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My question is in regards to a recently completed C&P exam I had taken for MH. I am quite worried about the statements made by the examiner and a few other sections as well. I have tried to highlight the sections that worried me I am not sure if I had missed anything of importance. Normally I would take this issue up with my VSO but she is out sick. I do not know who else or where else to turn to for information about this. I am most worried about the statements made by the examiner in the final paragraph. I did as I was told by my VSO and others in the VA and are assisting me currently in matters of mental health. That was be honest and it will all be okay. Well turns out it might not be okay and I was completely honest with this examiner!!! Date/Time: 21 Jan 2016 @ 1330 Note Title: C&P MENTAL DISORDER Location: Chalmers P Wylie VA Outpatnt Signed By: Co-signed By: Date/Time Signed: 21 Jan 2016 @ 1650 ------------------------------------------------------------------------- LOCAL TITLE: C&P MENTAL DISORDER STANDARD TITLE: MENTAL HEALTH C & P EXAMINATION CONSULT DATE OF NOTE: JAN 21, 2016@13:30 ENTRY DATE: JAN 21, 2016@16:50:27 AUTHOR: EXP COSIGNER: URGENCY: STATUS: COMPLETED *** C&P MENTAL DISORDER Has ADDENDA *** Initial Post Traumatic Stress Disorder (PTSD) Disability Benefits Questionnaire * Internal VA or DoD Use Only * Name of patient/Veteran: SECTION I: ---------- 1. Diagnostic Summary --------------------- Does the Veteran have a diagnosis of PTSD that conforms to DSM-5 criteria based on today's evaluation? [ ] Yes [ ] No 2. Current Diagnoses -------------------- a. Mental Disorder Diagnosis #1: Diagnosis Deferred Comments, if any: The veteran was asked to be evaluated for PTSD, the stressor has been conceded as he has been awarded the Combat Infantry Badge. The diagnosis is deferred as the examiner is unable to offer a specific diagnosis with any level of scientific certainty. The veteran was administered the MMPI-2-RF, although it appears he understood and responded to the items in a consistent manner, the remainder of the profile is not able to be interpreted due to an over-reporting of symptomatology that is not common even in individuals with known severe psychopathology. There are a number of potential reasons for this profile to include it being a "plea for help", it may be a phenomenologic style to over report and to be traumatized (this pattern is frequently seen in Dependent and Histrionic Personality Disorders and Depressive Mood Disorders) or the individual is trying to look worse than they are for some secondary reason. Unfortunately it is impossible to determine the reason behind this pattern of responding in this case without resorting to speculation. His service treatment records suggest that he did not report PTSD symptoms while in the military. While he has been diagnosed and treated recently for PTSD, the requirements for a clinical diagnosis differ from the requirements for an independent/forensic evaluation. In the latter situation the examiner is required to consider other factors for an individual's complaints while a clinician takes their patient's report as being valid. Please note that the 2507 requested that the examiner complete both the mental disorder and Initial PTSD DBQ's, only the Initial PTSD DBQ will be completed as completing the Mental Disorder DBQ is redundant. In regards to the question as whether or not the veteran's sexual dysfunction is at least as likely as not approximately due to or the result of PTSD, while the veteran reports he has some difficulties sexually due to his prescriptions the veteran remains sexually active and furthermore there are other physical conditions as well as medications that may be negatively impacting his sexual dysfunction, as such the final decision is deferred to a physician. In regards to question whether the veteran's insomnia is at least as likely as not approximately due to are the result of PTSD; this would be a redundant opinion as chronic sleep difficulties are a symptom of PTSD (and depression), they are not a separate diagnosis/syndrome. Mental Disorder Diagnosis #2: Cluster B traits Mental Disorder Diagnosis #3: Alcohol Use Disorder - in self-reported remission b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): see medical records 3. Differentiation of symptoms ------------------------------ a. Does the Veteran have more than one mental disorder diagnosed? No response provided. 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) No response provided. 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? No response provided. 