I'm currently rated at 50% for Anxiety Disorder NOS. I have a few issues with some of the things he wrote because some were flat out wrong, but I don't know if I should fuss about it.
Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination Request? [X] Yes [ ] No SECTION I: ---------- 1. Diagnosis ------------ a. Does the Veteran now have or has he/she ever been diagnosed with a mental disorder(s)? [X] Yes [ ] No ICD code: F41 If the Veteran currently has one or more mental disorders that conform to DSM-5 criteria, provide all diagnoses: Mental Disorder Diagnosis #1: Generalized Anxiety Disorder ICD code: F41 Mental Disorder Diagnosis #2: Major Depressivve Disorder ICD code: F33 Mental Disorder Diagnosis #3: Panic Disorder ICD code: F41 b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): Per Veteran, Headaches 2. 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: The Veteran's anxiety is secondary to Generalized Anxiety Disorder (GAD). Depression and feelings of guilt are secondary to Major Depressive Disorder (MDD). Panic Attacks are secondary to Panic Disorder. Symptoms of low energy, low concentration, low motivation, low sex drive, irritability and insomnia are secondary to both GAD and MDD. c. Does the Veteran have a diagnosed traumatic brain injury (TBI)? [ ] Yes [ ] No [X] Not shown in records reviewed 3. 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 level of occupational and social impairment, is it possible to differentiate what portion of the occupational and social impairment indicated above is caused by each mental disorder? [X] Yes [ ] No [ ] No other mental disorder has been diagnosed If yes, list which portion of the indicated level of occupational and social impairment is attributable to each diagnosis: GAD and MDD both appear to have a significant impact in his level of dysfunction. They are both complex, overlapping in symptoms and interactive in nature. 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)2. History ---------- a. Relevant Social/Marital/Family history (pre-military, military, and post-military): The Veteran currently lives in Silverdale, Washington, with his partner of seven years and her their children. He stated that his relationship with her was, "Rocky...I'm just hard to deal with. She's told me multiple times that she wants to leave." He stated that he'd remained emotionally connected to his children. He has two friends who he has rare contact with. He spends his time reading, listening to music, watching tv and on the internet. He explained that he often spent time alone in his room because he was anxious and felt disconnected from others. He denied having problems with activities of daily living. b. Relevant Occupational and Educational history (pre-military, military, and post-military): The Veteran is currently unemployed. He most recently worked for one week in 2009 as a sterile processing tech. He struggled with anxiety, panic attacks and depression which led to him leaving the position. He said, "I can become violent sometimes." He hadn't been employed since then. He said, "My mental health provider recommended me to take care of myself." c. Relevant Mental Health history, to include prescribed medications and family mental health (pre-military, military, and post-military): The Veteran has been in mental health treatment at the VA in Seattle since 2013. He's currently prescribed prozac, clonazepam, lithium and hydroxyzine. He said he'd been diagnosed with GAD, MDD and Panic Disorder. He was previously in mental health treatment at the Front Street Clinic in Poulsbo, Washington. d. Relevant Legal and Behavioral history (pre-military, military, and post-military): The Veteran reported that he'd been convicted of a misdemeanor in 2013 after pushing a police officer. No other history of legal issues were reported. e. Relevant Substance abuse history (pre-military, military, and post-military): The Veteran reported that he most recently consumed alcohol in February 2013. He said he abused alcohol "off and on" since 2008. He's been in substance abuse treatment in Silverdale, Washington, "for almost one year." He meets criteria for Alcohol Use Disorder. f. Other, if any: No response provided. 3. 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] Chronic sleep impairment [X] Impairment of short- and long-term memory, for example, retention of only highly learned material, while forgetting to complete tasks [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 [X] Inability to establish and maintain effective relationships 4. Behavioral observations -------------------------- See Remarks below. 5. Other symptoms ----------------- Does the Veteran have any other symptoms attributable to mental disorders that are not listed above? [ ] Yes [X] No 6. Competency ------------- Is the Veteran capable of managing his or her financial affairs? [X] Yes [ ] No 7. Remarks (including any testing results), if any: --------------------------------------------------- Clinical Examination: The Veteran was interviewed for approximately 61 minutes to obtain a psychosocial history, assess clinical symptoms, and evaluate quality of life and functional status. The examiner Psy.D., is a Washington state licensed clinical psychologist who is privileged at the VAMC, Puget Sound, to perform Mental Disorders, PTSD and cognitive screening C&P exams. Limits of confidentiality for this assessment were reviewed. It was explained that the resulting report, which includes a review of medical records, would be sent to regional office for determination of benefits. The Veteran did not express any concerns about this. Additionally, the Veteran was informed that if he/she presented as a danger to him/herself or others or reported that elders or children were being harmed, confidentiality would be breached. Clinical Measures: The Veteran completed psychological evaluations to assess for the presence of anxiety and mood disorders. Specifically, the Veteran completed self-report measures to for PTSD (PCL-5), depression (PHQ-9), and alcohol use (Audit-C). The