C&p Report Received, Need Opinions

[Devildog3043]

I just received a copy of my C&P exam for Mental Disorder and I asking some opinions of what rating will be used. I have checked the rating schedule and alot of things fall under 2 categories but not sure. Here is a transcription of the report:

Axis I- Social Phobia/ Major Depressive Disorder (2 diagnosis)

Axis III-1. The patient reported having obstructive sleep apnea. 2. High Blood pressure.

Axis IV-Psychosocial and Environmental Problems: Military service including Recruiting Duty

Axis V- Current GAF: 49

DIFFERENTIATION OF SYMPTOMS

A. Does the veteran have more than one mental disorder? Yes

B. Is it possible to differentiate what symptoms are attributable to each diagnosis? Yes

Regarding to the list of rateable symptoms in section II on this exam, depressed mood, chronic sleep impairment, disturbances of motivation and mood, and suicidal ideation are more strongly associated with major depressive disorder. Anxiety, panic attacks, and difficulty establishing and maintaining work and social relationships are more strongly associated with social phobia. He also has impaired concentration which is associated with both conditions.

OCCUPATIONAL AND SOCIAL IMPAIRMENT

Occupational and social impairment with reduced reliability and productivity

SYMPTOMS FOR RATING PURPOSES

Depressed mood, Anxiety, Panic attacks more than once a week, chronic sleep impairment, Disturbances in motivation and mood, Difficulty in establishing and maintaining work and social relationships, Suicidal ideations, Impaired concentration.

COMPETENCY

Is the veteran capable of managing his or her own financial affairs? Yes

This is the majority of the report without the history portion. From what I see, it can fall into the 50%-70& range but I could be wrong. What do you think?

[deanbrt]

Maybe if you are not working and taking psychotropic medication....

[PsychoPath318]

Hey Veldrina, does it hurt to mention alcohol consumption to deal with problems?

[Veldrina]

alcohol consumption is kinda part & parcel of the "medicating" for PTSD symptoms Doesnt help or hinder...though if it is found to be becuz of the PTSD u are drinking & later on u develop cirrhosis or something like that due to drinking, that has the chance of being service connected secondary to PTSD by extension. SO i guess the short answer is no, doesn't hurt. Just wont bump up ur PTSD by adding it.

Edited June 22, 2013 by Veldrina

[Motherof3]

Veldrina, Is it okay to ask you to take a look at my C&P exam and your opinion? I'm sitting at Preparation For Decision and I plan to fax hardship letter with support documents to see if I can get my claim expedited; next week.

[Veldrina]

sure, i just appreciate when ppl can either put it right here or PM it to me so i dont have to go scrolling everywhere for it. If u can do that I'll be happy to take a looksee.

[Motherof3]

Thanks in advance. I truly wish I knew about this site years ago. It really helps a lot of veterans and is such a blessing no matter what our claim results are. I tried to delete all my personal information.

C&P EXAM IU/PTSD

Date/Time: 23 May 2013 @ 0930

Note Title: C&P EXAMINATION

Location: VA TENNESSEE VALLEY HEALTHCARE SYSTEM - NASHVILLE DIVISION

Signed By: GOODNOW,ANNE C

Co-signed By: GOODNOW,ANNE C

Date/Time Signed: 23 May 2013 @ 0930

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

LOCAL TITLE: C&P EXAMINATION

STANDARD TITLE: C & P EXAMINATION NOTE

DATE OF NOTE: MAY 23, 2013@09:30 ENTRY DATE: MAY 23, 2013@10:52:38

AUTHOR: GOODNOW,ANNE C EXP COSIGNER:

URGENCY: STATUS: COMPLETED

Review Post Traumatic Stress Disorder (PTSD)

Disability Benefits Questionnaire

Name of patient/Veteran:

Your patient is applying to the U.S. Department of Veterans Affairs

(VA) for disability benefits. VA will consider the information you provide on

this questionnaire as part of their evaluation in processing the Veteran's

claim. Please note that this questionnaire is for disability evaluation, not

for treatment purposes.

