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Whirly Bird

Ptsd C&p Notes (What Percentage Should I Expect?)

Question

Hi all. I finally got a copy of my PTSD C&P and was hoping that some of you that understand this stuff might be able to give me some guesses as to what percentage I am looking at. I highlighted the only problem that I seen with the report. The doctor wrote that I have panic attacks 3-4 times per week, which is correct and is all through my medical records, but then he checked the box for "Panic Attacks weekly or less often". Will the rater see this descrepancy and go with the correct info?

Also, the doc states in several places (including G) that my conditon causes substantial impairment in my social and occupational functioning, but then he checks the box for [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

Doesn't that contradict the rest of his report which states that my condition is more severe than that?

He also left out a couple of my stressors, but I guess that doesn't really matter.


Anyway, please WAG away!


Does the Veteran have a diagnosis of PTSD that conforms to DMS-5 criteria based on today's evaluation?
[X] Yes [ ] No
2. Current Diagnoses
--------------------
a. Mental Disorder Diagnosis #1: Post-Traumatic Stress Disorder (PTSD)
Mental Disorder Diagnosis #2: Major Depressive Disorder
Mental Disorder Diagnosis #3: Psychological Factors Affecting Other Medical Conditions
Mental Disorder Diagnosis #4: Alcohol Use Disorder in remission (per self report)
b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): sleep apnea, fibromyalgia, chronic fatigue syndrome, irritable bowel syndrome, hypertension, arthritis in legs and back (per self-report.)
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?
[ ] 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:
Veteran has symptoms of Post-Traumatic Stress Disorder (PTSD) and meets the requisite criteria for this diagnosis. He also meets the criteria for Major Depressive Disorder; Psychological Factor Affecting Other Medical Conditions; and Alcohol Use Disorder, which is in remission per his report. These problems coalesce to exacerbate his symptoms of anxiety and depression. The symptoms are overlapping and intermingled and this makes it difficult to differentiate the symptoms to each diagnosis.