PTSD Symptom Scale Interview (PSSI) was completed as a structured interview for PTSD and further assessment of other anxiety disorders and depression was completed as well. RESULTS OF DIAGNOSTIC INSTRUMENTS: The Veteran scored 58/80 on the PCL-5, indicating significant symptoms of PTSD (below 38 indicates subclinical symptoms of PTSD). He scored 18/27 on the PHQ-9 (indicating moderately severe depressive symptoms). PHQ-9 scores from 5-9 represent mild depression, 10-14 moderate, 15-19 moderately severe, and 20 or above severe (Kroenke, Spitzer, & Williams, 2001). The Veteran score 12/40 on the AUDIT-C, indicating alcohol use appears to be a concern for the Veteran at this time. MENTAL STATUS APPEARANCE AND BEHAVIOR: The Veteran drove to the evaluation with his partner. Presented as cordial. Was casually dressed and well-groomed. Eye contact was good. Hygiene and dress were adequate and appropriate on all accounts. Level of activity was normal. Veteran was cooperative and talkative during the interview process. ORIENTATION AND CONSCIOUSNESS: The Veteran appeared fully oriented to time, place, person, purpose. MEMORY LOSS OR IMPAIRMENT: The Veteran did not display any obvious signs of memory problems across the interview, as evidenced by his ability to track questions and produce response from immediate, short term, long term and episodic memory. SPEECH: Speech was normal in volume and pace; verbalizations were relevant, logical, well-organized, and coherent. Veteran could articulate thoughts. At times, the Veteran was off-topic due to heightened emotions. THOUGHT PROCESS AND CONTENT: There was no significant impairment in organization of thinking or communication; thinking was goal-directed and focused. FUND OF KNOWLEDGE AND COGNITIVE FUNCTIONING: At least average intellectual abilities, as evidenced by the Veteran's use of language, fund of knowledge and academic achievement. MOOD: Mood appeared to be anxious and irritable. AFFECT: The Veteran presented with an expansive affect which was appropriate in nature. MOTIVATION AND ENERGY: Motivation for improvement is good. IMPULSE CONTROL: No impairment based on behavior during the evaluation. PSYCHOSIS: Veteran denied hallucinations and prominent delusions and did not present with any obvious signs of psychosis across the interview. ACTIVITIES OF DAILY LIVING AND SELF-CARE: Based on the Veteran's report, he performs most basic activities of daily living, including meeting basic requirements for nutrition, shelter, and hygiene and grooming. He denied experiencing any notable problems with ADLs. DIAGNOSTIC FORMULATION The Veteran experiences persistent anxiety in response to a wide range of issues in his life. He discussed that "little things" often trigger his anxiety. He often spends time in isolation while he feels disconnected from others. He struggles with low attention, low energy, insomnia and low motivation on a regular basis. He's depressed on a daily basis. He experiences panic attacks multiple times per week. He also reported low sex drive and a fluctuating appetite. Stressors were identified as, "Chores, my family, being around people." He meets criteria for Major Depressive Disorder, Generalized Anxiety Disorder and Panic Disorder. RISK ASSESSMENT At the time of the evaluation, the Veteran denied feeling hopelessness or experiencing suicidal ideation. He reported experiencing passive thoughts of suicide several days per week. On occasion, he experiences more intense thoughts of harming himself, although he denied having a plan. DISCUSSION In summary, this is a 32-year-old male Veteran who presents for evaluation of Mental Disorder. After carefully reviewing the Veteran's electronic medical records, psychometric data, and interviewing the Veteran, it is my opinion that the Veteran meets DSM-V criteria for Generalized Anxiety Disorder, Major Deprssive Disorder and Panic Disorder. It's believed that his current psychiatric symptoms are a continuation of the mental disorder that had been diagnosed in the past. The Veteran's psychiatric symptoms include persistent anxiety, depression,irritability, feeling emotionally empty, feeling distant from others, lacking drive and motivation, panic attacks, disturbance in sleep and a low sex drive. These issues appear to have a moderate to severe impact in his ability to work a full-time job. He often isolates while he has minimal trust in others. He's likely to have difficulties working with co-workers, while agitation is easily triggered. More severe symptoms, compared to a few years ago, were noted as irritability, scattered thinking and panic attacks. It's believed that he's unable to adapt to mild stress in a work environment. For the purpose of this evaluation, the severity of the impairment is believed to be best classified as, "Occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood." The Veteran is competent for VA purposes. He is capable of managing his benefit payments and financial affairs in his own best interest.
My issues with his report: Should I leave it alone or request it to be fixed?He said I told him my most recent alcohol use was in February 2013. No, I specifically said February of this year. Then he said I have been in alcohol treatment for 1 year currently, NO, i was in alcohol treatment in 2013. So he got those mixed up.He said I drove to the appointment with my partner. NO-I specifically told him my mom drove me to the appointment because I cannot handle driving long distances.Stuff about the hygiene and ADL's-NO, I specifically told him I sometimes do not want to eat or get out of bed. I also told him my girlfriend keeps track of when I shower because I'm not able to gauge how frequently I do it and she told me I've showered 3-4 times in the last 6-8 weeks.That's about it that I can tell from first read through...I dunno how big of a deal those things are but still.To me, at first glance, looks like he is saying that I couldn't work a full time job and probably not even a part time job. Or maybe I'm reading it wrong. I'll wait for some of you guys to chime in.