RAM0311

I have terrible habit of downplaying symptoms, and even worse talking about them. So I probably am at my own fault for my rating. I have PTSD with insomnia... Is that something that should be looked at separately. My sleep sucks. I haven't approached a sleep study. Or do they get rated together?

I guess I'm not sure which exam you are requesting. I've had two C&P exams, but no other C&P type exams. I guess I"ll need clarification to which exam you are requesting, Thanks

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: F43.10 2. Current Diagnoses -------------------- a. Mental Disorder Diagnosis #1: PTSD ICD Code: F43.10 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? [ ] Yes [X] No 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 due to mild or transient symptoms which decrease work efficiency and ability to perform occupational ****************** Page 6 of 19 tasks only during periods of significant stress, or; symptoms controlled by medication b. For the indicated level of occupational and social impairment, is it possible to differentiate what portion of the occupational and social impairment indicated above is caused by each mental disorder? [ ] Yes [ ] No [X] No other mental disorder has been diagnosed 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 Evidence Comments: PCMHI Clinic Note, ***** - "PRESENTING COMPLAINTS: is a ******-year-old SERVICE CONNECTED % - 40 married veteran who presents with symptoms of PTSD, anxiety, concentration SUBJECTIVE: The patient discussed continued symptoms of PTSD in his current work environment, most specifically around helicopters. He is continuing to adapt to functioning as a nurse in a demanding medical environment, and is enjoying the work." *********************************** PCMHI Consult Note, ******* - "HISTORY OF PRESENTING ILLNESS: The patient is 30% SC for PTSD. PTSD symptoms since first deployment. Current symptoms of PTSD include hyperactive startle response, hypervigilance, anxiety, "I feel like I am fine in the head, but I have that antsy feeling". The patient reports he will stay busy to manage his symptoms of PTSD. He reports daily intrusive thoughts/images of traumatic events in combat. He discussed that when he was on deployment he loaded two of his friends on medical helicopters. This was an emotional and traumatic experience for him. He currently works as an **************** (new *****************), and in his role as an ******** he finds himself loading patients into medical helicopters. He stated his work ********************* Page 7 of 19 circumstances reminds him of combat experiences, but he feels it is a form of exposure therapy and while difficult is helpful for him. The patient stated he has problems with staying focused, and maintaining attention. Even though he had these problems in nursing school, he graduated with a high GPA. He is able to focus as needed at work. After first deployment he had problems with short-term memory "always like a haze or a fog I have going on, sort of like sinus congestion". Memory problems only developed after deployment. In nursing school he did well because he could focus exclusively on classes. He has a history of not remembering what he is told, if he doesn't make a note of it. He also stated he has some compulsive cleaning behavior. In February of 20** a close friend from ********* school committed suicide. This loss has been emotionally difficult for him." ******************************************* MHBS Consult Note, 01/07/2013 - SM was noted to attend group orientation with no follow up. 2. Recent History (since prior exam) ------------------------------------ a. Relevant Social/Marital/Family history: SM is 30% SC for PTSD and was last evaluated for C&P in 2012. Current assessment will review symptom progression since that time. SM reports having gotten married in 20**. They have no children; "Just my animals...******************." He reports purchasing his first home with his wife in 20**. SM denies engagement in hobbies or interests but generally reports walking his dogs or frequenting the gym in his leisure time. b. Relevant Occupational and Educational history: SM reports graduating from nursing school in 20** and began working in the ********************). He reports continuing to work in the ED and explained, "I do pretty good. Working as a coreman and then dealing with what happened in Afghanistan, it makes my job now rewarding. There are times when I have patients that remind me of losing *********, especially when having to load or unload patients. It is overwhelming to a certain point, but I work through it." ******************** CONFIDENTIAL Page 8 of 19 c. Relevant Mental Health history, to include prescribed medications and family mental health: SM denies contiuous engagement in mental health since 20** and explained, "I really devoted all of my time to getting my education once I got out, but when finishing up school I had a professor to encourge me to see someone. I did briefly but then in 20***, I was working a lot because we were purchasing a home. I do pretty good until I have long periods of time where I am not doing anything. I am still really overly startled, especially being in a residential area. I hear everything, people dropping things and loud noises really startle me." SM denies engagement in medication management but has been intermittently engaged in psychotherapy; "I was just seen in January, but requested another appointment because I'm coming into another wave where I have been feeling more anxious. 20** I had a number of guys that were in my unit to die...two suicides, one ******************* Regarding re-experiencing symptoms and alterations in cognitions, SM explained, "There is not a day that goes by that I do not think about it...the bad events of course and how I changed as a person. I think about what if I would not have gone over there...would some of my views be different. I think about what could have been different, especially when ***** got injured. I was always the point man. I always did the sweep and this day someone else took over for me, that is when *** stepped on the IED. That never happened on my missions. Nightmares are not very common but I recently had a nightmare of a helicopter but theatre was at home. I have also had dreams where someone was standing over me, staring at me. " SM reports ongoing difficulties with hyperarousal; "I am always keyed up but there have been times lately where I am more anxious. I'm not sure why. I really don't know why but it tends to be really bad when I do not have anything to do. It is really an issue with my sleep. My mind just goes and goes. I really want to go off the Ambien but if I don't take it, I do not go to sleep. Even with the Ambien I am still ************ CONFIDENTIAL Page 9 of 19 waking up. I am generally getting 3-4 hours." Regarding hypervigilence he explained, "I watch people sitting in their cars. If they are pulling off the same time as me, I seem to need to watch to determine if I need to chnage my path...a little weird but that is just me. I'm not as overly alert when I am working because I am busy and it helps to keep me distracted. I am most alert on my days off, when I don't have that distractions." SM reports ongoing avoidance and explained, "I have to keep my mind busy, so working in the ******* works in my favor. It is very high pace, which is how I like to do things. My take on the memories has been, as long as it is stashed away, it doesn't exist...that's kind of my thing. I don't generally talk about me, it is easier that way. I do not really avoid anywhere in particular but helicopter bring up a lot of anxiety. I am trying to address that. When I hear one, I try to go outside and look at it. I am planning to do a ride with our crisis team to help with that too." With regard to other changes in mood he explained, "I get along well with everyone but I don't have any close friends. Last year, I got with all of my brothers as we laid*********to rest and that was very therapeutic to me. I think I am really socially awkward. I am just not comfortable, I don't know what to even talk about. I want to connect to people and I keep people laughing at work, but I just have a hard time with getting close, other than my wife. I am in good communication with my family. I talk to my dad a couple times a week, sometimes I can be a bit short with my mom. I deal with angry patients all the time. I don't let myself get upset or lash out...I just take a moment and hold it in." d. Relevant Legal and Behavioral history: SM denies e. Relevant Substance abuse history: SM denies *********** CONFIDENTIAL Page 10 of 19 f. Other, if any: No response provided. 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) [X] Witnessing, in person, the traumatic event(s) as they occurred to others [X] Learning that the traumatic event(s) occurred to a close family member or close friend; cases of actual or threatened death must have been violent or accidental; or, experiencing repeated or extreme exposure to aversive details of the traumatic events(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse); this does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related. 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] Marked physiological reactions to 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, ***************** CONFIDENTIAL Page 11 of 19 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). 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, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others. [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] Exaggerated startle response. [X] Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep). Criterion F: No response provided. 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] Anxiety [X] Suspiciousness [X] Chronic sleep impairment ****************** CONFIDENTIAL Page 12 of 19 5. Behavioral observations -------------------------- SM presented as well-groomed and neatly dressed. He was fully oriented to person, place, time and circumstance. SM was fully engaged and exhibited good eye contact throughout the assessment. His mood appeared anxious, with constricted affect. Speech was clear and of normal rate and tone. Thought processes were congruent and goal directed. There was no evidence of psychosis, delusions or perceptual disturbance. SM denies active SI/HI, plan or intent. Overall, judgement and insight appeared intact. SM was made aware of the 24-hour Veterans Crisis Hotline in the event of worsening distress. He expressed an understanding. 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: --------------------------------------------------- Prior to beginning the interview, the undersigned examiner informed the veteran of the purpose of the evaluation, the role of the undersigned examiner, and the limits of confidentiality. The veteran indicated understanding of the aforementioned information. Per VA Memorandum titled Information Bulletin: Updated Guidance for the Fifth Edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-5) use in Compensation and Pension Examinations, dated August 28, 2014 this examination was conducted using DSM-5 criteria. Of note, the DSM-5 no longer requires computation of a GAF score. ************************************************************** DBQ PSYCH PTSD Review The following contentions need to be examined: post-traumatic stress disorder (PTSD) with sleep disorder Active duty service dates: Branch: Marine Corps **************** CONFIDENTIAL Page 13 of 19 EOD: *******20** RAD: *******20** DBQ PSYCH PTSD Review: Please review the Veteran's electronic folder in VBMS and state that it was reviewed in your report. The veteran is service connected for post-traumatic stress disorder (PTSD) with sleep disorder and requires a routine future exam for this disability. Please examine the Veteran to determine the current level of severity. If more than one mental disorder is diagnosed please comment on their relationship to one another and, if possible, please state which symptoms are attributed to each disorder.

Good morning everyone, This is my first post as member, I've read these forums for some time. But anyways, I'm a former 0311 USMC 2 combat tours in afghanistan, discharged honorably in 2012. I initiated my claims and was granted 30% for PTSD with insomnia in 2013, had my re-eval in feb of 2018. I have been treated with sleep meds and had a few therapy sessions, got back 30%. I was fearful to appeal because of the horror stories of decreased ratings. I've read through the different ratings and based on the symptoms it appears I should fall in the 50 percentile range, maybe 70%. I've been started on SSRI's for my symptoms, I don't seek therapy through the VA because the scheduling is so far out my work schedule is not forgiving and I have to continuously reschedule. I can post my last C&P exam for reference if that may help if y'all think it is worth investigating an increase. I read a lot about getting a private medical exam, but I'm not sure where to go, or if that is something my VSO could assist me finding me a good examiner. The last few years have been very busy between school/work and I have a very ill wife I have to put first. The years are adding and I feel right now I'm at a good point to get my business taken care of. I currently have several exams for other items I'm having increased. I've exhausted my google searches. I appreciate all your advice, the years of reading in the background of posts has been helpful. Cheers, RAM0311