Jump to content
  • Searches Community Forums, Blog and more

Search the Community

Showing results for tags 'results'.



More search options

  • Search By Tags

    Type tags separated by commas.
  • Search By Author

Content Type


Forums

  • General VA Disability Compensation Benefits Claims Forums
    • VA Disability Compensation Benefits Claims Research Forum
    • Appeals Modernization Act AMA
    • RAMP Rapid Appeals Modernization Program
    • Appealing Your Veterans Compensation Disability Claims NOD, DRO, BVA, USCAVC
    • Veterans Compensation & Pension Exams
    • E-Benefits Questions
    • Vets.gov
    • PTSD Post Traumatic Stress Disorder Claims
    • Entitlement - Veterans Compensation Benefits Claims
    • Eligibility - Veterans Compensation Benefit Claims
    • CHAMPVA
    • TDIU Unemployability Claims
    • CUE Clear and Unmistakable Error
    • Success Stories
    • OEF/OIF Veterans
    • VA Caregiver Benefits for Post 9/11 Veterans
    • SMC Special Monthly Compensation
    • IMO Independent Medical Opinion
    • Veterans Benefits State & Federal
    • VA Medical Centers Navigating through it
    • Medication – Prescription Drugs-Health Issues
    • VA Training & Fast letters, Directives, Regulations, Other Guidance Documents
    • MEB/PEB Physical OR Medical Evaluation Forum
    • VA Regional Offices
    • VA Disability Claims Articles and VA News
    • VA Law
  • VA Claims References
    • Title 38 / 38 CFR
    • 38 CFR 3 Adjudication
    • 38 CFR 4 Schedule for Rating Disabilities
  • Specialized Claims
    • TBI Traumatic Brain Injury
    • Mefloquine / Lariam
    • Gulf War Illness
    • Agent Orange
    • ALS - Amyotrophic Lateral Sclerosis
    • MST - Military Sexual Trauma
    • Radiation Exposure from Operation Tomodachi (Japan Earthquake Fukushima Nuclear Assistant)
    • Project SHAD/Project 112
    • Vocational Rehabilitation
    • VA Pensions
    • DIC
    • FTCA Federal Tort Claims Action
    • 1151 Claims
  • Veterans Helping Veterans Podcast
    • Veterans Helping Veterans VA Claims Podcast
  • Welcome Aboard
    • Help Files - How To Use The Forum
    • Introduce Yourself
    • Test Posting Messages Here
    • Roll Call
    • Technical Support For Forum
  • Extras
    • Hiring an Attorney Discussions on S. 3421
    • Social Security Disability Questions
    • VA Scandals
    • Discounts for Veterans
    • Federal Register Announcements
    • Active Duty MEB/PEB Physical OR Medical Evaluation Forum
  • Social Chat
  • Veterans Social Chat's Social
  • Veterans Social Chat's Topics
  • Hollie Greene's Multiple Sclerosis

Find results in...

Find results that contain...


Date Created

  • Start

    End


Last Updated

  • Start

    End


Filter by number of...