c. Does the Veteran have a diagnosed traumatic brain injury (TBI)?
[ ] Yes [ ] No [X] 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 conversationDoesn't this contradict the rest of his report which states that my condition is more severe than that?
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:
Veteran has symptoms of Post-Traumatic Stress Disorder (PTSD) and meets the requisite criteria for this diagnosis. He also meets the criteria for Major Depressive Disorder; Psychological Factors Affecting Other Medical Conditions; and Alcohol Use Disorder, which is in remission per his report. These problems coalesce to exacerbate his symptoms of anxiety and depression. The symptoms are overlapping and intermingled and this makes it difficult to differentiate the symptoms to each diagnosis. The symptom picture presented comes together to cause substantial impairment in his social and occupational functioning.
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
In order to provide an accurate medical opinion, the Veteran's claims folder must be reviewed.
a. Medical record review:
Was the Veteran's VA e-folder (VBMS or Virtual VA) reviewed?
[X] Yes [ ] No
Was the Veteran's VA claims file reviewed?
[X] Yes [ ] No
If yes, list any records that were reviewed but were not included in the Veteran's VA claims file:
If no, check all records reviewed
[ ] Military service treatment records
[ ] Military service personnel records
[ ] Military enlistment examination
[ ] Military separation examination
[ ] Military post-deployment questionnaire
[ ] Department of Defense Form 214 Separation Documents
[ ] Veterans Health Administration medical records (VA treatment records)
[ ] Civilian medical records
[ ] Interviews with collateral witnesses (family and others who have known the Veteran before and after military service)
[ ] No records were reviewed
[ ] Other:
b. Was pertinent information from collateral sources reviewed?
[ ] Yes [ ] NO
2. History
----------
a. Relevant Social/Marital/Family history (pre-military, military, and
post-military):
Veteran was raised by his biological parents who remain married. He denied having a positive relationship with them while growing up and said, "I had a great childhood. It was small townwith a loving family and a big extended family. There are no complaints." He has a somewhat distant relationship with his parents currently and said, "I get along with them but I don't see them or talk to them that much. They know that I have PTSD and tiptoe around it." He has weekly contact with his parents and noted they work cattle on property adjoining to his. Veteran has one younger sister and described the relationship with her while growing up as "Real good. We lived in the country and we were buddies growing up." He has a distant relationship with his sister currently and said, "We get along but we don't talk that much. It's about like my parents. She lives ten miles away and I only see her once a week if it's that." He denied getting into any significant trouble as a child or ever running away from home. He also denied a history of physical or sexual abuse as a child.
Veteran is currently married and has been since 1992. He described the relationship with his wife as strained and said, "She tolerates me. We have split up a dozen times over the 20 years and shehas moved back to the west coast. She couldn't deal with my drinking. The last time I quit, she moved back." His wife has been with him steady for the past eight years. He noted, "It's not a lovingrelationship." He and his wife have four children - a daughter, age 24, sons, ages 13 and 11, and a daughter, 18 months. He described having a positive relationship with his children and said, "I get alongfine with my kids. The oldest daughter is not living at home anymore.
My condition bothers them because they want dad to go out to their ball games and I can't do that. They try to deal with it for the most part."
b. Relevant Occupational and Educational history (pre-military, military, and post-military):
Veteran described having a positive educational experience and said, "It was fine. I had a lot of friends. There were no problems at all. We all knew each other and were friends." He denied difficulties with the authority figures at school and said, "It was fine. My mother was the principal's secretary." Veteran denied being expelled or suspended from school, denied having to repeat any grades, and denied any history of special education. He graduated high school in 1987. He denied receiving any additional education.
Veteran is currently employed out of his home doing data entry. He has worked at home for 1.5 years and he explained, "They figured it was better for everyone if I worked at home." He has been working for this agency since 2003. He said, "Before that it was six months here and six months there. I had trouble holding onto jobs. I get along fine for a while and then something would set me off and I would be off to a different one." He has a low level of satisfaction with his current job and said, "It's a paycheck. I don't like it." He rated his work performance as low as well and said, "It's poor now but it used to be fair to good. I can't concentrate and focus anymore." Veteran had a strained relationship with his coworkers and employers while working. When asked about his current limitations to employment, he said, "I'm supposed to travel several times a year. I have gotten out of that but they're starting to pressure me to go. I don't want to go because I have panic attacks when I'm in new places and around new people. It's also the concentration. What I do on the computer is getting worse andworse and it scares me."

