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What rating would you guess? 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: Posttraumatic Stress Disorder (PTSD) ICD code: F43.10 Comments, if any: Traumatic military experiences followed by intrusive memories (daily); nightmares (2x/week); flashbacks ("sometimes"); psychological distress and physiological reactivity on exposure to trauma cues; efforts to avoid cues associated with previous trauma; diminished participation in activities; estrangement from others; persistent negative emotional state (anger, fear, depressed mood); diminished ability to experience positive emotions; impaired sleep; irritability; impaired concentration; hypervigilance; and h/o reckless/destructive behavior (alcohol abuse) Mental Disorder Diagnosis #2: Alcohol Use Disorder in remission Comments, if any: History of alcohol dependence Currently in treatment. b. Medical diagnoses relevant to the understanding or management of the mental health disorder (to include TBI): back pain 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: Please see specific symptoms associated with each disorder in the comments under each diagnosis. Additionally, alcohol abuse may also be categorized as "reckless and self-destructive behavior" as part of the DSM 5 PTSD criteria. 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 reduced reliability and productivity 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: Previous alcohol abuse likely impacted his functioning. However, he used alcohol, in part, to cope with the symptoms and difficulties associated with PTSD. As such, it is not possible to determine the impact each of these disorders has had on his functioning separately. 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 post-military): The veteran reported that he graduated from high school. He denied that he was ever diagnosed with a learning disability and he denied behavioral issues ever impeded his ability to learn. He completed two years of college at King's College prior to service. Following his discharge from service, he completed Job Corps in 2011. The veteran enlisted in the USAF on MAR 20,2007 and was separated at the rank of E1 with a General discharge on JUN 11,2009. He served as a heavy equipment operator was deployed in support of OIF. While in military service, he reported that he was given an Article 15 for the DUI. He was reduced in rank from E3 to E1 and he was separated from service. he denied that he was ever referred to ADAPT. He denied issues with his work performance and reported adequate reliability up until that time. He reported "I was the best operator in the shop." He also denied a pattern of conflict with command or coworkers. He reported that following his return from deployment, he would come to work intoxicated due to drinking the night before. He reported that he would be written up for this, but mostly told to rest before getting back to work because he was a great worker. At the current time, the veteran reported that he is currently working as the power director in Delaware. He reported "I work by myself at a desk." He reported that he used to work in the field, but he had difficulty getting along with management. He reported "my union recommended I take a desk job." He has worked in this position two years. When questioned about his work performance, he denied any issues. When asked about reliability, he reported that he calls out from work up to four times a month, which is a decrease from when he worked in the field. He reported "I try to keep up with it because the job has rules on how often you can call out." He reported "I've broken the rules twice already and I don't want to be fired." When asked about conflict, he reported conflict with a coworker. He denied any escalations that required disciplinary actions against him or police interventions. H reported " they don't know how to talk to you and I don't like that. We're not friends." He worked in the field for six years with the same company prior to his current position. He described experiencing many more problems with immediate supervisors and coworkers in general during that time. To questioning, the veteran denied any history terminations. c. Relevant mental health history, to include prescribed medications and family mental health (pre-military, military, and post-military): The veteran denied mental health history prior to service. He denied mental health contact while in service. The veteran reported his first mental health contact following his discharge from service at the VAMC in 2018. He reported that he was initially seen by Dr. Viola, VA psychiatrist. He reported that he is currently followed by Dr. Kampman, VA psychiatrist, who has prescribed prazosin, venlafaxine, and vivitrol. He denied any history of psychiatric hospitalizations. He reported participation in support and treatment groups. He reported that he initially started in AA when he was found passed out in Job Corps in 2010. To questioning about family mental health history, the veteran denied any. d. Relevant legal and behavioral history (pre-military, military, and post-military): The veteran denied criminal history or legal concerns prior to service. he was disciplined by his command for a DUI while in service. Following discharge from service, the veteran reported that he was charged with drunk and disorderly in 2013 and a DUI in 2018. He reported that he was mandated to treatment through "Veteran's court." e. Relevant substance abuse history (pre-military, military, and post-military): To questioning about substance use, the veteran denied current alcohol and illicit drug use. He reported that he discontinued alcohol use in Mar, 2019 when he began treatment. When asked about nicotine use, he reported vaping all day. f. Other, if any: Medical History: The veteran reported a medical history remarkable for back pain. 