Joined

  • Start

    End


Group


AIM


MSN


Website URL


ICQ


Yahoo


Jabber


Skype


GooglePlus


Military Rank


Location


Interests


Service Connected Disability


Branch of Service


Residence


Hobby

Found 5 results

  1. I received my C&P over the weekend. My exam was nearly three hours and I think the report is accurate and fair and represents how things are. I was as honest as I could be with the examiner and despite being nervous to the point of an anxiety attack about it the day before calmed down a bit and was OK during the visit. The doctor did a good job asking questions and made me feel at ease which is saying something. The report ended up being 18 pages which surprised me. I had PMd the results to a handful of people here on HADIT and a couple recommended I post it for more input. I was hesitant to do so but decided my desire for more information is more important than my paranoia of posting it. I'd really like to get the opinions of some senior HADIT posters like Berta and others. I'm thinking this is a good C&P for my claim but would like a more seasoned opinion than my own completely inexperienced one. I've posted the opinion and rationale below. . Thank you. JW. ___________________________________ 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] Mild memory loss, such as forgetting names, directions or recent events [X] Disturbances of motivation and mood [X] Difficulty in establishing and maintaining effective work and social relationships [X] Suicidal ideation REQUESTED OPINION: Based on information from the clinical interview, review of records (C-file and VA medical records), and psychological assessment measures, It is my opinion that the veteran meets DSM-5 diagnostic criteria for (1) Post-Traumatic Stress Disorder (PTSD) due to childhood sexual trauma with delayed onset, and (2) Major Depressive Disorder (MDD), Recurrent, with Mood-Congruent Psychotic Features secondary to PTSD. While his PTSD and MDD were less likely than not to have been caused by an in-service stressor, both conditions were more likely than not incurred in service (i.e., delayed onset with clinically significant symptom presentation beginning while on active duty). PSYCHOLOGICAL ASSESSMENT / OBJECTIVE TESTING: Objective psychological assessment measures administered: -- Personality Assessment Inventory (PAI): valid profile without any evidence to suggest inattention, inconsistency, or negative/positive impression management; primary code type - DEP/ARD (97T/85T) * Summary/interpretation of results: Briefly, the veteran's responses on the PAI were suggestive of significant tension, unhappiness, and pessimism, with various stressors (past and/or present) contributing to low mood and self-esteem. Individuals with similar profiles often see themselves as ineffectual and powerless to change the direction of their lives and feel uncertain about goals, priorities, and what the future may hold. In addition to depression, the veteran endorsed significant distress on measures of suicidal thoughts, traumatic stress, and social discomfort or detachment. His profile was most consistent with major depression, and while some traumatic stress concerns were indicated, he did not endorse the full range of concerns typically seen among individuals with PTSD. RATIONALE FOR OPINION: 1. The veteran's symptoms meet DSM-5 diagnostic criteria for PTSD due to childhood sexual trauma. The veteran's history of childhood sexual abuse is well-documented across multiple sources and during the current evaluation, he endorsed the full range of trauma-related symptoms meeting criteria for a diagnosis of PTSD. He was first diagnosed with PTSD while on active duty in xxxx by a DOD psychiatrist and mental health records (private and VA) dating back to xxxx also show that multiple mental Health providers have diagnosed and treated PTSD. Although the veteran experienced some symptoms immediately following the assault (bed wetting, night terrors), these symptoms largely resolved by the time he was in middle school due to reported "traumatic amnesia." His only residual symptoms throughout the remainder of middle school and high school were associated with a chronic mistrust of others and related social detachment. His enlistment exam was silent for any relevant concerns, as were STRs from the time of his enlistment in xxxx until the first disclosure of the assault and associated symptoms in xxxx and xxxx. Thus, there is no evidence to suggest that the veteran was experiencing clinically significant symptoms of PTSD prior to his enlistment and thus the question of aggravation is moot. Records clearly document onset of symptoms while the veteran was on active duty and indicate chronic trauma-related symptoms and impairments since then. 2. The veteran's current mental health symptoms also meet DSM-5 diagnostic criteria for Major Depressive Disorder (MDD), Recurrent, with Mood-Congruent Psychotic Features, secondary to underlying PTSD. His current depressive symptoms are a continuation of those first diagnosed in service as Dysthymic Disorder, and the veteran has been treated for MDD by multiple mental health providers (private and VA) since at least xxxx. As indicated above (Rationale #1), there is no evidence to suggest Clinically significant symptoms of depression prior to military service, and he was first diagnosed with a depressive disorder while psychiatrically hospitalized in service (xxxx). Subsequent records indicate chronic problems with depression since his discharge from active duty. 3. The veteran's history is suggestive of some underlying Personality features which are likely contributing to some of his on-going concerns (e.g., schizoid and avoidant features). Although he was diagnosed with a personality disorder in service, there is insufficient evidence to warrant a personality disorder diagnosis at present, as some of his on-going symptoms can be attributed to underlying PTSD (e.g., mistrust of others, social/interpersonal detachment, avoidance of intimate relationships). 