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Found 1,115 results

  1. C&P Exam PTSD:MST Eating Disorder.pdf ^^^^^^Well the attached report indicates to me a 10% PTSD rating. I am currently 30% and I do not understand how this happened but I might be in for a reduction. I thought the exam went well. I had a PTSD and Eating Disorder C&P. Regarding the occupational/social impairment she checked the one that resembles 10% and for "b" she marks YES and goes on to say my trauma impacts my occupational/social impairment. Look at the symptoms she notes: Anxiety; Panic Attacks more than once a week; Chronic sleep impairment; difficulty in establishing and maintaining effective work and social relationships She even stated in the exam that I was BDD (Body Dysmorphic Disorder) but her reports indicates while I have BDD characteristics I don't warrant the BDD rating. She states for the VA established diagnosis of SPECIFIED TRAUMA AND STRESSOR RELATED DISORDER, there is NO CHANGE in the diagnosis. At this time the claimant's condition is active. Does this Exam mean I am going to be reduced or would I fall under the below??? 3.344 Stabilization of disability evaluations. (a) Examination reports indicating improvement. Rating agencies will handle cases affected by change of medical findings or diagnosis, so as to produce the greatest degree of stability of disability evaluations consistent with the laws and Department of Veterans Affairs regulations governing disability compensation and pension. It is essential that the entire record of examinations and the medical-industrial history be reviewed to ascertain whether the recent examination is full and complete, including all special examinations indicated as a result of general examination and the entire case history. This applies to treatment of intercurrent diseases and exacerbations, including hospital reports, bedside examinations, examinations by designated physicians, and examinations in the absence of, or without taking full advantage of, laboratory facilities and the cooperation of specialists in related lines. Examinations less full and complete than those on which payments were authorized or continued will not be used as a basis of reduction. Ratings on account of diseases subject to temporary or episodic improvement, e.g., manic depressive or other psychotic reaction, epilepsy, psychoneurotic reaction, arteriosclerotic heart disease, bronchial asthma, gastric or duodenal ulcer, many skin diseases, etc., will not be reduced on any one examination, except in those instances where all the evidence of record clearly warrants the conclusion that sustained improvement has been demonstrated. Ratings on account of diseases which become comparatively symptom free (findings absent) after prolonged rest, e.g. residuals of phlebitis, arteriosclerotic heart disease, etc., will not be reduced on examinations reflecting the results of bed rest. Moreover, though material improvement in the physical or mental condition is clearly reflected the rating agency will consider whether the evidence makes it reasonably certain that the improvement will be maintained under the ordinary conditions of life. When syphilis of the central nervous system or alcoholic deterioration is diagnosed following a long prior history of psychosis, psychoneurosis, epilepsy, or the like, it is rarely possible to exclude persistence, in masked form, of the preceding innocently acquired manifestations. Rating boards encountering a change of diagnosis will exercise caution in the determination as to whether a change in diagnosis represents no more than a progression of an earlier diagnosis, an error in prior diagnosis or possibly a disease entity independent of the service-connected disability. When the new diagnosis reflects mental deficiency or personality disorder only, the possibility of only temporary remission of a super-imposed psychiatric disease will be borne in mind. (b) Doubtful cases. If doubt remains, after according due consideration to all the evidence developed by the several items discussed in paragraph (a) of this section, the rating agency will continue the rating in effect, citing the former diagnosis with the new diagnosis in parentheses, and following the appropriate code there will be added the reference “Rating continued pending reexamination ___ months from this date, §3.344.” The rating agency will determine on the basis of the facts in each individual case whether 18, 24 or 30 months will be allowed to elapse before the reexamination will be made. (c) Disabilities which are likely to improve. The provisions of paragraphs (a) and (b) of this section apply to ratings which have continued for long periods at the same level (5 years or more). They do not apply to disabilities which have not become stabilized and are likely to improve. Reexaminations disclosing improvement, physical or mental, in these disabilities will warrant reduction in rating.
  2. Hi there! Long time member here but been MIA for awhile. Life has been busy and I have been dealing with health issues. Long story short, I went through a battery of tests to find out what is wrong with me. I did an ANA-TITER test, and it was positive for an auto immune disease. Was referred to the RA doctor for further testing to see if I had lupus. The RA doctor did blood tests and determined I don't have lupus. We did additionally physical exam at the VA back in May and he determined I had Fibromyalgia and diagnosed me with it. We discussed that my Fibromyalgia co-exists with PTSD/MST and IBS. We also discussed that Fibromyalgia can be secondary to my already service-connected PTSD/MST or even maybe my IBS. I discussed this with my representative and we decided to file a claim for Fibromyalgia (non-service connected disability) to an already service-connected disability. Either PTSD/MST or IBS and we asked that they evaluate either causation or aggravation. We filed in July and I had my C&P exam in September. The examiner was asked by the rater to give his medical opinion as to the Fibro being secondary to my PTSD/MST. The rater did not ask if it was possible to be secondary to my IBS like we requested. The examiner did a C&P DBQ for Fibro and that was positive. I do have Fibro, that isn't the issue. The medical opinion is what was disturbing. I was with the examiner for less than 5 minutes. He stated he physically examined me when he did not and he seemed very unknowledgeable about Fibro/PTSD-MST/IBS as co-existing and determining either causation or aggravation. Of course the medical opinion stated, "less likely than not". I was floored, so I went to work for my claim. I contacted my RA doctor and we talked with my representative on the phone as well. By the end of the call he was confident enough to link my PTSD/MST as aggravation to my Fibromyalgia. He wrote a one/two paragraph letter on my behalf. We sent that to the rater. Then I spoke to my MH provider last week and she too wrote me a very good NEXUS letter. That was sent to the rater yesterday. Both my doctor's are at the VA and both stepped out on a limb for me. I am hoping their medical opinions outweigh the negative C&P medical opinion. I am attaching the C&P exams (redacted), the two medical opinions (redacted) - I am hoping I am successful because this will make me 100% scheduler. I am currently 94% overall rated. C&P _Redacted.pdf nexus 2_Redacted.pdf redacted.pdf redacted2.pdf
  3. Does the Veteran have a diagnosis of PTSD DSM-5 criteria on today's eval? [X] Yes [ ] No 2. Current Diagnoses,1PTSD 2Panic Disorder 3Agorophobia 4Major Depressive Disorder b. Medical diagnoses relevant. obstructive sleep apnea, fibromyalgia, hypothyroidism. 3. Differential a. Does the Veteran have more than one mental disorder diagnosed? [X] Yes [ ] No 4. Occupational and social impairment [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) Vet has multiple co-morbid psych dx and therefore cannot differentiate level of impairment due to each mental disorder due to overlap in symptoms. Does stressor meet Criterion diagnosis of PTSD)? [X] Yes [ ] No Is the stressor related to the Veteran's fear of hostile military terrorist activity? [X] Yes [ ] No Is the stressor related to personal assault, e.g. military sexual trauma? [X] Yes [ ] No Criterion A: Exposure to [X] Directly experiencing the traumatic event(s) Criterion B: Presence of [X] Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). [X] Recurrent distressing dreams [X] Dissociative reactions [X] Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic [X] Marked physiological reactions to internal or externalcues that symbolize or resemble an aspect of the traumatic Criterion Persistent avoidance of [X] Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated traumatic event(s). [X] Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, Criterion Negative alterations [X] Persistent and exaggerated negative beliefs or expectations about oneself, others [X] Persistent, distorted cognitions about the cause or consequences of the traumatic event that lead the individual to blameherself others. [X] Persistent negative emotional state [X] Markedly diminished interest or participation in significant activities. [X] FeelingsofdetachmentEstrangement [X] Persistent inability positive emotions Criterion E: Marked alterations arousal [X] Irritable behavior angry outbursts [X] Hypervigilance. [X] Exaggerated startle response. [X] Problems with concentration. [X] Sleep disturbance Criterion F: [X] Duration disturbis more than month. Criterion G: [X] The disturbance causes clinically significant distress or impairment in social, occupational, or other important Criterion H: [X] The disturbance is not attributable to the physiologicaleffects of a substance Criterion I: Which stressor contributed to the Veteran's PTSD diagnosis?: X] Stressor #1 5. Symptoms [X] Depressed mood [X] Anxiety [X] Suspiciousness [X] Panic attacks more than once aweek [X] Chronic sleep impairment [X] Mild memory loss, such as forgetting names, directions or recentevents [X] Flattened affect [X] Impaired judgment [X] Disturbances of motivation a [X] Difficulty in establishing and maintaining effective work and social [X] Difficulty in adapting to stressful circumstances,including worklike setting [X] Obsessional ritualsInterfereActivities [X] Neglect personalAppearance hygiene DSM 5 Diagnosis:PTSD-Panic d/o with agoraphobia-Generalized Anxiety D/o Vet meets the DSM-5 diagnostic criteria for PTSD as level of severity - severe. Relationship of mental disorders to each other Vet's MDD, recurrent,moderate is secondary to her PTSD.HerPanicDisorder, Agorophobia and FSAD are also secondary to her PTSD. It is my medical opinion that vet's MST stressor is as least as likely as not suppported by and consistent with the in service marker evidence. Her agorophobia preclude her from functioning satisfactorily in work environments.
  4. "During a live webcast on Oct. 16, VA's new Under Secretary for Benefits, Paul R. Lawrence, Ph.D. said that VA will begin reviewing tens of thousands of PTSD claims filed by veterans who suffered Military Sexual Trauma (MST). " https://www.military.com/militaryadvantage/2018/10/17/va-reexamining-military-sexual-trauma-claims.html Any veteran who has an MST claim or was rejected or low-balled on an MST claim should take note of the above. If you know a vet with this situation, please let them know. If you know a VSO, let them know. Hope it helps someone.
