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NoliMeTangere
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Question

I'm not sure what information to give so I will just post what I think is most relevant.

The disturbance causes clinically significant distress or impairment in social, occupational or other important areas of functioning: Yes

Description of the onset of symptoms: Chronic

Frequency, severity and duration of PTSD symptoms found: See above re nightmares. Avoids reminders of the war, as they regularly bring back distressing recollections of it for him. He seems largely emotionally disconnected from nearly everyone.

Does the veteran meet the DSM-IV stressor criterion? Yes

Does the veteran meet the DSM-IV criteria for a diagnosis of PTSD? Yes

Axis I : PTSD, Depressive disorder NOS, Hx of alcohol abuse

Explanation: Vet's drinking has clearly been to a point of causing problems for him. His depression appears to at least partially be a consequence of his PTSD, but there may be additional factors leading to it as well. The depression is responsible for the difficulties he has with mood regulation.

Axis II : No dx

Axis III : See problem list

Axis IV : Few social connections

Axis V : GAF 55 current functioning

Is the total occupational and social impairment due to PTSD signs and symptoms? No

Do PTSD signs and symptoms result in deficiencies in the following areas (judgment, thinking, family relations, work, mood or school)? No

Is there reduced reliability and productivity due to PTSD symptoms? Yes

Examples: Re work, see above concerning difficulties feeling comfortable around others. Re school, family relations, see above. Judgment seems ok at this point. Thinking notable for difficulty with absorbing new material, especially of a technical nature. Mood dysphoric, but not seriously depressed at this point (has been in past, though).

I'm not sure what the last part is about because I know that I've never felt worst. I also don't understand why he would put that I have no deficiencies in my family relations, work and mood. Seems like that contradicts with the rest of the exam and everything we talked about. Any input would be greatly appreciated.

Thanks

BH

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