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Helter

C&p Results

Question

Let me know what you guys think and maybe a guess at the rating. Thanks!

05/13/2011 ADDENDUM STATUS: COMPLETED

Initial Posttraumatic Stress Disorder (PTSD) Examination

This examination does not constitute adisability rating decision. Disability rating decisions are made solely by theVBA Regional Office after all available data have been reviewed and verified.Questions or concerns regarding disability rating decisions should be directedto the VBA Regional Office and/or an appeals board.

THE VETERAN'S C-FILE WAS REVIEWED.

1. Diagnosis

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

a. Does the Veteran have a diagnosis of PTSD that conforms toDSM-IV criteria?

[X] Yes [ ] No

Name of diagnosing facility or clinician: VA

c. If there is a diagnosis ofPTSD, does the Veteran also have any other Axis-I-IV

diagnoses? [X] Yes [ ] No

Additional mental health disorder diagnosis #1: Cognitive Disorder NOS(Provisional)

Name of diagnosing facility or clinician: VA

Indicate the Axis category: [X] Axis I [ ] Axis II

Describe its relationship to PTSD: Unclear.

2. Medical History

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

See C-file.

3. DiagnosticCriteria

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

The diagnostic criteria for PTSD, referred to as Criteria A-F, are fromthe Diagnostic and

Statistical Manual of Mental Disorders, 4th edition (DSM-IV).

Criterion A: The person has beenexposed to a traumatic event in which both of the following have been present:

[X] The person has experienced,witnessed, or been confronted with an event or events that involve actual orthreatened death or serious injury, or a threat to the physical integrity ofoneself or others.

[X] The person's response involvedintense fear, helplessness, or horror. Note: in children, it may be expressedinstead by disorganized or agitated behavior.

Criterion B: The traumatic event is persistently re-experienced in atleast one of the following ways:

[X] Recurrent and intrusive distressingrecollections of the event, including images, thoughts, or perceptions. Note:in young children, repetitive play may occur in which themes or aspects of thetrauma are expressed.

[X] Recurrent distressing dreams of theevent. Note: in children, there may be frightening dreams without recognizablecontent

[X] Acting or feeling as if thetraumatic event were recurring (includes a sense of reliving the experience,illusions, hallucinations, and dissociative flashback episodes, including thosethat occur upon awakening or when intoxicated). Note: in children,trauma-specific reenactment may occur.

[X] Intense psychological distress atexposure to internal or external cues that symbolize or resemble an aspect ofthe traumatic event.

[X] Physiologic reactivity uponexposure to internal or external cues that symbolize or resemble an aspect ofthe traumatic event

Criterion C: Persistent avoidance of stimuli associated with the traumaand numbing of general responsiveness (not present before the trauma), asindicated by at least three of the following:

[X] Efforts to avoid thoughts,feelings, or conversations associated with the trauma

[X] Efforts to avoid activities,places, or people that arouse recollections of the trauma

[X] Inability to recall an importantaspect of the trauma

[X] Markedly diminished interest orparticipation in significant activities

[X] Feeling of detachment orestrangement from others

[X] Restricted range of affect (e.g.,unable to have loving feelings)

[X] Sense of foreshortened future(e.g., does not expect to have a career, marriage, children, or a normal lifespan)

Criterion D: Persistent symptoms of increasing arousal (not presentbefore the trauma), indicated by at least two of the following:

[X] Difficulty falling or stayingasleep

[X] Irritability or outbursts of anger

[X] Difficulty concentrating

[X] Hyper-vigilance

[X] Exaggerated startle response

Criterion E:

[X] The duration of the symptoms described above in Criteria B, C,and D is more than 1 month.

Criterion F:

[X] The symptoms described above in Criteria B, C, and D causeclinically significant distress or impairment in social, occupational, or otherimportant areas of functioning.

4. Evidence Review

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

Was the Veteran's VA claims file reviewed? [X] Yes [ ] No

If yes, list any records, that were reviewed but were not included inthe Veteran's VA

claims file: N/A.