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 ------------------ In order to provide an accurate medical opinion, the Veteran's claims folder must be reviewed. a. Medical record review: ------------------------- Was the Veteran's VA e-folder (VBMS or Virtual VA) reviewed? [X] Yes [ ] No Was the Veteran's VA claims file (hard copy paper C-file) reviewed? [ ] Yes [X] No If yes, list any records that were reviewed but were not included in the Veteran's VA claims file: If no, check all records reviewed: [ ] Military service treatment records [ ] Military service personnel records [ ] Military enlistment examination [ ] Military separation examination [ ] Military post-deployment questionnaire [ ] Department of Defense Form 214 Separation Documents [ ] Veterans Health Administration medical records (VA treatment records) [ ] Civilian medical records [ ] Interviews with collateral witnesses (family and others who have known the Veteran before and after military service) [ ] No records were reviewed [X] Other: The veteran's electronic medical records (CPRS & VistAWeb) were reviewed. The veteran was referred for a compensation and pension examination. The veteran was informed verbally of the nature and purpose of the examination and confidentiality limits. He appeared to have a basic understanding of the purpose of the examination and confidentiality limits. He was provided with a chance to ask questions about the evaluation procedures. All questions were answered to reasonable satisfaction or referred to other resources. He was informed that this examiner is not his treating clinician or the legal determiner of compensation or pension benefits. Instead, he was informed that this examiner is an independent provider of clinical information and expertise to assist those who review and make legal compensation and pension claim decisions and would not be participating in his healthcare. He was given information about the Veteran's 24 hour Crisis Line. The veteran indicated understanding of these terms and explicitly and freely consented to the evaluation. The judgments of symptoms and opinions in this evaluation report are offered to a reasonable degree of psychological certainty and are only based upon the information available at the time of the evaluation. The DSM 5 criteria have been considered in this evaluation. This report was dictated using Dragon Naturally Speaking dictation software, the report has been proofread however due to time constraints there still may be some typographical errors due to the nature of the dictation software. b. Was pertinent information from collateral sources reviewed? [ ] Yes [X] No 2. History ---------- a. Relevant Social/Marital/Family history (pre-military, military, and post-military): The veteran is a 28-year-old single male, he is not currently in a relationship. He currently lives in a homeless shelter, he has one roommate in addition to 6 other veterans living in the house. He has no children. [Later during the interview the veteran reported having met a woman using a smart phone dating app (Tinder), although they are not in a relationship they still get together occasionally for sex]. The veteran is the younger of 2 children, he does not get along with his sister saying "she had a rough time with drugs." The veteran says that he does not like "the way she treats my mother and my nephew." Apparently one of her 3 children is living with the veteran's mother and this causes difficulties in that relationship as well as the veteran's relationship with his sister. The veteran says his parents were never married saying "my father left prior to my birth." He would continue to see his father for a couple of weeks a year however. The veteran says his mother never remarried however she had several long-term boyfriends. The first long-term boyfriend entered the picture around the time of the veteran's birth, this gentleman died of a heroin overdose when the veteran was 6 years old. His mother then started another long-term relationship, they are still together, the veteran says he considers this man to be his stepfather/father figure. He maintains a good relationship with this man as well as then "outstanding" relationship with his mother. The veteran notes that his mother lives in Massachusetts and he has not been able to see her in the past 2-1/2 years although they talk several times a week. The veteran is hopeful that he will be able to buy a house and have his mother, her boyfriend and the veteran's nephew all moved to Ohio so that he can take care of them. The veteran says he has an "okay" relationship with his biological father although he said "we just don't talk very much, we don't have much in common." When asked to describe his childhood the veteran says it was "okay, there was a lot of issues. I had everything I needed and occasionally stuff I wanted." The veteran says at the time he thought his childhood was very good and that he was spoiled however he says looking back on the situation and comparing his childhood with the childhood of different people he has met over the years he realizes his childhood was not necessarily very good. The veteran says his mother was using drugs during his childhood although she stopped her drug use when the veteran was 14 years old. When asked about physical or sexual abuse the veteran says "just small (stuff), hitting and stuff." b. Relevant Occupational and Educational history (pre-military, military, and post-military): The veteran says that he graduated from high school in 2008, when asked how he did in school he says "not good", he says his grades were "roughly D's and C's. I had pretty severe anger issues. I just wanted to fight everybody." He did not repeat any grades although he had to take night school the last semester of classes for English and math so he