  5. OEF female vet here just starting the process of my PTSD/MST and Tinnitus claims. I'm gonna be really honest here : For many years I didn't file anything because I felt guilty filing claims next to soldiers missing limbs and suffering from TBI and other horrors. At the urging of a fellow friend and vet, I've started the process and have quickly gone from feeling guilty to becoming a total trainwreck. I met with a VSO last week and have slowly started working on my statement and I feel like a giant hole has been ripped open and everything is spilling over. It's affecting my job, my family, everything. I am having panic attacks and crying uncontrollably off and on. I really am shocked at what is coming out. I thought the two years of private therapy immediately after my deployment was enough. Did anyone else feel the same way? Please tell me that putting myself/family through this and reliving these traumas, coupled with the tedious maze of claim do's and don'ts is truly worth it? I think I may need to start counseling again to get through this. Thanks.
  6. zuluvictor81

    Male Mst

    I have a few questions that I hope this site can answer. Back in 2000 I joined the army national guard and was sent to AIT while there and living in the barracks we had what i guess is called hazing going on. I was the new guy who already had a unit patch, rank and a list of ribbons so i was already out of place in the barracks. At first stupid stuff like being called a FNG or a NUG and lifting my bunk off the ground while i was in it and slamming it to the ground, or a tossed bunk or my lock pooped and my locker tossed. Yes it pissed me off but nothing worth crying to the drill sergeants about. After a few weeks a couple of my class mates where standing around and laughing looking at pictures and one calls me over and ask me if i knew what Tea Bagging was i honestly had no clue and said making a cup of tea. Then the kids shows me a Polaroid picture of me asleep in my bunk and another male placing his private parts on my face. I was told that this had happened many times. I went down to the office and proceeded to inform our Senior drill sergeant/acting first sergeant who tell me he will look into it. I leave think of i reported shit is going to hit the fan. Instead the Senior Drill sergeant came upstairs into our bay and tells everyone to gather round. I was thinking her we go.. Instead he yells out that he understands some teas bagging on going on and that it was just gay to let another man put his bare nuts on your face and that he better not see any of that stuff going on. I was shocked and freaking out because I am not gay never was and never will be. After this i began getting threatened and call a blue falcon i was woken up one night to chem light being poured in my mouth and other night having actual pubic hair sprinkled over my face. Other times buckets of water would be thrown onto me in my bunk i was to hyper vigilant that if they could not get close enough to me to mess with me they would throw boots or other objects at me. I called and talked to my home unit PSNCO and told him what was going on and refereed me to contact our home SGM in charge of all training which i did. He told me to avoid them and he was making some calls. The next day i got called over to the base national Guard liaison SGM who proceeded to yell at me to suck it up and stop whining and that if i was such a xxxxx i never should have joined the Army. Again i reported it and WTF is going on. I left and called my home SGM and told him what had happened and he just said WTF and told me to keep my head down and avoid them at all cost that there was not much he could do from where he was. In the middle of all this i had slipped on some heavy ice and went down a flight of stairs and was on a profile and going through rehab for my knee and lower back. One mourning i got my Sick call slip signed before the battalion went on there run at 0400. The rule was no one is allowed up in the barracks during PT period which meant i had to go into the day room until my scheduled therapy time. I was the only on a profile at the time so it was just me. I screwed up and fell asleep and over slept (at this time i was barley sleeping so i crashed hard.) I woke up and saw the time was 0800 and freaked out ran up stairs changed uniforms and caught a cab to school. A few hours later one of our Drill Sergeants came and pulled me out of class and asked me why i missed my rehab appointment and i told him the truth. The next day at lunch time i was called into the office where the SR DS handed me a counseling statement and saying that i had forged a sick call slip to get out of PT. I said i never forged a slip and he said that i had filled out a slip and had them sign it and that i did not use the slip for it intended purpose and i was getting a AR15 i asked to see JAG and was told i would be taken within 3 days. 3 days went by and i asked one of the DS when i would be going to JAG and was told opps we forgot to schedule you. That afternoon i was called over to the SGM NGB Liaisons office again. Where he proceeded to yell at me for getting into trouble and pulled out another counseling statement and began writing that i had supposedly gotten 3 AR15's and that he was chaptering me out on a chapter 14. I said that i had not even received 1 yet that the only thing i got in trouble for i have not seen JAG for so 3 was impossible. At this point tons of yelling lots of curse words and a demand to shut the hell up and just sign the document i once again asked to see JAG and was told i would be scheduled. A few more days go by and i get called into the commanders office where he wants me to sign my chapter papers and i once again say i have not even seen JAG yet. He tells me it does not matter i am just being sent back to my unit with a Under Honorable Conditions and that as long as i do not get into any more trouble for 6 months it will convert to full Honorable. I get back to my unit and they place me on none reporting status and tell me to go to the VA for MH and to finish rehabbing my knee and back. I got turned away from the VA with them telling me that they had not received my medical files and that i did not have enough concurrent active duty time to qualify for services. I tell my unit and they hook me up with a civilian doc who ended up doing surgery on my knee less then a year later. During my recovery after surgery i get a letter in the mail that i was discharged from the National Guard and in the signature box just said soldier not available. I called my unit and they were just as shocked as i was and said that there was nothing they could do about it now. Years have gone by and i was diagnosed with severe anxiety and PTSD. This is the tricky part the Doctor who diagnosed me was a civilian i saw at his private practice but he also worked full time at a VA CBOC. I honestly tried to live in denial of what happend and began drinking and did some dumb things and that is all on me. I hit pretty low and began seeing a shrink who helped me quite drinking and helped me with some coping tools like caring a calendar around so i would stop forgetting stuff. About a year my counselor who was also a vet told me to apply to the VA for PTSD and i told him that i had tried back in 2002 and was denied because they could not locate any of my medical files or service files. I was told by a bunch of VFW guys that because i did not complete the training that i would never get approved anyway that i was technical never a soldier. MY counselor told me things have changed and to file again. So i did on my own we don't have and VSO's out where i live and they only come through once a month and they only alot 30 mins for you anyway. I am embarrassed that what happened to me did. I was supposed to be a soldier and stronger then that a defender to the weak how was i so weak that it happened to me. I chocked up my fear and filled out the 781 and sent it in. I submitted all my doctors and just last week got a letter in the mail telling me that what i wrote on my 781 was not enough they needed more. Also calling the 800 number they still can not find my medical file so that's a major problem. So i sit down a write out a 7 page explanation of before during and after and resubmit it. Can someone please tell me how this will work out and if denied then what. I was told that if they can not find proof they will not even give me a comp and penn appoint and just deny me. I do not know if i am strong enough to do a appeal and have to go tell my story in a court room... Can some please walk me through this process and help turn the crazy down in my brain a little bit please?
  7. Had a C&P last month for mental health for increase for depression(30%) and new claim for Ptsd, MST, and have on appeal for TBI. Well, I can't see the C&P because it was done by VES. I was told by my VA rep. that I was diagnose with all four and that it doesn't matter about my stressor because I am already service connect for depression. I know Va only pay for one mental illness, so my question is will VA take all four inconsideration, when rating my claim.
  8. I was trying to get any first hand knowledge concerning MST/PTSD residential programs that accept men. If anyone reading this forum has been to any inpatient mens programs anywhere in the country I would greatly appreciate your experiences. I would like to know about any facilities good or bad. Also, was it a walk in or did you have to get a referral to go there?? Any help will be much appreciated!! Hopefully some of you have been to some good facilities... Chris P 100% IU
  9. Hello All, I have a question that i have asked several times and never really get a straight answer... (maybe there isn't one) I was rated 80% disabled and 70% of that is for PTSD/MST w/ MDD, Anxiety, Opioid use disorder, Alcohol use disorder and Stimulant use disorder, 30% right ankle and 10% Tinnitus and was later granted Individual Unemployability by the VA. I must give credit where credit is due and say that VA was very good with my claims and I am grateful that I was fortunate enough to get a rater that gave a crap about disabled veterans. I am now curious if anyone has any knowledge concerning if or when my IU could possibly become Total and Permanent. I'm sure its different for many people but i have been told some strange things concerning this. I did hear some valid statements like because i am 43 y/o they won't even consider making it permanent until i'm 55. I hear that PTSD for mental disorders will never become permanent because you may someday be cured... I could go on and on of things i have come across but i'm sure there is someone looking at these forums that will possibly have some first hand knowledge. Any information will be greatly appreciated. Thank you for taking the time to read my post. Respectfully, Chris P
  10. Any help will be appreciated... I am rated 30% for right leg issues and 10% for Tinnitus. I was recently rated 70% for PTSD/MST... (Total combined 80%) This past week my Individual Unemployability was granted rating me 100%. This is the part that gets me confused, my Psych Dr., my therapist and the C&P Doctor diagnosed me with several more disabilities. I know about pyramiding and only being able to be rated for one mental disorder but do the VA Raters even take them into account or are they only allowed to look at the C&P Doctors findings concerning the PTSD/MST? I know my PTSD/MST was rated 70% by itself. It seems crazy to me that with all the other disorders that were granted, they don't appear to be considered at all for the 70% rating. Can anyone shed some light on this for me?? My Decision letter stated the following: "Evaluation of Posttraumatic Stress Disorder with Alcohol Use Disorder, Stimulant use Disorder and Opioid use Disorder, also claimed as Anxiety, Depression and Cocaine Addiction is Granted with an evaluation of 70%. I hope this isn't a silly question... I may not be seeing the obvious but i figured i'd ask you guys... Thank you
  11. I am in the process of putting together a claim package for mental health issues related to MST. Try as I might, I cannot find a VSO with experience in my situation. It's taken me years to accept that I need help and that I need to address this once and for all, so when I say that I cannot handle doing this twice (submitting a sub par claim and then doing appeals) I really mean it. From day to day, I vacillate between thinking my problems are actually other people's inability to cope OR feeling like there is no point to me and that I'm a burden.If it weren't for the whole not being able to pay bills and risking alienating my kids for all eternity, I'd be perfectly content letting the world turn while I hang out at home and being maladjusted and mean. In my perfect world, there would be a check list of things to submit for a fully developed claim. On this checklist, there would be a list of key phrases or high points that would help sway the decision makers into awarding adequate compensation. I haven't been able to find anyone that has had success doing this with a case like mine. I have police reports from the MST. I have trauma counseling records and AD medical records that clearly state a d/x for PTSD related to rape on X date. My counseling sessions identified dissociation behaviors, PTSD, and anxiety. One doctor even noted that I was combative and stated that I wished harm on my attackers. Obviously, the Navy handled this clear cut case of rape, with evidence and my complete cooperation, like they do any scandal. They buried it and came after me. That might be a secondary stressor, but I've been warned that claiming a secondary stressor could hose up everything and to keep my mouth shut? kind of amazing that the advice that is meant to help, sounds a lot like the advice that sent me careening out of control all those years ago. Anyhow, I survived, got married, got out, and went in and out of counseling. Over the years, I've been diagnosed with PTSD, Chronic Depression, Chronic Adjustment Disorder, Agoraphobia, Generalized anxiety Disorder, and Dissociation Disorder. I don't trust military medicine or the government, so most of my counseling was done through non-profit organizations and women's shelters. They're so secretive, that I felt it'd be safe to tell them what I went through and my statements wouldn't end up in the Navy's summary of Mishaps... again. So, I don't really have records of those, except for prescriptions that were reported to Tricare. I do have my civilian medical records. It has page after page of doctors complaining that I broke down, was combative, emotional etc, etc. I do have a few sessions with shrinks at MTFs in the last couple years. They were not keen on actual diagnostics, they just gave me the pills I asked for. I'm shopping shrinks to assess me and give diagnosis. I'm not sure I need a nexus letter, but I'm thinking it wouldn't hurt. I have a letter from my ex boss describing how my work performance plummeted over the years and how he made accommodations to keep me on. I also have a letter from me, describing my bad days and my rituals to get through them. My husband and his best friend were witnesses to the fallout of my rape, in terms of the military's response to me. They can verify in statements that I did report it and go into counseling. They can also verify that I'm socially isolated and very codepenedent on them to meet new people or get involved in activities. I don't have a single friend that they didn't make for me, first. I do not know how to people. I don't have friends from work. I don't have "my own" friends from church. I don't even have people who like me well enough, and include me in things, without my husband and his best friend acting as intermediaries. oh, I also have the most recent sentencing transcripts for the ringleader of my attackers. The judge stated that he felt this dude was unrepentant and a monster. He cited his past sex crimes, "both in the record and that didn't make it to trial" and his history of convincing others to help him conceal his crimes. If that's not a shout out from the bench, I don't know what is. Anyhow, I guess my question is, has anyone here done a fully developed MST claim with multiple bullet points for anxiety, phobia, ptsd, and depression, and get 100% or at least, a high enough rating to qualify for unemployability? Without having to go through appeals and lawyers? Was a police report enough, even if the military dropped it? Should I give the C&P my evidence, letters, and my personal statement too? I'm sure I have 1000 more questions, but I'm mostly looking for someone who has done what I'm trying to do.