5. Stressors

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

a. Stressor(s): Hostile military orterrorist activity.

Describe circumstance of stressor(s): Military war zone activity.

Are the Veteran's symptoms related to this stressor(s) [X] Yes [ ] No

Does this stressor(s) meet Criterion A (i.e., is it adequate to supportthe diagnosis of PTSD)? [X] Yes [ ] No

Is the stressor(s) related to the Veteran's fear of hostile military orterrorist activity? [X] Yes [ ] No

6. Symptoms:

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

For each level below, check all symptoms that apply.

Level I

Does the Veteran have any symptoms from the list below?

[X] Yes [ ] No

If yes, check all that apply:

[X] Depressed mood

[X] Anxiety

[X] Suspiciousness

[X] Panic attacks that occur weekly or less often

[X] Chronic sleep impairment

[X] Mild memory loss, such as forgetting names, directions or

recent events

Level II

Does the Veteran have any symptoms from the list below?

[X] Yes [ ] No

If yes, check all that apply:

[X] Flattened affect

[X] Circumstantial, circumlocutory or stereotyped speech

[X] Panic attacks more than once a week

[X] Impairment of short- and long-term memory, for example,

retention of only highly learned material, while forgetting to

complete tasks

[X] Disturbances of motivation and mood

[X] Difficulty in establishing and maintaining effective work

and social relationships

Level III

Does the Veteran have any symptoms from the list below?

[X] Yes [ ] No

If yes, check all that apply:

[X] Suicidal ideation

[X] Obsessional rituals which interfere with routine activities

[X] Speech intermittently illogical, obscure, or irrelevant

[X] Impaired impulse control, such as unprovoked irritability

with periods of violence

[X] Difficulty in adapting to stressful circumstances, including

work or a worklike setting

[X] Inability to establish and maintain effective relationships

Level IV

Does the Veteran have any Level IV symptoms?

[ ] Yes [X] No

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. Differentiation of symptoms

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

Are you able to differentiate what portion of the symptom complex above

is caused by each diagnosis? [ ] Yes [X] No

9. Functional Impairment

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

Occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood.

10. Current Global Assessment of Functioning (GAF) Score: 41

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

11. Competency

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

Is the Veteran capable of managing his or her financial affairs?

[X] Yes [ ] No

12. Diagnostic testing

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

Has any mental health testing been performed?

[ ] Yes [X] No

13. Functional impact

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

Does the Veteran's PTSD (and other mental disorders) impact his or her ability to work?

[X] Yes [ ] No

If yes, describe impact, providing one or more examples: See above for details.

The Veteran was given a draft of the above exam to review prior to its signature and asked to provide feedback to the examiner regarding its accuracy and completeness. The Veteran was then given the completed and signed examination for his or her records.

Signed by: /es/ --------

PSYCHOLOGIST

5/13/2011

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Helter,

Welcome.

That's a nice form that should really help the provider to support

the claimant's issue.

I wish there were something in there where the doc supported the opinion more

like in this part,

" Does the Veteran's PTSD (and other mental disorders) impact his or her ability to work?

[X] Yes [ ] No

If yes, describe impact, providing one or more examples: See above for details."

I feel it would be good if the doc gives specific rationale and relate it to dates

of the medical evidence kind of like who, when where and why.

This looks like at least 50 percent to me.

JMHO

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Well if the VA rates you the way they should then you would be at 70%

Occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships ...................................... 70%

http://www.vva.org/ptsd_levels.html

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"Disability rating decisions are made solely by theVBA Regional Office after all available data have been reviewed and verified.Questions or concerns regarding disability rating decisions should be directedto the VBA Regional Office and/or an appeals board."

