood most of the day, nearly every day * markedly diminished interest in or pleasure in all, or almost all, activities most of the day, nearly every day * significant weight loss when not dieting or weight gain (not related to physiological condition) or decrease or increase in appetite nearly every day * insomnia or hypersomnia nearly every day * psychomotor agitation or retardation nearly every day (observable to others) * fatigue or loss of energy nearly every day * feelings of worthlessness or excessive or inappropriate guilt nearly every day * diminished ability to think or concentrate, or indecisiveness, nearly every day * recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation or suicidality OVERLAPPING SYMPTOMS OF PTSD/MDD, include, but is not limited to: sleep problems (related to onset and maintenance); fatigue; concentration difficulties; difficulties experiencing positive emotions; feeling isolated or disconnected from others; loss of interest in previously enjoyable activities; having strong negative beliefs about oneself, the world, others. As well as feelings of worthlessness or excessive or inappropriate guilt nearly every day. Symptoms associated with veteran's panic disorder include: * palpitations, pounding heart, or accelerated heart rate * excessive perspiration/sweating * trembling or shaking * sensation of shortness of breath or smothering * feelings of choking * chest pain or discomfort * nausea or abdominal distress * feeling dizzy, unsteady, light-headed, or faint chills or heat sensations * derealization (feelings of unreality) or depersonalization (being detached from one-self) * fear of losing control or "going crazy" * fear of dying * persistent fear or worry about additional panic attacks or their consequences * significant maladaptive change in behavior related to the attacks 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 deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood 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: It is not feasible to parse out the veteran's level of occupational/social impairment (a global assessment of impairment) into diagnostic categories as the conditions have a significant, bidirectional impact on one another with significant overlap in symptoms. NOTE: The overall functional impairment of this veteran is best conceptualized via the chosen statement above in Section 1, Item 4a ("occupational and social impairment...") and NOT the symptoms checklist at the conclusion of this report (see section 2, Item 3 - "Symptoms") as symptom endorsement alone do not capture the frequency or severity of their presence. c. If a diagnosis of TBI exists, is it possible to differentiate which occupational and social impairment indicated above is caused by the TBI? [ ] Yes [ ] No [X] Not Applicable (N/A) SECTION II: ----------- Clinical Findings: ------------------ 1. Evidence Review ------------------ Evidence reviewed (check all that apply): [X] VA e-folder [X] CPRS [X] Other (please identify other evidence reviewed): Veteran's electronic C-File (through VBMS) and CPRS medical records were reviewed. Particular attention was directed to previous C&P examination dated: n/a prior mental health notes: CPRS VBMS documents including, but not limited to: buddy/lay statement DD-214; STRs (negative for psych, depression, anxiety) VA Form 21-0781 VA Form 21-526EZ No collateral information was available in C-file and no collaterals joined veteran to C&P evaluation. Evidence Comments: DBQ PSYCH PTSD Initial: Please review the Veteran's electronic folder in VBMS and state that it was reviewed in your report. MEDICAL OPINION REQUEST TYPE OF MEDICAL OPINION REQUESTED: Direct service connection OPINION: Direct service connection Does the Veteran have a diagnosis of (a) post traumatic Stressor disorder that is at least as likely as not (50 percent or greater probability) incurred in or caused by (the) personal trauma during service? Rationale must be provided in the appropriate section. 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. Additional remarks for the examiner: Tab B (Stressor Statement in VBMS) Stessor Statement VAF 21-0781 Tab C (Stressor Statement in VBMS) Stessor Statement VAF 21-0781 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: sexual harrasment (mainly verbal with some physical posturing) Does this stressor meet Criterion A (i.e., is it adequate to support the diagnosis of PTSD)? [ ] Yes [X] No Is the stressor related to the Veteran's fear of hostile military or terrorist activity? [ ] Yes [X] No If no, explain: sexual harrassment 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. MST event b. Stressor #2: physical assault while pregnant by significant other (which prompted her military discharge) 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 If no, explain: personal assault 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. see above 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 associated with the traumatic event(s), beginning after the traumatic event(s) occurred: [X] No criterion in this section met. 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 the traumatic event(s). [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 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] Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame). [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] Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects. [X] Reckless or self-destructive behavior. [X] Hypervigilance. [X] Exaggerated startle response. [X] Problems with concentration. [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 #2 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] Panic attacks more than once a week [X] Near-continuous panic or depression affecting the ability to function independently, appropriately and effectively [X] Chronic sleep impairment [X] Disturbances of motivation and mood [X] Difficulty in adapting to stressful circumstances, including work or a worklike setting [X] Inability to establish and maintain effective relationships [X] Suicidal ideation [X] Neglect of personal appearance and hygiene [X] Intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene. 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 -------------------------------------------------- As part of this C&P evaluation, veteran was administered the PTSD Checklist - DSM 5 (PCL-5) & Beck Depression Inventory - Second Edition (BDI-II). The PTSD Checklist - DSM 5 is a 20-item self-report instrument for measuring the severity of criteria for posttraumatic stress disorder. Ms.(......) PCL score of 68 is above the recommended score that is typically indicative of PTSD symptomatology (31-33 based on Bovin et al., 2015, Psych Assessment; maximum score of 80). No previous administration(s) of this instrument were located in the veteran's records. The PCL is considered a screening measure and does NOT include validity scales. As such, it is susceptible to positive and negative impression management. The Beck Depression Inventory - Second Edition (BDI-II) is a 21-item self-report instrument for measuring the severity of depression in adults and adolescents aged 13 years and older. Ms. (........) BDI-II score of 46 is indicative of severe depressive symptoms being endorsed at the present time. No previous administration(s) of this instrument were located in the veteran's records. The BDI-2 is considered a screening measure and does NOT include validity scales. As such, it is susceptible to positive and negative impressions. Timeline C and p exam done Monday 12/31/2018 Results ready/claim status change to prep for decision on Thursday 01/03/2019 Friday 01/04/2019 pending decision approval
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