  12. Well, I just sent out this email and sure hope I get a helpful reply. If I do not have a reply by Friday morning I am going to my VA Regional Office in person and try to get to the bottom of this. carlie Under Secretary Veterans Benefits Administration U.S. Department of Veterans Affairs March 31,2015 Your Honorable Allison A. Hickey, My name is Carlie. I am an honorably discharged US Army veteran. I am in receipt of service connected disability at the 100 percent rate along with SMC/S, adjudicated to be permanent and total by both the Social Security Administration and the VBA. Service Connected conditions by the VBA are as follows: Major Depressive Disorder 100%, effective date March 23, 2004 Seizure Disorder 40%, effective date 1978, day following separation Impaired Hearing 0%, effective date over 10 years Bronchitis,Chronic 60%, effective date over 5 years Degenerative Arthritis of the Spine 30%, effective date over 5 years Ear Disease 10%, effective date over five years Superficial Scars 0%, effective date April,26 2005 Traumatic Brain Disease 10%,effective date over 5 years Bursitis 0%, effective date over 5 years Tinnitus 10%, effective date over 5 years SMC/S, effective date March 23,2004 DEA & Chapter 35 benefits granted, effective date 2004 Full Commissary and Base Exchange privileges, etc. ALL of the above conditions are of record with my VAMC and Vet Center,as being static in nature, with no improvement for over ten years. Today I had an appointment at Bay Pines VAMC, with my psychiatrist. While I was in this appointment I received a telephone message stating, "Ms Carlie this is XXXXX calling from the Compensation and Pension Department here at the VA. We've received a request from the Regional Office to get you scheduled for an evaluation for your service connected disability. If you could please call me as soon as you receive my message, my number is XXX XXX XXXX, extension XXXXX. Thank you." I listened to the message above as I was walking from my psychiatrist appointment, to the hospital next door for a thyroid ultrasound appointment. I then came home and called my psychiatrist and am waiting for a return call. I need your help as I feel this unneeded and unjustified C&P examination, is just plain emotional torture from the St.Petersburg, Fl. VA Regional Office. I have no claims open for additional benefits or claims that are in process or under appeal. All of my prior claim issues are of record as being fully satisfied and closed. I can not understand this additional C&P examination request made by the St.Petersburg VA Regional Office. I feel that this is doing nothing wasting resources another veteran could be utilizing and traumatizing me and probably many more veterans that are already sick, physically, mentally and of the VBA process as a whole. I already have concerns and horrible anxiety in even attending yet another additional C&P examination. All that needs to happen is that I get assigned a C&P examiner that's in a foul mood, got a ticket on their way into work, has their own stress such as a sick child or family member and BOOM !, I get a letter stating my benefits are revoked. This really should not happen as I have received continuity of care from Bay Pines VAMC and St. Petersburg Vet Center, for decades. As I stated, this should not happen, but knowing what I do know, I do know that it is a big possibility. So here I sit with my anxiety at a very high level, getting ready to take some of my VAMC RX's anxiety medication's. I ask this, at a time when there continues to be a huge back log, VBA and VHA are under the gun so to speak, with the media on a daily basis, when resources are limited . . . WHY, is the St.Petersburg Regional Office, requesting this additional C&P exam. Going by the regulation below, they should not be requesting this examination, so about all I can conclude is they want to torment veterans. Is it possible for you to help me with this situation. The last four of my social are XXXX. My phone number is XXX XXX XXXX. My address is: Carlie XXX - Helpavet Ave Sinkingin, XX. XXXXX This issue is time sensitive. Thanks you for any help or direction you might be able to provide. Carlie 38 CFR - Clearly states: §3.327 Reexaminations. (a) General. Reexaminations, including periods of hospital observation, will be requested whenever VA determines there is a need to verify either the continued existence or the current severity of a disability. Generally, reexaminations will be required if it is likely that a disability has improved, or if evidence indicates there has been a material change in a disability or that the current rating may be incorrect. Individuals for whom reexaminations have been authorized and scheduled are required to report for such reexaminations. Paragraphs (b) and © of this section provide general guidelines for requesting reexaminations, but shall not be construed as limiting VA's authority to request reexaminations, or periods of hospital observation, at any time in order to ensure that a disability is accurately rated. (Authority: 38 U.S.C. 501) (b) Compensation cases—(1) Scheduling reexaminations. Assignment of a prestabilization rating requires reexamination within the second 6 months period following separation from service. Following initial Department of Veterans Affairs examination, or any scheduled future or other examination, reexamination, if in order, will be scheduled within not less than 2 years nor more than 5 years within the judgment of the rating board, unless another time period is elsewhere specified. (2) No periodic future examinations will be requested. In service-connected cases, no periodic reexamination will be scheduled: (i) When the disability is established as static; (ii) When the findings and symptoms are shown by examinations scheduled in paragraph (b)(2)(i) of this section or other examinations and hospital reports to have persisted without material improvement for a period of 5 years or more; (iii) Where the disability from disease is permanent in character and of such nature that there is no likelihood of improvement; (iv) In cases of veterans over 55 years of age, except under unusual circumstances; (v) When the rating is a prescribed scheduled minimum rating; or (vi) Where a combined disability evaluation would not be affected if the future examination should result in reduced evaluation for one or more conditions. © Pension cases. In nonservice-connected cases in which the permanent total disability has been confirmed by reexamination or by the history of the case, or with obviously static disabilities, further reexaminations will not generally be requested. In other cases further examination will not be requested routinely and will be accomplished only if considered necessary based upon the particular facts of the individual case. In the cases of veterans over 55 years of age, reexamination will be requested only under unusual circumstances. Cross Reference: Failure to report for VA examination. See §3.655. [26 FR 1585, Feb. 24, 1961, as amended at 30 FR 11855, Sept. 16, 1965; 36 FR 14467, Aug. 6, 1971; 55 FR 49521, Nov. 29, 1990; 60 FR 27409, May 24, 1995]
  13. Hello all. I had a c&p exam for my ptsd/mst claim on 1/19/17 at the VA Outpatient center in Fort Worth and just got the results back today. I was quite shocked by the notes. I feel that the c&p psychologist did not review the merits of my case properly and just opined hat I was exaggerating my symptoms based on a 15 question "MENT" test which consisted of me differentiating between happy, angry and sad faces. She also asked me to remember 5 items after 5 minutes (which she gave me the answer after I couldn't remember 2 of them). She asked me nothing about my symptoms or about the events of the trauma. She picked what parts of my VA medical records she included in the report (i.e., sleep disturbance). I feel like I have been shafted. She is basically refuting the diagnosis given by my TWO VA psychiatrists, VA psychologist and my VA social worker. I waited over 25 years to file my sexual assault claim due to me being extremely embarrassed and unable to bring myself to talk about the events that occurred while I served as a submariner in the Navy. The assault happened in 1988; back before don't ask, don't tell. Needless to say I was traumatized and afraid of being kicked out. Nonetheless, I was medically discharged a year later due to asthma brought on by anxiety and panic attacks while onboard my duty station. So, now I am at the point where I am finally seeking help and I spend 20 minutes with a c&p psychologist who seems to be indifferent about my condition. I almost feel like I should have just retreat back to my home in silence instead of being treated like a liar!!! What can I do about this? Here is my c&p exam: LOCAL TITLE: COMP & PEN MENTAL HEALTH/PSYCHOLOGY EXAM STANDARD TITLE: PSYCHOLOGY C & P EXAMINATION CONSULT DATE OF NOTE: JAN 19, 2017@09:30 ENTRY DATE: JAN 19, 2017@11:27:37 AUTHOR: EXP COSIGNER: URGENCY: STATUS: COMPLETED 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 [X] No 2. Current Diagnoses a. Mental Disorder Diagnosis #1: No Diagnosis Comments, if any: Psychological Testing A test of response bias specifically related to PTSD symptoms was administered to the veteran during this examination to assess the credibility of his self-report. The name of this measure is withheld in this report in order to protect the integrity of the test. This test was specifically standardized on a sample of veterans applying for financial remuneration for a claim of disability resulting from PTSD. The veteran's score on this test was significantly above the established cutoff, indicating that his performance was not consistent with persons diagnosed with PTSD but was consistent with the test performances of disability claimants simulating symptoms of PTSD. As such, there is reason to suspect symptom exaggeration and a response style indicative of attempts to portray himself as worse off than he actually may be with regard to PTSD symptoms. Based on the Veteran's scores, additional testing was performed to further evaluate the possibility of overreporting or exaggeration of mental health symptoms. A second test of response bias was given that was specifically designed to assess the credibility of reported psychopathology symptoms of response bias related to mental illness. Each item on this test was designed to evaluate