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Found 5,808 results

  1. 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.
  2. Hi, I have recently started the claims process with the VA (I filed an informal claim on 04-Sept-2013 I see a private therapist and have a current diagnosis of PTSD, Bipolar II, poly substance abuse. My therapist agrees with me that my disorders are SC I've taken the initiative already to get copies of my DD214 as well as my private medical records. Currently I'm trying to track down my records from when I was placed on a 72 hr hold in a psych ward in 2000. My prescribing Psychologist, who puts in time at the practice I go to, is also a VA doc. I guess my question is this. If my therapist tells me that they have diagnosed me with the above disorders does that mean that my Psychologist (the VA doc) had to have signed off on the diagnosis and if so does this mean that I should have an easier time with the VA? I'm also concerned that I may have to track down treatment records from the Army (I assume those would be in my DD214?) Where would I look for any SMR's that I may need? I also wonder if maybe I should try and track down any relevant records from my old Unit to show things such as an Article 15 and any evaluations done that would show the onset of my conditions. Also if anybody could advise me of what else I should be doing at this early stage to present an effective claim please feel free to advise me. Thank you in advance for any and all help Jason
  3. Hello everyone I am new to the site. And I recent submit a the dbq for an increase for my PTSD and I trying to understand it but im just not getting it. So I figured would ask you all. Below is what the examiner put in the record. Review Post Traumatic Stress Disorder (PTSD) Disability Benefits Questionnaire Name of patient/Veteran: ========= Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination Request? [X] Yes [ ] No SECTION I: ---------- 1. Diagnostic Summary --------------------- Does the Veteran now have or has he/she ever been diagnosed with PTSD? [X] Yes [ ] No ICD Code: F43.1 2. Current Diagnoses -------------------- a. Mental Disorder Diagnosis #1: PTSD ICD Code: F43.1 b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): No response provided. 3. Differentiation of symptoms ------------------------------ a. Does the Veteran have more than one mental disorder diagnosed? [ ] Yes [X] No c. Does the Veteran have a diagnosed traumatic brain injury (TBI)? [ ] Yes [ ] No [X] Not shown in records reviewed 4. Occupational and social impairment ------------------------------------- a. Which of the following best summarizes the Veteran's level of occupational and social impairment with regards to all mental diagnoses? (Check only one) [X] Occupational and social impairment with reduced reliability and productivity b. For the indicated level of occupational and social impairment, is it possible to differentiate what portion of the occupational and social impairment indicated above is caused by each mental disorder? [ ] Yes [ ] No [X] No other mental disorder has been diagnosed c. If a diagnosis of TBI exists, is it possible to differentiate what portion of the occupational and social impairment indicated above is caused by the TBI? [ ] Yes [ ] No [X] No diagnosis of TBI SECTION II: ----------- Clinical Findings: ------------------ 1. Evidence Review ------------------ Evidence reviewed (check all that apply): [X] VA e-folder (VBMS or Virtual VA) [X] CPRS Evidence Comments: MENTAL HEALTH OUTPATIENT FOLLOW UP NOTE [excerpts] DATE OF NOTE: MAR 05, 2018 AUTHOR: ========,NP NURSE PRACTITIONER CHIEF COMPLAINT: "same old same old" INTERVAL HISTORY: Veteran is here for 6 week follow up for PTSD, Alcohol Use Disorder, unspecified, episodic. At last appointment, low dose venlafaxine was added, aripiprazole, prazosin, and melatonin were continued. He reports symptoms are about the same. His wife is pregnant with twins, so he is trying to minimize arguments at home. He worries he will not be able to connect with the babies, because he struggled so much with his daughter and points to her persistence as the reason they are close now. He see no change in sleep, remains irritable, and more hypervigilant due To recent car break ins on his street. He has cut down on drinking, and denies any binges since last appointment. He continues to have fleeting SI, but denies intent. He often has thoughts of hurting others, but strongly denies acting on the thoughts. No recent hallucinations. He does talk to himself when he is trying to work something out, but denies hearing voices other than his own. It can be embarrassing as coworkers and wife have caught him. ASSESSMENT AND TREATMENT PLAN GOALS: DSM 5 Diagnostic Impression PTSD Alcohol Use Disorder, Unspecified, episodic Goals: 1. Decrease irritability and anger- does not interfere with home or work life more than one time per month, ongoing, improving 2. Improve feeling of connection with others- enjoying and developing relationships, ongoing, no change 3. Decrease avoidance of social situations/crowds- can tolerate Wal Mart, enjoy outings with family, ongoing, no change 4. Improve sleep- no difficulty falling asleep, sleep 6 to 8 hours nightly, ongoing, worsening PLAN AND PROGRESS TOWARDS TREATMENT PLAN GOALS: reviewed records and discussed options - increasing venlafaxine to 75 mg - continuing aripiprazole, prazosin, and melatonin - suggested individual supportive counseling at the Vet Center after Dr. Bhatia leaves. - monitoring labs at next appointment - Will continue to follow closely. RTC 6 weeks/PRN 2. Recent History (since prior exam) ------------------------------------ a. Relevant Social/Marital/Family history: Last C&P PTSD DBQ May 2016 Lives in Moncks Corner, SC with wife of 9 years and daughter age 4. Daily routine: Lay down for bed 2100. Will fall asleep 2300. Wake frequently. "I have to do certain things to calm down. I need my gun next to me. I have to check the house make sure its locked. Make sure the alarm is on. If I hear something, it wakes me right up and I have to check it out." +Nightmares, night sweats. "Sometimes I'm swinging and yelling and talking in my sleep, so my wife leaves for a different room. I wake up and she's not there and it freaks me out." Prescribed melatonin for sleep, prazosin for nightmares. Abilify for PTSD. Diagnosed sleep apnea by sleep study in 2013, prescribed CPAP and is compliant. Relationship with wife: "We almost got divorced a few times. She didn't understand what was going on. She started reading up on it. The whole reason I went to mental health was because of her." Relationship with daughter: "She is scared of me. She has seen me Snap a few times. She is on guard. She doesn't know if I'm going to be up or down. She is my heart. She is the only thing that makes me feel normal." Will watch cartoons and read books together. Hobbies: play basketball, go to gym "but now I just sit in the House watch TV or just in the room." Likes anime. Support: father "he's been with me through everything." And is Veteran too, wife "but there is a wall there where I don't open up." b. Relevant Occupational and Educational