c. Relevant Mental Health history, to include prescribed medications and family mental health (pre-military, military, and post-military):
Veteran was unaware of any problems with his mother's pregnancy or delivery of him and denied difficulties attaining his developmental milestones. He denied being hospitalized as a child. Veteran assessed his current health as "poor" and said his current medical conditions consist of sleep apnea, fibromyalgia, chronic fatigue syndrome, irritable bowel syndrome, hypertension, and he has pain in his legs and back due to arthritis. Veteran was hospitalized in 1991 for leg and ankle surgery. All of his current medications are prescribed by the VA and he is taking them as prescribed. He noted having an increased level of fatigue and cited this as a side effect with his current medication regimen.
Veteran denied being hospitalized for psychiatric or mental health reasons. He has had overnight stays in the emergency room due to anxiety attacks. He has been working with a psychiatrist and psychologist at the VA facility for one year. He described this experience as "Neutral. I don't feel like it's helped me. My anxiety has actually gone up." He denied any previous mental health treatment. He denied past or present suicidal ideation and denied past or present homicidal ideation.
d. Relevant Legal and Behavioral history (pre-military, military, and post-military):
Veteran currently possesses a valid driver's license and initially denied difficulties operating a vehicle. He said, "I don't go to the big city traffic. I let somebody else drive me there." He denied a history of DWI or DUI. He denied any history of arrest as an adult and denied any current or pending legal matters.
e. Relevant Substance abuse history (pre-military, military, and post-military):
Veteran denied smoking currently and said he discontinued this approximately ten years ago. He smoked for 17 years prior to this. He uses smokeless tobacco on an "occasional" basis. He denied current alcohol consumption and said that his last use of alcohol was in 2012. When drinking his heaviest, he was consuming "a 12-pack a night or a half a fifth a night. I was drinking to the point of passing out four or five times a week." He drank at this rate from 1991 until 2012.
He denied use of marijuana, crack, cocaine, amphetamines, psychedelic substances, or heroin. He also denied a history of prescription drug abuse.
f. Other, if any:
When asked about his current psychological and mental health difficulties, Veteran said, "I'm a Gulf War veteran and I've had these problems for 20 years. I decided to get help VA. I went through CPT and that made my anxiety worse. I've been seeing a psychology doctor for about a year and they said my PTSD is related to my combat experiences." He went on to say, "Anxiety is my biggest thing. I get panic attacks three or four times a week. I wake up with lots of dreams at least every other night." He said the content of the nightmares involve his military service and said, "I was on a helicopter as a machine gunner and I get that in my dreams. I see a lot of dead people. We had gas alarms all the time and I get dreams of those. I have sleep apnea and I wear the mask at night and I wake up thinking that it's the gas mask. One night I was asleep on the plane (helicopter) and I had two frag missles hit close to me and I thought I was going to die for sure that night." He then noted, "I have a lot of problems with people. I'm having to work at home. Loud noises and crowds bother me. I mainly stay at home a lot." He noted having anger difficulties and said, "I kept getting into it with the people at work. It wasn't physical, it was verbal." His sleep is poor and he explained, "I wake up a lot during the night." He estimated obtaining "five to six" hours of sleep in a 24 hour period. He described some of the more distressing tasks that he was involved in while in the military and talked about doing clearance and confiscation of the enemy's equipment down one of the main highways in Iraq. In the course of doing this, he saw many dead bodies, dismembered bodies, and burnt bodies. He described having hyper vigilant symptoms, is easily startled, and has problems concentrating at work. He said, "It's everyday and it's embarrassing."
Veteran indicated being exposed to actual or threatened death and serious injury by directly experiencing a traumatic event or witnessing, in person, a traumatic event that occurred with others. This series of events, which are stated elsewhere in this report, occurred while he was in the military service. There have been recurrent, involuntary, and intrusive distressing recollections of the trauma; recurrent distressing dreams in which the content or effect o the dream is related to that trauma event; and dissociative reactions and flashbacks in which there is a feeling that the traumatic event is reoccurring. There has also been intense or prolonged psychological distress and physiological reaction when exposed to internal or external cues that resemble aspect of the trauma. He indicated having an avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the trauma along an avoidance of or efforts to avoid external reminders that arouse distressing memories, thoughts, or feelings about or closely associated with events. He has a persistent and exaggerated negative beliefs or expectations about himself, others, or the world. He has persistent, distorted cognitions about the cause or consequences of the traumatic event(s) and this leads him to blame himself or others. He has a persistent negative emotional state; a markedly diminished interest of participation in significant activities; feelings of detachment or estrangement from others; and a persistent inability to experiencepositive emotions. Additionally, he has irritable behavior and angry outbursts with little or no provocation; reckless or self-destructive behavior; hypervigilance and an exaggerated startle response. He also noted having problems with concentration and difficulty falling asleep, staying asleep and/or restless sleep.
He indicated suffering from pain in one or more anatomical sites and this is the predominant focus of the clinical presentation. His level of pain is of sufficient severity to warrant clinical attention. His pain causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Both psychological factors and a general medical condition are judged to have important roles in the onset, severity, exacerbation, or maintenance of the pain. The symptoms indicated above do appear to be significantly impairing his social or occupational functioning.