could graduate. He did not participate in any special education services. The veteran did not participate in any extracurricular activities. While in high school the veteran worked for Sears as a mechanic. The veteran says that after graduating from high school he decided to join the military because "there was nothing there." The veteran felt that if he stayed at home he would "be deeper into drugs." The veteran served in the Army from 2008 until 2014, his MOS was 11B, the veteran received a general discharge with a final rank of E-5. The veteran says he was administratively discharged for misconduct, he had received a felony conviction. The veteran was deployed to Iraq in 2010/2011 into Afghanistan in 2012. The veteran says that he moved to Ohio to move in with one of his friend's family. The veteran says he was on probation for the felony conviction in Hawaii and in order to relocate from Hawaii he had to be able to prove he had a job and a place to live. He worked for his friend's father for 2 or 3 months doing interior paining until he got a better job. The veteran worked for 2 months at Columbus Castings, he stopped working after a failed suicide attempt in 2015. The veteran says he has recently appealed a Social Security Disability denial, he is hopeful he will eventually qualify for these benefits. c. Relevant Mental Health history, to include prescribed medications and family mental health (pre-military, military, and post-military): The veteran says he currently sees Dr. McGill for psychotherapy although he notes she is on maternity leave currently. The veteran says that therapy was "going great", and he is hopeful he will be able to return to therapy upon her return. The veteran currently sees Dr. Schwartz for psychiatric services, he is prescribed Zoloft, prazosin and quetiapine. When asked how the medications are working for him the veteran says "I haven't seen much of a difference." The veteran says that in April 2015 he had tied a rope to a guard rail, he tied the other in to his neck he then drove away in his truck the rope apparently broke however he sustained significant internal scarring to his neck and currently has a tracheotomy and feeding tube. While in the military the veteran completed the ASAP program twice (following DUIs), he also recently completed the SATP program through Chillicothe. d. Relevant Legal and Behavioral history (pre-military, military, and post-military): The veteran says he was frequently suspended while in school for fighting or misconduct towards teachers. While in the Army the veteran received one article 15 in 2011 for DUI, he says they did not pursue the second article 15 proceedings following his second DUI because being separated from the military. The veteran reported being arrested in 2011 for DUI, in 2013 he was arrested and convicted of a felony for unauthorized entry into a vehicle. He received his second DUI in 2014 however he says his lawyer was eventually able to get the charges dropped. The veteran is currently on probation for 3-1/2 years for the felony conviction. e. Relevant Substance abuse history (pre-military, military, and post-military): When asked about his current alcohol use the veteran says that "currently I'm trying to do the sober thing" the veteran says he last drank "just after Christmas", he says he had 3 L of Mad Dog 20/20. The veteran says he would have to mix the liquor with ice so that he could drink it. In the past the veteran says he has poured alcohol straight into his feeding tube. When asked about current drug use the veteran denied any. Veteran says he last had any drugs in late 2014, at the time he was using cocaine. The veteran says he stopped his drug use because he is on probation. f. Other, if any: ===================================================================== **IMPORTANT NOTE** ---> There is a glitch in the DBQ reporting software such that if the examiner does not check off any of the boxes in Section II, Number 4 ("PTSD Diagnostic Criteria") [below], because the Veteran does not exhibit those symptoms, the software will produce "No response provided", which makes it sound as if the examiner simply forgot to answer those items, which is not the case. In this instance the software should, instead, produce something like, "No PTSD diagnostic criteria were found during this exam." ===================================================================== ===================================================================== **IMPORTANT NOTE** ---> There is a glitch in the DBQ reporting software such that if the examiner does not check off any of the boxes in Section II, Number 5 ("Symptoms") [below], because the Veteran does not exhibit those symptoms, the software will produce "No response provided", which makes it sound as if the examiner simply forgot to answer those items, which is not the case. In this instance the software should, instead, produce something like, "None of the listed symptoms were found during this exam." ===================================================================== 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: Only one stressor was elicited from the veteran, he was rather uncomfortable during this portion of the evaluation and since the stressors are being conceded the examiner chose not to inconvenience the veteran by forcing him to recall more than 1 stressor. The veteran says while he was in the convoy the vehicle in front of them was hit by an IED and flipped over. The veteran says he was afraid that all of the occupants were dead, fortunately they were able to survive. 