history: Working for passport services for 3 years. "Its rough at times. There's a lot of people in there. They had to move my seat because I'm too jumpy. They moved it so I'm not around a lot of people. It is hard to focus. I have to use sticky notes. They have been pretty supportive. I've had good supervisors." Was counselled about days missing for work; "I had a blow up at my co-workers so they spoke to me about that." Miss 2-3 days per month. "When I get to work, I drive around the Building and if I see something I don't like, I just go home." Military history: E4, MP, Separated 2014, Honorable, Served about 6 years. c. Relevant Mental Health history, to include prescribed medications and family mental health: Mental health treatment with prescriber and therapist. No history of hospitalizations. Was in group therapy "but I didn't like it." d. Relevant Legal and Behavioral history: "When I was in Japan I got us into trouble because of my alcohol abuse. I got into a car accident and hit 3 cars." Was sent to ADAP for anger and PTSD. A month ago got into a physical altercation with sister's boyfriend "I laid hands on him. So then I went to a hotel room and stayed there and then I went on a drink binge." e. Relevant Substance abuse history: Alcohol - "I abused it really bad. My PCM said it was affecting My liver." Was drinking4-5 25 oz beers, drink a bottle of liquor over The weekend. Now will drink 1-2 beers. Tobacco - 2-3/day Denies other substances. f. Other, if any: Current reported symptoms: Anger: "I black out and become very violent. I knock TVs off walls. My wife was ready to leave me." Triggers: "foggy day and rain." "Ignorant and stupid people." Social avoidance. "If a car is behind me too long, I start to think he is following me. There is a particular truck that I know and he gets too close to me. I got sick of it and one day I followed him home. I didn't do anything, but I blacked out mad. I knew I needed help." Flashbacks - "I was shopping with my wife, and this guy had a turban on his head and I thought I was back there. Its constant, its all the time." Hygiene - "My wife got on my because I went a week without washing And I didn't even realize it." Suicide - "I thought about driving into traffic at the light. One Time I sped up and got on railroad tracks when a train was coming. I thought, what am I doing? I went into store parking lot." Reports this occurred 2 weeks ago. "I keep a picture of my daughter in the car to keep me from [doing it]." 3. PTSD Diagnostic Criteria --------------------------- Please check criteria used for establishing the current PTSD diagnosis. The diagnostic criteria for PTSD, are from the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5). The stressful event can be due to combat, personal trauma, other life threatening situations (non-combat related stressors). Do NOT mark symptoms below that are clearly not attributable to the Criterion A stressor/PTSD. Instead, overlapping symptoms clearly attributable to other things should be noted under #6 - "Other symptoms". Criterion A: Exposure to actual or threatened a) death, b) serious injury, c) sexual violence, in one or more of the following ways: [X] Directly experiencing the traumatic event(s) [X] Witnessing, in person, the traumatic event(s) as they occurred to others Criterion B: Presence of (one or more) of the following intrusion Symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred: [X] Recurrent, involuntary, and intrusive distressing Memories of the traumatic event(s). [X] Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s). [X] Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings). [X] Intense or prolonged psychological distress at exposure To internal or external cues that symbolize or resemble an aspect of the traumatic event(s). [X] Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s). Criterion C: Persistent avoidance of stimuli associated with the Traumatic event(s), beginning after the traumatic events(s) occurred, as evidenced by one or both of the following: [X] Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). [X] Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). Criterion D: Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: [X] Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., "I am bad,: "No one can be trusted,: "The world is completely dangerous,: "My whole nervous system is permanently ruined"). [X] Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others. [X] Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame). [X] Markedly diminished interest or participation in significant activities. [X] Feelings of detachment or estrangement from others. [X] Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings.) Criterion E: Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: [X] Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects. [X] Reckless or self-destructive behavior. [X] Hypervigilance. [X] Exaggerated startle response. [X] Problems with concentration. [X] Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep). Criterion F: [X] The duration of the symptoms described above in Criteria B, C, and D are more than 1 month. Criterion G: [X] The PTSD symptoms described above cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Criterion H: [X] The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition. 4. Symptoms ----------- For VA rating purposes, check all symptoms that actively apply to the Veteran's diagnoses: [X] Depressed mood [X] Anxiety [X] Suspiciousness [X] Chronic sleep impairment [X] Mild memory loss, such as forgetting names, directions or recent events [X] Flattened affect [X] Impaired judgment [X] Disturbances of motivation and mood [X] Difficulty in adapting to stressful circumstances, including work or a worklike setting [X] Suicidal ideation [X] Impaired impulse control, such as unprovoked irritability with periods of violence [X] Neglect of personal appearance and hygiene 5. Behavioral observations -------------------------- Veteran was open and forthright with no evidence of exaggeration or feigning symptoms. Affect blunted. Minimal eye contact. Speech regular rate, tone, volume. Thought process linear, logical, goal directed. Thought content absent for delusions, hallucinations, paranoia or HI. Endorses SI with no active plan, but drove car onto train tracks last week. Discussed safety, crisis line, Veteran has MHC appointment next week. Veteran reports safety to return home today. 6. Other symptoms ----------------- Does the Veteran have any other symptoms attributable to PTSD (and other mental disorders) that are not listed above? [ ] Yes [X] No 7. Competency ------------- Is the Veteran capable of managing his or her financial affairs? [X] Yes [ ] No 8. Remarks, (including any testing results) if any: --------------------------------------------------- PCL-5 score 72, indicating probable diagnosis of PTSD. Veteran continues to meet criteria for PTSD. He reports social withdrawal, sleep problems, memory problems, irritability, anger that is both verbal and physical, suicidal thoughts. He has work accommodations because of his PTSD symptoms. He misses several days of work a month because of his symptoms.
