Pstd Imo Letter -- Doctor Can't Write Decent Letter. Aleady Sunk $1000 Into This...

[DrBarbae]

Hello all,

First post here. I have a long story to start with that leads up to some simple questions...

I am SC'd 30% for PTSD, but have filed a NOD. To bolster that NOD with new evidence, I am paying out of pocket for an Independent Medical Opinion (IMO). I chose a doctor than had experience with forensic psychology that had an impressive background based on my Internet research. Well, I converse with him back and forth through email a few times, told him I wanted to meet him for treatment, psychometrics, examinations, etc, then get a report for the VA as a result of our meeting. I asked if he was familiar with the right verbiage to "answer the mail" for the VA, and he said yes; he would charge me $1000 for it all. Well, fast forward a few week later, I have the appointment, pay him the $1000, and now I have the report.

In short, the report does not answer the mail (I explain why in a bit), and I am not that certain that he would be capable of putting the report with the right verbiage, even if I told him what was needed. It's a lot like asking a kindergartner to write a doctoral thesis---it is just not possible. First of all, my last name is inconsistently spelled throughout the report, and the grammar is terrible. The details I provided are vague or missing, especially with what I painfully shared regarding my main PTSD stressor. When asked if I had any thoughts of suicidal ideation, I admitted I had thought of a plan, but have never attempted it (in the report, it mentions I denied any suicidal ideation). I think you all get the picture---there is no beef to this report to make it supportive of any case I would make, whether that my PTSD has gotten better, worse, or stayed the same. Ineed the professional product I paid for if I want to get anywhere with the VA.

Because of this, the only practical way of moving forward with this is if I write the letter, and he sign it. The doctor is likely amenable to this based on some of the conversation we had before I left the office. Thus, I have retyped his letter, and put in the details that need to be there. This feels quite awkward, and is a situation I did not expect or want to find myself in. Since I have already sunk $1000 into this and several weeks of my time, I don't want to start over. I just want to get this behind me and not play this back-and-forth game with the VA for years or decades like my dad did. I just want an effective letter that is quite clear about the findings and submit my new evidence.

Ok....so now the questions:

Is this "letter writing" on behalf of doctors that don't know how to write for the VA common by vets that are gathering new evidence to support a claim?

Is the following quoted statement at the end of the letter with the diagnosis normal? "The overall evidentiary record shows the severity of the patient's disability most closely approximates the criteria for 100% disability as listed in 38 CFR § 4.130-2".

What should I do in this situation? Any suggestions or comments?

Thanks!

[carlie]

I still have the question of,

"What is the date of your rating decision that granted PTSD as SC'd at 30 percent?"

[carlie]

All,

Here is the report in full, below the asterisks. I also attached it as a file.

To all: I really appreciate the replies and the helpful advice. I’ll respond to some of the replies I got when I get a minute later today, but want to get this letter out here first. Any comments on it in the meantime?

Will this letter make much a difference if I am filing for an increase from 30%?

DB

**** **** **** ****

Evaluation Report On Mr X

Referred to this examiner upon inquiry from nearby hospital X was formerly in the military for 11 years and earned the rank of X. He suffered Post Traumatic Stress Disorder and was seeking re-assessment for the classification of disability.

During the process, Mr. X exhibited a capacity for independent functioning and cooperated with the evaluation enough to provide useful interpretive information.

He was administered two (2) Structured Clinical Interviews, Mini Mental Status Examinations [MMSE], and the Minnesota Multiphasic Personality Inventory-2 [MMPI-2]

Presentation

Mr. X currently resided in X and worked approximately 80 hours/week, he said. He had desk-job and did not consider it to be too demanding, considering the he worked long hours. He felt fortunate to have private living quarters where can resort to watching movies, personal pleasures, and fitness training. Mr X claimed to enjoy the “simple life” in X.

IMO - The above info does not support a criteria higher than 30 percent.

Mr. X reported pessimistic cognitions and always feeling “on edge”. He believed the worst would happen to him. Generally, his mood appeared to be low most of the time, he added.

Since 2004, Mr. X has been suffering from frequent anxiety attacks that occurred twice/week. He indicated that e-mails and the ringing of a phone trigger the onset of anxiety symptoms. During such attacks, he would feel “heartbeat racing faster” [palpitations], physically hot and sweaty; in addition there would be a lack the ability to concentrate for a few minutes during and after the attack. Mr. X has no problems with short-term or long-term memory.

Specific Stressor

Mr. X described the he had five (5) near-death experiences that “were horrific”. The first and most traumatic incident which occurred in 2004 was in Iraq. Following was his description:

“I was sleeping. All of a sudden I woke up startled to a loud noise. I just froze there. I did not know how to react. It’s like I lost perception of time. You wouldn’t understand. You’d have to be there. I was quite shaken up.”

