ptsd Psychiatric Qtc Examination

[cannoncocker]

This is a very specific question or can be answered in general either being of great help to me.

I am scheduled for a QTC SC Chronic Anxiety in Asheville, NC and I don't really know a more appropriate place to post this question.

As we all know everybody is biased on any given subject even before the facts are heard/sight unseen. So my question is if anyone of us has been to a psychiatric exam in Asheville with the QTC psychiatric examiner/contractor and if so are they fair arbiters for ptsd or any other SC psychological problems. I mean do they already have their minds made up? If that were the case is there anything I could do to counter that?

I know it's almost ridiculus to ask this without the examiners name but I wouldn't want somebody putting my ID Info out here on the internet so I would not do that to them. Although i presume they only have one for that area so you would know automatically who it was.

Thank you for any pointers and info

Too, any pointers on how to approach an exam like that would be really helpful since the VA psychologist is the only exam like that I have been to.

[Wings]

Cannoncocker,

I wanted to respond to your question about the anxiety C&P. However, having no idea as to the issues in your claim I went back and read as many of your old post I could find. The best way to deal with a bias is with better medical evidence.

If your service medical records are silent for any anxiety or other psychological complaints and you were not treated until years after your discharge direct service connection for an anxiety disorder not including PTSD would be a miracle. From what I have read it appears that you have not been in treatment for a psych condition up to this point. One of your posts shows a diagnosis. However, it appeared that it was your guess as to what the diagnosis should be. If I am wrong on this let me know. If that diagnosis was made by a shrink it does not relate it to the hearing condition.

I found some statements that indicate that you are specifically advancing the claim for anxiety as secondary to the sc’d hearing problem. The sc’s hearing condition being rated at 0%. It would be a good idea to bring to the attention of the anxiety examiner the reasons the hearing problem specifically causes you anxiety. Make it very clear as to the difficulty you have at work and in your personal life. Give specific examples of events that have been problematic due to the hearing problems. As far as how you are doing I always tell them “things could be better, I dodge bullets every day”. Now the ball is in their court. They have to try and figure out why I said that. Then I go into specific details as to how I am confronted by simple everyday events that endanger me as a result of my physical limitations. I guess if you have a hearing problem you would be dodging the problems associated with mis understood conversations and an occasional automobile that crosses paths with you.

If you have not been in treatment and you are relying on this single C&P to diagnosis and relate your condition to the hearing problem I would not expect a high rating. High ratings are hard to get from the VA. If you need a high rating some ongoing psych treatment would be a good idea.

I have a brother with hearing loss. Sometimes it is like talking to a wall.

x

x

x

Excellent post Hoppy!!!

[cannoncocker]

Yes sir, those are some issues you guys bring to my attention. I, probably like most of you and 99% of the world keep our emotional baggage in our back pocket and only bring it out rarely. That is to say it is not like having the flu, take some asprin, rest, get back to work.... There are so many responses that deserve a page each but since we can't do that I put as much as I can out there. First, I have a degree in psychology, which for those in the know, without a Masters Degree, that and 3 dollars will get you a cup of coffee, but it does give me the language, procedures, DSM info.....So I have that to help me contend on their field.

Most of this is going to be directed to Hoppy as his response was well beyond the norm! First I was in Field Artillery spending a large portion of my time in Special Weapons, which specifically was a section chief in tactical nuclear weapons which obviously required me to maintain a security clearance. So if you cared about keeping your position and staying in you basically kept any of your psychological problems to yourself. As a matter of fact regardless of your MOS or job I did not see lines in front of the psychiatrists office while I was in. As LarryJ pointed out you really push all the problems to the back until you find yourself in a position, like his and mine, because I got exactly that way when the VA psychologist got finished with me I was crying like a newborn. I had never been so embarrased in my life. I could hardly keep showing for appointments but I felt like if all that was inside I needed to give it a try to resolve it. I actually have been taking mood medications: steraline, diazepam, and paroxetine. Currently taking the paroxetine and had to stop taking diazepam because they made my body ache. Point is I started dealing with this in 2006. I don't drink/smoke/take drugs so I am not dealing with those issues.