constructs and behaviors useful in identifying overreporting. This test was developed and validated using both simulation and known-groups designs to identify individuals attempting to overreport symptoms of mental illness. In addition, the validity of this exam has been generalized across various racial/ethnic groups, genders and settings. The Veteran's total score on this measure was above the cutoff, indicating that his responses were not consistent with persons diagnosed with any mental illness. In addition, the Veteran's scores on this interview indicate that his behavior was inconsistent with his reported symptoms and he endorsed very extreme and uncommon symptoms, symptom combinations that are both unlikely and inconsistent with common mood and psychotic disorders, and he had a tendency to endorse severe and unusual psychotic symptoms. He also endorsed an unusual course of illness that is inconsistent with the course of most psychiatric disorders recognized in clinical practice. It is possible that the veteran suffers from a mental illness. However, I am ethically unable to provide a diagnosis at this time given the veteran's response pattern of overreporting on three objective, reliable and valid psychological tests. Providing a diagnosis would require this examiner to resort to mere speculation and would violate the American Psychological Association's (APA) Ethical Principles of Psychologists and Code of Conduct. b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): Deferred to a physician 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 [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] No mental disorder diagnosis 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 2. History a. Relevant Social/Marital/Family history (pre-military, military, and post-military): Family - Veteran was raised in a "normal" environment by his mother. "I wasn't that close to my father." Veteran has two brothers and two sisters. Veteran's mother was a kindergarten teacher and his father was a "mobile home constructor". Veteran denied any childhood medical/mental health problems. Veteran denied a family history of mental illness. Marital - Veteran has never been married. His last relationship ended around October of 2016 due to his "agitation." "She wanted to talk about stuff and I didn't want to discuss issues with her." Veteran has three sons (ages 16, 20 and 22). "My oldest two sons I don't really talk to since they're gone-one is overseas and the other I think moved up North. I call them every now and then and try to reach them but I hardly get in contact with them. I have a close relationship with my youngest son. He keeps me going." Social - "I had a lot of friends growing up but over the years they sort of fell to the wayside. I had friends going into the military and in boot camp but after sub school I stayed to myself. I had some associates but I didn't want to make any friends after sub school. Currently I have a few associates but I wouldn't call them friends." Prior to the military, the veteran enjoyed running track, playing football, singing in the choir and being in the art club ("I was the cartoonist for the school paper."), science and chess club. "During the military I didn't have any activities other than working on my rating. After I got out I got into oil painting, swimming, cycling and home renovation. I can no longer cycle or swim because of my back and respiratory issues. I haven't attended church in three years and my mother is now a pastor." b. Relevant Occupational and Educational history (pre-military, military, and post-military): Educational - Veteran earned a Bachelor's Degree in Electrical Engineering in 1995 and a Master's Degree in Biomed Engineering in 2009. Veteran informed that he was a good student and denied a history of suspensions, expulsions or learning problems. Occupational - Veteran's job history prior to the military includes custodian and lawn care (self-employed). Veteran serve in the Navy from July 13, 1987- May 16,1989. Veteran was a college student from 1990-1997 and 2004-2009. Since being discharged from the military the veteran has worked as an RF engineer/consultant (1997-2004: "I got into an argument with my supervisor because he always wanted to include me on projects he was working on and I thought that was inappropriate. I thought he had an interest in me even though he didn't say it outright. He wanted to go out and do stuff outside of work hours."); and bioengineer/prosthetic designer for the Department of Commerce (2010-March of 2016: "I got in several arguments because of space and eventually withdrew and stopped producing. I had to share a small space with a coworker and he was constantly rolling back in his chair asking me questions and tapping me on the shoulder so it finally came to a head."). Occupational problems reported include poor social interaction ("Shouting at people and avoiding contact with guys in the office. I worked better with females."), difficulty concentrating ("Because I was focused on not being in a vulnerable position. I missed deadlines or didn't finish tasks because I couldn't focus. I asked to have my own office but you can't have one as a junior engineer."), difficulty following instructions ("If men tried to get close to me because it reminded me of sub school and the threat of not being advanced or promoted."), forgetfulness, and increased absenteeism ("In 2015 I couldn't deal with the office so I started working from home but my supervisor didn't want me to sever myself from the office totally. I had anxiety about going back and sharing an office with another male. I felt better working by myself because I was more productive."). In regards to reprimands, the veteran informed that he was written up for poor work performance, absenteeism, being AWOL and conflicts with his officemate. "The conflicts with my officemate led to me being fired." Veteran informed that he has applied for one job since being fired. When asked if he was a productive and reliable employee he stated, "As long as I was alone and no one was being touchy with me." Veteran denied the following occupational problems: assignment of different duties and tardiness An October 5, 2016 MH OUTPT NOTE states, "He is unemployed and uses income from renting rooms to pay living expenses." An October 5, 2016 MH Attending note states, "Lost his last job as a biomedical engineer in March 2016 after "tussling" with an older man in his office who would repeatedly come up behind him and touch/pat his shoulders which reminded him of his Navy experience...Owns home and rents out rooms for income." c. Relevant Mental Health history, to include prescribed medications and family mental health (pre-military, military, and post-military): Mental Health Veteran began mental health treatment at the North Texas VA in August of 2016 and is compliant with his medication regimen of risperidone, prazosin and sertraline despite feeling "groggy and spaced-out." Veteran denied a history of psychiatric hospitalizations. An October 12, 2016 SLEEP TELEPHONE NOTE states, "I called the patient and explained their sleep test results in detail. I explained him that the study did not show significant sleep apnea despite his sleeping on his back. He is unable to sleep on his side due to his shoulder problems...Encouraged the patient to lose weight." A November 2, 2016 MH PTSD INDIVIDUAL NOTE states, "Veteran believes that gay men are going to hurt him. He also informed worker that he has experienced a lot of fear and worry this Halloween with people who are transgender, to the point that he is not sleeping for fear they will break into his home. Veteran is worried that he may have to "barricade" his home with bars on the windows." A November 3, 2016 MH Attending Note states, "Updates that since last appt, his GF ended their relationship, "she said I was over agitated." Last week, he describes an incident at a restaurant when a transgendered person was standing by him, he turned and saw the person, got so upset that he ran out of the restaurant and vomited. Since last week has felt progressively worse. "It's harder to tell which people to stay aware from.. it's a whole new ballgame with transgendered [people]...I don't know who my enemy is." He states he needs to set a perimeter on his house, put bars on his windows/doors, and update his security alarm. Reports poor sleep, gets out of bed 3-4x/night to check doors/windows and frequency of NMs has increased. Appetite is low. Feels that he cannot focus, "I'm constantly thinking how to avoid these people." Reports hearing male voices talking outside of his windows so he fears they will break in (reason for "setting perimeter"). When he is in public he has thoughts of "I need to get them before they get me" when he passes male strangers. Has not had any violence but does say he has had verbal arguments (told someone in the Wal-Mart line to back up and they argued with him, for example)...+ MST in Navy- unwanted taunts, suggestive remarks and genital contact and kissing from supervisor." A December 5, 2016 MH ATTENDING NOTE states, "Updates writer that he has spent ~$3000 since last visit adding bars to the outside of his first floor home window and installing a security system with cameras. Reports he still plans to add more cameras to monitor his roof because "maybe someday deterred by the barricade downstairs might want to get in up there." Reports vague AH of hearing footsteps on his second floor when he is down on the first floor. Denies hearing voices from upstairs or outside his window like he endorsed last visit. Reports nighttime is the hardest for him because "that's when they are outside...the enemy, the transsexuals." Denies actually seeing anyone outside of his house at night. Reports he is comfortable with certain people coming up to his house, like the mailman, but states he is not comfortable when strangers come up. States he is not aggressive but tells them to go away. Does not take his gun with him to the front door. States he now feels better with his house more protected. Is able to watch movies and enjoy them during the day. His security system is on his phone app and he checks it every 3 hours. At night he "secures the perimeter" every 2 hours, has an alarm set." d. Relevant Legal and Behavioral history (pre-military, military, and post-military): Behavioral - "In 2005 I grabbed a guy that was dressed like a female. We were meeting for a date but his profile said he was a female. Two months ago a person behind me in line was transgender. I pushed him to the side and ran outside." Legal - Veteran denied a history of legal problems. e. Relevant Substance abuse history (pre-military, military, and post-military): Substance Abuse - Veteran denied a history of substance abuse. f. Other, if any: No response provided. 