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Does this sound or look right to anyone? Denied TDIU... ========================================================================= Date/Time: 20 Jun 2017 @ 0800 Note Title: C&P MENTAL DISORDER Location: Chalmers P Wylie VA Outpatnt Signed By: HOULE,ALLISON C Co-signed By: HOULE,ALLISON C Date/Time Signed: 20 Jun 2017 @ 1641 ------------------------------------------------------------------------- LOCAL TITLE: C&P MENTAL DISORDER STANDARD TITLE: MENTAL HEALTH C & P EXAMINATION CONSULT DATE OF NOTE: JUN 20, 2017@08:00 ENTRY DATE: JUN 20, 2017@16:41:06 AUTHOR: HOULE,ALLISON C EXP COSIGNER: URGENCY: STATUS: COMPLETED *** C&P MENTAL DISORDER Has ADDENDA *** Review Post Traumatic Stress Disorder (PTSD) Disability Benefits Questionnaire Name of patient/Veteran: xxxxxxx 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 2. Current Diagnoses -------------------- a. Mental Disorder Diagnosis #1: Posttraumatic Stress Disorder ICD Code: F43.10 Mental Disorder Diagnosis #2: Opioid Use Disorder, Severe, In early remission, on maintenance therapy ICD Code: F11.20 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: The veteran's symptoms are primarily related to his PTSD since he has not used substances in more than six months. 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: The veteran's impairment is related to his 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 ------------------ Evidence reviewed (check all that apply): [X] VA e-folder (VBMS or Virtual VA) [X] CPRS Evidence Comments: The veteran's electronic medical records (CPRS & VistAWeb) and military records (VBMS) were reviewed. The veteran was referred for a compensation and pension examination. The veteran was informed verbally of the nature and purpose of the examination and confidentiality limits. He appeared to have a basic understanding of the purpose of the examination and confidentiality limits. He was provided with a chance to ask questions about the evaluation procedures. All questions were answered to reasonable satisfaction or referred to other resources. He was informed that this examiner is not his treating clinician or the legal determiner of compensation or pension benefits. Instead, he was informed that this examiner is an independent provider of clinical information and expertise to assist those who review and make legal compensation and pension claim decisions and would not be participating in her healthcare. He was given information about the Veteran's 24-hour Crisis Line. The veteran indicated understanding of these terms and explicitly and freely consented to the evaluation. The judgments of symptoms and opinions in this evaluation report are offered to a reasonable degree of psychological certainty and are only based upon the information available at the time of the evaluation. This report was dictated using Dragon Naturally Speaking dictation software. The report has been proofread; however, there still may be some typographical errors due to the nature of the dictation software. The veteran began participating in recovery services at the VA in May 2017. His last group note was dated 5/31/17. A note dated 2/26/17, by Dr. Laurie Berger, indicates that the veteran began therapy at the Vet Center in October 2016. He attends therapy on a weekly basis. He attended six sessions with Dr. Berger when this note was written. The veteran was initially evaluated for a C&P exam by Dr. Janine Schroeder on 3/22/17. 2. Recent History (since prior exam) ------------------------------------ a. Relevant Social/Marital/Family history: The veteran was born and raised in xxxx. He was raised by his mother and father until they divorced when he was 7 years old. The veteran then lived with his mother until he was 14 years old. The veteran's mother remarried when he was 11 years old and he reported that he did not get along well with his stepfather. He went to live with his father at 14 years of age due to being disrespectful towards his stepfather. The veteran has one older sister and one younger brother. The veteran's father did not remarry, but he was in a relationship with the same woman for 20 years. He reported physical abuse by his father throughout his adolescent years. He recalled one incident where he got a black eye after his father hit him. He denied any Child Protective Services involvement. The veteran describes his father as emotionally absent. His father died in 2007 from a heart attack. The veteran is a 36-year-old, divorced male. He was married in 2001 for five years and divorced in 2006. The veteran reported that they divorced due to his drug use. They have a 1X-year-old daughter together. His ex-wife and daughter live in xxxxx. He maintained some contact with his daughter, but has not seen her in several years. The veteran reported that he was involved in a relationship for a few years following his divorce. They are no longer in a relationship, but are close friends. The veteran reported that he has spends time with three friends from high school. The veteran stated that he enjoys gardening. b. Relevant Occupational and Educational history: The veteran reported that he did not enjoy school and did not want to do the work. He frequently skipped school to go skating. He stated that he would "have a few beers and smoked pot" when he skipped school. He reported being suspended several times for truancy, fighting, and disrespect towards