NOTE: If the Veteran experiences a mental health emergency during the

interview, please terminate the interview and obtain help, using local resources as appropriate. You may also contact the Veterans

Crisis Line at 1-800-273-TALK(8255). Stay on the Crisis Line until help can link the Veteran to emergency care.

The following health care providers can perform REVIEW examinations

for PTSD:

a board-certified or board-eligible psychiatrist; a licensed

doctorate-level

psychologist; a doctorate-level mental health provider under the close

supervision of a board-certified or board-eligible psychiatrist or

licensed

doctorate-level psychologist; a psychiatry resident under close

supervision

of a board-certified or board-eligible psychiatrist or licensed

doctorate-level psychologist; a clinical or counseling psychologist

completing a one-year internship or residency (for purposes of a

doctorate-level degree) under close supervision of a board-certified

or

board-eligible psychiatrist or licensed doctorate-level psychologist;

or a

licensed clinical social worker (LCSW), a nurse practitioner, a

clinical

nurse specialist, or a physician assistant, under close supervision of

a

board-certified or board-eligible psychiatrist or licensed

doctorate-level

psychologist.

SECTION I:

----------

1. Diagnostic Summary

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

This section should be completed based on the current examination and

clinical findings.

Does the Veteran now have or has he/she ever been diagnosed with PTSD?

[X] Yes[ ] No

If yes, continue to complete this Questionnaire.

If no diagnosis of PTSD, and the Veteran has another Axis I and/or

II

diagnosis, then continue to complete this Questionnaire and/or the

Eating

Disorders Questionnaire.

2. Current Diagnoses

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

a. Diagnosis #1: PTSD, chronic

ICD code: 309.81

Indicate the Axis category:

[X] Axis I [ ] Axis II

Comments, if any:

THE VETERAN'S PTSD HAS ALREADY BEEN ACCEPTED AS SERVICE CONNECTED. THE VETERAN REPORTS AND EXHIBITS MORE IMPAIRMENT THAN HER 50% RATING INDICATES.

INDIVIDUAL UNEMPLOYABILITY:

THE IMPACT OF PTSD WITH MDD ON BOTH ACTIVE AND

SEDENTARY EMPLOYMENT IS:

-concentration difficulties with short term memory impairment render her unable to effectively study and/or learn new skills

-low energy and amotivation render her unable to effectively study and/or learn new skills

-low frustration tolerance render her unable to handle

the stress of being challenged in academic and occupational

settings

-anxiety, fear, and anger when put in an inferior

position render her unable to effectively work with supervisors, bosses, and/or teachers due to mood swings and emotional outbursts

-irritability renders her unable to effectively interact with

co-workers, clients, and/or fellow students

Diagnosis #2: MDD, recurrent, severe without psychotic features

ICD code: 296.33

Indicate the Axis category:

[X] Axis I [ ] Axis II

Comments, if any:

THE VETERAN'S MDD IS MORE LIKELY THAN NOT SECONDARY TO THE STRESS OF LIVING WITH PTSD AND THE MANNER IN WHICH IT HAS NEGATIVELY IMPACTED HER LIFE.

Diagnosis #3:

ICD code:

Indicate the Axis category:

[ ] Axis I [ ] Axis II

Comments, if any:

Diagnosis #4:

ICD code:

Indicate the Axis category:

[ ] Axis I [ ] Axis II

Comments, if any:

If additional diagnoses, describe (using above format):

b. Axis III - medical diagnoses (to include TBI): See TVHS record and

medical

C&P examination

ICD code:

Comments, if any:

c. Axis IV - Psychosocial and Environmental Problems (describe, if

any): low social support, health, unemployment, limited financial

resources

d. Axis V - Current global assessment of functioning (GAF) score:

45-50

Comments, if any:

3. Differentiation of symptoms

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

a. Does the Veteran have more than one mental disorder diagnosed?

[X] Yes[ ] No

If yes, complete the following question:

b. Is it possible to differentiate what symptom(s) is/are attributable

to

each diagnosis?

[ ] Yes[X] No[ ] Not applicable (N/A)

If no, provide reason that it is not possible to differentiate

what portion of each symptom is attributable to each diagnosis:

There is overlap between the symptoms of PTSD and MDD.