  4. SECTION I: ---------- 1. Diagnostic Summary --------------------- Does the Veteran have a diagnosis of PTSD that conforms to DSM-5 criteria based on today's evaluation? [X] Yes [ ] No ICD code: F43.10 2. Current Diagnoses -------------------- a. Mental Disorder Diagnosis #1: Post-traumatic stress disorder ICD code: F43.10 Mental Disorder Diagnosis #2: Cannabis use disorder, mild ICD code: F12.10 b. Medical diagnoses relevant to the understanding or management of the mental health disorder (to include TBI): No response provided. 3. Differentiation of symptoms ------------------------------ a. Does the Veteran have more than one mental disorder diagnosed? [X] Yes [ ] No b. Is it possible to differentiate what symptom(s) is/are attributable to each diagnosis? [X] Yes [ ] No [ ] Not applicable (N/A) If yes, list which symptoms are attributable to each diagnosis and discuss whether there is any clinical association between these diagnoses: Cannabis use disorder accounts for persistent use despite negative consequences and large amounts of time spent using. All other symptoms are due to the PTSD. 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 occupational and social impairment, is it possible to differentiate which impairment is caused by each mental disorder? [ ] Yes [X] No [ ] Not Applicable (N/A) If no, provide reason: Veteran has not had meaningful sobriety from cannabis in some time so it is not possible to determine the level of impairment caused by her PTSD alone. c. If a diagnosis of TBI exists, is it possible to differentiate which occupational and social impairment indicated above is caused by the TBI? [ ] Yes [ ] No [X] Not Applicable (N/A) family mental health (pre-military, military, and post-military): Veteran first received counseling services as a child, related to DCFS involvement. She reported a history of suicidal ideation and self-destructive behavior around age 7-8. One inpatient hospitalization at this time. Still with suicidal ideation, "I really hate being here," estimated once per day. Has engaged in reckless behavior, like fast driving. Cites children as deterrent. Also fears not succeeding and being chronically disabled. History of self-injurious behavior (cutting and burning) 4-5 years ago. Cries daily. Limited enjoyment of activities. Able to care for children. Unclear how much assistance she receives from family me mbers. "I feel like a bad mom." Does not have many friends. Prefers to be alone. Currently attending therapy once per week. Cannot discuss trauma because she becomes too distressed. "I constantly remember or think about ways I could have gotten away or done things differently. I feel like a weak person. I can't protect myself. How can I protect my children?" Taking medications Seroquel and Lamictal along with sleep aid (Trazodone). Medications not helpful. No adverse side effects. Misses 2 doses per week. Sleep disrupted by dreams of "being trapped." Weight fluctuates along with eating. Prefers not to sleep. Wants to stay alert to surroundings. Occasionally sees "shadows." d. Relevant legal and behavioral history (pre-military, military, and post-military): Juvenile legal involvement for stealing and truancy. History of fighting as a juvenile. e. Relevant substance abuse history (pre-military, military, and post-military): 1-2 grams cannabis daily. Able to be sober 1-2 years while looking for a job or while pregnant. No problems related to use. History of alcohol use, which she stopped due to father's history of alcoholism. 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: 2 rapes by fellow service members 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. Unplanned pregnancy documented 9/4/2008. Delivery 5/4/2009. Disclosure of MST to multiple providers, including non-VA providers. Veteran's statement in support of claim dated 8/11/2018. 4. PTSD Diagnostic Criteria --------------------------- Note: Please check criteria used for establishing the current PTSD diagnosis. Do NOT mark symptoms below that are clearly not attributable to the Criterion A stressor/PTSD. Instead, overlapping symptoms clearly attributable to other things should be noted under #7 - Other symptoms. The diagnostic criteria for PTSD, referred to as Criterion A-H, are from the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5). Criterion A: Exposure to actual or threatened a) death, b) serious injury, c) sexual violence, in one or more of the following ways: [X] Directly experiencing the traumatic event(s) Criterion B: Presence of (one or more) of the following intrusion symptoms to associated with the traumatic event(s), beginning after the traumatic event(s) occurred: [X] Intense or prolonged psychological distress at exposure internal or external cues that symbolize or resemble an aspect of the traumatic event(s). Criterion Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic events(s) occurred, as evidenced by one or both of the following: [X] Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with traumatic event(s). "I Criterion Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) the following: [X] Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g. I am bad,: "No one can be trusted,: "The world is completely dangerous,: "My whole nervous system is permanently ruined"). [X] Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others. [X] Markedly diminished interest or participation in significant activities. [X] Feelings of detachment or estrangement from others. Criterion E: Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: [X] Reckless or self-destructive behavior. [X] Hypervigilance. [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 5. Symptoms ----------- For VA rating purposes, check all symptoms that actively apply to the Veteran's diagnoses: [X] Depressed mood [X] Anxiety [X] Suspiciousness [X] Chronic sleep impairment [X] Flattened affect [X] Disturbances of motivation and mood [X] Suicidal ideation 6. Behavioral Observations -------------------------- The Veteran arrived on time and alone for her appointment, and sat calmly in the waiting room until her name was called. She responded promptly, and walked steadily and without assistance. No psychomotor abnormalities, such as tics or tremor, were observed. The Veteran displayed fair eye contact and adequate grooming, and was generally cooperative with the evaluation. Her speech was spontaneous and fluent, with soft volume and slowed rate. She provided short responses to questions. The Veteran described her mood as "depressed." Affect was distressed, tearful, and congruent with her stated mood. Thought process was linear and organized. Associations were coherent. Thought content was without delusions or homicidal ideation. Veteran reported passive suicidal ideation without intent or plan. She has no firearms at home and cited deterrents for suicide. She planned to meet with her psychiatrist after her C&P appointment and was not considered an imminent risk of self harm. The Veteran reported atypcial hallucinations of music and shadows. She did not appear to be responding to internal stimuli during the evaluation. The Veteran was alert and oriented. Attention was intact via conversation. Intellect was estimated as average. Insight and judgment were thought to be intact. 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 MEDICAL OPINION SUMMARY ----------------------- RESTATEMENT OF REQUESTED OPINION: a. Opinion from general remarks: Military Sexual Trauma (MST) b. Indicate type of exam for which opinion has been requested: 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: The Veteran meets minimum diagnostic criteria for post-traumatic stress disorder. The current level of severity is moderate. Veteran reported ongoing symptoms despite medications and therapy. It is at least as likely as not that the Veteran's PTSD is due to her reported military sexual trauma (MST). It is patently impossible to determine whether or not the veteran's claimed experiences of MST are factual based only upon the evidence provided in her claims file. To be clear, the veteran has reported that these incidents occurred and there is nothing contained in her service treatment records that contradicts her report. There is evidence to support her claim starting with the diagnosis of pregnancy on 9/4/2008. This examiner can see no reason to doubt the veracity of the MST events that she has reported. The veteran's ongoing mental health symptoms are consistent with symptoms often reported by individuals who have a history of sexual assault, which serves to further substantiate the claimed events. In light of the evidence reviewed today, and the veteran's self-report, it is the opinion of this examiner that it is at least as likely as not that the MST events reported above did in fact occur. The Veteran's diagnosis of cannabis use disorder is a separate diagnosis and is not secondary to the PTSD. The mental disorders of PTSD and cannabis use disorder affect the Veteran's occupational functioning in terms of her ability to get along with others and maintain concentration. No formal cognitive assessment was performed today, nor has any been documented in records. Veteran did not display any overt cognitive deficits. She reported she is largely independent for activities of daily living, including caring for her three children. She is able to drive a car.