teachers. He was never held back a grade. He was expelled his junior year of high school due to nonattendance. He earned his GED in 1997. The veteran worked for his father from 1997 until 1999 doing ironwork. The veteran enlisted in the Navy in October 1999. He reported several disciplinary issues while in the service related to going AWOL, being late, and underage drinking. He reported that the sexual assault occurred in the summer of 2001. The veteran received a general under honorable conditions discharge in September 2001 for misconduct. The veteran worked in Virginia Beach beginning in September 2001 doing ironwork. He worked at a company for one year and was fired due to not showing up for work and using alcohol and drugs. He then worked for Roofing Services Incorporated from September 2002 until August 2003. The veteran then earned his tanker men certification, z card, and AB certification to work on tugboats. He worked on boats from September 2003 until March 2005. At that time his wife left him and he moved back to Ohio to be closer to his family. The veteran continued working on boats in Ohio until the summer of 2005 when he got fired. The veteran was incarcerated from 2006 until 2016. After his release from prison, he worked with friends doing landscaping and painting. He began working at ABS Money Systems in January 2017, a company that his mother owns. The veteran reported that he was working 30-40 hours per week for the first two months. He stated that his hours have declined significantly since March and he is currently working 5-6 hours per week. He stated that his work has declined due to his mental health symptoms. However, according to the initial C & P exam, "he is unable to do a lot for her because she works serving ATM machines in banks and with his record he isn't allowed to work in banks." He also reported that his employment since the military has been "short-lived due to his drug and alcohol use." c. Relevant Mental Health history, to include prescribed medications and family mental health: The veteran reported that he was diagnosed with ADHD during childhood and received treatment. The veteran reported a suicide attempt in 2001 after he was discharged from the military. He began attending treatment at the Vet Center in October 2016. He reported that he attends individual therapy twice per week with Dr. Berger. The veteran described his mood as "anxious, paranoid, and depressed." He stated that he feels as though he "can't get a break." He reported having passive thoughts of suicide, but stated that he does not have a plan or intention to kill himself. He stated "I couldn't do that to my family." He stated that he has had difficulty dealing with his emotions since he is no longer using substances and does not have an escape. He stated "I don't have the coping skills." He described having difficulty sleeping and stated that he does not sleep every night. He stated that he is not feel safe in his bed. d. Relevant Legal and Behavioral history: The veteran reported that he had several misdemeanor offenses as a juvenile, including truancy, driving without a license, and theft. He reported that he was arrested for selling drugs at 18 years of age and was placed on probation for one year. According to the previous exam, he was arrested numerous times from June 1998 to September 1999. The veteran was convicted of armed robbery for robbing three pharmacies with a weapon. He served a 10-year prison sentence beginning in October 2006 and was released in September 2016. He is currently on parole for five years. e. Relevant Substance abuse history: The veteran reported that he first drank alcohol at 10 years of age. He began regularly drinking alcohol during high school. He began smoking marijuana at 15 years of age on the weekends. He also experimented with mushrooms and pain/anxiety medication that he took from his father. The veteran's alcohol use increased significantly while in the military. He denied using any drugs while in the service. After his discharge from the service, he continued using alcohol and marijuana. In 2002, he began using narcotic pain medication. He also began using heroin and reported that he eventually used heroin intravenously. The veteran reported using substances throughout his time in prison. He reported that he has been clean from drugs and alcohol since October 2016. He has maintained sobriety using Suboxone. He currently attends AA meetings approximately once per week. He attends substance abuse groups at the VA twice per month. 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 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) 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 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). 