4. The veteran showed no signs of significant exaggeration/feigning or minimization of mental health symptoms on objective testing, during the interview, or when comparing his self-report to the evidence in the record. As such, information from this evaluation is believed to be an accurate reflection of the veteran's current mental health concerns and relevant background.
  2. Hello Fellow Vets, I'll try to make this a quick an easy read. I joined the Navy in July 2008 and served 5 years of continuous duty. By the time I was out I had several issues that were not present at my join date and eventually filed a claim for my benefits. Upon departure from the Navy, I filed a claim and was denied benefits for headaches, depression, a left knee and right knee condition. When I received my decision packet, it stated that these conditions could be granted a rating if found service connection. When I met with the DAV representative, he stated that if I could have my primary care doctor write a letter and say the conditions were service connected I would be able to have it reconsidered. So my Primary Care Doctor who is a medical doctor, reviewed my medical record and she drafted a nexus letter that supported my claim (with proper language *more than likely service connected) for all the conditions I listed above (and others I will have to go back and file for at a later date). In addition, she diagnosed my headaches as being migraines as opposed to just headaches ( after I gave her the symptoms I had been experiencing). I submitted this letter in June of 2016. In September 2016 my claim went to preparation for decision and then was kicked back and the VA requested a C&P exam. This exam was conducted by a Nurse Practitioner. She opined that my headaches were due to elevated levels of estrogen and that I was cleared from physical therapy in August 2012 so neither condition was service connected. As I result I dug through my medical record and found evidence of reports of "severe and unusual headaches" on documents that were dated as early as October 2008 before I was ever on birth control. And reports of me complaining of knee pain after I was cleared from physical therapy in the year 2013. Though I found proof that I had been reporting these issues and nothing was being done about it, I also questioned how a science assumption could be made in this matter. If indeed I was suffering from elevated estrogen levels, shouldn't the NP have conducted some sort of blood work? It was not done....EVER. So my question today is Do you think that the opinion of the NP will out weigh the opinion of my MD ( who is also an employee of the VAMC in Atlanta, GA? Thanks For your time!
  3. I had a C & P done recently., which was outsourced and not done at a VA facility. When I called the toll free number, they told me that I need to make a written FOIA request. They also said that the results of the exam have already been uploaded. I would like to get my copy of the results as soon as possible and would drive down to the St. Petersburg Office to get them, but I am not getting any results trying to find out where the Release of Information Office is in St. Petersburg. Your thoughts are appreciated. Thank you.
  4. 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. 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.
  5. Hello all. I would like to thank all of you for your work on this site. I am a long time lurker, first time poster. I received my C&P Results back and would appreciate any feedback. I understand that there is no way to be fully accurate when trying to guess a rating based off of this information. I am just under immense stress lately as I have watched my life fall apart piece by piece over the last few years. I had good rapport with the interviewer but don't know what to make of some of the things he wrote. Thanks in advance for your insights you all do great work here. 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: 309.81 2. Current Diagnoses -------------------- a. Mental Disorder Diagnosis #1: PTSD ICD code: 309.81 Mental Disorder Diagnosis #2: Alcohol Abuse, in Remission ICD code: 305.03 Mental Disorder Diagnosis #3: No response provided. 