Family background

Mr. X originated from X city, and came from a middle class socio-economic class family. He referred to his childhood as “good and innocent”, in which his father and mother worked hard to provide for the family. His father passed away at the age of 57 due to a heart attack. His mother re-married. His younger sister, who is 5 years younger, is currently married.

He claims to have no close ties to any family members and feels indifferent towards their behavior. Family history appears to be void of psychiatric/mental illness, although Mr. X believes his mother may be depressed.

He met his partner online [internet] and they were married for approximately 2 years, obtaining a divorce in 2008. Mr. X admitted that his ex-wife would describe him as “controlling, demanding, and short-tempered”. He revealed that the divorce upset him very much but now indicated feeling “indifferent”.

History Brief

Earning a high school diploma, Mr X described himself as an average student. He claims ho have had a few close friends throughout his school years. Due to the nature of his work, he lost contract with them and has no idea of there whereabouts. As a young boy, he wanted to be an engineer. At the age of 20, Mr X decided to go the military. After serving 11 years in the military, he requested an Honorable Discharge. He was faced with “unnecessary and reasonable demands” as well as “extremely stressful situations”.

Mr. X suffered from the medical condition Alopecia, which refers to loss of hair from the head or body. Information on his medical history must be obtained from his physician.

He reported occasional consumption of alcohol, 3 beers per month, and there is no indication of substance use or abuse patterns. Mr. X did not report a criminal record or any legal issues.

Interpersonal relations

He has a difficulty in establishing and maintaining friends. Also, Mr X lacks the interest and motivation in initiating conversations in social settings. He seems detached from any interpersonal relationships.

Seeming to have poor social skills, Mr X was unable to relate to other people comfortably. He is dependent, over controlled, and unable to express or assert himself adequately. He tended to withdraw from unpleasant social situations and cold spend a great deal of time and energy in fantasy and rumination. He reportedly felt chronically inadequate and seemed incapable of relating to others on an equal, mature basis. He also had strong feelings of sexual inadequacy.

This can result in being self-absorbed and unskilled in gender-role behavior. To develop a rewarding intimate relationship would be difficult.

Mr. X is a highly introverted and interpersonally avoidant person who feels very uneasy in close interpersonal involvements, although he can act extrovert for a short period of time in a given situation. His emotional detachment appeared to be long-standing in duration. He appeared to be insecure, lacked self-confidence in social situations, and becomes quite anxious around people. Typically rigid and over controlled Mr. X tended to worry a great deal and experience periods of low mood in which he would withdraw significantly from others.

Summary

When answering clinical interview topics and psychometric items for this psychological intervention, the some endorsements were intense as a result of careful item response pattern. He apparently understood the items content and considers the symptoms descriptive of his current functioning.

His self-description as disturbed required further consideration because he claimed many more symptoms than most patients do. Two likely possibilities require further evaluation. It is possible that he overstated his symptoms as a result stress and the need to seek a great deal of attention for his problems.

Exaggerated response set can be ruled based on life circumstances, it may be that his extreme responding resulted from psychological troubles.

Mr. X is apparently experiencing a great deal of psychological distress, including tremendous anxiety, tension, and repetitive thoughts of self-doubts. He appeared to be experiencing an intense period of anxiety at this time, compounded by a chronic problem of maladjustment and difficulty fitting into society.

He reported sleep disturbance and was bother by feeling inadequacy and guilt. Mr X maw having difficulty concentrating and making decisions. Pre occupied with his problem and precarious in his adjustment, he appeared to have difficulty controlling his thinking.

He showed a meager capacity to experience pleasure in life.

The info at the top is contradictory to this statement.

The tendency to be pessimistic rendered a world view in a highly negative manner, developing a worst-case scenario to explain events affecting him. Mr. X tended to worry and interpret events as problematic. His self-critical nature prevented him from viewing relationships possibilities positively.

Mr. X is impacted by symptoms of Post Traumatic Stress Disorder affecting his social functioning. This was also contributory to high levels of anger control.

The Mini Mental Status Examination was with normal limits and showed no neuro-psychological issues at the time of this assessment. He responded logically and appropriately. No sign of memory impairment. Psychotic episodes were not cited. Suicidal and homicidal intent was not indicated in his history, nor reported by Mr. X.

IMO - Everything underlined above will not be factored in for an increase.

Diagnosis

AXIS I: Post Traumatic Stress Disorder [DSM-IV-TR 309.81]

AXIS II: none specified

AXIS III: Alopecia

AXIS IV: Psychosocial problems occurring contribute to the mental health issues that lead to PTSD.