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: MST February-April of 1988: CPRS states, "A male teacher began touching him during class and stepped over lines trying to get too close that made him feel very uncomfortable. Veteran says there was never genital contact because there was touching and kissing on the part of the instructor." Veteran's stressor statement states, "One trainer would come up behind me and massage my shoulders. He also grabbed my waist and pressed himself against me. I could feel his erect penis against my buttocks. He also made sexual innuendos and jokes. He also asked me if my nipples were hard because I was glad to see him. He then said, 'I bet you have a nice sized tool'. He then touched my left nipple and kissed my neck. When I confronted him he stated that if I didn't cooperate, I may not pass through with my classmates. He then grabbed my crotch and said, 'Pass or no pass. You make the determination.' My relationship with my long time high school sweetheart ended that summer (June of 1988) because I withdrew fro the relationship and was too ashamed to confide in her." Please note that this last statement is in contrast to the statement provided by his former girlfriend who stated that the veteran "mentioned that a sexual assault happened to him during training that changed him and that he needed time to work through it." 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 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. Veteran's treatment records, buddy statement and stressor statement were reviewed. However, there are no markers in the veteran's STRs or personnel records which the VBA has confirmed. 4. PTSD Diagnostic Criteria No response provided. 5. Symptoms No response provided. 6. Behavioral Observations MENTAL STATUS EXAM - Appearance, Behavior, and Speech Veteran's appearance and dress were appropriate for the exam. His speech was normal in rate and tone. Veteran's response to the evaluation was guarded but engaged. Rapport was easily established with the Veteran who put forth a conscientious effort to answer all questions to the best of his ability. Thought Process - There was no evidence of loose associations, flight of ideas, circumstantial, or tangential thought process. Veteran completed similarities and interpreted proverbs accurately. Thought Content - Veteran denied having any obsessions or suicidal/homicidal ideations. However, delusions regarding the security of his home and transgenders were reported. "Transgenders are trying to get back at me because I grabbed the transgender that I was supposed to go on a date with. His profile said he was female. I have to hone in and decipher whether someone is male or female because my initial problems came with my sexual assault in training so I've distanced myself from males who are the enemy. The transgender caught me off guard and now they're trying to trick me. It's a whole new ball game." Perceptual Abnormalities - "I keep hearing my instructors voice in my head. Especially if I get around someone who has to make choices that involve me. I keep hearing 'pass or no pass' which is what he said to me. I hear a human voice outside my windows. When I go look there's nothing there so I don't know if they've run away or what. That's why I put up security cameras." Mood and Affect - Veteran's mood was "indifferent" and his affect was flat. Sensorium and Cognition - Sensorium was clear. Veteran was oriented to time, place and person. Immediate memory was good as he was able to repeat five of seven numbers forward and six of seven numbers in backwards sequence. Recent memory was fair as he recalled two of three items after five minutes. Remote memory was fair as he recalled the names of the last three presidents, the name of his high school, his youngest son's birthday, and his first job. Veteran was unable to recall the name of his elementary or junior high school nor his siblings or two oldest sons birthdays. In regards to concentration, Veteran spelled world forward and backwards and completed simple mathematics, serials 3's, and serial 7's. His intelligence appeared to be average. Judgment and Insight - Veteran's insight is good as he understands the outcome of his behavior and the choices he makes. His judgment is impaired but he informed that he would return a library book to the library if found, pull over for the police, and return a wallet he found to the owner. 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 Financial: "My brother pays any bills that I can't pay online." NOTE: VA may request additional medical information, including additional examinations if necessary to complete VA's review of the Veteran's application.
  14. Looking for the Wisdom of the crowd here. I have not fie a claim with the VA – yet. I intend to file an intent to file before the end of the month, so it would give me a year to further gather evidence and proof of my intended anticipated claims to be made and preserve ‘the month of ‘March of 2018’ as my file date. I already had received some files from St. Louis, but unfortunately not all clinic visits were included, and several other documents I know were supposed to be in there. So, I faxed St. Louis again today for everything – well see. I am a Vietnam Vet – so Agent Orange and all it is connected with will be on the list I intend to be checked out for. Of the missing clinic visits, the more important issues where problems diagnosed with my ears, that made me dizzy and nauseated daily, about 2pm everyday while on duty. Also, was a diagnosis and treatment with what I remember as a fungus that supposedly ate my skin pigment and left white circles on my tanned torso, I was given topical medication and pills of some sort. Yet another issue was the flaking of my skin on my head, face, mostly around the base of nose, eyebrows, and forehead. Seems like I was given topical meds and antibiotics. None of this was in the file I received. The clinic I was treated at was located in the secured compound housing HQ of the HHC 1st Aviation Brigade, Crypto Bunker and where I worked, , AVDAC (Aviation Data Analysis Center). Worse, I can’t find anything about where this was located on Long Binh base, or any information on it. There is noting in my file other than my assignment to HHC 1st Aviation Brigade, and I just noticed my file doesn’t even contain a review from HHC 1st Aviation Brigade, or AVDAC, just 3 hash marks under my review from the 101st Admin Company in Phi Bai. As far as I can tell, AVDAC received high praise, but our data and purpose were absorbed by other operations, as it should have been as technology advanced. So, I don’t know how to find anything about AVDAC, or how to find out what the clinic name was, who the doctor was, or how I might obtain the files if they are not sent to me in the request for all files today. We worked in a secured fenced in area and the tiny clinic treated mostly officers, lots of Generals, and the enlisted personnel that worked in the compound so we never had to be gone from or duty to the base clinic/hospital. I was told the old doctor, who was a hell of a nice guy, was the Surgeon General of Vietnam, but then, my Colonel (Colonel Short – about 6’6”) in charge of AVDAC really liked joking around with us. Any suggestions – I am stuck and the conditions that developed I in VN I had been able to control by various means for decades, but have always flared up with stress, illnesses, heat, dryness, etc. but the past several years have been very hard to control and painful. Every doctor I see says it is something different then the last doctor. So, before the year passes, I intend to be thoroughly examined by outside of the VA doctors, and I’ll take appropriate DBQ with me, even if they will not fill it out, maybe they’ll go over the checkboxes with me. Any Suggestions? Of the claims I intend to make, PTSD and MST PTSD will be on the list – top of the list in many ways. The PTSD has affected my life for about 44 years now, my kids and wife have suffered but all still love me. I have alienated nearly all my family, and have most other signs, there is no doubt I have PTSD, it depends if I am diagnosed with it. I started to going to a shrink a decade or so, but stopped short of being open, just couldn’t do it. Once again, any suggestions. I am also concerned as how to handle MST part of my PTSD. I have issues from VN, but the MST happened on base in our barracks on Bragg. The issue gets very complicated, but I know the truth just how to prove it will be the crux of the matter. I am also afraid, as I have been for 44 years to push it, as I might lose any claim to PTSD for other stressors. Last question for the people familiar with MST, what do you think of the 2 MST Agents in very state, I think they work for the VA, maybe each state. Are they people I can trust – I have breathed a word of this to anyone except family and 1 old army buddy since I left the army. OMG – this is a book already and I haven’t scratched the surface of what I need help with
  15. The VA lists 2 Military Sexual Trauma Coordinators in every state - a male and a female. https://www.publichealth.va.gov/exposures/coordinators.asp I am not sure what their purpose is, I think they are suppose to guide a MST victim through the process, and keep things confidential. But I have many questions as to their expertise, how they are trained, and if it is advisable to contact them before you get your case together, be it as it may. Or is part of their duty to aid and guide you in putting your case together, opening doors for so so you have access to information that is otherwise difficult to obtain?? Other words - are they worth their Salt? Guidance please. I've read many MST cases here and elsewhere, I can't believe the crap they have to go through to prove what happened, the degree their efforts are challenged, and how often any disability is denied. All I can say is, be strong, be united, and both Women and Men need to take more action, united.