If yes, list which symptoms are attributable to each diagnosis:

c. Does the Veteran have a diagnosed traumatic brain injury (TBI)?

[ ] Yes[ ] No[X] Not shown in records reviewed

Comments, if any:

If yes, complete the following question:

d. Is it possible to differentiate what symptom(s) is/are attributable

to

each diagnosis?

[ ] Yes[ ] No[ ] Not applicable (N/A)

If no, provide reason that it is not possible to differentiate

what

portion of each symptom is attributable to each diagnosis:

If yes, list which symptoms are attributable to each diagnosis:

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)

[ ] No mental disorder diagnosis

[ ] A mental condition has been formally diagnosed, but symptoms

are not

severe enough either to interfere with occupational and social

functioning or to require continuous medication

[ ] Occupational and social impairment due to mild or transient

symptoms

which decrease work efficiency and ability to perform

occupational

tasks only during periods of significant stress, or; symptoms

controlled by medication

[ ] Occupational and social impairment with occasional decrease in

work

efficiency and intermittent periods of inability to perform

occupational tasks, although generally functioning

satisfactorily,

with normal routine behavior, self-care and conversation

[ ] Occupational and social impairment with reduced reliability and

productivity

[ ] Occupational and social impairment with deficiencies in most

areas,

such as work, school, family relations, judgment, thinking

and/or mood

[X] Total occupational and social impairment

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?

[ ] Yes[X] No[ ] No other mental disorder has been diagnosed

If no, provide reason that it is not possible to differentiate

what portion of the indicated level of occupational and social

impairment is attributable to each diagnosis:

There is overlap between the symptoms of PTSD and MDD. As

such, it is not possible to ascertain the extent to which each

condition individually contributes to her current impairment without

resorting to speculation.

If yes, list which portion of the indicated level of

occupational and social impairment is attributable to each diagnosis:

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

If no, provide reason that it is not possible to differentiate

what

portion of the indicated level of occupational and social

impairment

is attributable to each diagnosis:

If yes, list which portion of the indicated level of

occupational and

social impairment is attributable to each diagnosis:

SECTION II:

-----------

Clinical Findings:

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

1. Evidence review

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

If any records (evidence) were reviewed, please list here:

is a 52-year-old, female veteran who is

currently 50% service connected for PTSD.

The following is a review/increase

C&P examination to address the veteran's contention that an increased

rating is warranted. All available records were reviewed, including the

veteran's TVHS record, Vista Web records, and Virtual VA records.

He last C&P examination for PTSD was conducted in 8/2011. The emphasis of the present examination will be on how the veteran has fared since that time.

2. Recent History (since prior exam)

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

a. Relevant Social/Marital/Family history:

The veteran's TVHS record documents that she was homeless as of

11/2011. She had been living in Arkansas with her family until

approximately 9/2011 but decided to move to Clarksville because

living near her family of origin had become unhealthy. Moreover, she

had lost her job in Arkansas. She is documented to have been staying at

a friend's apartment as of 11/7/2011. She was experiencing

difficulty finding employment at that time.

The veteran's psychosocial difficulties are documented to have

worsened in a 11/8/2012 SWS note as follows:

"Veteran reports she has been having a really hard time coping

with her limited resources, lack of support, lack of transportation,

environment she lives around, and difficulty coping with feeling alone.

Veteran reports she is doing a little better but having a hard

time getting her needs met because of lack of support and decline of

her benefits. Veteran has had to cancel appointments because of

having not transportation. She reports she has trouble making ends meet

with her money and then trouble having food because there is only so much

a person can take on a bus. She was very tearful, reports feeling

very sad, stays afraid of people around her, and now has her son

living with her with no job or means of supporting himself and this just

make things worse."

Her psychiatrist was concerned enough about her psychosocial

impairment and associated mental health symptoms that psychiatric

hospitalization was recommended on 12/14/2012. The veteran declined

hospitalization at that time and did not exhibit enough risk of harm to self or

others to warrant involuntary hospitalization.

currently resides in an apartment in Clarksville, TN.

Her son had been living with her until May 13, at which time she "had to

put him out". She elaborated that her son was not respectful toward

her and got aggressive with her at times. These experiences triggered her PTSD symptoms because of her past abuse history with his father. She is relieved to have her son out of her home. However, the whole

experience was very painful.