This initial diagnosis was after one or two sessions so it is not complete but plan on obtaining and submitting to the DAV and VARO after our next seesion

My diagnosis in DSM IV form:

AXIS1 300.1 Panic disorder/o Agoraphobia

311 Depressive Disorder NOD

300.02 Generalized Anxiety Disorder

Axis II 799.9 Deferred

Axis III Chronic pain, hypothyroidism, hyperlipidemia, hypertension

Axis IV limited social support

Axis V GAF:50

How the chronic anxiety was suppose to have been submitted as secondary to:

1.(primary) A situation that could have gotten my entire crew and anybody else within the kill zone of a 155mm artillery round. The situation was entirely my fault, event though I was not entirely trained for that job but nevertheless I took it and was responsible when I accepted that job.

2.(secondary) Chronic pain from pinched S1Nerve Root, protruding discs/extruding discs/segrgated disc material/old disc material leakage/current disc material leakage. This restricts my range of motion severely which is is entirely contrary to my nature. It is driving me crazy to not do the things I could do, not just economically, or the constant pain, but as the pain increased over the years it affected me psychologically.

I cannot give any further info than that in a public forum on number 1 but Many of you are so right that I/you had no idea how things like that will affect the decisions you make the rest of your life. I personally tend to be obsessive and that has prevented me from taking jobs, for instance I took a job as a County Safety and Health Manager which required me to make those same life and death decisions so I had to walk away from that job. I have only 1 clinical nursing and one micribiology to finish the requirements for an RN Nursing degree but I can't take those life and death decisions. I guess it comes down to the fact this created a lack of trust in myself which has pretty much wrecked my career choices and didn't even recognize why till I started therapy. Being on the obssive compulsive side this has amplified the affects on my economic life and personal life. Come to find out this has affected pretty much my entire life and I really hadn't connected the dots until the last few years. Now that I know the orgin it is hard to say if that is good or bad. That is a heavy burden that there is no logical physical reason we are not dead, my crew and anybody else in the area. That round with a time fuse and round with point detonating fuse should have detonating. Why it didn't kill us all, there is no reasonable explanation.

So that is pretty much me. Hearing is a whole separate issue and has nothing to do with my psychological state. QTC has has ordered the psychiatric exam and evidently need further information from the QTC Audiologist.

Should I submitt an ammended 4138 to the VARO explaining this and or explain this to the QTC examiner?

I do appreciate you guys taking the time to track my info down and give such excellent insights. Hopefully one day I can do the same but if I tried now I would only mess their claim up royally. Like they say, you need to know your limitations.

[cannoncocker]

I had neglected to mention the fact I attempted suicide right after this situation in the service but all that is left is a scar that is unfortunately obvious what it is. I just wrapped it up and let it heal on my own and since it was in the field during the winter it was easy to conceal, concealed for the reasons i mentioned above. To many it probably wouldn't mean much but I took my responsibility seriously especially nearly killing my friends and crew and knowing the ripple effect it would have had on the theirs famalies.

And my chain of command did not write this situation up since they were partially at fault for assigning me to a position that I was not accutomed to. We just punched the round out of the tube and continued on but I never felt the same about myself and while i was at that unit there was no trust left. That was about the worst part of that becauuse I had to live with that everyday I saw them. It just never seemed to end.

[john999]

I believe that many of these anixeity disorders are covered up or ignored by vets because the vet actually thinks he is losing his mind. I could not explain this to the army psychiatrist I saw. He just sort of looked at me.

[Hoppy]

Cannoncocker

This post starts off a little discouraging and gets better as it goes. I am still in a fog about the issues in your claim so this is the best way for me to explain what know about the VA. I also studied psychology and completed all the core classes for a BS at UCLA. I had some tutoring from a Service officer who had a masters degree in psychology, worked at a VA hospital for ten years, was a rating specialist for the VA for twenty years and switched over to a service organization and was a service officer for ten more years.

Have you been on VA boards or are you new to VA compensation? Are you familiar with the laws that apply to service connection of a disability? Have you read any BVA cases? I am still not seeing the types of statements that you need to win service connection. Are you seeking nexus statements? Does the psychologist specifically say your current condition is related to military service? He has to say this. You can write letters to the VA in support of your claim stating your logic. If you do not have a masters degree working under the direct supervision of a PHD the raters probably will not even read your arguments. Even if the psychologist states that your current condition is related to service the VA is not required in all cases to accept his opinion.