  16. Recently I was DX and granted SCD for PTSD due to personal trauma (MST). I have also noticed a dramatic reduction in performance capabilities as well. I have not mentioned this to any of my doctors, VA or private. It's been hard enough to admit to the MST, without having to add the ED to it. But I've reached a point where I can no longer ignore it. I'm only 44 years old and have far too much life left to live to continue ignoring the ED. I'd like to hear any suggestions or guidance as to the best way to file a claim for this as secondary to my SCD PTSD. Any and all suggestions from all parties are welcome. Also, should I start with making an appointment with my PCP? Thank you to all who read and respond to this delicate and humbling matter. Semper Fi Andy
  17. M21-1MR on Evaluating Competency http://www.warms.vba.va.gov/M21_1MR.html Chapter 8 - Competency, Due Process and Protected Ratings Section A. Evaluating Competency Overview In this Section This section contains the following topics: Topic Topic Name See Page 1 Guidelines for Evaluating Competency 8-A-2 2 Considering Competency While Evaluating Evidence 8-A-4 3 Process for Making Competency Determinations 8-A-6 4 Changing Competency Status 8-A-8 5 Evaluating Competency in Special Circumstances 8-A-10 1. Guidelines for Evaluating Competency Introduction This topic contains information on the guidelines for evaluating competency, including · who has the authority to determine competency · the effect of judicial findings on the rating activity · presuming competency · making a finding of incompetency, and · considering the Veterans Service Center Manager’s (VSCM’s) opinion. Change Date December 13, 2005 a. Who Has Authority to Determine Competency The rating activity has sole authority to make determinations of competency and incompetency for Department of Veterans Affairs (VA) purposes. Reference: For more information determining incompetency, see · M21-1MR, Part III, Subpart v, Chapter 9, and · 38 CFR 3.353(b). b. Effect of Judicial Findings on Rating Activity Judicial findings of a court with respect to competency of a veteran are not binding on the rating activity. However, if a veteran is declared by a court to be incompetent, develop all necessary evidence for a rating determination. c. Presuming Competency In the absence of clear and convincing evidence to the contrary, presume that a person is competent. Reference: For more information on presuming competency, see 38 CFR 3.353(d). Continued on next page 1. Guidelines for Evaluating Competency, Continued d. Making a Finding of Incompetency A finding of incompetency cannot be made without a definite expression by a responsible medical authority, unless the medical evidence of record is · clear · convincing, and · leaves no doubt as to the beneficiary’s incompetency. Reference: For more information on medical authority in a finding of competency, see 38 CFR 3.353©. e. Considering the VSCM’s Opinion After development of information with regard to social, economic, and industrial adjustment, the Veterans Service Center Manager (VSCM) may be of the opinion that a beneficiary rated, or proposed to be rated, incompetent is actually capable of handling, without limitation, the funds payable. In this case, he/she will refer the evidence and finding to the rating activity. The rating activity should consider the VSCM’s finding as new evidence and, after any necessary additional development, prepare a rating based on the evidence of record. Reference: For more information on procedures related to evidence of incompetency, see M21-1MR, Part III, Subpart v, 9.B. 2. Considering Competency While Evaluating Evidence Introduction This topic contains information about evaluating the evidence and considering the competency of · veterans · helpless children, and · other beneficiaries. Change Date December 13, 2005 a. Considering the Competency of a Veteran If the claimant is a veteran, consider competency an inferred issue · in every case of a totally disabling mental disorder, or · if other evidence raises a question as to the beneficiary’s mental capacity to contract or to manage his/her own affairs, including disbursement of funds without limitation. Reference: For more information on inferred issues, see M21-1MR, Part III, Subpart iv, 6.B.3. Continued on next page 2. Considering Competency While Evaluating Evidence, Continued b. Considering the Competency of a Helpless Child If the claimant is a helpless child, the rating activity must resolve the issue of competency for a child over age 18, because entitlement depends upon permanent incapacity for self-support due to physical or mental disability. If incapacity is due to mental disability · consider competency a factor in determining whether the child is permanently incapable of self-support · determine competency under the same criteria applicable to veterans, and · record the determination in a rating. References: For information on · due process procedures in incompetency cases, see M21-1MR, Part III, Subpart v, 9.B.6, and · conditions which determine permanent incapacity for self-support, see 38 CFR 3.356. Note: Since the incompetency procedures referred to in M21-1MR, Part III, Subpart v, 9.B.6 are for payment purposes, do not apply those procedures except in cases where the child would receive direct payment in his/her own right. c. Considering the Competency of Other Beneficiaries If there is evidence of incompetency and the claimant is another beneficiary, such as a surviving spouse, parent, or VA insurance beneficiary · consider competency a rating issue under 38 CFR 3.353 except when there has been a judicial determination of incompetency, and · propose a rating on the issue or undertake any required development. References: For more information on · rating actions required after judicial determinations of incompetency, see M21-1MR, Part III, Subpart v, 9.B.5.g, and · development required with different determinations of competency, see M21-1MR, Part III, Subpart v, 9.B.5.f and M21-1MR, Part III, Subpart v, 9.B.6. 3. Process for Making Competency Determinations Change Date August 3, 2009 a. Process for Making Competency Determinations The table below describes the actions involved in making competency determinations. Reference: For more information on due process in incompetency determinations, see M21-1MR, Part III, Subpart v, 9.B.6. Stage Who Is Responsible Action 1 Rating Veterans Service Representative (RVSR) Prepares a rating decision proposing a finding of incompetency after receiving clear and convincing evidence that the payee is incapable of managing his/her own affairs, including disbursement of funds without limitation. Note: A rating is not necessary for any payee besides a veteran, if there is a finding of incompetency by a court. For all payees, however, a court adjudication waives the due process requirement. 2 Veterans Service Representative (VSR) · Provides the payee notice of - the proposed incompetency rating, and - the opportunity for a hearing · clears any pending end product (EP) that would normally be taken at this point · establishes EP 600 to control the proposal of incompetency, and · allows 65 days for a response. Notes: · EP 600 controls the incompetency proposal in any claim, including an original claim for benefits. · If a request for a hearing is received within 30 days of the notice, no rating action can be completed until the hearing is held or the payee fails to report. At the hearing, allow the next of kin or any other person of the payee’s choice to participate and assist the payee. Continued on next page 3. Process for Making Competency Determinations, Continued a. Process for Making Competency Determinations (continued) Stage Who Is Responsible Action 3 RVSR Makes a final decision based on all of the evidence of record. 4 VSR · Clears EP 600 upon completing action on the final rating decision and notification on the competency issue · establishes EP 290 to control the appointment of a fiduciary, and · prepares VA Form 21-592, Request for Appointment of a Fiduciary, Custodian, or Guardian, for use by the fiduciary activity. 4. Changing Competency Status Introduction This topic contains information about changing competency status, including · proposing a loss of competency · determining restored competency · limitations after competency is restored, and · evidence required to restore competency. Change Date August 3, 2009 a. Proposing a Loss of Competency Issue a rating proposing a change in competency status if the evidence of record will result in a change in competency status from competent to incompetent. This proposal may be included in a rating addressing other issues, such as evaluation of a mental disorder. Reference: For more information on procedures to follow upon receipt of evidence of incompetency, see M21-1MR, Part III, Subpart v, 9.B. b. Determining Restored Competency In any case in which the beneficiary has been rated incompetent, take necessary development and rating action to determine whether competency has been regained if so indicated in a · hospital summary · report of release to or discharge from non-bed care, or · report of other material change in condition. c. Limitations After Competency Is Restored Restored competency does not of itself · warrant a reduction in the evaluation of a veteran’s disability, or · establish that a parent or surviving spouse is no longer entitled to Aid and Attendance (A&A). Continued on next page 4. Changing Competency Status, Continued d. Evidence Required to Restore Competency Any evidence showing the beneficiary may be capable of handling funds should be referred to the rating activity. The rating activity will consider this evidence, along with all other evidence of record, to determine whether competency should be restored. Under 38 CFR 3.353(b)(3), a beneficiary is not required to undergo a psychiatric examination and/or field examination before his/her competency may be restored. However, a current psychiatric examination and/or field examination may be requested if needed to properly evaluate the beneficiary’s mental capacity to handle his/her own funds. 5. Evaluating Competency in Special Circumstances Introduction This topic contains information about evaluating competency in special circumstances, including · a competency rating after a decree by a court, and · appropriate action after court adjudication. Change Date August 3, 2009 a. Competency Rating After a Decree by a Court Use the table below to decide how to proceed with a competency rating of payees who have been found incompetent by a court. Note: Judicial findings of a court with respect to the competency of a veteran are not binding on the rating activity. If determining the competency of … Then … non-veteran beneficiaries such as a · parent · surviving spouse, or · helpless child a rating is not required except under certain conditions. Reference: For more information on a child’s permanent incapacity for self-support, see M21-1MR, Part III, Subpart iii, Chapter 7. Continued on next page 5. Evaluating Competency in Special Circumstances, Continued a. Competency Rating After a Decree by a Court (continued) If determining the competency of … Then … a veteran · develop all necessary evidence for a rating activity determination, such as - an examination - hospital observation, or - a field examination · give great weight to a court decree of incompetency in conjunction with hospitalization for a mental condition, and · do not make a rating of competency unless there is clear and convincing evidence of that fact. Important: In the following cases a payee may be considered to have had notice and hearing under the laws of the state, so that additional notice and hearing are not required: · a payee held by a court of jurisdiction to be incompetent, or · a payee for whom a court having jurisdiction has appointed a guardian by reason of incompetency. Note: If the veteran continues to be rated incompetent, prominently note the finding of competency by a court on the rating. Continued on next page 5. Evaluating Competency in Special Circumstances, Continued b. Appropriate Action After Court Decrees Use the table below to determine the appropriate action after court decrees concerning competency. Reference: For more information on competency payment code award data, see M21-1, Part V, 13.05. If a court decree … Then … declares a veteran, previously rated incompetent, competent · take the necessary development action, and · prepare a new rating, prominently entering a notation of the court’s declaration on the rating, if incompetency is confirmed and continued. applies to a non-veteran beneficiary for whom a rating of incompetency is not required request the VSCM to promptly certify the validity of the decree so that direct payments may be made to the beneficiary.
  18. I have been working with a VSO to file my claim. I am currently in the process of gathering information. Only thing, file for MST with PTSD or file PTSD. VSO was hung up on the sexual part of MST. Background: Was in service 1991-2000. In 1995 was involved with a female soldier, who also was involved with another male (married) soldier. After an exercise and the last night sleeping together she asked me to kill his wife. After the second time I went to CID and wore a wire twice. While the Article 32 hearing was going on she was let out of pre-trial and started harassing me, being around me. I was moved from my company to another, and ultimately to the brigade HQ (rear detachment). Brigade HQ was deployed then. Both the female soldier and male soldier were other than honorable discharged, but I was exiled for a year. Not the same after. As I was getting out in 1999 I learned that she had asked other people in the unit to kill me. I was seen at a Vet center into 2000. Same time as the Article 32, my chain of command was trying to discipline me for an Article 15/court martial. The incident was with the female soldier (before she had asked me) and was on a trumped up charge. Even had the 1st sergeant threatened me in his office about "if he could not get me on that charge he would find another". After my time in Brigade HQ I returned to almost a new unit, only 5% knew me. All I wanted was out, but he harassed me every day to change my mind and go to the promotion board. Would not even let anyone drive me to airport to PCS. It took my wife to point out that when I get harassed or witness it at work that I am affected by it. I am currently being seen for it by the Vet center I was seen at before. The vet center had listed me as PTSD and marked as military trauma. Also, I don't have anything from that time as I was not in a good place and as a 26 year old did not want the reminders in my barracks room. So if anyone knows how to get the CID or JAG records I am all ears.