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) of the following: [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] 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] Depressed mood [X] Anxiety [X] Suspiciousness [X] Chronic sleep impairment [X] Disturbances of motivation and mood [X] Difficulty in establishing and maintaining effective work and social relationships 5. Behavioral observations -------------------------- The veteran arrived 10 minutes late for his appointment and was pleasant upon meeting. The veteran was oriented to person, place, situation, and time. His grooming and hygiene were adequate. He made appropriate eye contact and presented with a depressed mood with a congruent affect. His speech was within normal limits for tone, volume, and rate. His thoughts were logical, linear, and goal-directed. He did not evidence any psychotic symptoms, including responding to auditory or visual hallucinations and delusional beliefs. On a brief mental status exam he was able to freely recall two of three words presented after a brief delay. He was able to recall six digits forward and three digits backward. He was able to complete a serial seven subtraction task with no errors to seven places. He was able to spell the word WORLD forwards and backwards. He was able to complete a two-digit addition and subtraction tasks. He was able to compare an apple and banana and was able to reason abstractly when comparing a poem and a statue. His response to the proverb "don't cry over spilled milk" was good. He was not able to provide a response to the proverb "people in glass houses should not throw stones." 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: --------------------------------------------------- The veteran was administered a psychological measurement that is useful for interpreting the veracity of other data provided by an examinee during a psychological or neuropsychological examination. This assessment can assist in evaluating and making a clinical opinion regarding the veracity of an examinee's purported symptoms. Research has determined that this tool is a useful instrument to administer in order to screen for possible feigning of PTSD symptoms. The following results should be interpreted in light of the fact that the measurement that was chosen is a screening tool and not designed as a definitive measure of whether or not an individual is feigning mental illness. The Veteran's total score was not elevated beyond the cut-off score. Therefore, his PTSD symptoms are considered to be credible. The veteran was administered the Minnesota Multiphasic Personality Instrument-2-Restructred Form (MMPI-2-RF), which is a self-report psychological assessment used to identify a variety of psychological syndromes. The veteran was provided a quiet, private room to complete the testing. It appears the veteran understood the items and responded to the items in a consistent manner. The veteran over-reported psychological dysfunction, which is evidenced by a considerably larger than average number of infrequent responses. The veteran also possibly overreported symptoms associated with non-credible memory complaints. Although there is evidence of over reporting of symptoms, the profile is considered valid and will be interpreted. Overall, the veteran endorsed considerable emotional distress that is likely perceived as a crisis. The veteran reported feeling sad and dissatisfied with his currently circumstances. He reported a lack of positive emotional experiences, a lack of energy, and a lack of interest in activities. He also reported experiencing various negative emotional experiences including anxiety, anger, and fear. The veteran also reported a significant history of antisocial behavior. This behavior includes involvement with the criminal justice system, difficulty with authority figures, conflictual interpersonal relationships, impulsivity, juvenile delinquency, and substance abuse. The veteran also endorsed various unusual thought and perceptual processes. The veteran endorsed a diffuse pattern of cognitive difficulties including memory complaints. He also reported past suicidal ideation and feelings of helplessness. The veteran endorsed feelings of anxiety, being anger prone, and experiencing multiple fears that restrict his activity inside and outside of the home. He also reported being unassertive and shy. The veteran endorsed not enjoying social events and avoiding social situations. He also reported disliking being around people. On a scale of personality pathology, the veteran endorsed being self-critical and guilt-prone. He also endorsed being pessimistic and feeling depressed. The veteran is currently diagnosed with Posttraumatic Stress Disorder and Opioid Use Disorder, Severe, In early remission, on maintenance therapy. The veteran currently lives alone and is not involved in a romantic relationship. He maintains phone contact with his daughter. He has a close relationship with his mother, sister, and two friends. He is currently working for his mother's company. He reported experiencing symptoms of PTSD. He is attempting to cope with his emotions without the use of drugs. The veteran has been employed numerous times and has been fired for tardiness or alcohol and drug use. He is currently working 5-6 hours per week for his mother's company. According to the previous C&P exam, he is not able to work many hours due to not being permitted to work inside of a bank due to his felony record. The veteran reported that he was "working" during his 10 years in prison selling drugs. He denied having any difficulties while in prison. The veteran is capable of following instructions and performing simple tasks. He is able to concentrate on a simple task and respond appropriately to coworkers and supervisors. /es/ ALLISON C HOULE, PHD C&P Psychologist Signed: 06/20/2017 16:41 06/20/2017 ADDENDUM STATUS: COMPLETED The veteran presented for his appointment. The report from the C&P Exam was completed in Capri by Allison Houle, PhD; procedure code 99456 and 96101. /es/ ALLISON C HOULE, PHD C&P Psychologist Signed: 06/20/2017 16:42