ptsd Destroyed Records

[jsdwd]

I have received my rating decision letter and am still digesting it. One of the things I've noticed is that no account seems to have been taken of psychological treatment I received for nearly four years by a private psychologist. The C & P examiner noted this Treatment, but it was not mentioned in the Rating Decision Report. I paid him cash so there is not insurance record (I didn't want psychological treatment in my files which would be available to prospective employers). The psychologist died and the custodian of his records (also a psychologist I know) destroyed records once they were seven years old. That included mine.

Am I wasting my time in trying to get the reviewer to take note of this treatment. PTSD, alcoholism and the symptoms arising from those was a primary topic of many of those sessions, but the only source for that is me.

What's the best way to go about this? I'd ask my VSO but don't have a lot of faith in him at this point.

Thx. This board is a Godsend.

Edited July 21, 2009 by jsdwd

[Pete53]

IF VA destroyed or lost evidence there is a name for it and you can put it into your claim. Carlie knows the name I think

[carlie]

Spoliation .

[LarryJ]

Spoliation .

Carlie is hereby appointed "The Keeper of The Name"!

[jsdwd]

jsdwd,

How about posting the following sections of your Rating Decision:

1) Evidence

2) Reasons and Bases

carlie

I received 60% overall.

30% for ptsd with secondary alcoholism (in remission), depression and anxiety.

20% for Diabetes II/Agent Orange

10% for Tinnitus

All effective to date of claim, and

10% peripheral neuropathy secondary to the diabetes, effective to the date of the exam.

The claim was opened informally a year ago (7/08) and formally in October of 08, so the claim took about a year to process. The claim went before the rating board on May 15th, 2009 and was rated on July 14th. So the rating took about two months. The claim was opened in Oakland, sent to Phoenix for record gathering and was rated in Seattle (that's where the rating explanation came from although the cover letter was from Oakland). My case is a sample of one and I have no idea how typical it is nor do I know whether it is more complex or less complex than the average case, but, in any case, those are some timelines.

Evidence:

EVIDENCE

o Service treatment records from April 5, 1968 through August l,I97Z

o Military personnel records from June 2I, 1968 through August 7, l97Z

o Joint Services Records Research Center (JSRRC)

o Navy report in regards to your service in Vietnam

o Form 2l-0781(Statement in Support of Claim for Service Connection for Post-

Traumatic Stress Disorder (PTSD)) received October 6,2008

o Statement, D***********l, dated September 29,20A8 (eyewitness to two stressors)

e Statement, J*********, dated December 6,2008 (statement of ex-wife)

o Statement, Dr. K*****, dated June 1 1,2007 with treatment report dated March 16,

1995 (liver transplant work-up report - did not have transplant)

o Consultation Report, Dr. M*****, from May 7,2006 through May 9,2006 (contains DMII diagnosis)

o vet center record, Jeanne Miller, M.s., and Philip Buglione, M.A., dated August 14,

2008 (assigns GAF of 32)

o Treatment records, Palo Alto VAMC, from September 16,2008 through October 28,

2008

o VA Mental Health exam dated March 30, 2008 (PTSD C & P)

o VA examination dated March 30,2009 (Diabetes II C & P)

o Eye exam dated October 10, 2008 (neg. for retinopathy)

° VA Audiology exam dated April 27,2009

Some documents submitted are not on list. Some the documents on the list were not in the C-File when the ptsd examiner conducted the exam and they do relate to the ptsd. I had brought copies and gave them to her during the exam. I need to go and see my C-File and find out what is and is not in it. I didn't want to do that while it was being rated as it would have been taken out of the queue.

One document not listed above is from a psychiatrist at Stanford who, in 1995, gave an opinion that my alcoholism was due to ptsd. The relationship is acknowledged in the rating letter (alcohol dependence secondary to ptsd), but doc. is not mentioned. It is acknowledged in C & P exam report but not mentioned in rating. I'm not sure if this matters, but it does show how mixups with documents plague the system.