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: Currently, no symptoms are attributed to alcohol abuse, because alcohol abuse is in remission. All symptoms are attributable to 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 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? [X] Yes [ ] No [ ] No other mental disorder has been diagnosed If yes, list which portion of the indicated level of occupational and social impairment is attributable to each diagnosis: Currently, no occupational or social impairment is attributed to alcohol abuse, because alcohol abuse is in remission. All occupational and social impairment is attributable to PTSD. c. If a diagnosis of TBI exists, is it possible to differentiate what portion of the occupational and social impairment indicated above is caused by the TBI? [ ] Yes [ ] No [X] No diagnosis of TBI SECTION II: ----------- Clinical Findings: ------------------ 1. Evidence review ------------------ In order to provide an accurate medical opinion, the Veteran's claims folder must be reviewed. a. Medical record review: ------------------------- Was the Veteran's VA e-folder (VBMS or Virtual VA) reviewed? [X] Yes [ ] No Was the Veteran's VA claims file (hard copy paper C-file) reviewed? [ ] Yes [X] No If yes, list any records that were reviewed but were not included in the Veteran's VA claims file: If no, check all records reviewed: [X] Military service treatment records [ ] Military service personnel records [ ] Military enlistment examination [ ] Military separation examination [ ] Military post-deployment questionnaire [X] Department of Defense Form 214 Separation Documents [X] Veterans Health Administration medical records (VA treatment records) [ ] Civilian medical records [ ] Interviews with collateral witnesses (family and others who have known the Veteran before and after military service) [ ] No records were reviewed [X] Other: MTR - govt and nongovt, VA documents and forms, b. Was pertinent information from collateral sources reviewed? [X] Yes [ ] No If yes, describe: Buddy or lay statement from who was Veteran's ex-girlfriend, 2. History ---------- a. Relevant Social/Marital/Family history (pre-military, military, and post-military): Relevant social history, birthplace, (mostly) happy childhood memories, (-) homeless currently, (-) rent currently, (+) own currently, (#0) of household occupants in addition to Veteran, (-) close friends, Veteran states that he feels estangement from others, he reached out to one of his military friends two weeks ago, this was the first tome to do that for one year, Veteran used to be active on Facebook, but he is no longer active on facebook, he began experiencing the idea that his thoughts were being communicated in a certain way by others, (-) attend social activities, (+) hobbies or interests, Video games, all kinds, grand theft auto, mad and football, wrestling, Veteran used to be an avid sports fan, he used to know the lines of college and professional football teams, he does not do that anymore, Relevant marital history, (S) civil status, he used to have a girlfriend, they were together for 3 years, he used to yell and scream at her, he states that it took everything within him to keep from hitting her, but he never hit her, she left and she did not come back; Veteran states he never assaulted his ex-girlfriend prior to their breakup; alternatively, he states that he choked his girlfriend in the heat of the moment 2 times, but she did not pass out, (#0) number of marriages, (#0) number of divorces, (#1) number of childrren y/o son, Veteran's son's mother does not allow Veteran's son to have unsupervised visits with Veteran, Relevant family history, (-) emotional or mental problems, (+) heart disease, PGF has CAD and h/o CABG, (+) both parents living, (-) close to them, he rarely talks with them, (#1) siblings living, 1 sister, (-) close to her, they have not spoken for 2 years Pre-military, Veteran states he killed his first animal at 10 y/o, which was a deer, and he gutted and cleaned it at that age. Post-military, Veteran states that he carries a gun wherever he goes. He was closer to his family and other people pre-military and military. Post-military, he has become distant with family and friends. His parents live inand have a home there . Post-military, after finishing his contract work in which he mostly worked on military instillations for the federal government, he lived with his parents for 2 months in He moved f to to go to College in 2012. He did not start having problems from symptoms of PTSD until after he finished his contract work, which was more like being in, rather than out of, the military, and began living more as a civilian. b. Relevant Occupational and Educational history (pre-military, military, and post-military): Relevant occupational history, (-) currently working outside the home, (2012) year last worked outside the home, (F) P = part time, F = fulltime, (security) type of work, (nothing) current source of income, Veteran indicates that he has used up his savings and now he is behind on many of his bills, (+) emotional or mental symptoms associated with occupational problems, Veteran was fired from his last two jobs, Relevant educational history, (+) learning difficulties, (-) learning disabilities, (he has two years of college) level of education, (+) emotional or mental symptoms associated with educational problems, difficulty concentrating, Veteran graduated from HS at 18 y/o. He went to college for one year. He worked seasonal work, restaurant work, cabinet factory, met a woman, had a son, was in and out of legal troubles, and entered the USA at 23 y/o. He was discharged from the USA at 27 y/o. He worked for as a regional supervisor for 5 years. . ; Veteran states he was a distinguished soldier during basic training. He became the best mechanic while in stationed in Germanny. He was a leader and NCO in the Ranger battalion. He did not get DUIs and he did not get into fights. Veteran states that he laughed at the PTSD symptoms checklist when he first came back from his deployment to Iraq. but now