The VA rating system is very technical. It is very different than other systems such as social security. If you go to a social security psychologist and he decides you have an anxiety disorder and even relates it to military service you can get compensation from the Social Security administration. That is of course you do not work and are unemployable. SSA only compensates total disability.

If you go to a psychologist and he says you have an anxiety disorder and he relates it to your military service and his opinion is based entirely on your subjective statements of historical events that occurred in the military and your SMR is silent for any complaints of psychology symptoms the VA generally is not allowed to give weight to the diagnosis if you were not to be determined to have been in combat. See BVA citation 9925065 below.

Do you know what the requirements for meeting the criteria for the VA to determine that you were in combat? Do you meet these requirements? Non combat veterans who file claims years after the military for injuries sustained and mental conditions whose military records are silent for the injuries and mental conditions generally cannot meet the requirements for service connection.

I have seen some exceptions that might work in your favor if you are a non combat veteran who worked at a dangerous job. I have seen panic disorders that were service connected after service based on specific jobs that were highly stressful. I will post them as I find them. I have seen panic disorders service connected almost the same way as PTSD. I will try and find these cases and post them. It is possible that BVA recognizes the types of long term stress situations that predate panic disorder. There is significant research that shows that individuals with long term stressors develop panic disorder at a rate four times higher than the general population. It would be a question if they feel your assignment or MOS in the military was capable of being a long term stressor. Definitely get the psychologist you are working with to work stress related to your MOS or assignment into the report. Find some research and get the psychologist to work it into the report. The trick is to get the RO to make the award. The RO may not be as thorough as the BVA.

A concern is that I could also find cases that were denied based on the lack of in-service symptoms.

Note that in both cases below the doctors specifically relate the current condition to stress in the military service.

BVA Citation Nr: 9925065

“A medical opinion which is based entirely upon a reported history from a veteran himself lacks a clinical foundation and accordingly lacks any significant probative value.”

----------------------------------------------------------------------------

Citation Nr: 0313005

Decision Date: 06/17/03 Archive Date: 06/24/03

DOCKET NO. 01-02 085 ) DATE

)

)

On appeal from the

Department of Veterans Affairs Regional Office in Boston,

Massachusetts

THE ISSUE

Entitlement to service connection for a generalized anxiety

disorder with agoraphobia.

REPRESENTATION

Appellant represented by: Vietnam Veterans of America

WITNESS AT HEARING ON APPEAL

Appellant

ATTORNEY FOR THE BOARD

Robert C. Scharnberger, Associate Counsel

INTRODUCTION

The veteran served on active duty from April 1951 to December

1953.

This case comes before the Board of Veterans' Appeals (the

Board) on appeal from an October 2000 rating decision of the

Boston, Massachusetts, Department of Veterans Affairs (VA)

Regional Office (RO).

The veteran testified at a personal hearing before the

undersigned Veterans Law Judge on February 15, 2002. A copy

of the transcript of that hearing has been associated with

the record on appeal.

FINDINGS OF FACT

1. All evidence necessary for an equitable adjudication of

the veteran's claim for service connection for a low

back disability has been obtained by the RO.

2. The veteran's generalized anxiety disorder with

agoraphobia is shown to be causally related to service.

CONCLUSION OF LAW

The veteran's generalized anxiety disorder with agoraphobia

was incurred in active service. 38 U.S.C.A. § 1110 (West

2002); 38 C.F.R. §§ 3.102, 3.303 (2002).

REASONS AND BASES FOR FINDINGS AND CONCLUSION

I. Background

As an initial matter, the Board notes that there has been a

significant change in the law during the pendency of this

appeal. On November 9, 2000, the President signed into law

the Veterans Claims Assistance Act of 2000 (VCAA),

38 U.S.C.A. § 5100 et seq. (West 2002); see 38 C.F.R.

§§ 3.102, 3.156(a), 3.159, 3.326(a) (2002). This law

eliminated the concept of a well-grounded claim, redefined

the obligations of VA with respect to the duty to assist, and

imposed on VA certain notification requirements.