In a number of instances language in the rating was a toned-down version of the C & P exam or the examiners findings weren't mentioned at all. For example what the examiner noted as "...markedly diminished interest in social activities..." is noted as "..you reported you are socially isolated..." The examiner's "...intense psychological distress at symbolic cues ..." (e.g. war movies) is not mentioned at all. The examiner's note about "...it is highly unlikely that (I) will be employed again. His lack of return to competitive work appears related to the combination of his medical and mental health problems, however, for the purposes of this examination his post traumatic stress disorder with secondary depression, anxiety, and alcohol dependence is considered sufficient grounds for his unemployability" becomes "...occasional decrease in work efficiency with intermittent periods of inability to perform occupational tasks." My twice-reported exaggerated startle response is not mentioned at all.

"Intense psychological distress at exposure to internal and external cues ..." and "...exaggerated startle response..." are both wording in the examiners report straight from the DSM-IV key indicators of ptsd. They should have been included and are evidence of seriousness of condition.

The examiner assigned a GAF of 45. A previous mental health exam by a psychologist at the local outpatient clinic (listed in the evidence) assigned a GAF of 32. While I realize that GAF is only one factor, etc., etc., everything I've read about GAF and rating indicates I should be getting at least 50% and more likely 70%. Why the relatively low 30%?

Interestingly the following appears in their decision report:

"We have assigned a 50 percent evaluation based on the overall disability picture shown at

the VA Mental Health exam."

What does this mean? I ended up with 30%. Is this a mistake?

The rating has a lot of personal information that I'm not sure I want in the public domain so I'm not sure I want to post it in full. I redacted some names in the Evidence section above. I don't mind sharing the explanation privately with you or other elders and I do have several questions about it (some of which are above). Am I being too cautious?

I have what is called end-stage liver disease. It is Alcoholic Cirrhosis. I was on the liver transplant list at Stanford for quite a while, but have never been sick enough to get near the top of the list. I have received Social Security disability for several years now. The disability is due to alcoholic cirrhosis which is secondary to alcoholism which, is secondary to ptsd as is pointed out in the rating and also what the psychiatrist from Stanford said. Shouldn't that count for something here? Social Security obviously thinks I am "completely and totally" disabled (their words). If the ptsd brought on the alcoholism which brought on the Cirrhosis shouldn't this be accounted for? How do I go about putting these things into an appeal?

I understand that reconsideration is a faster way to begin to appeal rather than the formal NOD process. How does one do that? Is the first step in any case to write a simple bare-bones, NOD letter in any case.

I have been in touch with my VSO and sent him copies of the reports. I am not optimistic about his helpfulness, however, based on his past behavior.

[WHOLESALE]

30+20+10+10 = 50% (54.64) according to VA math.

"We have assigned a 50 percent evaluation based on the overall disability picture shown at

the VA Mental Health exam."

Probably mean all your disabilities COMBINED (overall disability) = 50%

Frank

I received 60% overall.

30% for ptsd with secondary alcoholism (in remission), depression and anxiety.

20% for Diabetes II/Agent Orange

10% for Tinnitus

All effective to date of claim, and

10% peripheral neuropathy secondary to the diabetes, effective to the date of the exam.

The claim was opened informally a year ago (7/08) and formally in October of 08, so the claim took about a year to process. The claim went before the rating board on May 15th, 2009 and was rated on July 14th. So the rating took about two months. The claim was opened in Oakland, sent to Phoenix for record gathering and was rated in Seattle (that's where the rating explanation came from although the cover letter was from Oakland). My case is a sample of one and I have no idea how typical it is nor do I know whether it is more complex or less complex than the average case, but, in any case, those are some timelines.

Evidence:

EVIDENCE

o Service treatment records from April 5, 1968 through August l,I97Z

o Military personnel records from June 2I, 1968 through August 7, l97Z

o Joint Services Records Research Center (JSRRC)

o Navy report in regards to your service in Vietnam

o Form 2l-0781(Statement in Support of Claim for Service Connection for Post-

Traumatic Stress Disorder (PTSD)) received October 6,2008

o Statement, D***********l, dated September 29,20A8 (eyewitness to two stressors)

e Statement, J*********, dated December 6,2008 (statement of ex-wife)

o Statement, Dr. K*****, dated June 1 1,2007 with treatment report dated March 16,

1995 (liver transplant work-up report - did not have transplant)

o Consultation Report, Dr. M*****, from May 7,2006 through May 9,2006 (contains DMII diagnosis)

o vet center record, Jeanne Miller, M.s., and Philip Buglione, M.A., dated August 14,