Veteran served in the United States Marine Corp from 1988 until 1994. His MOS was helicopter crew chief and door gunner. He attained the rank of E5 and denied having any disciplinary action while in the military. He reported heavy and problematic alcohol use after being deployed and described how he was self-medicating. He denied drug usage while in the military. Veteran was injured and said, "I busted up my left leg and ankle. I've got screws and plates in my left ankle." He also noted having shrapnel in his left eye and said this was removed. He was deployed to Iraq from August 1990 until April 1991 and was exposed to combat during these eight months of deployment.
His social support consists of three fellow marines and said, "We were in the same unit." Other support consists of his wife and mental health workers. His activities of pleasure and relaxation consist of fishing and walking in the woods "where I can get away from everything." He denied having any religious affiliation. When queried about his strengths, he said, "Playing guitar." Veteran described his mood today as "I was anxious when I came in but now I'm just kind of blah, I guess. I'm here." He said his mood most days is "About the same. I don't have big fluctuations of emotions."

3. Stressors
------------
a. Stressor #1: Combat Exposure in Iraq -- two frog missles hit near
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
Is the stressor related to personal assault, e.g. military sexual trauma?
[ ] Yes [X] No

b. Stressor #2: dead bodies, dismembered bodies, and burnt bodies
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
---------------------------
Please check criteria used for establishing the current PTSD diagnosis. Do
not mark symptoms below that are clearly not attributable to the criteria A
stressor/PTSD. Instead, overlapping symptoms clearly attributable to other
things should be noted under #6 - other symptoms. The diagnostic criteria
for PTSD, referred to as Criteria A-H, are from the Diagnostic and
Statistical Manual of Mental Disorders, 5th edition (DMS-5).

Criterion A: Exposure to actual or threatened a) death, b) serious injury, c) sexual violatrion, in one or more of the following ways:
[X] Directly experiencing the tramuatic event(s)
[X] Witnessing, in person, the traumatic event(s) as they occurred to others


Criterion B: Presence of (one or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred:
[X] Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s).
[X] Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s).
[X] Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings).
[X] Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
[X] Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).


Criterion C: Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic events(s) occurred, as evidenced by one or both of the following:
[X] Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
[X] Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).


Criterion D: Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:
[X] Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., "I am bad,: "No one can be trusted,: "The world is completely dangerous,: "My whole nervous system is permanently ruined").
[X] Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame).
[X] Markedly diminished interest or participation in significant activities.
[X] Feelings of detachment or estrangement from others.
[X] Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings.)


Criterion E: Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:
[X] Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects.
[X] Hypervigilance.
[X] Exaggerated startle response.
[X] Problems with concentration.
[X] Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).


Criterion F:
[X] Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month.
Criterion G:
[X] The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Criterion H:
[X] The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition.


5. Symptoms
-----------
For VA rating purposes, check all symptoms that apply to the Veterans diagnoses:

[X] Depressed mood
[X] Anxiety
[X] Panic attacks that occur weekly or less often (THIS SHOULD BE 3-4 times per week per my direct response to the doctor listed above)

[X] Chronic sleep impairment
[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


6. Behavioral Observations
--------------------------
No response provided

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, if any
------------------
The Veterans diagnoses of Post-Traumatic Stress Disorder (PTSD); Major
Depressive Disorder; Psychological Factors Affecting Other Medical
Conditions; and Alcohol Use Disorder are as least as likely as not (50/50
probability) caused by or is a result of his military service, per the
distressing experiences he indicated being exposed to, while in the
military. These are outlined in other sections of this report.

Edited by Whirly Bird

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I just submitted the following statement thru ebenefits in support of this claim. Maybe I can get the rater to check these

discrepancies before it is to late....

Re: Final evidence in support of my claim for service connection of PTSD

To Whom It May Concern, I recently acquired a copy of my C&P exam for PTSD and found a couple of

discrepancies that I would like to point out before my claim is rated. I have attached a copy of the C&P

exam below and highlighted the discrepancies in yellow, and I responded in RED TEXT.

First: The doctor asked me how often I had panic/anxiety attacks and I responded 3-4 times per week,

which coincides with documentation in my medical file. The doctor wrote that in the report, but then

went on to check the box for “panic attacks that occur weekly or less often”. I want my rating decision

based on the correct information, which is 3-4 times per week.