  19. My heart goes out to all of my fellow survivors of MST ... For me, I have found I can no longer suppress and manage the daily physical and emotional affects of the sexual assault that took place on December 25, 1985 while serving on active duty. In effort to find some help, relief and hopefully someday healing I am starting the uphill journey to deal with this and try to share some of the highlights of my battle. I will be the first to admit I have no idea what I am doing and can only hope that God the father.... will guide my feet day by day. First step locating documentation of the event. A few weeks ago I was able to locate the police dept. and requested a copy of the report. I received a copy of the 15 page report this past week and it makes me emotionally and physically sick just to look at the envelope it's in. I also tried to locate medical records over the years from prior mental health therapists and physicians that would have documented my history as it related to these events, but the practices were closed or my records were no longer available due to time. April I called the VA to inquire about mental health services for MST and hesitated to start the process because the MST would not be marked in my record for all my providers to see. This was a big hurdle mentally as I have always hid this event at all costs from my providers. I am sure this did not help my physicians treat me and fully understand my ongoing medical problems especially those in which are usually brought on by some big life event which I always adamantly denied when asked. May 2nd 2017, I submitted a "intent to file". May 4th 2017, I went to a VSO rep?? to asked questions about the process to file a claim related to MST. The rep was belittling, insulting, hurtful, rude and I walked out of that office with no more information and the psychological affects were pretty devastating. At the encouragement from my daughter to go straight to the patient advocate office and file a complaint....I did just that. I found myself have a total mental breakdown just trying to give the details of what just went down and was thankfully met with support and many reassurances that I would have a team of people helping moving forward and that person would be brought in...dealt with and re-trained. I will spare you all the details. My next step is hearing from the mental health dept. to set up an appt. to do some type of baseline evaluation of my symptoms etc. as it related to MST... I guess to get an official diagnosis on record and to get me the specific therapy I need started. I will likely opt for tele-therapy once I have a few sessions onsite at the VA. That's it for now
  20. Anybody have any idea or know anything about the part of the PTSD criterion relating to derealization and or dissociation? I experienced them both during my multiple MST events...still do.
  21. New here so sorry if i am confusing Can anyone give me some insight on if MST/PTSD claims are paid back to the service/discharge date? I just recently opened a claim for disability, part of which is a MST claim. Sadly, I was unaware I could open a claim, I was an activated navy reservist and once I was off deployment I never looked back, didnt ask questions, i just wanted to put my deployment behind me. with that being said, i dont recall or have record of ever getting a discharge physical. I have heard multiple answers which i am sure all are correct, but maybe someone can clarify why some claims are paid back to the service date and some only to the claim date. Also, I know there are appeals and such, but there is another service member that personally knows of her friend getting back paid to the date of service on her first initial claim and it was 3-4 years past her discharge date. Oh I have my claim physical and psych eval on the 28th, and i am honestly really nervous and dont know what to expect.. some pointers would be greatly appreciated thanks. USNR 2004-2008 IRR:2008-2012 ACTIVE 2006-2007
  22. May 2016 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: [X] Military service treatment records [ ] Military service personnel records [X] Military enlistment examination [ ] Military separation examination [X] Military post-deployment questionnaire [X] Department of Defense Form 214 Separation Documents [X] Veterans Health Administration medical records (VA treatment records) [X] 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: VHA medical record (CPRS) and VA e-folder (VBMS records) were reviewed. There was no physical C-File available as all documents were available in e-folder per C&P exam instructions. 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): Pre-military: Veteran was born in Weslaco, Texas and raised in Alamo, Texas. He was raised by both parents and grew up with a brother. Veteran described his childhood as "okay, my mom was a stay at home mother, my dad worked, and was also an alcoholic, always talking down to me and hitting my older brother when he was drunk." Veteran reported that he got along with other children and teachers while growing up. He participated in baseball and football while in school. Military: Veteran reported that he got along "pretty good" with other soldiers. Post-military: Veteran lives with his spouse and two children, seven year-old son and one year-old daughter. Veteran and his wife have been married since 2005. He described his relationship with his wife as "married, have our ups and downs." Veteran described his relationship with his children as "nice." He spends most of his time with his daughter. His hobby is to "coach a travel selected team for softball." He stated he spends time with friends "on the weekends" barbecuing. b. Relevant Occupational and Educational history (pre-military, military, and post-military): Pre-military: Veteran obtained a high school degree from Pharr-San Juan-Alamo High School. He reported that his grades were average and denied having any learning or attention problems. Military: Veteran served active duty in the Army from April 17, 2002 to April 16, 2005. MOS: 92F, Petroleum Supply Specialist. Rank at Discharge: E-3. Discharge: Honorable. Veteran was awarded the Army Lapel Button, National Defense Service Medal, Global War on Terrorism Expeditionary Medal, Global War on Terrorism Service Medal, Army Service Ribbon. Veteran served in Southwest Asia from February 7, 2004 to August 24, 2004. Post-military: Veteran completed a certificate for medical assistant in 2015 from Southern Careers Institute. Veteran is current unemployed; he was last employed February 2015. Veteran stated he was a heavy equipment operator for the city of Donna from December 2014 to February 2015. He stated he was fired because his "director told [him] [his] position was no longer needed." He denied having disciplinary problems at this job. c. Relevant Mental Health history, to include prescribed medications and family mental health (pre-military, military, and post-military): Pre-military: Veteran denied mental health history including hospitalizations for mental health problems. Veteran reported that his father was "always drinking alcohol." Military: Veteran stated that he was diagnosed with depression "January 2004." He reported that he was hospitalized for two weeks at John Randolph hospital in Virginia. Veteran reported, "When I came back from my tour in 2004, I woke up one morning and decided to cut my wrist with my Gerber knife. Then I realized what the hell I was doing, I drove myself to the local hospital in Virginia." Veteran denied seeing anyone wounded, killed or dead during deployment when he completed September 2, 2003 Post-Deployment Health Assessment. He did endorse feeling like he was in great danger of being killed. Veteran denied having little interest in doing things, feeling depressed, nightmares, avoidance behavior, hypervigilance, and feeling detached from others. He reported that his health in general was "very good." According to Report of Consultation from John Randolph Medical Center dated January 19, 2005, Veteran was "admitted to psychiatric services with depression." According to the Behavioral Health Initial Assessment from John Randolph Medical Center dated January 15, 2005, "He is in the process of getting divorced from his wife who lives in Texas. He said that he has been feeling stressed since this past weekend and yesterday he held a knife in his hand and wanted to hurt himself. He reported feeling depressed, having decreased energy, decreased appetite, decreased sleep. He has been having some flashbacks and nightmares about the war in Iraq." Post-military: Veteran is prescribed Buspirone and Fluoxetine; he stated he is compliant with psychotropic medication. Veteran attended primary care mental health integration initial appointment on January 19, 2016. He then attended mental health initial evaluation on February 10, 2016. Veteran attended VPTT Consult on February 23, 2016. He was no-show to follow-up appointment for VPTT on May 2, 2016 and May 9, 2016. Veteran denied current auditory and visual hallucinations. He denied current suicidal and homicidal ideation, intent, or plan. Nonetheless, he was provided with Veterans Crisis Line information. Veteran was instructed to monitor symptoms, including emergence of suicidal or homicidal ideation, and to utilize this number, call 911, or go to nearest ER at closest hospital, in case of mental health emergency. d. Relevant Legal and Behavioral history (pre-military, military, and post-military): Pre-military: Veteran denied legal and behavioral history. Military: Veteran reported he lost rank "for being late so many times." He denied receiving Article 15s. Post-military: Veteran denied legal and behavioral history. e. Relevant Substance abuse history (pre-military, military, and post-military): Pre-military: Veteran denied substance use including alcohol and cigarettes. Military: Veteran reported that he drank alcohol "like every weekend." He stated that he smoked cigarettes "just the weekends probably like six or seven cigarettes." Veteran denied use of other substances. Post-military: Veteran reported that he drinks "2 - 3 beers a week." He stated he is no longer smoking cigarettes. Veteran denied use of other substances. f. Other, if any: No response provided. 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: Veteran reported that he served in Kuwait and Iraq. He denied engaging in direct combat. Veteran reported, "We were, I was doing guard duty one night and we heard the patriotic missiles, there were SCUD missiles coming in," "cause we were near Camp Virginia," "and we had to put on MOPP [mission oriented protective posture] gear" "because there was blood pathogen in the air." He stated, "one of my friends getting killed" "something I heard about." "We saw some dead bodies on our way back from Iraq," "we were 50 miles close to border line, coming back to Kuwait." 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 ----------- For VA rating purposes, check all symptoms that actively apply to the Veteran's diagnoses: [X] Anxiety [X] Disturbances of motivation and mood [X] Difficulty in establishing and maintaining effective work and social relationships 6. Behavioral Observations -------------------------- Veteran was alert and oriented x3. Dress was casual but appropriate. Attitude was cooperative and polite. Speech was clear, coherent, and relevant. Mood was "pretty good." Affect was consistent with mood and topics discussed. Thought processes were logical, linear, and goal-oriented. Thought content was WNL, with no signs or reports of A/V hallucinations, delusions, paranoia, or homicidal ideation/plan/intent. Veteran denied current suicidal ideation/plan/intent. Memory appeared intact. Judgment appeared adequate. 