Without deciding whether the notice and development

requirements of VCAA have been satisfied in the present case

with respect to the issue of service connection for a

generalized anxiety disorder with agoraphobia, the Board

finds that no undue prejudice to the appellant is evident by

a disposition by the Board herein, as the grant of his claim

of service connection for a generalized anxiety disorder is a

complete grant of the benefits sought on appeal. Cf. Bernard

v. Brown, 4 Vet. App. 384 (1993); see also Grantham v. Brown,

114 F.3d 1156 (Fed. Cir. 1997); see also Barrera v. Gober,

122 F.3d 1030 (Fed. Cir. 1997) (where appealed claim for

service connection is granted, further appellate-level review

is terminated as the Board does not retain appellate

jurisdiction over additional elements of claim: original

disability rating and effective date).

II. Service connection for a generalized anxiety disorder

with agoraphobia

In general, service connection will be granted for disability

resulting from injury or disease incurred in or aggravated by

active military service. 38 U.S.C.A. § 1110 (West 2002); 38

C.F.R. § 3.303 (2002). If a condition noted during service

is not determined to be chronic, then generally a showing of

continuity of symptomatology after service is required for

service connection. 38 C.F.R. § 3.303(B) (2002). Service

connection may also be granted for any disease diagnosed

after discharge when all the evidence, including that

pertinent to service, establishes that the disease was

incurred in service. 38 C.F.R. § 3.303(d) (2002).

In order to grant service connection, it is required that the

evidence shows the existence of a current disability, an

inservice disease or injury, and a link between the

disability and the inservice disease or injury. Watson v.

Brown, 4 Vet. App. 309, 314 (1993). This principle has been

repeatedly reaffirmed by the United States Court of Appeals

for the Federal Circuit, which recently stated that "a

veteran seeking disability benefits must establish . . . the

existence of a disability [and] a connection between the

veteran's service and the disability". Boyer v. West, 210

F.3d 1351, 1353 (Fed.Cir. 2000).

The veteran's service medical records do not show any

treatment for or complaint regarding anxiety or any other

psychiatric disability. The veteran's separation examination

is negative for any psychiatric disability. An August 1954

physical examination done for reserve purposes revealed a

normal psychiatric system.

Private medical treatment records indicate that the veteran

has been treated for anxiety since 1965 and the first

indication that he began taking Valium was in April 1965. VA

outpatient treatment notes dated from July 1997 to April 2001

indicate that the veteran has been treated for depression and

for a panic disorder with agoraphobic features.

The veteran underwent a VA examination in April 2000. The

veteran told the examiner that his anxiety suddenly developed

while he was in service and that he had difficulty flying

home. The examiner noted that there was no record of

treatment in service, but from the veteran's description, it

was quite clear that the anxiety disorder began while in

service. The examiner noted a long history of anxiety that

interfered with employment. The examiner diagnosed

generalized anxiety disorder with agoraphobia. The diagnosis

was based on the veteran's restlessness, constant fatigue,

difficulty concentrating, anxiety, and sleep disturbance.

The examiner also indicated that the veteran suffered from

panic attacks.

The veteran testified at a personal hearing in February 2002.

He testified that he first experienced a panic attack while

flying home on leave while in the military in 1952. He

indicated he had additional panic attacks while aboard a ship

in the service but that he never sought treatment while in

service. The veteran testified that he began treatment in

about 1955, and that he has been taking Valium since about

1965. He indicated he has had anxiety and panic attacks

continuously since they first began in service.

The Board sought a VHA opinion. The opinion of Dr. Kaup,

dated in January 2003, was that it was at least as likely as

not that the veteran's anxiety/depression symptoms began

during his military service. Dr. Kaup stated that the

service medical records were negative for any mention of a

psychiatric disability, but that based on the veteran's

statements and his medical expertise, it was at least as

likely as not that the veteran's disability began in service.

Dr. Kaup reviewed the claims folder including the private

treatment notes and the April 2000 VA examination report.