Second: Throughout the report the doctor mentions several times that my condition causes clinically

significant distress or impairment in social, occupational, or other important areas of functioning. I have

highlighted those areas below, but then the doctor checked the box for 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. This does not reflect the overall severity of my condition as outlined in the rest of the

report. I want my rating to reflect the actual severity of this condition.

Please take a look at these discrepancies prior to rating my claim. I have nothing further to submit.

Thank you,

Edited by Whirly Bird

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Hi all. I finally got a copy of my PTSD C&P and was hoping that some of you that understand this stuff might be able to give me some guesses as to what percentage I am looking at. I highlighted the only problem that I seen with the report. The doctor wrote that I have panic attacks 3-4 times per week, which is correct and is all through my medical records, but then he checked the box for "Panic Attacks weekly or less often". Will the rater see this descrepancy and go with the correct info?

Also, the doc states in several places (including G) that my conditon causes substantial impairment in my social and occupational functioning, but then he checks the box for [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

Doesn't that contradict the rest of his report which states that my condition is more severe than that?

He also left out a couple of my stressors, but I guess that doesn't really matter.

Anyway, please WAG away!

Does the Veteran have a diagnosis of PTSD that conforms to DMS-5 criteria based on today's evaluation?

[X] Yes [ ] No

2. Current Diagnoses

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

a. Mental Disorder Diagnosis #1: Post-Traumatic Stress Disorder (PTSD)

Mental Disorder Diagnosis #2: Major Depressive Disorder

Mental Disorder Diagnosis #3: Psychological Factors Affecting Other Medical Conditions

Mental Disorder Diagnosis #4: Alcohol Use Disorder in remission (per self report)

b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): sleep apnea, fibromyalgia, chronic fatigue syndrome, irritable bowel syndrome, hypertension, arthritis in legs and back (per self-report.)

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?

[ ] 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:

Veteran has symptoms of Post-Traumatic Stress Disorder (PTSD) and meets the requisite criteria for this diagnosis. He also meets the criteria for Major Depressive Disorder; Psychological Factor Affecting Other Medical Conditions; and Alcohol Use Disorder, which is in remission per his report. These problems coalesce to exacerbate his symptoms of anxiety and depression. The symptoms are overlapping and intermingled and this makes it difficult to differentiate the symptoms to each diagnosis.

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

[ ] Yes [ ] No [X] 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 conversationDoesn't this contradict the rest of his report which states that my condition is more severe than that?

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:

Veteran has symptoms of Post-Traumatic Stress Disorder (PTSD) and meets the requisite criteria for this diagnosis. He also meets the criteria for Major Depressive Disorder; Psychological Factors Affecting Other Medical Conditions; and Alcohol Use Disorder, which is in remission per his report. These problems coalesce to exacerbate his symptoms of anxiety and depression. The symptoms are overlapping and intermingled and this makes it difficult to differentiate the symptoms to each diagnosis. The symptom picture presented comes together to cause substantial impairment in his social and occupational functioning.

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

In order to provide an accurate medical opinion, the Veteran's claims folder must be reviewed.

a. Medical record review:

Was the Veteran's VA e-folder (VBMS or Virtual VA) reviewed?

[X] Yes [ ] No

Was the Veteran's VA claims file reviewed?

[X] Yes [ ] No

If yes, list any records that were reviewed but were not included in the Veteran's VA claims file:

If no, check all records reviewed

[ ] Military service treatment records

[ ] Military service personnel records

[ ] Military enlistment examination

[ ] Military separation examination

[ ] Military post-deployment questionnaire

[ ] Department of Defense Form 214 Separation Documents

[ ] Veterans Health Administration medical records (VA treatment records)

[ ] Civilian medical records

[ ] Interviews with collateral witnesses (family and others who have known the Veteran before and after military service)

[ ] No records were reviewed

[ ] Other:

b. Was pertinent information from collateral sources reviewed?