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Wait for the "Big" brown envelope. If you are unemployable due to the SC PTSD and can prove it if the award isn't what you think you are entitled to, and again if you can prove it and are willing to go through another C&P then you need to apply for TDIU. Keep taking your meds, keep all of your mental heath appointments, if you're not in a group then find one of your peer group and go to the meetings. First time around for me was 70% PTSD, 10% each for hearing and tinnitus. Applied for TDIU, 6 months later 2nd C&P, 4 months later awarded 100% PTSD P&T, 30% Hearing. I didn't get there because I'm very smart, my brothers and sisters @ hadit got me there every step of the way, so post your questions.

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I agree, that you should get either 70% or a 100% (or TDIU) but knowing the VA, they will probably award 30% and if you're lucky 50%. This is based on past performance but I've noticed a good change lately, as they seem to be awarding proper award percentages. You'll have to wait and see. jmo

pr

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      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 -------------------------------------------------- In my opinion, the veteran meets DSM 5 diagnostic criteria for posttraumatic stress disorder, which is more likely than not secondary to military trauma. In this veteran's case, there is a strong component of shame that is also associated with his military service and is foundationally related to his depressive disorder. His experience of freezing during 3 artillery attacks is something that is associated with feelings of overwhelming shame, worthlessness, helplessness, and inadequacy for the veteran. These thoughts and feelings contribute significantly to his depressive condition, and contribute meaningfully to his PTSD symptoms as well. The veteran also experienced significant losses during military service that have likely aggravated his PTSD and depressive conditions. Notably, the veteran's grandfather died in 2011 when the veteran was deployed to Afghanistan, and his best friend committed suicide on Christmas day in 2013. Both losses were experienced by the veteran as emotionally traumatic and contribute to his symptomatology. The veteran has developed a dysfunctional coping mechanism of excessive alcohol intake in his efforts to suppress negative feelings associated with his traumas. As his excessive alcohol use appears to be largely in the service of avoidance of distress and suppression of intrusive/reexperiencing symptoms, it is my opinion that his alcohol use disorder is secondary to his PTSD and depressive disorders. The veteran's mental health symptoms have severely impaired his functional capacity. He is socially disengaged and avoidant. He has difficulty expressing himself emotionally, showing empathy, or forming emotional bonds with others. Occupationally, the veteran has exhibited significant dysfunction as he has been unable to maintain employment due to anxiety, depression, avoidance, alcohol abuse, irritability, shame. Hs shame about his reactions of freezing during artillery attacks prompts him to avoid interpersonal interactions as much as possible as he fears that the topic of his military service will arise. Recently, the veteran has begun outpatient mental health treatment in the form of individual counseling, and he is awaiting an appointment for trial of medication.
    • By weep4souls
      I'm a Gulf War veteran with 90% S/C for various conditions. Some conditions that have been denied have been frustrating since I'm still suffering with symptoms. How can I create a Nexus for sinusitis and sleep apnea? I'm 30% for asthma and tried to create a relation between sleep apnea and asthma, but that was a no go. I was thinking trying again and tying my PTSD to that. Any thoughts? 
      I was also shot down on sinusitis from the get go, but I thought all I had to do was tie my gulf war time to that condition. I guess I was wrong.
    • By tw4904
      So I pretty much have my statements together. I feel pretty confident especially since I do have a CAB. However, I am already diagnosed with Chronic PTSD by my psychiatrist who works for the VA. I am also being treated by him with medication. And it helps me out alot. Will the doctor who I see during the examination judge me off of how he see's me in my current condition and say I am fine even though I am medication to help with PTSD? I typed up a very lengthy paragraph in the remarks section of the 21-0781 and stated two incidents like directed. Surely they wouldnt judge on my current well being because I am being treated. Also it has been 1 year and 3 months since I got out, and I have been on medication for about 2 and a half months. Also, one of my parents committed suicide a day after I got back from deployment. I was on the fence about bringing this up, but I would be lying through my teeth if I brought up all the things that happened since I was 19 and didnt bring this up. Will this hurt my case in any way?
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