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: The veteran reported that there was a knife incident with the guy he escorted. While deployed, it was his job to order sand and other rock material from places off base. The drivers were locals and they would escort them on to base and then escort them off. He and the guy he escorted got into an argument about where the load needed to be dropped. He veteran reported that he was new at the time -and he argued about where they used to drop vs where he needed to drop that day. He reported later the found out the guy he escorted was caught sneaking a knife on to the base and they believed he was planning to use it on the veteran. 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? [X] Yes [ ] No Is the stressor related to personal assault, e.g. military sexual trauma? [ ] Yes [X] No b. Stressor #2: They stopped in Bilad when first touched down on their deployment to Iraq . He reported that they were supposed to be there on layover. However, they ended up spending a week and half there. He recalled bombs and IEDs going off. They were detailed to pave a road. They were not initially assigned for the. "It was so scary we had to go out there and drop rock and pave roads" in a hostile zone. Does this stressor meet Criterion A (i.e., is it adequate to support the diagnosis of PTSD)? [X] Yes [ ] No Is the stressor related to the Veteran's fear of hostile military or terrorist activity? [X] Yes [ ] No Is the stressor related to personal assault, e.g. military sexual trauma? [ ] Yes [X] No c. Stressor #3: The veteran reported that he had an accident on the dump truck while deployed "and I was not supposed to be there." He reported that he worked the day shift--worked 12 hours. New guys were still on their way in but they needed a dump truck dropped off immediately. MSgt ordered him to drop it off and they would send someone to pick him up when the shift started. He reported that he opened the door-was in the dark. He rolled his ankle, fell back on metal rack, and it sliced his back open. He reported "it was the worst pain I ever felt in my life; my back seized; and I couldn't move." He reported "thought I was going to die or be paralyzed-I couldn't feel legs. I could barely walk." and they put him back to work. "I still walk with a hunch back." 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: Accident while working during his deployment. Is the stressor related to personal assault, e.g. military sexual trauma? [ ] Yes [X] No 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] Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). [X] Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s). [X] Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings). [X] Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect 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 C: Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic events(s) occurred, as evidenced by one or both of the following: [X] Avoidance of or efforts to avoid 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 D: Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: [X] Persistent 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. [X] Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings.) 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] 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 [X] Stressor #3 5. Symptoms ----------- For VA rating purposes, check all symptoms that actively apply to the Veteran's diagnoses: [X] Depressed mood [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 establishing and maintaining effective work and social relationships [X] Difficulty in adapting to stressful circumstances, including work or a worklike setting 6. Behavioral Observations -------------------------- During the clinical interview, the veteran was alert and oriented to person, place, time, and situation. He was appropriately dressed and groomed. He was cooperative and pleasant during the evaluation. He maintained appropriate eye contact. He responded to questions appropriately appearing to be a reliable historian. The veteran's speech was spoken at normal rate and tone. His attitude was appropriate for this setting. Psychomotor activity was agitated; he shuffled papers and fidgeted throughout the evaluation. Intellectual functioning appeared to be within normal limits. The veteran's behavior was appropriate for this setting. Thought process was logical and goal-directed. Thought content was appropriate and devoid of hallucinations or apparent delusions at the time of this evaluation. There was no evidence of any psychotic thinking. The veteran's mood was depressed. His affect was congruent with his mood. He denied current and previous suicidal and homicidal ideation at the time of this evaluation. The results of this evaluation were deemed an accurate reflection of his current psychological functioning. 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 -------------------------------------------------- The veteran met criteria for PTSD IAW DSM 5, which was caused by combat trauma and traumatic stressors he experienced while deployed during his military service. He also reported depressive symptoms that are secondary to PTSD and were categorized under "persistent negative emotional state." The veteran also met criteria for Alcohol Use Disorder that was deemed secondary to PTSD and has been in remission since March, 2019. PTSD symptoms were rated in the moderate range with impact on emotional, social, and aspects of his occupational functioning. The veteran denied symptoms associated with mania, disordered impulse-control, and/or psychosis at the current time.