Dr. Kaup indicated that the veteran most likely has an

anxiety disorder/

Based on the above, the Board finds that service connection

for generalized anxiety disorder with agoraphobia is

warranted. The veteran currently suffers from this

disability based on the medical records and the April 2000 VA

examination. While the service medical records are negative

for any mention of a psychiatric disability, the VA examiner

indicated that it was quite clear that an anxiety disorder

began in service. Dr. Kaup considered the clinical records,

the veteran's history and, based on his medical training,

assessed that it was as likely as not that the veteran's

current disability is related to service. There is no

competent opinion suggesting that current psychiatric

disability does not owe its etiology to service. Giving the

benefit of the doubt to the veteran in this case, the Board

finds that service connection is warranted for a generalized

anxiety disorder with agoraphobia. 38 U.S.C.A. §§ 1110,

5107(B) (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2002).

ORDER

Entitlement to service connection for a generalized anxiety

disorder with agoraphobia is granted.

____________________________________________

THOMAS J. DANNAHER

Veterans Law Judge, Board of Veterans' Appeals

IMPORTANT NOTICE: We have attached a VA Form 4597 that tells

you what steps you can take if you disagree with our

decision. We are in the process of updating the form to

reflect changes in the law effective on December 27, 2001.

See the Veterans Education and Benefits Expansion Act of

2001, Pub. L. No. 107-103, 115 Stat. 976 (2001). In the

meanwhile, please note these important corrections to the

advice in the form:

? These changes apply to the section entitled "Appeal to

the United States Court of Appeals for Veterans

Claims." (1) A "Notice of Disagreement filed on or

after November 18, 1988" is no longer required to

appeal to the Court. (2) You are no longer required to

file a copy of your Notice of Appeal with VA's General

Counsel.

? In the section entitled "Representation before VA,"

filing a "Notice of Disagreement with respect to the

claim on or after November 18, 1988" is no longer a

condition for an attorney-at-law or a VA accredited

agent to charge you a fee for representing you.

Citation Nr: 0627773

Decision Date: 09/05/06 Archive Date: 09/12/06

DOCKET NO. 98-09 648 ) DATE

)

)

On appeal from the

Department of Veterans Affairs Regional Office in St.

Petersburg, Florida

THE ISSUE

Entitlement to service connection for an acquired psychiatric

condition, including a panic disorder.

REPRESENTATION

Appellant represented by: Disabled American Veterans

WITNESSES AT HEARING ON APPEAL

The veteran and his wife

ATTORNEY FOR THE BOARD

Linda E. Mosakowski, Associate Counsel

INTRODUCTION

The veteran served on active duty from October 1967 to

October 1969.

This matter comes to the Board of Veterans' Appeals (Board)

on appeal from a rating decision by the Department of

Veterans Affairs (VA) Regional Office (RO) in St. Petersburg,

Florida.

After the RO issued the February 2006 supplemental statement

of the case (SSOC), the veteran submitted additional evidence

with respect to his appeal. Generally, if, after

certification to the Board, pertinent evidence is submitted

without notice that the veteran has waived his procedural

right to have the agency of original jurisdiction consider

the evidence, the appeal is remanded to the RO for initial

consideration of the evidence and issuance of a supplemental

statement of the case. 38 C.F.R. § 20.1304©. That

regulation also provides, however, that the evidence need not

be referred to the RO if the Board determines that the

benefit to which the evidence relates may be fully allowed on

appeal without such referral. Id. Since the veteran's claim

for service connection is granted below, no referral to the

RO will be made.

FINDINGS OF FACT

1. The veteran currently has a diagnosis of a panic

disorder.

2. The veteran incurred an injury during service, described

variously as traumatic experiences and as duties that

required constant vigilance.

3. The veteran's current panic disorder is related to active

military service.

CONCLUSION OF LAW

The criteria for service connection for an acquired

psychiatric condition, including panic disorder, have been

met. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R.

§§ 3.102, 3.303 (2005).

REASONS AND BASES FOR FINDINGS AND CONCLUSION

To establish service connection for a claimed disability, the

evidence must demonstrate that a disease or injury resulting

in a current disability was incurred during active service.

38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Generally, service

connection requires: (1) existence of a current disability;

(2) existence of a disease or injury during service; and (3)

a nexus between current disability and any injury or disease

incurred in service. See Watson v. Brown, 4 Vet. App. 309,

314 (1993)

(a determination of service connection requires a finding of

the existence of a current disability and a determination of

the relationship between that disability and an injury or

disease incurred in service).

