ptsd Exam Results Opinions Please

[doubleD]

2. Current Diagnoses

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a. Diagnosis #1: PTSD

[X] Axis I

b. Diagnosis #2: Depressive Disorder NOS

[X] Axis I

c.b. Diagnosis #2: Panic Disorder with agoraphobia

[X] Axis I

d. Axis V - Current global assessment of functioning (GAF) score: 45

3. Differentiation of symptoms

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

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

[x ] Yes

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

each diagnosis?

[x] yes

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

No

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)

[X] Occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgement, thinking and or mood

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

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

SECTION II:

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Clinical Findings:

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

1. Evidence review

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

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

claims file available and reviewed in its entirety

2. Recent History (since prior exam)

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

a. Relevant Social/Marital/Family history:

Veteran currently lives with husband ......

b. Relevant Occupational and Educational history:

Veteran reports that she has been out of work since July 2013 ........

c. Relevant Mental Health history, to include prescribed medications and

family mental health:

Veteran continues to get treatment for PTSD; she is prescribed

meds. she reports that she feels the

medications do not help. she has been getting treatment since 2006

d. Relevant Legal and Behavioral history:

none

e. Relevant Substance abuse history:

none

3. PTSD Diagnostic Criteria

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

Criterion A is met: The Veteran has

[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.

Criterion B is met: 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] 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

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

[X] Markedly diminished interest or participation in

significant activities

[X] Feeling of detachment or estrangement from others

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] 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 PTSD symptoms described above cause clinically

significant distress or impairment in social,

occupational, or other important areas of functioning.

4. Symptoms

-----------

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

diagnoses:

[X] Depressed mood

[X] Anxiety

[X] near continuous panic or depression affecting the ability to function independently appropriately and effectively

[X] Chronic sleep impairment

[X] difficulty in adapting to stressful circumstances including work or a work like setting

[X] difficulty in establishing and maintaining effective work and social relationships

[X] Disturbances of motivation and mood

[X] Suicidal ideation

2. Restatement of requested opinion

The veteran has a verified PTSD stressor of fear of enemy attacts while stationed in country and in an imminent danger pay area.

3. Medical opinion for direct service connect.

[X] The claimed condition was at least likely as likely as not (50% or greater)

[jbasser]

The opinion is in your favor but I gant get a read on percentage as I didnt see a Gaf Score.

SWAG would be 70 percent with Possible IU since you are not working because of this issue.

J

[doubleD]

gaf was at the beginning ...its 45

[jbasser]

45 is pretty low so the rating should be higher. You need to be concerned about the low score. I didnt see where you can handle your finances. I have seen fudiciaries issued with scores in the 40's

J

[doubleD]

it said i could handle my finance.) However the doctor didn't ask, if she had asked I would have said my husband and I share responsibilities.

[Navy04]

DoubleD,

Keep us posted. You never know, My GAF was a 42 when the Navy retired me back in February, and the VA C&P Examiner listed everything as Severe and I only received 30% from the VA. I think that in my case the VA low balled me, cause the Navy retired me for my Crohn's Disease. I currently have a FDC in to have my %s increased. You should get 50-100%, but it is usually Temporary then they will reevaluate you. Good luck and I wish you the best.

[meghp0405]

the VA has issued a fast letter concerning GAF scores. The VA is not using them in the determination of the % of any mental health disability.