AXIS V: Current GAF = 51 due to PTSD [overly cautious, depression, anxiety, hypervigilance, exaggerated startle response, intrusive thoughts, irritability, internalized anger, sleep disturbance due to obsessional cognition, stress over simplicities, lack of emotional connectedness, apathy, social isolation preference]

JMHO - but in the Presentation at the very top, "working 80 hours a week" with no difficulties and enjoyment

of "personal pleasures" will not result in an increase in compensation for a mental health disability for higher

than the current 30 percent.

Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events) . . 30

This report is submitted.

Respectfully

Dr. Y

[DrBarbae]

My award for 30% SC for PTSD was 11 Apr 2011. NOD through DRO was received by VA on 09 Sep 2011. The date of the IMO was at the end of June 2012, just a few weeks ago.

It seems this letter is utterly useless, and needs a complete overhaul. It's frustrating. Would you recommend I send the criteria for a 70% rating and ask the doctor to write to that?

I am feeling a bit of pressure to get this done quickly because it has been one year since the DRO was requested. What if the DRO makes its decision before I get the IMO ironed out and submitted? Will I "lose" this battle?

When I read that other vets have spent decades doing this, it puts extra pressure on me to get this done right the first time, and would hate to miss the mark when the opportunity to get it right is at hand. Thanks so much for the help.

DB

Edited July 9, 2012 by DrBarbae

[DrBarbae]

Award letter for 30% SC for PTSD was 11 Apr 2011. The NOD via DRO process was received by St Louis VARO on 09 Sep 2011. IMO exam was around 23 Jun 2012.

Questions and concerns now:

Carlie, based on what you have put in your post, this IMO is utterly useless. It seems the best thing to do now is to send the doctor the page right out of the schedule of ratings for 70%, and have him make the IMO address those points, head-on, leaving out the medical nexus from the primary stressor. I am a bit frazzled with information overload, and a sense of urgency to get this letter done correctly and quickly, because I requested a DRO about 10 months ago, which brings me to my next question

What happens if the DRO is completed before I get a properly-worded IMO submitted to support it? Just file another NOD, and watch the clock start over, or would this all be in vain?

DB

[carlie]

Award letter for 30% SC for PTSD was 11 Apr 2011. The NOD via DRO process was received by St Louis VARO on 09 Sep 2011. IMO exam was around 23 Jun 2012.

Questions and concerns now:

Carlie, based on what you have put in your post, this IMO is utterly useless. It seems the best thing to do now is to send the doctor the page right out of the schedule of ratings for 70%, and have him make the IMO address those points, head-on, leaving out the medical nexus from the primary stressor. I am a bit frazzled with information overload, and a sense of urgency to get this letter done correctly and quickly, because I requested a DRO about 10 months ago, which brings me to my next question

What happens if the DRO is completed before I get a properly-worded IMO submitted to support it? Just file another NOD, and watch the clock start over, or would this all be in vain?

DB

IMO - the hired gun does not provide support for an increase but actually verifies you

are working 80 hours without difficulty and enjoying life fairly well.

The DRO is authorized to make a decision factoring in all evidence of record.

I would mainly suggest that you make sure all of your therapy and treatment progress

notes are of record up to current date and get those in there if they show support for

an increase higher than 30 percent.

I do not see an increase coming your way if you are working full time with no difficulties

and pretty much enjoying life.

If you have missed some excess days of work due to your PTSD and have documentation

of medical days off from HR- I would submit copies of these to the DRO for consideration,

also, of course any hospitalization documentation.

The IMO what you posted, really - to me doesn't provide a whole lot of support even for your

current 30 percent. The GAF is on target but that's about all I see that is and there are several

other factors considered in the evaluation, most of what was mentioned is already compensated

for at your 30 percent level, but still a bit questionable even at that.

Perhaps your current mental health provider would fair better than what you get from the hired gun.

I would much prefer to submit current evidence from the provider you currently see.

Always keep in mind that whether you pay a grand or even more for an IMO - it is still up to the

doc to write their opinion and assessment, even if it's not what we think we want to

hear or pay for. Their license is on the line and they have to support their opinion

with full medical rationale.

Sorry, but with what you've posted so far, I can't school you on how to get this to happen.

JMHO

[Berta]

You posted yesterday:

“Is the following quoted statement at the end of the letter with the diagnosis normal? "The overall evidentiary record shows the severity of the patient's disability most closely approximates the criteria for 100% disability as listed in 38 CFR § 4.130-2".

I was swayed by that quoted statement, because it is possible,in some cases

But I don't see any statement like that in the IMO nor any medical rationale for it in the actual letter you posted here,nor anything that would warrant a higher rating.

I agree with Carlie.

Edited July 9, 2012 by Berta