he cannot get a job due to such symptoms. He has not been able to hold down a job for the past 3 years. c. Relevant Mental Health history, to include prescribed medications and family mental health (pre-military, military, and post-military): Relevant mental health history, (-) mental health care before military service, (-) mental health care during military service, (+) mental health care after military service, (#0) previous suicide attempt(s), (#0) previous hospitalization on psychiatric ward(s), (#0) previous court orders for involuntary treatment, (+) currently seeing a provider for the purpose of medication management, (-) currently attending individual psychotherapy and/or group therapy, he used to go to groups, he lost his driver's license, therefore he has not been going, because it is difficult getting there, (+) h/o severe emotional trauma, (-) h/o head trauma, (-) h/o evaluation for TBI, (+) current emotional or mental problems, (+) mood often blue or sad, (+) anger, (+) h/o ever experiencing seven or more days of manic excitement (i.e., abnormally, discretely, and persistently elevated, expansive, or irritable mood), decreased need for sleep, racing thoughts, or pressured speech, Veteran states that he has gone for many days without sleeping, he would keep busy because he was unable to sleep, he used to self-medicate insomnia by drinking alcohol to the point of blacking out, he has h/o anxiety and paranoia, racing thoughts, increased goal directed behavior (in terms of playing a video game), agitation (in terms of pacing around the apartment), he was not talking faster or more than usual, no significant change in self-esteem or grandiosity, no significant distractability, (+) behavior for the purpose of pleasure with potentially painful consequences (alcohol problem), (+) h/o of hallucinations, he used to have these when he was drinking alcohol, he used to have alcohol hallucinosis, he has been sober since June 2015, (+) h/o delusions, he has h/o delusions of reference, Prescribed medications, List, propranolol, sertraline, and trazodone; he was remotely taking aripiprazole and valproate, he was taking quetiapine when going through inpatient treatment for alcohol abuse, he has h/o risperidone and risperidone-associated akathisia, (+) adverse events with one or more of these, his sleep is too deep with trazodone, then he has disturbing dreams, then he cannot wake up out of these disturbing dreams, because his sleep is too deep, (-) beneficial effects with each of these, propranolol was previously helpful while he was on risperidone to decrease the akathisia associated with risperidone, sertraline is not yet producing a beneficial effect, Family mental health, Please see above under "relevant family history." d. Relevant Legal and Behavioral history (pre-military, military, and post-military): Relevant legal history, (+) symptoms associated with legal problems, (+) h/o arrests for assault, battery, or violence, (+) h/o arrests, convictions, or sentencing (to jail or prison), (-) currently on parole or probation, (-) current conservator or guardian, (+) h/o DUI, #1, Relevant behavioral history, (+) symptoms associated with behavioral problems, Veteran states that he does not talk with anyone, he does not do anything, he enrolled in school, he cannot deal with that anymore, he dropped out of College, he cannot deal with the people there, he believes he is viewed by others as a time bomb, after he was arrested for eluding an officer. (yesterday) last time to be in a heated argument with another person, (June, 2015) last time that to be in a physical altercation with another person, (poor) quality of sleep generally, Pre-military: Veteran had reckless driving charges and assault with a deadly weapon charges prior to USA service. He was charged with reckless driving. He ended up doi of house arrest for reckless driving. He took assault with a deadly weapon to a jury who did not find him guilty as charged. It was determined that he was defending himself, and he was absolved of any wrong doing. Military: Veteran has one negative counseling statement for missing formation one morning due to oversleeping when they had a power outage, when his roommate was on leave, but other than that he did not have any other LOCs, no LORs, no Article 15s, and no other non-judicial or judicial punishments. Postmilitary: Veteran was arrested in 2013, and he was placed in a mental health safe cell while in jail, because he drove off from a traffic stop away from an officer. He was initially written up for felony eluding, but the charges were plea bargained down to a misdemeanor. Veteran has pending charges. He has a warrant out for his arrest. This is for criminal speeding (99 mph in a 45 mph zone). e. Relevant Substance abuse history (pre-military, military, and post-military): (+) tobacco during past 30 days, (today) when last used, (-) alcohol during past 30 days, (July 2015) when last used, he got out of treatment June 8th, he relapsed in July, for 2 days, (+) h/o alcohol problem or alcohol abuse, (-) illicit drugs during past 30 days, (prior to March, 2014) when last used, he has not used spice (synthetic MJ since prior to his first inpatient treatment program, (+) h/o inpatient or outpatient treatment for alcohol or illicit substances, 2 times, (+) currently attending AA, NA, or other support groups, Veteran does not believe that he suffers from alcoholism, Veteran smoked a joint of