Two doctors have diagnosed the veteran with a panic disorder.

The veteran has received treatment for a panic disorder for

several years. The record clearly establishes the first

requirement of service connection--that the veteran currently

has a panic disorder disability.

There is conflicting evidence about whether the veteran

incurred his panic disorder during active military service.

The veteran's service medical records contain no indication

that he had a psychiatric condition during service. His exit

examination also is silent as to any psychiatric conditions.

And while the veteran states that he received treatment

within two years of separation from service, neither the

veteran nor the RO could obtain the treatment records from

the veteran's physician.

On the other hand, two doctors have specifically stated that

the veteran's current panic disorder is related to his active

military service. Service connection may be granted for any

disease diagnosed after separation when all the evidence

establishes that the disease was incurred in service.

38 C.F.R. § 3.303(d). If evidence sufficiently demonstrates

a medical relationship between the veteran's in-service

experiences and his current disability, it follows that the

veteran incurred an injury in service. See Godfrey v.

Derwinski, 2 Vet. App. 352, 356 (1992). From their

discussions with the veteran about his experiences during

service, both doctors determined that his current disability

stemmed from his active military service.

Dr. Suarez expressed the opinion that the veteran's panic

attacks with agoraphobia were related to "his duties in the

Army from 1967 to 1969 which required a constant vigilance."

The VA examiner in January 2006 related the veteran's panic

disorder to his "traumatic experiences in the military."

It, therefore, follows that the veteran incurred an injury in

service. See Godfrey, supra.

Other evidence in the record supports the doctor's opinions.

The veteran himself testified that, immediately following

service, he was subject to panic attacks that became so

severe he sought medical treatment. His wife testified that

right after the veteran's active service, he had trouble

breathing, one of the symptoms of his panic disorder. He was

also very nervous after his service. She testified that

before he went in the Army, he did not manifest those

symptoms. Thus, the second requirement for service

connection is met on this record.

Finally, at the veteran's January 2006 VA examination, the

examiner explicitly stated that it is more likely than not

that the veteran's current panic disorder is related to his

military experience. Since the record demonstrates all three

requirements for service connection, the veteran's claim will

be granted. Accordingly, there is no need to address whether

VA met its duty to notify and to assist the veteran in

obtaining evidence sufficient to substantiate his claim.

(CONTINUED ON NEXT PAGE)

ORDER

Service connection for an acquired psychiatric condition,

including a panic disorder, is granted.

____________________________________________

MARY GALLAGHER

Veterans Law Judge, Board of Veterans' Appeals

Edited July 19, 2009 by Hoppy

[Hoppy]

cannoncocker

This is the second long post in a row. I hope this works in your favor.

As you have figured out by now I do try to dig around and find out exactly how the claim is being advanced. The VA has little technicalities that can cause a valid claim to get denied without proper development. I posted some research that relates to you situation at the bottom.

It sounds like you are just beginning the diagnostic process. I say process because I have seen situations similar to yours wind up with five different diagnoses prior to getting rated. It is good that you are dealing with a VA shrink. Relying on a single C&P does not always work. If you get a poor workup by the C&P examiner then the claim will be denied. My recommendation is that you focus on linking any depression directly to the military as secondary to panic disorder and the back pain. You need to get the clinicians to back you up with their reports.

A problem may occur with VA treating physicians. Everything goes fine, they make diagnoses then when you tell them you want to get an opinion relating the current condition to military you hit a brick wall. As of yet you have not discussed this VA treating clinicians attitude about making a determination that your current condition is related to service. It is good that they have scheduled the C&P. The C&P examiner should address the relationship between the current condition and the military. There are numerous veterans on this board who have had to override C&P examiners reports with IMO's. You never know what you will get from a C&P. This is especially true when you consider the problem you brought up about biases. This is why I try to get a VA clinician to write a report prior to the C&P. When finances are available I even get an IMO prior to the C&P. If you can get a favorable opinion from the VA treating physician that the current condition is related to the military then the C&P examiner is put in a position of rebutting the treating clinicians statement. I am going to explain what I have ran into with a veteran who I am assisting at this time for panic disorder. I hope this will prepare you in the event you start running into difficulty with the VA examiner.