[ ] Yes [ ] NO

2. History

----------

a. Relevant Social/Marital/Family history (pre-military, military, and

post-military):

Veteran was raised by his biological parents who remain married. He denied having a positive relationship with them while growing up and said, "I had a great childhood. It was small townwith a loving family and a big extended family. There are no complaints." He has a somewhat distant relationship with his parents currently and said, "I get along with them but I don't see them or talk to them that much. They know that I have PTSD and tiptoe around it." He has weekly contact with his parents and noted they work cattle on property adjoining to his. Veteran has one younger sister and described the relationship with her while growing up as "Real good. We lived in the country and we were buddies growing up." He has a distant relationship with his sister currently and said, "We get along but we don't talk that much. It's about like my parents. She lives ten miles away and I only see her once a week if it's that." He denied getting into any significant trouble as a child or ever running away from home. He also denied a history of physical or sexual abuse as a child.

Veteran is currently married and has been since 1992. He described the relationship with his wife as strained and said, "She tolerates me. We have split up a dozen times over the 20 years and shehas moved back to the west coast. She couldn't deal with my drinking. The last time I quit, she moved back." His wife has been with him steady for the past eight years. He noted, "It's not a lovingrelationship." He and his wife have four children - a daughter, age 24, sons, ages 13 and 11, and a daughter, 18 months. He described having a positive relationship with his children and said, "I get alongfine with my kids. The oldest daughter is not living at home anymore.

My condition bothers them because they want dad to go out to their ball games and I can't do that. They try to deal with it for the most part."

b. Relevant Occupational and Educational history (pre-military, military, and post-military):

Veteran described having a positive educational experience and said, "It was fine. I had a lot of friends. There were no problems at all. We all knew each other and were friends." He denied difficulties with the authority figures at school and said, "It was fine. My mother was the principal's secretary." Veteran denied being expelled or suspended from school, denied having to repeat any grades, and denied any history of special education. He graduated high school in 1987. He denied receiving any additional education.

Veteran is currently employed out of his home doing data entry. He has worked at home for 1.5 years and he explained, "They figured it was better for everyone if I worked at home." He has been working for this agency since 2003. He said, "Before that it was six months here and six months there. I had trouble holding onto jobs. I get along fine for a while and then something would set me off and I would be off to a different one." He has a low level of satisfaction with his current job and said, "It's a paycheck. I don't like it." He rated his work performance as low as well and said, "It's poor now but it used to be fair to good. I can't concentrate and focus anymore." Veteran had a strained relationship with his coworkers and employers while working. When asked about his current limitations to employment, he said, "I'm supposed to travel several times a year. I have gotten out of that but they're starting to pressure me to go. I don't want to go because I have panic attacks when I'm in new places and around new people. It's also the concentration. What I do on the computer is getting worse andworse and it scares me."

c. Relevant Mental Health history, to include prescribed medications and family mental health (pre-military, military, and post-military):

Veteran was unaware of any problems with his mother's pregnancy or delivery of him and denied difficulties attaining his developmental milestones. He denied being hospitalized as a child. Veteran assessed his current health as "poor" and said his current medical conditions consist of sleep apnea, fibromyalgia, chronic fatigue syndrome, irritable bowel syndrome, hypertension, and he has pain in his legs and back due to arthritis. Veteran was hospitalized in 1991 for leg and ankle surgery. All of his current medications are prescribed by the VA and he is taking them as prescribed. He noted having an increased level of fatigue and cited this as a side effect with his current medication regimen.

Veteran denied being hospitalized for psychiatric or mental health reasons. He has had overnight stays in the emergency room due to anxiety attacks. He has been working with a psychiatrist and psychologist at the VA facility for one year. He described this experience as "Neutral. I don't feel like it's helped me. My anxiety has actually gone up." He denied any previous mental health treatment. He denied past or present suicidal ideation and denied past or present homicidal ideation.

d. Relevant Legal and Behavioral history (pre-military, military, and post-military):

Veteran currently possesses a valid driver's license and initially denied difficulties operating a vehicle. He said, "I don't go to the big city traffic. I let somebody else drive me there." He denied a history of DWI or DUI. He denied any history of arrest as an adult and denied any current or pending legal matters.