  5. I need to learn more about inferred claims and how they are decided/spotted by the va raters and acted on. The situation is I was rated 70% PTSD in 2013 around july was that C&P. In april 2013 I had a C&P for Bilateral Hearing loss and one for Sleep apnea. I knew nothing about secondary conditions, inferred claims, etc and by this time my VSO was awol dealing with pancreatic cancer (so I don't blame him). This year in July I was notified about a Review PTSD C&P, and that started me on the information hunt. I learned that ED, which was well documented in my VA med records before the first C&P, was/could be a secondary to PTSD. I also learned the Sleep Apnea was/could be a secondary to PTSD and my Sleep Study produced a CPAP and diagnosis of OSA and my Epworth Sleepiness Scale: 20/24 Since I knew nothing about secondary claims then I did not file for them then. With the PTSD Review this year I filed a claim for SMC-K for the ED. Today when Ebenefits was unaccessible I called Peggy who told me the claim was partially complete and a letter had been/was being mailed out today. The only issue left was on dizziness. This was in the A.m. Around 1 p.m. I tried ebenefits again and it was up. Under my disabilities tab it shows that I am 0% for ED Service Connected and awarded SMC-K1 with an effective date of 20 Aug 2018 the date I filed that claim I have filed an ItF on the SA claim but was waiting until this cleared. What I need to find out are the boundaries on "inferred claims". Meaning what does and does not need to be in the record for me to claim an EED back to the date of my PTSD claim. The ED was in my record before the PTSD C&P and the doc and I discussed it. He did not opine either way and the benefits award letter is completely void of any reference to it. Is it likely to be worth the trouble trying to file a claim for the EED on this? the evidence is there but no statement tying the two together back then, but I feel i should have been inferred by the rater. The SA claim is the same but a little different. The VA recently changed its requirements for granting service connection for OSA. It used to be, until this year, that being prescribed the CPAP was considered to be sufficient to read as "being medically necessary", but the new regs require that specific statement in the file. For this claim I know I have to have the diagnosis made as service connected as a secondary to PTSD so what I would like opinions on are what the value of asking to have the VA decide based on the old standard as I was unaware it was even a ratable condition. No one at the VA mentioned it. The rater on my initial Claim did not comment on it in the Award Letter. I believe this should also have been inferred. the two items are all over my records as being present months before the C&P and I am hoping that the Duty to Assist which includes a Duty to Infer will cover my claims. Any thoughts?
  6. I have an 80% service connected disability rating. 70% of that comes from PTSD. I spent 7 years as an infantryman in the Army. I got out in 2016. I am currently looking at going back in as a social worker. I was previously enlisted but the new career field I am interested in is a direct commission position. I am not sure if the 70% will disqualify me from returning to Active duty. I would actually argue that I have been experiencing post traumatic growth and my experiences would allow me to better serve those on Active Duty. Doe anyone have any knowledge or experience about returning to Active Duty with a disability rating? Edit** I am going to be attempting this in the next few months so I will update this with any new information that may be useful to other people who are experiencing similar situations.
  7. 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
  8. "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.
  9. 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.
  10. 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?
  11. Hey Everyone, I provided a stressor -my best friend died when his boat sunk and I escorted his body home. The casualty records from when he passed away are not available so that wasn't verified however the VA conceded that he was my close friend as the statement I provided and he was also from my unit. I was diagnosed with PTSD on the VA exam and the Dr. provided a positive medical opinion stating -"the Veteran's current Posttraumatic Stress Disorder is at least as likely as not incurred in and/or caused by the Veteran's death of best friend and escort duty or remains following such death during service." I get the decision notice and I kid you not, I was denied and this was their rational - Based on a review of your military personnel records, service treatment records, and additional evidence of record, you did not directly witness the death of your close friend, evidence that you saw the body of your friend, or that you were placed on military orders to escort his remains home. The available evidence is insufficient to confirm a link between current diagnosis and the claimed in-service stressor. I'm wondering if that's correct. To me, it's pretty obvious that the rater missed the in-service stressor of 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.
  12. chgofire

    HELP needed~

    Hello brothers & sisters, been trying to post on another thread, however, I can't post on the Veterans from OIF, etc. But I can post here.. Weird! Anyway, I wanted to post a question to those that have more knowledge than me. I want to notify my employer of my service disconnected disabilities, I'm currently rated at 90% and it's been a PITA to reach a 100% but that's a topic for another discussion. What would be the best way to notify my employer of my service connected disabilities without providing them with too much information? I fear that they will require me to release my VA medical treatment records, etc. I have been working for 11 years in my career field and my service-connected issues don't affect my job performance or the ability to do my job. However, I do struggle a lot. I tend to keep my employer in limbo when it comes to my service connected disabilities out of fear that they may retaliate or something, not sure. Also, can a employer try to force you, coerce you into giving them permission to release your medical records? Due to HIPPA I'm assuming they can't? During my performance of my duties there's nothing documented as far as safety concerns, performance issues, or any psychological problems or any other concerns that would raise a red flag. So what would be the best way? I’ve been offered a service dog for my PTSD and since I work long hours at work, I can’t leave the dog at home for long stretch of time. I recently got divorce, I was financially destroyed, my ex wife couldn’t cope or deal with me so she hit the high road and abandoned me. I’m recovering slowly from this set back but I find myself spending way too much time alone, and at times I find myself hitting the bottle way too often than not, but I keep my job separate and my counseling, VA treatment totally separate from my employer. I would appreciate some feedback on this issue. Sorry that I had to post here, but I couldn’t post on the other thread forum… Again, thank you all in advance for the assistance~
  13. hi all, this is not a question but information. Here is a link to a recent vidéo on french TV , talking about curing PTSD French Version https://www.francetvinfo.fr/economie/emploi/metiers/armee-et-securite/veterans-de-la-plongee-pour-surmonter-le-stress-post-traumatique_2976669.html#xtor=AL-54-[video] [Admin Note] Translated Article English version of text Hope this helps (see last comment on end of french version page) Ask me if need a traduction , no prob. Xav
  14. ok so went for a c&p Monday and was checking ebenefits appeal tool and found this? ok so obviously lumbar blah blah is still going forward but that granted....does that mean ive won?
  15. GeekySquid

    CUE for OSA?

