Ptsd C&p Atl Vamc Exam W/gaf Rating Opinions

[BearGator56]

Finally got my C&P from MyHealtheVet Blue Button. It took just over a month from the time of this exam to posting. Any opinions on possible outcome of rating are welcome. I'm thinking 30%, but curious what others think and the possibility of 50%. Thanks in advance.

SECTION I:

----------

1. Diagnostic Summary

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

Does the Veteran have a diagnosis of PTSD that conforms to DSM-IV criteria

based on today's evaluation?

[X] Yes [ ] No

ICD code: 309.81

2. Current Diagnoses

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

a. Diagnosis #1: PTSD

ICD code: 309.81

Indicate the Axis category:

[X] Axis I [ ] Axis II

Diagnosis #2: Alcohol Abuse

Indicate the Axis category:

[X] Axis I [ ] Axis II

b. Axis III - medical diagnoses (to include TBI): GERD; osteoarthritis;

prostatitis

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

occupational problems;health concerns;absence of mental health

treatment

d. Axis V - Current global assessment of functioning (GAF) score: 58

3. Differentiation of symptoms

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

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

[X] Yes [ ] No

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

each diagnosis?

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

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

Symptoms attributable to PTSD are intrusive thoughts and memories

of the identified stressor; emotional reactivity to reminders of

the stressor; avoidance and emotional numbing; and, hyperarousal.

Symptoms attributable to Alcohol Abuse are recurrent use of

alcohol

despite associated difficulties, including legal; and, a

maladaptive pattern of alcohol use.

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

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

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 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

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?

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

If yes, list which portion of the indicated level of occupational and

social impairment is attributable to each diagnosis:

100% of the indicated level of occupational and social impairment

is attributable to PTSD. The abuse of alcohol is determined to be

a means of managing the trauma related symptoms.

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:

-----------

Clinical Findings:

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

1. Evidence review

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

a. Records reviewed (check all that apply):

[X] Claims folder (C-file):

[X] Yes

[ ] No

b. Was pertinent information from collateral sources reviewed?

[ ] Yes [X] No

2. History

----------

e. Relevant Substance abuse history (pre-military, military, and

post-military):

The Veteran was vague regarding his current consumption of alcohol.

He

stated that he now drinks less than he used to. He stated that he

used

to binge (6-7 drinks on a Saturday night). He reported his last binge

to have been a month and a half prior to this examination. He gave a

history of blackouts, but none in the past two years. He denied the

use of tobacco products, or other substances.

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

No response provided.

g. Other, if any:

No response provided.

3. Stressors

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

a. Stressor #1: The Veteran reported that while on a mission during

Operation

Desert Storm, he and his team were on patrol and came upon a tank

that

looked as if as enemy soldier was sitting in the commander's seat.

He

did not respond to their orders and when they approached the tank, saw

that about half of his head had been blown away. Brain matter was

splattered. This image comes to mind most frequently for the Veteran.

Does this stressor meet Criterion A (i.e., is it adequate to support

the diagnosis of PTSD)?

[X] Yes [ ] No

Is the stressor related to the Veteran's fear of hostile military

or

terrorist activity?

[X] Yes [ ] No

4. PTSD Diagnostic Criteria

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

a. 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.

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] Intense psychological distress at exposure to internal or external

cues that symbolize or resemble an aspect of the traumatic event

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] 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)

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

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.

b. Which stressor(s) contributed to the Veterans PTSD diagnosis?:

[X] Stressor #1

5. Symptoms

-----------

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

diagnoses:

[X] Depressed mood

[X] Anxiety

[X] Chronic sleep impairment

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

events

[X] Disturbances of motivation and mood

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

relationships

6. Other symptoms

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

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

mental disorders) that are not listed above?

[ ] Yes [X] No

7. Competency

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

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

[X] Yes [ ] No

8. Remarks, if any

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

Based on this examination and a review of the records, it is determined

that the Veteran meets DSM IV-TR criteria for PTSD. It is further

determined that this diagnosis is at least as likely as not (50/50

probability), a result of the identified in service stressor. The

diagnosis of Alcohol Abuse (per DSM IV-TR criteria) is determined to be

at

least as likely as not(50/50 probability) proximately due to or the

result

of the Veteran's PTSD. It is this examiner's opinion that the

Veteran has

come to use alcohol as a means of managing (albeit maladaptive and

counterproductive) PTSD symptoms.

The Veteran was provided with a card with the telephone number of the

Veteran's Crisis Line (880) 273-8255. He was encouraged to call the

24

hour number in the event of a worsening of symptoms; suicidal impulses;

or, for additional information about available mental health resources.

The Veteran also consented to a referral to the Trauma Recovery Program.

[stillhere]

This report seems to me to support a 50% rating. In my opinion.

Stillhere

[Philip Rogers]

The VA has supposedly done away w/using the GAF in deciding claims but I'd guess a 30% - 50% rating. You should also file a claim for alcohol use/abuse, secondary to PTSD.

pr

[BearGator56]

I just got the package back. 50% on PTSD. My Gulf War exam also attached. 30% IBS with another 10 for my wrist. Added to the previous 30, for a total of 80%.

There were a couple things not rated that they didn't service connect, and one for acid reflux that they said wasn't diagnosed but they've had me on omeprazole for 3 years.

Curious about adding alcohol abuse to this. Something I hadn't thought about.

Edited November 2, 2013 by BearGator56

[john999]

Are you going for TDIU? I would if I were you. Unless we have another war the VA will tighten up on regs eventually. I had a mental health exam similar to yours back in the day and I got 10%. I was later DX'ed with bipolar disorder and got 30% for major mental illness.

[Philip Rogers]

I'd appeal the 50% for ptsd. Adding alcohol won't increase the rating but will service connect any of the damage the alcohol may or may have caused. I'd also pursue TDIU, if you're unable to work. jmo

pr

[Chuck75]

At least the C&P shows up via the blue button.

My blue button results have been less than useful, and what info is available is often very incomplete.

(Atlanta VARO) It seems that every time a VA person gets into things, more info disappears than is added.