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 -------------------------------------------------- Please note that level of impairment is only based on Unspecified Trauma-and Stressor-Related Disorder and Major Depressive Disorder, in partial remission. Veteran has physical impairments, which were not assessed today. NOTE: VA may request additional medical information, including additional examinations if necessary to complete VA's review of the Veteran's application. /es/ MARIA T Artiaga, PsyD Supervised Psychology Staff Signed: 05/31/2016 11:28 Receipt Acknowledged By: 06/05/2016 16:22 /es/ DESI A. VASQUEZ, PHD SUPERVISORY PSYCHOLOGIST ------------------------------------------------------------------------- November 2016 2nd C&P Exam Initial Post Traumatic Stress Disorder (PTSD) Disability Benefits Questionnaire * Internal VA or DoD Use Only * Name of patient/Veteran: Edgar Sandoval 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 [X] No If no diagnosis of PTSD, check all that apply: [X] Veteran's symptoms do not meet the diagnostic criteria for PTSD under DSM-5 criteria [X] Veteran has another Mental Disorder diagnosis. Continue to complete this Questionnaire and/or the Eating Disorder Questionnaire: 2. Current Diagnoses -------------------- a. Mental Disorder Diagnosis #1: unspecified trauma-and stressor-related disorder ICD code: F43.9 Mental Disorder Diagnosis #2: persistent depressive disorder ICD code: F34.1 b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): deferred to medical 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? [ ] Yes [X] No [ ] Not applicable (N/A) If no, provide reason that it is not possible to differentiate what portion of each symptom is attributable to each diagnosis and discuss whether there is any clinical association between these diagnoses: symptom overlap 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 occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation 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 [X] No [ ] No other mental disorder has been diagnosed If no, provide reason that it is not possible to differentiate what portion of the indicated level of occupational and social impairment is attributable to each diagnosis: symptom overlap 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 2. History ---------- a. Relevant Social/Marital/Family history (pre-military, military, and post-military): He was born in Weslaco, Texas and raised in Alamo by his biological parents. He has one brother. He stated that his father was an alcoholic and would "talk down at [him]." He was also physically abusive. He got along with peers and teachers and played sports in school. The veteran was living with his wife, daughter, age two and 8-year-old son, but they separated and he is now living with a friend. He visits with his children regularly. He stated that he was arguing and irritable with his spouse and that he was "swearing" in front of his children. "I was getting mad for no reason." His mother died in a nursing home with stroke (09/2016) and his father died of "alcoholism" (10/2016). He stated the symptoms of depression have increased since they died. "The whole world's on top of me." He continues to coach softball with teenage girls on the weekends. Relationships were good in the military. b. Relevant Occupational and Educational history (pre-military, military, and post-military): He graduated high school with average grades. There were no learning or attentional problems. He worked part-time at a department store during his teenage years. He was active duty Army (2002-2005) with highest rank SPC and rank at discharge of PFC due to disciplinary problem. Discharge was honorable. He received GWOT, NDSM, Global war on terrorism expeditionary medal. He was in Southwest Asia (2004). Post-military, he received a certificate for medical Assistant (2015). He has been unemployed since February 2015 after having productivity problems in a position as heavy equipment operator. c. Relevant Mental Health history, to include prescribed medications and family mental health (pre-military, military, and post-military): He did not report pre-military mental health issues or family history of psychiatric problems, though his father drank heavily. Records indicate he was admitted to John Randolph Medical Center in January 2005 with "depression." Recent VA records show he has been receiving mental health treatment for trauma-related disorder and depression since January 2016. He has received both group and individual therapy. The veteran stated that symptoms of depression have been increased since his parents died 1-2 months ago. Currently, he reports symptoms of depression including feelings of guilt, decreased pleasure and interest in activities, decreased energy, irritability, tiredness, and problems sleeping. He stated that he feels guilty for not being with his parents anymore or with his family. He reports symptoms of trauma- and stressor- related disorder including occasional distressing dreams or intrusive memories, reactions to cues in the environment (seeing people with Middle Eastern clothing"), decreased interest in activities, irritability, hypervigilance, and problems sleeping. Medications: Buspirone, lisinopril. d. Relevant Legal and Behavioral history (pre-military, military, and post-military): none e. Relevant Substance abuse history (pre-military, military, and post-military): 6-pack of beer per month. f. Other, if any: No response provided. 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: Feeling that his life was threatened during deployment with danger of being killed. 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 b. Stressor #2: Seeing "dead bodies" when coming back from Iraq. 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: Hearing that one of his SM friends was killed. 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 --------------------------- 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) [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] Recurrent distressing dreams in which the content and/or affect of the dream are related to 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: No response provided. 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. 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] 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 #1 [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] Anxiety [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 -------------------------- MENTAL STATUS EXAMINATION Appearance: Casual, appropriate. Behavior: cooperative. Speech: WNL Mood/Affect: WNL, appropriate to content. Orientation: Oriented to all spheres. Cognitions: WNL, not formally tested. Safety: Danger to self/others? NO Safe to return home? YES Risk Factors assessment: [NO] Patient has current thoughts of hurting or killing themselves? [NO] Patient has current thoughts of hurting or killing someone else? [NO] Patient has is looking for a way to kill themselves or has a plan? [NO] Patient has taken actions to activate plan? [NO] Patient has history of compromised impulse control? Judgment: FAIR Insight: FAIR 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 -------------------------------------------------- Please comment on the effect of the Veteran's service connected disabilities on his or her ability to function in an occupational environment and describe any identified functional limitations. Please refrain from opining on if the veteran is unemployable or employable; instead focus and reflect on the functional impairments and how these impairments impact occupational and employment activities. Comment: The veteran is able to function independently and engage in activities of daily living. He is able to drive an automobile and research jobs or prepare for job interviews. However, symptoms of depression and trauma-and stressor-related disorder would negatively impact his motivation. Problems sleeping and tiredness may negatively impact performance and productivity. Irritability may cause interpersonal problems on the job. NOTE: VA may request additional medical information, including additional examinations if necessary to complete VA's review of the Veteran's application. **************************************************************************** Medical Opinion Disability Benefits Questionnaire Name of patient/Veteran: Edgar Sandoval ACE and Evidence Review ----------------------- Indicate method used to obtain medical information to complete this document: [X] In-person examination Evidence Review --------------- Evidence reviewed (check all that apply): [X] VA e-folder (VBMS or Virtual VA) [X] CPRS MEDICAL OPINION SUMMARY ----------------------- RESTATEMENT OF REQUESTED OPINION: a. Opinion from general remarks: Does the Veteran have a diagnosis of (a) unspecified trauma and stressor related disorder with major depressive disorder that is at least as likely as not (50 percent or greater probability) incurred in or caused by (the) friend killed in action during service? b. Indicate type of exam for which opinion has been requested: DBQ PSYCH PTSD INITIAL TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR DIRECT SERVICE CONNECTION ] a. The condition claimed was at least as likely as not (50% or greater probability) incurred in or caused by the claimed in-service injury, event or illness. c. Rationale: STRs show treatment for depression during service (2005). He served in Southwest Asia, feared for his life and found out that a SM friend of his was killed in service. He currently reports symptoms of depression and trauma-and stressor-related disorder, such as irritability, low energy, problems sleeping, intrusive memories, distressing dreams, reactions to cues in the environment. ************************************************************************* /es/ Paul Loflin, PhD Clinical Psychologist Signed: 11/23/2016 12:21
  23. I just submitted my first claim for PTSD from MST. When I was overseas, I was on guard duty was an infantryman. When in a guard tower, he exposed his penis and started playing with it. He was looking at me and wanted to me "help" him out. We were locked and loaded so I was fearful on what this man was going to do next. I just froze. I told his SGT and he was detained and sent back to garrison. The rules changed and I was looked at a different way since the incident. There was no touching but this incident has impacted my life and my sense of security. I'm fearful of everything and what's worse is that it's now effecting my children and my marriage and that's why I'm now filing. I haven't talked about it openly with my friends and now I'm expected to talk about it with a stranger for my c&p appointments? Any advice on what to expect and how long the whole process take.
  24. Hi, This afternoon I have my C&P exam for PTSD secondary to MST, with a contracted provider. I found out Friday evening after work. Fed Ex had delivered the paperwork earlier, but I didn't get a chance to see it until I got home from work. To say that I am nervous would be the understatement of the year. I am desperately trying to hold myself together. My digestive system is all out of whack. I did spend an hour on the phone last night with a wonderful person from a non VSO group. She is a Marine and has trauma history, so that made the connection pretty easy. She gave me a lot of good tips, if I could only remember them when it's crunch time. One of my biggest fears is that this will be just like my previous mental health C&P...where that examiner, a VA employee, when straight for the jugular and ignored my heaps of physical evidence. I don't know why I am even doing this. I fully expect to get more of the same....nothing. If I do get granted SC, the shock of that may well kill me...because that goes against the grain of what the VA has given me over the years....tons of grief and denials. Anyway, just wanted to write this down as some kind of therapy... No body has to read it, or respond. I'm not here anyway.........
  25. I sent this to my service officer to clear up some of the continuing lies, from the VA, in my claims: I Steven *** have been trying to get this claim problem straightened out with the VA, since my first claims filed, since my first claims in the 1990's. There is either a misunderstanding, or the VA is a purposely refusing to acknowledge that I worked with and was sickened by all of the following chemicals on active duty. Gasoline (Leaded), Jet-Fuel, Diesel Fuel, Trichloroethylene. I worked as a Fuels Specialist, and worked with Gasoline (leaded), Jet-Fuel, Diesel Fuel daily. I was soaked in those chemicals daily. I was sickened by those chemicals, and the U.S.A.F. doctors determined they made me very sick. The command was notified, and I was removed from that job. I was placed in a new job, at a weather squadron, at Ramstein Air Base, Germany. My duty had no chemical exposure. After a few weeks I was told to report to a new job. I was again working with petroleum chemicals (Trichloroethylene), which were used to clean printing presses. I again became very sick. I had no choice but to leave the U.S.A.F. because I had lost all jobs due to illnesses from chemicals. (5 years active duty). When I claimed for V.A. disability, I told the VA it was for all of the chemicals. Every decision the V.A. denies, they only deny Jet-Fuel related claims. They always fail to discuss all of the chemicals which made me sick. I told the V.A. so many times, I cannot count the times. At the DRO hearing (San Diego), I told them over and over about all of the chemicals. I told the DRO hearing that the other fuels were also a part of my every day contact, and that I was soaked in them every day. I was soaked in them from filling fuel tanks, with open and closed nozzles, distributing fuels, testing fuels, leaky valves, and more. My clothing and skin were soaked every day on active duty with these chemicals. I was then again soaked with Trichloroethylene from cleaning printing presses, the injuring continued from exposure (Repro-graphics specialist). The headaches, the extremely swollen skin and limbs. So swollen, that my limbs were bleeding from the skin unable to expand further. I want this part of the record. I have made printed and oral statements to correct the record with V.A. claims, but every attempt has been ignored. Please, finally make this part of the record. Add it to or find the records, if my earlier statement were destroyed, ignored, whatever. I am pleading for this to be done honestly and correctly, as this misunderstanding is from no-fault of my own, I am not a lawyer, and have no idea how to make sure these omissions by the V.A. can be corrected by any others way, except to make again one more statement, among many, about this huge problem with my claim not handled properly.
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