    Okay so my C-file arrived, and did so amazingly fast. Less than two months, not bad time. Going through all the files and sorting them but one of the first things I need to get together is the claim on OSA. I know the rules have changed about OSA ratings and now the med file must have a doctors saying specifically OSA is a medical condition From the MR21-1MR “When determining whether the 50-percent criteria are met, the key consideration is whether use of a qualifying breathing assistance device is required by the severity of the sleep apnea.” “Use absent a medical determination that the device is necessary does not qualify. The regulation requires that the device be necessary and this is a medical question.” So here is my situation. On 07/07/2013 I had my initial PTSD C&P which noted serious sleep problems, chronic fatigue, hypersomulance but it did NOT mention the SLEEP STUDY diagnosis given on 4/13/13 At that time the simple issuance of a CPAP was considered sufficient to getting a 50% rating for OSA, but as the change listed above notes that is not the case now. I have already filed a claim for OSA secondary to my PTSD. I did this before my Review C&P for PTSD exam, which resulted in getting bumped to 100% PTSD P&T. With the change in MR21, I suspect they may disapprove the OSA claim. If they do, would my path be to file a CUE because the record showed the apnea existed and a cpap was issued when they rated me for PTSD. The retro pay would be awesome! That would seem to be an error on their part and under the old standard I would have gotten a 50% rating for OSA as well as my 70% for PTSD and 10% for Tinnitus. The 70+50+10 calculation is 87 which rounds up to 90 for pay purposes and getting that retro 20% difference for 60+ months would be a nice holiday or new years present to me In the alternative, would I submit a NOD with the same information? or would I have to get a DOC to say that the CPA was medically necessary and would that mean I needed another Sleep Study? Thanks in advance. I am just trying to get things ready for whenever they make a determination on the existing claim.
  16. I have been discussing the subject question with a friend. If you are 100% for PTSD does it make you "unemployable"? I realize that it would be difficult to work, but does the 100% PTSD rating prevent you from working? Thank you. BobGeorge
  17. Hello all, Let me start by saying thank you in advance for any help or information provided. Quick backstory: The first time I filed was in May of 2012(I lived in El Paso, Tx at the time), it was for PTSD, bursitis in hips, carpal tunnel, and a slew of other joint problems, however life happened and I missed a C&P exam that I was unaware of and the claim was denied at the beginning of 2013. I understand that this is my fault, but I did learn that the VA found nothing in my army records to justify a claim for any of the physical problems. The second time I filed was in Feb of 2015(I lived in Tacoma, Wa at the time), it was for PTSD. I had a C&P thru QTC at the beginning of APR 2015 and attended, however during the C&P the doc diagnosed me with major depression and anxiety rather than PTSD. Also during that C&P I was made aware that the dates for one of my deployments was incorrect and did not match the stressors I had listed and thus he did not recommend a service connection and I was denied at the end of APR 2015. It should also be noted that I received no diagnosis or treatment prior to during the claim process(I still had no idea how the VA worked and was under the impression that I needed to be service connected.) Of note on this claim I attempted to use a VSO thru DAV, however when I went to the office I was given booklet titled "Federal Benefits for Veterans Dependents and Survivors" and the representative highlighted the address of the vet center near me and the ebenefits website instructing me that I needed to file the claim there. In JAN 2018 after a low point I finally went to the American Lake VA office to see what treatment was available to me. This is when I discovered I qualified for no copay visits and partial copay of medication. I went through the intake exam at the behavioral health clinic there and have been in individual counseling sessions almost weekly as well as attending a few of the group counseling programs offered. I have also been put on various medications to combat the anxiety, depression, and insomnia. Since starting the sessions I have been diagnosed with chronic severe PTSD, chronic severe MDD, chronic severe anxiety, and chronic severe insomnia. My third and current claim I put in on 02/27/2018(I live on Joint Base Lewis-McChoord, WA). It is for PTSD, MDD, anxiety, insomnia, as well as an application for TDIU. I listed the MDD, anxiety, and insomnia as secondary to the PTSD. I included my DoD service records and my DoD payment records to show that the dates of the deployment on my DD214 were incorrect. I uploaded my medical records from the VA American Lake office just in case there was going to be any issues for them to obtain them, they were reviewed and accepted on 04/04/2018. I had the C&P in MAR 2018, while there the doc said he was recommending all issues be service connected. I filled out the 21-4192 Request for Employment Info on 04/25/2018 the best that I was able and added an attachment to it explaining that my last employment was over 8 years ago and the reasons why I haven't been employed. On 05/03/2018 I submitted a 5103 Claim Decision Request. Other Info: In FEB 2018 I requested my military medical records, when I received them the only document there was the medical exam from MEPS, the one you do prior to joining. However while in service I was treated for bursitis over a period of two years(physical therapy and medication) I had the occasional trip to sick call, and at one point had an in grown toenail removed. I filed my current claim as a new claim, however they reopened my 2015 claim instead. My ETS was in FEB 2007 after being extended 7 months due to deployment. I spent my entire time in the military at Fort Hood, TX as part of the 4th Infantry Division(the division has since relocated to Fort Carson, CO) Questions: Q. Is there a way to obtain the medical records that are missing from my file so that I am able to claim the bursitis and joint issues? Q. I am planning to move from JBLM, WA to somewhere in Iowa(Wife's decision) at the end of AUG 2018. This will change my regional office. Will it effect my claim and what do I need to do to ensure my claim doesn't disappear? Q. Will them reopening my older claim instead of accepting a new one have any effect, beneficial or not? Q. Should I request my C-File now or wait until the claim is complete? Q. Does contacting the 800 number or using IRIS to check claim status affect my claim in any way? (I'm curious where it's at because it has passed the estimated date, and the last date it seems anything was done is 04/04/2018 when they reviewed medical records.) Thanks you again for any info or suggestions able to be given. T
  18. Long story short I filed for ptsd in 2004 and was denied in 2005. The doc that did my C&P stated I had a personality disorder and a she gave me a GAF of 38 even though I was working everyday in Corp enviroment for 6 years prior to the C&P lol . I filed again in 2012 for PTSD after getting a DX by two private docs stating I have ptsd. The VA stood by its findings again in 2014 stating I had a personality disorder. The VA basically stated due to the fact that I got into a fight with another Marine when I was a private and I got a divorce two years later I must have had a personality disorder prior to me entering the service.The really nutty thing is the doc that stated I had a personality disorder in 2005 said I had a normal childhood with no history of abuse of any kind (confused yet?) I was discharged honorably on top of it all. I saw combat in Desert Storm as a grunt I have a documented stressor I have been on meds since 2005 (private doctors) In 2014 I was granted 30% IBS 10% arthritis right knee and 0% left knee. Recently my VA mental health doc stated I have MDD he stated verbally to me that I didn't and never have had personality disorder. I asked him to state that in the med records and he will not although he is treating me for MDD and anxiety. It seems to me the guy knows I have PTSD but doesn't want to state it in my records as it would contradict the other doc DX of personality disorder. I will never be treated for ptsd so the chance of me getting better are zero. How do I get these guys to wake the hell up and do the right thing?