2008 (assigns GAF of 32)

o Treatment records, Palo Alto VAMC, from September 16,2008 through October 28,

2008

o VA Mental Health exam dated March 30, 2008 (PTSD C & P)

o VA examination dated March 30,2009 (Diabetes II C & P)

o Eye exam dated October 10, 2008 (neg. for retinopathy)

° VA Audiology exam dated April 27,2009

Some documents submitted are not on list. Some the documents on the list were not in the C-File when the ptsd examiner conducted the exam and they do relate to the ptsd. I had brought copies and gave them to her during the exam. I need to go and see my C-File and find out what is and is not in it. I didn't want to do that while it was being rated as it would have been taken out of the queue.

One document not listed above is from a psychiatrist at Stanford who, in 1995, gave an opinion that my alcoholism was due to ptsd. The relationship is acknowledged in the rating letter (alcohol dependence secondary to ptsd), but doc. is not mentioned. It is acknowledged in C & P exam report but not mentioned in rating. I'm not sure if this matters, but it does show how mixups with documents plague the system.

In a number of instances language in the rating was a toned-down version of the C & P exam or the examiners findings weren't mentioned at all. For example what the examiner noted as "...markedly diminished interest in social activities..." is noted as "..you reported you are socially isolated..." The examiner's "...intense psychological distress at symbolic cues ..." (e.g. war movies) is not mentioned at all. The examiner's note about "...it is highly unlikely that (I) will be employed again. His lack of return to competitive work appears related to the combination of his medical and mental health problems, however, for the purposes of this examination his post traumatic stress disorder with secondary depression, anxiety, and alcohol dependence is considered sufficient grounds for his unemployability" becomes "...occasional decrease in work efficiency with intermittent periods of inability to perform occupational tasks." My twice-reported exaggerated startle response is not mentioned at all.

"Intense psychological distress at exposure to internal and external cues ..." and "...exaggerated startle response..." are both wording in the examiners report straight from the DSM-IV key indicators of ptsd. They should have been included and are evidence of seriousness of condition.

The examiner assigned a GAF of 45. A previous mental health exam by a psychologist at the local outpatient clinic (listed in the evidence) assigned a GAF of 32. While I realize that GAF is only one factor, etc., etc., everything I've read about GAF and rating indicates I should be getting at least 50% and more likely 70%. Why the relatively low 30%?

Interestingly the following appears in their decision report:

"We have assigned a 50 percent evaluation based on the overall disability picture shown at

the VA Mental Health exam."

What does this mean? I ended up with 30%. Is this a mistake?

The rating has a lot of personal information that I'm not sure I want in the public domain so I'm not sure I want to post it in full. I redacted some names in the Evidence section above. I don't mind sharing the explanation privately with you or other elders and I do have several questions about it (some of which are above). Am I being too cautious?

I have what is called end-stage liver disease. It is Alcoholic Cirrhosis. I was on the liver transplant list at Stanford for quite a while, but have never been sick enough to get near the top of the list. I have received Social Security disability for several years now. The disability is due to alcoholic cirrhosis which is secondary to alcoholism which, is secondary to ptsd as is pointed out in the rating and also what the psychiatrist from Stanford said. Shouldn't that count for something here? Social Security obviously thinks I am "completely and totally" disabled (their words). If the ptsd brought on the alcoholism which brought on the Cirrhosis shouldn't this be accounted for? How do I go about putting these things into an appeal?

I understand that reconsideration is a faster way to begin to appeal rather than the formal NOD process. How does one do that? Is the first step in any case to write a simple bare-bones, NOD letter in any case.

I have been in touch with my VSO and sent him copies of the reports. I am not optimistic about his helpfulness, however, based on his past behavior.

Edited July 21, 2009 by WHOLESALE

[jsdwd]

30+20+10+10 = 50% (54.64) according to VA math.

"We have assigned a 50 percent evaluation based on the overall disability picture shown at

the VA Mental Health exam."

Probably mean all your disabilities COMBINED (overall disability) = 50%

Frank

60% is the over all rating. 54.64 rounds to 55 and since ratings are in multiples of 10% 55 becomes 60. And the 50% statement was sepcific to that exam.