MJ when he graduated from HS, he did not smoke MJ during the military, and he smoked MJ less than 6 times after the military. He drank alcohol 2 times during HS, he was a social drinker during college and the military, while in Germany, and he became an alcoholic after the military. He was drinking a lot with his friends, at the time of his deployment to Gerrmany, from dusk until dawn. Other times, he could drink until 2 AM, go to sleep, wake up at 5 AM, go to PT, and be fine, while in the regular Army battalion, but he was not able to keep that lifestyle while in the Ranger battalion, because they put him through too much. Veteran does not like talking with anyone about anything, even the weather. Veteran feels uncomfortable when in large groups of people. This triggers intense urges for drinking alcohol. Living with his emotions and feelings is more difficult without alcohol than with alcohol. 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: 1. Military Combat Trauma (Veteran observed traumatic events as experienced by others, including seeing a person get his face shot off, seeing people with their heads cut off, and seeing a dead body, he claims he saw a US missile hit a minivan carrying an entire family,) 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: No response provided. 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 Criteria 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 Criteria 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 violation, in one or more of the following ways: [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 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 to 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] 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] Panic attacks that occur weekly or less often [X] Chronic sleep impairment [X] Difficulty in establishing and maintaining effective work and social relationships [X] Inability to establish and maintain effective relationships 6. Behavioral Observations -------------------------- Appearance - attire is summertime casual, grooming is average, and presently, the veteran does not appear to intermittently be in distress as he intermittently discusses his taaumas. Behavior - eye contact is intermittent, and speech is of unremarkable rate, rhythm, volume, prosody, and articulation. Speech contains profanity in many sentences. Comportment suggests that the veteran gets along adequately with this writer. Affect is neutral. Thought processes are logical, linear, and goal-oriented. Presently, the veteran does not have a formal thought disorder. Thought content is without homicidal ideation or suicidal ideation. Perceptions - the veteran presently does not appear to be responding to internal stimuli. Insight is fair. Judgment is fair. Psychomotor activity - Veteran becomes agitated when talking about his experiences in Iraq. Muscular observation shows absence of focal motor deficits. Cognitions are grossly intact. Abstractions demonstrate at least average capacity for logical reasoning and systematic thought. 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 -------------------------------------------------- REQUESTS AND FINDINGS A. CLAIM TYPE - ORIGINAL, DBQ PSYCH PTSD Initial, the following contentions need to be examined - PTSD, The VARO has verified the veteran's combat service and the veteran has the following combat medals Combat Action Badge, Veteran is a y/o divorced, unemployed EA who served in a Ranger battalion while serving in the USA and experienced military combat while serving in Iraq. Veteran served in the USA from 2003 to 2007. He was in the motor pool division of the Ranger battalion. He observed traumatic events as experienced by others, including seeing a person get his face shot off, seeing people with their heads cut off, and seeing a dead body. He claims he saw a US missile hit a minivan carrying an entire family, because the US forces wanted to kill one enemy combatant inside the minivan. Veteran saw a VAMC on 10/01/2014, who diagnosed him with and treated him for PTSD. Veteran experienced military combat stressors. Currently, at night he has dreams, in which he cannot get his gun to shoot, because it will not fire. During the day, he has uncontrollable thoughts. He visions someone getting shot. Either he is shooting at the person getting shot or groups of people are shooting at the person getting shot. He hears someone getting shot. He states that it makes a very distinct sound. Thunderstorms, trigger he to "lose it," whereby he becomes diaphoretic, comes to, and finds himself on the floor in the prone position, after he has pulled his ex-girlfriend to the floor with him. He has trouble sleeping for one week following such events. Firecrackers on the 4th of July trigger he to "lose it," whereby he finds he has pulled his son to the ground with him, causing abrasions to his son's B/L knees. Veteran states that he avoids people, because when they find out that he is an Iraq War veteran, then they have a tendency to talk with him and ask him questions about his experiences. He states that he hates it when they state that they understand, and he states that they do not understand, because they were not there. Veteran voices his suspiciousness and states that as soon as groups of people at AZU, where he was in school, and groups of people where he has been employed find out that he has issues, then people talk about him and he is