  19. Seems the VA can on occasion consider obesity merely as a "symptom"* and perhaps even the type of symptom that the VA alleges is caused by the Veteran's own willful misconduct of overeating or being inactive so it can deny the claim. However, since the American Medical Association ( AMA ) recently in June of 2013 has officially declared that "obesity is a disease", might that allow disabled veterans whose service connected condition(s) led to excessive weight gain to now find more success claiming obesity as a ratable secondary medical condition or a disease aggravated by the Veteran's service connected condition(s)? *"Obesity Service connection is not warranted for obesity. Claiming service connection for obesity amounts to claiming service connection for a symptom, rather than for an underlying disease or injury which may have caused the symptom. In this respect, obesity, in and of itself, is not a disability for which service connection may be granted. The United States Court of Appeals for the Federal Circuit (Federal Circuit) has defined "injury" as "damage inflicted on the body by an external force." See Terry v. Principi, 340 F.3d 1378, 1384 (Fed. Cir. 2003), citing Dorland's Illustrated Medical Dictionary 901 (29th Ed. 2000). Thus, obesity caused by overeating or lack of exercise is the result of the veteran's own behavior, and as such is not an "injury" as defined for VA purposes. See Terry v. Principi, 340 F.3d 1378, 1384 (Fed. Cir. 2003) (defining "injury" as "damage inflicted on the body by an external force"). The Federal Circuit also defined "disease" as "any deviation from or interruption of the normal structure or function of a part, organ, or system of the body." Terry, 340 F.3d at 1384, citing Dorland's at 511. Obesity that is not due to an underlying pathology cannot be considered to be due to "disease," defined as "any deviation from or interruption of the normal structure or function of a part, organ or system of the body." Id. The body's normal storage of calories for future use represents the body working at what it is designed to do. It is well settled that symptoms alone, without a finding of an underlying disorder, cannot be service-connected. See Sanchez-Benitez v. Principi, 259 F.3d 1356 (Fed. Cir. 2001)." - from a BVA 2009 Decision ---and--- "Obesity or being overweight, a particularity of body type, alone, is not considered a disability for which service connection may be granted. See generally 38 C.F.R. Part 4 (VA Schedule for Rating Disabilities) (2009) (does not contemplate a separate disability rating for obesity). Rather, applicable VA regulations use the term "disability" to refer to the average impairment in earning capacity resulting from diseases or injuries encountered as a result of or incident to military service. Allen v. Brown, 7 Vet. App. 439, 448 (1995); Hunt v. Derwinski, 1 Vet. App. 292, 296 (1991); 38 C.F.R. § 4.1 (2009). The question is thus whether the current obesity is a disability-i.e. a condition causing impairment in earning capacity. In this case, there is no such evidence. The veteran has not asserted that obesity causes impairment of earning capacity; instead he asserts that his obesity has caused other disabilities to manifest. There is also no other evidence that the claimed obesity is a disability. Inasmuch as the Veteran does not have a disability manifested by obesity and obesity is not a disease or disability for which service connection may be granted, the Board concludes that obesity was not incurred in or aggravated by service and may not be presumed to have been so incurred. This claim is not in relative equipoise; therefore, the Veteran may not be afforded the benefit of the doubt in the resolution thereof. Rather, as a preponderance of the evidence is against the claim, it must be denied. 38 U.S.C.A. § 5107(b) (West 2002)" - from a 2010 BVA Decision But didn't the VA as early as 2006 already characterize obesity as a disease? "Obesity is a complex and chronic disease that develops from an interaction between the individual’s genotype and the environment." - http://www.healthquality.va.gov/obesity/obe06_final1.pdf "The AMA's decision essentially makes diagnosis and treatment of obesity a physician's professional obligation." - Los Angeles Times http://www.today.com/health/obesity-disease-doctors-group-says-6C10371394
  20. Hey all just want to share what I think of is good news, even though I still have to sit and wait. On 8//16/2018 I had a C&P review for my PTSD which was 70% with 10% Tinnitus rating. I was initially rated in 2013 and I had made no requests for adjustments. VA just mandated this C&P. Today, 8/24/2018 ebenefits was up and down all day so I could not really read anything on my statuses until 6 pm PST. I went in and I am, according to ebenefits, at 100% and in the letters I see my rating is P&T. I am over the moon. This RO must be the rocket docket or the QTC doc really wrote a solid case for the bump. or both. Either way I am now in the "watch the mailbox" phase since I won't believe it until i either get paid or the packet arrives. Thanks for all the input from everyone on other posts and my rambling questions.
  21. crazyhorse3022

    Smc (T) For Tbi

    Recently had my va psychiatrist fill out for 21-2680. For aid and attendance. He stated I required help shopping n preparing meals. Also help with med management. And help from girlfriend to help manage funds. Said I'm housebound 2 days a week. Main issues tbi ptsd, depression, migraines, scalp scarring from gunshot wound to head and alcoholism in remission for 16 months. I also take lorazpam daily. I hope they award it. I really need it. I'm already paid at 100% for tdiu which is permanent n total. I have an actual 90 % rating. Any insight if I'll stand a chance for aid n attendance for tbi.
  22. Greetings. Got good help here before, back for more! Got my rating for ptsd last year at 50%. Wasnt happy with it for a wide variety of reasons. Anyways, left it alone for a while until i logged onto my ebenefits, and found they listed my ptsd as "noncombat" related. Problem is everything stemmed from my involvement with the iraqi invasion (oif1). I told docs this through c&p process, had outside evidence and support. After this discovery, i met with my VSO and explaind my discontent and confusion why i was rated noncombat. She tells me that i need to have a CIB or CAB on my record. I told her that i was Artillery, and you dont get a CIB unless you are infantry. As for the CAB, it came out in 2005, and i ETSd in 2004, after serving in iraq in 2003. Thataward didnt even exist. She tells me its a grey area and that being rated noncombat vs combat doesnt effect anything. Is this true? Why does it bother me so much? I would assume that benefits vary for combat to noncombat. How do i go about correcting this?