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

Veteran denied smoking currently and said he discontinued this approximately ten years ago. He smoked for 17 years prior to this. He uses smokeless tobacco on an "occasional" basis. He denied current alcohol consumption and said that his last use of alcohol was in 2012. When drinking his heaviest, he was consuming "a 12-pack a night or a half a fifth a night. I was drinking to the point of passing out four or five times a week." He drank at this rate from 1991 until 2012.

He denied use of marijuana, crack, cocaine, amphetamines, psychedelic substances, or heroin. He also denied a history of prescription drug abuse.

f. Other, if any:

When asked about his current psychological and mental health difficulties, Veteran said, "I'm a Gulf War veteran and I've had these problems for 20 years. I decided to get help VA. I went through CPT and that made my anxiety worse. I've been seeing a psychology doctor for about a year and they said my PTSD is related to my combat experiences." He went on to say, "Anxiety is my biggest thing. I get panic attacks three or four times a week. I wake up with lots of dreams at least every other night." He said the content of the nightmares involve his military service and said, "I was on a helicopter as a machine gunner and I get that in my dreams. I see a lot of dead people. We had gas alarms all the time and I get dreams of those. I have sleep apnea and I wear the mask at night and I wake up thinking that it's the gas mask. One night I was asleep on the plane (helicopter) and I had two frag missles hit close to me and I thought I was going to die for sure that night." He then noted, "I have a lot of problems with people. I'm having to work at home. Loud noises and crowds bother me. I mainly stay at home a lot." He noted having anger difficulties and said, "I kept getting into it with the people at work. It wasn't physical, it was verbal." His sleep is poor and he explained, "I wake up a lot during the night." He estimated obtaining "five to six" hours of sleep in a 24 hour period. He described some of the more distressing tasks that he was involved in while in the military and talked about doing clearance and confiscation of the enemy's equipment down one of the main highways in Iraq. In the course of doing this, he saw many dead bodies, dismembered bodies, and burnt bodies. He described having hyper vigilant symptoms, is easily startled, and has problems concentrating at work. He said, "It's everyday and it's embarrassing."

Veteran indicated being exposed to actual or threatened death and serious injury by directly experiencing a traumatic event or witnessing, in person, a traumatic event that occurred with others. This series of events, which are stated elsewhere in this report, occurred while he was in the military service. There have been recurrent, involuntary, and intrusive distressing recollections of the trauma; recurrent distressing dreams in which the content or effect o the dream is related to that trauma event; and dissociative reactions and flashbacks in which there is a feeling that the traumatic event is reoccurring. There has also been intense or prolonged psychological distress and physiological reaction when exposed to internal or external cues that resemble aspect of the trauma. He indicated having an avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the trauma along an avoidance of or efforts to avoid external reminders that arouse distressing memories, thoughts, or feelings about or closely associated with events. He has a persistent and exaggerated negative beliefs or expectations about himself, others, or the world. He has persistent, distorted cognitions about the cause or consequences of the traumatic event(s) and this leads him to blame himself or others. He has a persistent negative emotional state; a markedly diminished interest of participation in significant activities; feelings of detachment or estrangement from others; and a persistent inability to experiencepositive emotions. Additionally, he has irritable behavior and angry outbursts with little or no provocation; reckless or self-destructive behavior; hypervigilance and an exaggerated startle response. He also noted having problems with concentration and difficulty falling asleep, staying asleep and/or restless sleep.

He indicated suffering from pain in one or more anatomical sites and this is the predominant focus of the clinical presentation. His level of pain is of sufficient severity to warrant clinical attention. His pain causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Both psychological factors and a general medical condition are judged to have important roles in the onset, severity, exacerbation, or maintenance of the pain. The symptoms indicated above do appear to be significantly impairing his social or occupational functioning.