talked about. Veteran states that people make jokes as to when would he be going postal and start shooting up the office. He states that he knows that others are talking about him, because when he goes into a room, then everyone stops talking. Veteran states that once people become uncomfortable with someone, then they plot and scheme. Veteran used to be a baseball player, where he learned that being calm and controlled worked to his advantage, but he states that he has lost the ability of being calm and controlled in order to work to his advantage. He recognizes that he has a "short fuse" and can suddenly go from neutral to angry, agitated, and combative with the right cue, as in someone older bossing him around and telling him what to do. He states "[he] wants to punch out a window over nothing." Veteran states that if he applies for a supervisor position, then he is offered an entry level position instead. He states in the past he was able to deal with supervisors, but now he cannot deal with supervisors. One of his supervisors was talking to him as though he was a child, then Veteran took his left hand, placed it across his supervisors neck, and pushed him against the wall. His supervisor "flipped out," talked about suing him, and talked about pressing charges. Then Veteran was immediately let go. He was told that they were going to consider it as though he was never hired. Veteran admits to being high strung and states that he used to be able to filter out supervisors telling him what to do kinds of stressors, but he is no longer able to do that. He states that yesterday when he took a urine drug test for a job that he would like to get, after waiting for 20 minutes and watching the receptionist doing one thing or another on the computer, he became irate and confrontational. Veteran denies suicidal ideation. He states his father's sister's husband killed himself. Veteran states that he would never do that. He would not do it on account of his mother and his son. Work impairments include being up for 3 nights at a time without sleeping, then he falls asleep while he is doing something routine, such as tying his shoes. He states that he has missed a few jobs on account of this problem. Veteran meets the following DSM 5 criteria for PTSD. 1.) Trauma, (+) Directly experiencing the events, (+) Witnessing the events as they occurred to others, (-) Learning that the traumatic events occurred to someone close, 2.) re-experiencing, (+) dreams or nightmares, (+) flashbacks, (-) illusions or hallucinations, (+) images, perceptions, or thoughts, (+) triggers cause emotional and mental distress, 3.) avoidance, (-) activities, he enjoyed American Sniper immensely, but he states that this stirred up emotions and feelings, (+) conversations, he avoids conversations with his Ranger friends, (-) feelings, (+) people, he avoids seeing his Ranger friends, (+) places, he states he does not like the VA, people came back without eyes and limbs, he came back with emotional and mental symptoms, (-) thoughts, 4. negative feelings or thoughts, (+) anhedonia, (+) decreased interest or participation in activities, (+) distorted cognitions about the cause or consequences of the events, he states that the entire Gulf War was "&$," (+) feeling detached and estranged, (-) forgetting details about the events, (+) negative beliefs about himself, others, or the world, he states that the US federal government is "&$," (+) negative emotions, 5.) Altered arousal and reactivity (+) angry outbursts, (+) irritable behavior, (+) hypervigilance, (+) exaggerated startle, (+) recklessness, (+) self-destructiveness, (-) concentration problem, if interested, then he can concentrate really well, if not interested, then he cannot concentrate very well, (+) sleep disturbance, 6.) (+) long-term duration, 7.) (+) dysfunction, 8.) (+) not due to a medical illness or substance, Veteran has decreased productivity at work, because he has emotional and mental symptoms affecting his ability to work, interpersonal problems affecting his ability to get along well with others, and authority and submission problems affecting his ability to get along well with supervisors. These problems are secondary to symptoms of PTDS. They occasionally, but not continuously, affect reliability. Otherwise, his ability to adapt to change, maintain a regular work schedule, pay attention, concentrate, and reason, show up for the job, maintain himself on the job, and complete the job are not impaired. Alcohol abuse is in remission. Functional limitations include working under a less than supportive supervisor, working around any more than 2 or 3 other people, and working indoors. B. ELECTRONIC CLAIMS FOLDER AVAILABLE, review Veteran's electronic folder in VBMS and state that it was reviewed. Veteran's electronic folder in VBMS and was reviewed. C. If more than one mental disorder is diagnosed, comment on their relationship to one another. Alcohol abuse is secondary to insomnia, which is secondary to PTSD. Alcohol abuse is in remission. D. If more than one mental disorder is diagnosed, state which symptoms are attributed to each disorder. Currently, no symptoms are attributed to alcohol abuse, because alcohol abuse is in remission. NOTE: VA may request additional medical information, including additional examinations if necessary to complete VA's review of the Veteran's application.
×
×
  • Create New...

Important Information

{terms] and Guidelines