  23. I am currently rated at 50% for PTSD and just had my C&P exam for an increase. Below is my current C&P results. Also I suffer from Major Depression and Erectile Dysfunction due to my medication. Could these two items be filed as secondary since the examiner did not list them in my C&P exam.Any input would be appreciated on to what my outcome may be. Thank you SECTION I: ---------- 1. Diagnostic Summary --------------------- Does the Veteran now have or has he/she ever been diagnosed with PTSD? [X] Yes[ ] No 2. Current Diagnoses -------------------- a. Mental Disorder Diagnosis #1: PTSD, moderate to severe, chronic Comments, if any: The trauamtic event was learning that a close friend of his killed two older female civilians. PTSD also causes secondary panic attacks 2-3 times per week. b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): No response provided. 3. Differentiation of symptoms ------------------------------ a. Does the Veteran have more than one mental disorder diagnosed? [ ] Yes[X] No c. Does the Veteran have a diagnosed traumatic brain injury (TBI)? [ ] Yes[ ] No[X] Not shown in records reviewed 4. Occupational and social impairment ------------------------------------- a. Which of the following best summarizes the Veteran's level of occupational and social impairment with regards to all mental diagnoses? (Check only one) [X] Occupational and social impairment with reduced reliability and productivity 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 ------------------ 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 no, check all records reviewed: [ ] Military service treatment records [ ] Military service personnel records [ ] Military enlistment examination [ ] Military separation examination [ ] Military post-deployment questionnaire [ ] Department of Defense Form 214 Separation Documents [ ] Veterans Health Administration medical records (VA treatment records) [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 [ ] Other: b. Was pertinent information from collateral sources reviewed? [X] Yes[ ] No If yes, describe: On 11/25/2014, Dr. XXX conducted a C&P Initial Evaluation for PTSD and diagnosed the veteran with PTSD with panic attacks. 2. Recent History (since prior exam) ------------------------------------ a. Relevant Social/Marital/Family history: Mr. XX is currently married to his wife of 10 years. He describes the quality of his current marriage as, "loving - but my wife puts up with me." He reports his irritability and anger can stress his wife. He adopted his wife's 14 year old daughter. He reports he has no friends of his own, but he reports he is friendly with many of his wife's friends. He tends to avoid crowds and group social activities. He is quite close with his parents. His main hobby is drumming and working on computers. Overall his social support is limited. He reports that the primary effect of his psychiatric symptoms on his social relationships are tension and distance caused by irritability, rage (including yelling, swearing, and very occasional violence towards inanimate objects - like punching a hole in the door), withdrawal, and emotional numbing. b. Relevant Occupational and Educational history: Mr. XXX highest level of education is some college. He served in the Airforce. He is currently employed as a cyber security analyst at XXX a telecommunications company called XXX. He has worked at XXX since 2011. In 2012, he was written up for "going off on a customer." He reports he works from home or calls in sick 4-5 days a month due to feeling stressed. He reports during times of stress he impulsively loses his temper when talking with customers or makes careless mistakes. He is a lead, and he has five other analysists who report to him. c. Relevant Mental Health history, to include prescribed medications and family mental health: Mr. XXX denied history of psychiatric hospitalization, receiving out-patient therapy, receiving any type of psychopharmacological treatment, or prior suicide attempts. He has been referred to a psychiatrist by his PCP but he is not currently engaged in therapy. He receives medication management from his private PCP, and he is currently maintained on a regimen of Zoloft, hydroxyzine, prazosin and diazepam. d. Relevant Legal and Behavioral history: No arrests. Received an article 15 in the military after he learned of the murders. e. Relevant Substance abuse history: No response provided. f. Other, if any: No response provided. 3. PTSD Diagnostic Criteria --------------------------- Please check criteria used for establishing the current PTSD diagnosis. The diagnostic criteria for PTSD, are from the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5). The stressful event can be due to combat, personal trauma, other life threatening situations (non-combat related stressors.) Do NOT mark symptoms below that are clearly not attributable to the Criteria A stressor/PTSD. Instead, overlapping symptoms clearly attributable to other things should be noted under #6 - "Other symptoms". Criterion A: Exposure to actual or threatened a) death, b) serious injury, c) sexual violation, in one or more of the following ways: [X] Witnessing, in person, the traumatic event(s) as they occurred to others [X] Learning that the traumatic event(s) occurred to a close family member or close friend; cases of actual or threatened death must have been violent or accidental; or, experiencing repeated or extreme exposure to aversive details of the traumatic events(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse); this does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related. Criterion B: Presence of (one or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred: [X] Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). [X] Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s). Criterion C: Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic events(s) occurred, as evidenced by one or both of the following: [X] Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). [X] Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). Criterion D: Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: [X] Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., "I am bad,: "No one can be trusted,: "The world is completely dangerous,: "My whole nervous system is permanently ruined"). [X] Markedly diminished interest or participation in significant activities. [X] Feelings of detachment or estrangement from others. [X] Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings.) Criterion E: Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: [X] Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects. [X] Hypervigilance. [X] Exaggerated startle response. [X] Problems with concentration. [X] Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep). Criterion F: [X] The duration of the symptoms described above in Criteria B, C, and D are more than 1 month. Criterion G: [X] The PTSD symptoms described above cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Criterion H: [X] The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition. 4. Symptoms ----------- For VA rating purposes, check all symptoms that actively apply to the Veteran's diagnoses: [X] Anxiety [X] Panic attacks more than once a week [X] Chronic sleep impairment [X] Disturbances of motivation and mood [X] Difficulty in establishing and maintaining effective work and social relationships 5. Behavioral Observations: --------------------------- Mr. XXX was casually dressed, and was cooperative throughout the examination. His speech was fluent. His psychomotor behavior was appropriate. His affect was constricted and his mood was anxious. His insight was intact. Thought process was linear, goal directed, and future oriented. No reported hallucinations or delusions. No reported homicidal or suicidal ideation. 6. Other symptoms ----------------- Does the Veteran have any other symptoms attributable to PTSD (and other mental disorders) that are not listed above? [ ] Yes[X] No 7. Competency ------------- Is the Veteran capable of managing his or her financial affairs? [X] Yes[ ] No 8. Remarks, (including any testing results) if any: --------------------------------------------------- Veteran's PTSD and panic attacks currently cause moderate socio-occupational impairment.