Veteran served in the United States Marine Corp from 1988 until 1994. His MOS was helicopter crew chief and door gunner. He attained the rank of E5 and denied having any disciplinary action while in the military. He reported heavy and problematic alcohol use after being deployed and described how he was self-medicating. He denied drug usage while in the military. Veteran was injured and said, "I busted up my left leg and ankle. I've got screws and plates in my left ankle." He also noted having shrapnel in his left eye and said this was removed. He was deployed to Iraq from August 1990 until April 1991 and was exposed to combat during these eight months of deployment.

His social support consists of three fellow marines and said, "We were in the same unit." Other support consists of his wife and mental health workers. His activities of pleasure and relaxation consist of fishing and walking in the woods "where I can get away from everything." He denied having any religious affiliation. When queried about his strengths, he said, "Playing guitar." Veteran described his mood today as "I was anxious when I came in but now I'm just kind of blah, I guess. I'm here." He said his mood most days is "About the same. I don't have big fluctuations of emotions."

3. Stressors

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

a. Stressor #1: Combat Exposure in Iraq -- two frog missles hit near

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

Is the stressor related to personal assault, e.g. military sexual trauma?

[ ] Yes [X] No

b. Stressor #2: dead bodies, dismembered bodies, and burnt bodies

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

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

Please check criteria used for establishing the current PTSD diagnosis. Do

not mark symptoms below that are clearly not attributable to the criteria A

stressor/PTSD. Instead, overlapping symptoms clearly attributable to other

things should be noted under #6 - other symptoms. The diagnostic criteria

for PTSD, referred to as Criteria A-H, are from the Diagnostic and

Statistical Manual of Mental Disorders, 5th edition (DMS-5).

Criterion A: Exposure to actual or threatened a) death, b) serious injury, c) sexual violatrion, in one or more of the following ways:

[X] Directly experiencing the tramuatic event(s)

[X] Witnessing, in person, the traumatic event(s) as they occurred to others

Criterion B: Presence of (one or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred:

[X] Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s).

[X] Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s).

[X] Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings).

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

[X] Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).

Criterion C: Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic events(s) occurred, as evidenced by one or both of the following:

[X] Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).

[X] Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).

Criterion D: Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:

[X] Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., "I am bad,: "No one can be trusted,: "The world is completely dangerous,: "My whole nervous system is permanently ruined").

[X] Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame).

[X] Markedly diminished interest or participation in significant activities.

[X] Feelings of detachment or estrangement from others.

[X] Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings.)

Criterion E: Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:

[X] Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects.

[X] Hypervigilance.

[X] Exaggerated startle response.

[X] Problems with concentration.

[X] Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).

Criterion F:

[X] Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month.

Criterion G:

[X] The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Criterion H:

[X] The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition.

5. Symptoms

-----------

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

[X] Depressed mood

[X] Anxiety

[X] Panic attacks that occur weekly or less often (THIS SHOULD BE 3-4 times per week per my direct response to the doctor listed above)

[X] Chronic sleep impairment

[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

6. Behavioral Observations

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

No response provided

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, if any

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

The Veterans diagnoses of Post-Traumatic Stress Disorder (PTSD); Major

Depressive Disorder; Psychological Factors Affecting Other Medical

Conditions; and Alcohol Use Disorder are as least as likely as not (50/50

probability) caused by or is a result of his military service, per the

distressing experiences he indicated being exposed to, while in the

military. These are outlined in other sections of this report.

I think it will turn out pretty good, personally I would not have submitted the rebuttal you

have yet other's may certainly disagree.

jmho

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Carlie, I hear ya and I was back and forth on sending it, but I finally decided that I would rather take a chance on pushing the decision out a few more months by submiting additional evidence, and getting the correct rating out of the gate, than waiting for a lowball decsion and having to go thru the NOD process. Still not sure I did the right thing, but those two little items mean the difference between a 30% rating and a 50% rating.

Edited by Whirly Bird

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Im seeing 50% just from the C&P exam results.

The narratives (medical rationale) support it in my opinion.

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Thanks Carlie, thats what I'm thinkin too, possibly 70.....But that's probably just wishful thinkin.

Anybody else care to take a guess?

Edited by Whirly Bird

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