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 4. PTSD Diagnostic Criteria --------------------------- No response provided 5. Symptoms ----------- No response provided 6. Behavioral Observations -------------------------- No response provided 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 -------------------------------------------------- On a brief mental status exam he was able to freely recall 2 of 3 words presented after a brief delay, he was able to recall the final word after being provided with a simple verbal prompt. He was able to recall 6 digits forward and 4 digits backward. He was able to complete a serial 7 subtraction task with no errors to 7 places. He was able to spell the word WORLD forwards and backwards. He was able to complete simple 2 digit addition and subtraction. His responses to proverbs were good. Although the veteran denied current suicidal ideation saying "I don't want my mom to bury me", however he says that "if my mom died ..." (He would seriously consider making another suicide attempt). The veteran denied any homicidal ideation. He denied hallucinatory experiences. When asked to describe his mood on most days the veteran says he is "depressed and anxious." The veteran reports significant episodes of anxiety says he has "never had one where I'm frozen." Based on his report of symptoms he would appear to be depressed, anxious and suspicious. The veteran says he forgets "simple things", he has never been diagnosed with a head injury although he claims he suffered a concussion in the military where he was momentarily disoriented. The veteran says he knew that if he sought medical attention he would be taken off admission status and he felt he could not do that to the soldiers under his command so he convinced the medic to not report this incident. While the veteran complains of memory problems he did not display significant memory problems during the evaluation today. The veteran says he has significant problems motivating himself saying that occasionally he still will stay in bed all day. He says this occurs about 2-3 times a week. Socially the veteran described himself as being isolated saying "I have a hard time connecting with people." The veteran says "I don't talk to anyone." The veteran says the only activities he engages in is to go to the gym 2-3 times a week "if I can." He describes his energy level is "awful" saying "other than the gym I can't exert too much." The veteran says that occasionally he may go over to his female friend's house while she is at work and spend time with her dogs. The veteran says that he averages 4-5 hours of sleep "lately, he feels that the weeks leading up to the different C&P examinations have been hard on him prior to this he was getting "around 6" hours of sleep per night. The veteran says he has difficulty falling and staying asleep. The veteran says he has dreams/nightmares "at least 3 times a week." The veteran says although he may try to take a nap "it's just more me laying there." The veteran says he tends to avoid situations involving a lot of noise. He also attempts to avoid talking about his traumatic stresses. He appeared to be particularly relieved when the examiner said it was only necessary to focus on one traumatic event. Based on his self-report veteran reports exaggerated negative beliefs about himself and the world, he tends to blame himself scribed traumatic stressor saying that he was too complacent. The veteran describes his temper control is being currently "fairly good", historically prior to the military he appears to have had very poor temper control. The veteran was administered the MMPI-2-RF, although it appears he understood and responded to the items in a somewhat consistent manner remainder of the profile is not able to be interpreted due to an over-reporting of symptomatology that is not common even in individuals with known severe psychopathology. There are a number of potential reasons for this profile to include it being a "plea for help", it may be a phenomenologic style to over report and to be traumatized (this pattern is frequently seen in Dependent and Histrionic Personality Disorders and Depressive Mood Disorders) or the individual is trying to look worse than they are for some secondary reason. Unfortunately it is impossible to determine the reason behind this pattern of responding in this case without resorting to speculation. NOTE: VA may request additional medical information, including additional examinations if necessary to complete VA's review of the Veteran's application. Clinical Psychologist Signed: 01/21/2016 16:50 01/21/2016 ADDENDUM STATUS: COMPLETED C&P Exam completed in Capri by PhD; procedure code 99456. /es/PhD Clinical Psychologist Signed: 01/21/2016 17:28 Any assistance or opinions on this matter are greatly appreciated!!! Thank you for your time and for reading this as well!