  24. Good Morning Hadit members, I have been reading the forum for a while now and would like to thank all the members for helping out with the many questions and concerns veterans have when it comes to disability claims, I recently put in a claim for an increase in my PTSD rating on 03/14/18 (Currently rated 80% combined - 70% PTSD, 10% tinnitus, 10% lower back, 10% GERD) due to the severity of my PTSD symptoms and how it is keeping me from maintaining substantial gainful employment. I left my job on 03/12/18 and was put on FMLA leave by my employer, on the FMLA form filled out by my VA psychiatrist it states that my condition is ongoing and that I am unable to work due to my symptoms, My employer requested a return date was needed for the FMLA leave to be approved and my psychiatrist wrote a second letter stating I will return to work on 06/15/18 pending improvement in my mental health condition. I completed a C & P exam on 04/20/18, checked ebenefits the following day and the status to my claim was updated to preparation for decision. On 04/23/18 I receive a call from the VA regional office from the VSR or rater working on my claim, she asked me if I am going to return back to work and I tell her no because I cant due to my PTSD, she tells me that my C & P results do not meet a 100% increase but that she will grant me individual unemployability as soon as I submit VA-form 21-8940. I filled out and submitted the form yesterday and my claims status has been updated to pending decision approval with an estimated completion date of 04/19/18 - 05/05/18. Im fairly surprised by how fast my claim has moved and hope that every other veteran is experiencing the same quickness with their claims, I was more surprised by the phone call from the regional office, at this point it sounds like I will be granted a 100% IU or TDIU rating but I'm still skeptical until I received my letter, I receive my bachelors in psychology in 2016 while enrolled in the Vocational Rehabilitation and Employment program and earn over the SGA level but my symptoms for PTSD have gotten more severe causing me to not be able to work. I appreciate anyones input and thank you for taking time to read my post.
  25. Hi all. I am new here and if i put this in the wrong section please help me get it to the right one. My main question, and i have dozens on several topics, is about TDIU/IU and its effects after a review by C&P at 5 year mark. Primarily do I have to accept an 'inferred" TDIU claim decision? As I understand it the RO can make this determination without my applying for TDIU, and there are some long term problems with being rated TDIU verses 100% Schedule. Here are the salient details. 1) I am currently homeless, living in my car 2) I have advanced education some of which is paid by VR&E some by student loans. 3) The School and VR&E made decisions that denied me the most important classes in the degree I was seeking. I was forced to take second best or get kicked out of VR&E according to my case manager. I took out 100K in student loans to offset the lack of those particular classes/certifications and got an MBA. It is not helping me re-enter the workforce. 4). I have a long gap in work because of my PTSD and then 5 years in school. Trying to get employment with that huge gap and the lack of the specifics classes I was denied, is proving to be a barrier I am unable to overcome. 5) Two days ago I had a C&P review at QTC (outside contractor) and Doc indicated that my condition and the current situation has me a millimeter from being, in his words "toast' in terms of being functional and able to work. 6) SSVF has made a similar determination to the above review. 7) VR&E has reopened my claim and is considering allowing me to get that additional training but I have to stabilize living situation first among several other requirements. 8 ) I am a vet who has fought the VA for 25 years just to get treatment, which finally started in 2013. They literally denied I was in the military, that the events actually took place, that I had applied, that I had a "real" problem, and a dozen other bogus statements over the years. 9) I am currently rated as SC 70% PTSD, w/chronic anxiety, chronic depressive condition, and 3 or more other related things, 10% tinnitus, 10) I have never applied for ratings increase or attempted to challenge what the docs said to the ratings board. 11) I learned last year that my claim for bilateral hearing loss had been denied because they only looked at the records from one of my enlistments, but did say the tinnitus was SC. 12) I have sleep apnea with VA CPAP issued but cannot "document" it started around the same time as my other stuff. 13) The meds they gave me, a huge collection of dangerous drugs, caused excessive skin conditions that have not healed even though I stopped taking their meds (which were of no help anyway). Now the complicated part to explain without going on for pages. The doctor told me what he was going to write in his report to the raters. He claimed that I can expect to know in 5 weeks what the increase in my rating will become. I don't know how true that is but it is what he said is the "normal" time frame his company is experiencing for the vets they evaluate. He informed me that the VA gives them a list of 7 sentences with which they must use to define each diagnosis and then provide their supporting narratives. These sentences are in the DBQ's. Essentially he stated that for each of my conditions not specifically rated, i.e. chronic depression, chronic anxiety, etc. I am between 30% and 70% on each of them. AT a minimum my PTSD alone has worsened and should (his words) bump up significantly from 70%. To be clear he stated that they were NOT supposed to put out what they think the raters will decide but he said the way he was writing the report his patients usually fall in that category when they are like me. Using the VA Disability Calculator, I end up at a minimum bump to 80%. All other scenarios take me to 96% or 97% with the exception of them just choosing to NOT increase my rating, which is always a possibility. There is a significant likelihood that the VR&E will institute an "inferred TDUI" claim which seems to be in their purview. They do this by denying my VR&E and stating the reason as TDIU and the RO will process that whether I want it or not. The other way to get TDIU or IU is to apply for it, which I have not done and did not know before now that I could. I also found out recently that a change in the Dept of Ed, originally started by the Obama administration but Congress would not vote on, has been now passed and the Trump administration is taking credit for the change. That change automates a process for Veterans who are 100% SC via Schedule or through TDIU or IU to get their student loans forgiven. The VA and the Dept of Ed and Social Security are sharing information and if you are rated at 100% they will actually notify you and you only have to sign a form, or you can start the process yourself. There is a problem with this though. If you are 100% through Schedule, then you are good to go. You can make as much money as you want and your loans are still forgiven. IF however you get the forgiveness based on TDIU or IU then you can only earn Federal Level Poverty line income, no more. In this scenario the Dept of Ed says that if your TDIU resolves you will be on the hook for those loans again. If on TDIU you earn more than Fed Level Poverty line you have to pay back any income over the poverty level that you received as a benefit. The change also makes it so the IRS does not treat the loan forgiveness as taxable income, which is a huge change. Of course in both cases you can never get another Fed Student loan, without agreeing to paying back the old loans. So my problem is understanding what I might do about avoiding getting an "inferred TDIU" rating if my latest evaluation does not get bumped to 100% Schedule. I plan on working and the idea of only being able to legally earn 13K a year poverty level income does not work for me. Until this exam I had not even considered asking for a review to increase my percentage, so getting 100% or any increase is pretty much a bonus that I had not looked for. I just don't want to screw myself by not knowing how to avoid the VA doing what it wants instead of what is best for me in the long run Thanks in advance for any help
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