The veteran reported that she has some casual friends.

However, she pulls away from people whenever she feels that they are getting

too close. She stated that she is unable to trust anyone. The

veteran denied incidents of physical aggression over the past year.

However, she acknowledged having verbal outbursts. She stated that she

often snaps at people and then feels guilty about having done so.

b. Relevant Occupational and Educational history:

The veteran has not been gainfully employed since her last

C&P

examination in 8/2011. The following is documented in a

5/16/2013 SWS note with regard to her occupational functioning:

"Vocational rehab tells her she is unable to work or go to

school and this frustrates her yet SS won't approve her for disability it

makes no sense."

applied for vocational rehabilitation in late 2012.

Her mental health treatment team at the Clarksville VA Clinic filled

out paperwork associated with her application. The following

barriers to employment and/or successful participation in an academic

program were documented:

-inability to pace herself

-minimal ability to maintain persistence/low frustration tolerance

-trouble coming to work daily due to physical, personal, and

emotional issues

-mood swings and hypersensitivity affect her ability to effectively

interact with others

-difficulty making decisions; "markedly" limited social interaction ability

-"markedly" limited concentration ability

-"markedly" limited memory ability

-side effect of mirtazapine is sedation, which can reduce productivity

-incapable of even working in a "low stress" occupation

stated that her vocational rehabilitation counselor

informed her that she was too psychologically impaired to go to school or

work at the present time. As such, her application was denied. The

veteran expressed a great deal of discouragement, helplessness, and

sadness about her occupational difficulties.

c. Relevant Mental Health history, to include prescribed medications

and family mental health:

The veteran transferred her outpatient mental healthcare to the

TVHS on 12/13/2011 after running out of her psychiatric medications that

had been prescribed by her provider at the Memphis VAMC. She has

been prescribed the following medications since transferring her care

to the TVHS:

-bupropion: d/c'ed 5/21/2012

-zolpidem: d/c'ed but not well documented when

-mirtazapine: increased 6/7/2012; increased 11/30/2012;

increased 12/14/2012; the veteran reported that she self d/c'ed

mirtazapine many weeks ago

The veteran has also received individual psychotherapy through

the SWS since 7/9/2012. Appointments have been once monthly or less

frequent. Her last session was on 5/16/2013.

d. Relevant Legal and Behavioral history:

Denied.

e. Relevant Substance abuse history:

The veteran denied regular use of alcohol. The veteran reported

that

she occasionally uses marijuana. Her last use of marijuana was

in 12/2012-1/2013. She stated that smoking marijuana helps to

improve her appetite and helps her to relax enough to be able to fall

asleep.

f. Sentinel Event(s) (other than stressors):

g. Other, if any:

3. PTSD Diagnostic Criteria

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

Please check criteria used for establishing the current PTSD

diagnosis. The diagnostic criteria for PTSD, referred to as Criteria A-F, are from the Diagnostic and Statistical Manual of Mental Disorders, 4th edition

(DSM-IV).

Criterion A: The Veteran has been exposed to a traumatic event

where both of the following were present:

[X] The Veteran experienced, witnessed or was confronted with an

event that involved actual or threatened death or serious injury,

or a threat to the physical integrity of self or others.

[X] The Veteran's response involved intense fear, helplessness or horror.

[ ] No exposure to a traumatic event.

Criterion B: The traumatic event is persistently reexperienced in

1 or more of the following ways:

[X] Recurrent and distressing recollections of the event,

including images, thoughts or perceptions

[X] Recurrent distressing dreams of the event

[X] Acting or feeling as if the traumatic event were recurring;

this includes a sense of reliving the experience, illusions, hallucinations and dissociative flashback episodes, including those that occur on awakening or when intoxicated

[X] Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event

[X] Physiological reactivity on exposure to internal or external cues

that symbolize or resemble an aspect of the traumatic event

[ ] The traumatic event is not persistently reexperienced

Criterion C: Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by 3 or more 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