The veteran I am assisting was diagnosed by VA clinicians on multiple reports since 2006 with panic disorder and MDD. The VA required new and material evidence to re-open the claim. The RO stated they would not schedule a C&P until new medical evidence was submitted that addressed the issue that the current condition was related to the military. We have since dealt with five different VA clinicians.

We first went to the VA clinician who was running a panic attack group meeting that he was attending. We asked the clinician to read the SMR and make a statement addressing the relationship between the current condition and t5he military. The veteran had been to sick bay and psychiatrists while in the military with complaints that meet the DSM IV requirement for panic attacks and panic disorder. The veteran was seen over a sixteen month period in the military and was discharged for a personality disorder. This was at a time the DSM II was in effect. Panic disorder was not in the DSM II. Getting these old DSM II diagnoses changed to ratable conditions is not that difficult. I have assisted on at least 5 claims where this was done. The VA clinician (PHD) refused to read the SMR. After a visit to the customer care representative the clinician was advised by a psychiatrist that she had to read the SMR . The clinician read the SMR and wrote a report that did not address any relationship between the current condition and the SMR. The clinician cited VHA directive 2007-24. The clinician stated that they were an acute care facility and was not required to make the requested assessment. I have run into this problem before and it did not surprise me.

The second clinician was a VA psychiatrist who was prescribing him medication for his mental conditions. Initially the psychiatrist was interested in helping and read the SMR and wrote a report that the symptoms in the military were panic attacks. However, he said that there was no evidence of panic disorder. There was clear evidence of panic disorder in the military. I though the psychiatrist missed something, I went back to the psychiatrist and asked him to sign an addendum that he was aware of the notes in the SMR that specifically related to panic disorder and was still of the opinion that the requirement of panic disorder were not met. The problem was that if he signed the addendum it would show his incompetence. He was trying to sweep the panic disorder diagnosis under the carpet. Had he made the diagnosis of panic disorder it made the veterans claim for service connection very strong. An argument ensued during which the psychiatrist said he would no longer get involved because the veterans panic disorder was not related to the military because he had a predisposition for the condition when he entered the military. This psychiatrist was way off track. Predispositions are an entirely different issue that has been resolved by the VA’s General Council as being irrelevant. Additionally, the cause of panic disorder and the time frame that it can onset does not limit events to those that would predate service. There was no factual basis to his predisposition theory. Rather than argue with this guy it became time to get another clinician to address the veteran’s claim.

We did get his new primary doctor to read the SMR and write a nexus statement that should be sufficient to re-open the claim and get a C&P exam. In other claims I have had three primary doctors refuse to get involved for every one that will get involved. We got lucky with his new primary doctor.

Since then the VA has sent him to a new clinician who is of the opinion that panic disorder is curable with medication and therapy. This does not surprise me. The internet is loaded with clinicians who view panic disorder as curable. In expectation of an opinion that the panic disorder is not disabling I have sought reports linking the MDD as secondary to the long term untreated panic disorder. This veteran’s main problem is depression. 50% of all individual with panic disorder develop Major Depressive Disorder (MDD). He had symptoms of panic attacks in the military and was not treated. He was discharged with an opinion from a military psychiatrist that treatment would not be beneficial. The condition went untreated for 25 years. Now they are trying to say they can cure the panic disorder. They need to try and cure a long term untreated MDD. Lot’s of luck to the VA on this.

Below is the research that I feel would best link your symptoms to the military. The VA shrinks try and push everything back onto childhood experiences.

Recent life events

A number of authors claim that a major stressful event can be traced in the recent history of most PD patients (Barlow, 1988; Margraf et al., 1986), even though Shulman et al. (1994) reported that a precipitating factor could be identified in only 40% of PD patients in their sample. Several studies have shown that, indeed, panic patients experience more significant life events in the year preceding the onset of PD, especially those involving perception of lack of control, and that they see the impact if life events as more negative than controls (Faravelli, 1985; Faravelli & Pallanti, 1989; Rapee et al., 1990).

Edited July 19, 2009 by Hoppy