[ ] Inability to recall an important aspect of the trauma

[X] Markedly diminished interest or participation in significant activities

[X] Feeling of detachment or estrangement from others

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

[X] Sense of a foreshortened future (e.g., does not expect to

have a career, marriage, children or a normal life span)

[ ] No persistent avoidance of stimuli associated with the

trauma or numbing of general responsiveness

Criterion D: Persistent symptoms of increased arousal, not

present before the trauma, as indicated by 2 or more of the

following:

[X] Difficulty falling or staying asleep

[X] Irritability or outbursts of anger

[X] Difficulty concentrating

[X] Hypervigilance

[X] Exaggerated startle response

[ ] No persistent symptoms of increased arousal

Criterion E:

[X] The duration of the symptoms described above in Criteria B,

C and D is more than 1 month.

[ ] The duration of the symptoms described above in Criteria B,

C and D

is less than 1 month.

[ ] Veteran does not meet full criteria for PTSD

Criterion F:

[X] The PTSD symptoms described above cause clinically

significant distress or impairment in social, occupational, or other

important

areas of functioning.

[ ] The PTSD symptoms described above do NOT cause clinically

significant distress or impairment in social, occupational, or

other important areas of functioning.

[ ] Veteran does not meet full criteria for PTSD

4. Symptoms

-----------

For VA rating purposes, check all symptoms that apply to the Veterans

diagnoses:

[X] Depressed mood

[X] Anxiety

[X] Suspiciousness

[ ] Panic attacks that occur weekly or less often

[ ] Panic attacks more than once a week

[X] Near-continuous panic or depression affecting the ability to

function independently, appropriately and effectively

[X] Chronic sleep impairment

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

events

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

only highly learned material, while forgetting to complete tasks

[ ] Memory loss for names of close relatives, own occupation, or

own name

[ ] Flattened affect

[ ] Circumstantial, circumlocutory or stereotyped speech

[ ] Speech intermittently illogical, obscure, or irrelevant

[ ] Difficulty in understanding complex commands

[ ] Impaired judgment

[ ] Impaired abstract thinking

[ ] Gross impairment in thought processes or communication

[X] Disturbances of motivation and mood

[X] Difficulty in establishing and maintaining effective work and social

relationships

[X] Difficulty in adapting to stressful circumstances, including work or a

worklike setting

[ ] Inability to establish and maintain effective relationships

[ ] Suicidal ideation

[ ] Obsessional rituals which interfere with routine activities

[ ] Impaired impulse control, such as unprovoked irritability with periods

of violence

[ ] Spatial disorientation

[ ] Persistent delusions or hallucinations

[ ] Grossly inappropriate behavior

[ ] Persistent danger of hurting self or others

[X] Neglect of personal appearance and hygiene

[ ] Intermittent inability to perform activities of daily living,

including maintenance of minimal personal hygiene

[ ] Disorientation to time or place

5. Other symptoms

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

Does the Veteran have any other symptoms attributable to PTSD (and

other mental disorders) that are not listed above?

[X] Yes[ ] No

If yes, describe:

-irritability/anger outbursts

-concentration difficulties

-amotivation; lethargy; stays in bed all day unless she is forced to leave her home

-unable to enjoy anything in life

-significantly reduced appetite with a 30 pound weight loss

-increased urges to resume drinking alcohol to self-medicate

-feelings of worthlessness

-discouragement and hopelessness about the future

6. Competency

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

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

[X] Yes[ ] No

If no, explain:

7. Remarks, if any:

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

INDIVIDUAL UNEMPLOYABILITY:

THE IMPACT OF PTSD WITH MDD ON BOTH ACTIVE AND SEDENTARY EMPLOYMENT IS:

-concentration difficulties with short term memory impairment render her

unable to effectively study and/or learn new skills

-low energy and motivation render her unable to effectively study and/or

learn new skills

-low frustration tolerance render her unable to handle the stress of being

challenged in academic and occupational settings

-anxiety, fear, and anger when put in an inferior position render her

unable to effectively work with supervisors, bosses, and/or teachers due

to mood swings and emotional outbursts

-irritability renders her unable to effectively interact with co-workers,

clients, and/or fellow students

NOTE: VA may request additional medical information, including

additional examinations if necessary to complete VA's review