ptsd Mental Health C&p Any Opinions Appreciated

[Rx7mike]

This is for an appeal of my current VA 60% i was Retired @90% and am on SSDI due to SC issues Thanks for insight

Mental Disorders
(other than PTSD and Eating Disorders)
Disability Benefits Questionnaire

SECTION I:
----------
1. Diagnosis
------------
a. Does the Veteran now have or has he/she ever been diagnosed with a mental
disorder(s)?
[X] Yes[ ] No

If the Veteran currently has one or more mental disorders that conform to
DSM-5 criteria, provide all diagnoses:

Mental Disorder Diagnosis #1: Bipolar I Disorder, Severe, Most Recent
Episode
Depressed (296.53)

Mental Disorder Diagnosis #2: Panic Disorder, without agoraphobia (300.01)

b. Medical diagnoses relevant to the understanding or management of the
Mental Health Disorder (to include TBI): Deferred to medical provider.

Comments, if any:
The examinee reported a number of medical complaints that are beyond
the scope of this referral. Nonetheless, this writer would suggest
that
he be evaluated further by a qualified medical professional to address
such concerns.


2. 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

If yes, list which symptoms are attributable to each diagnosis:
The veteran's symptoms of mood instability, impulsivity,
irritability,
and concentration difficulties are related to his diagnosis of
Bipolar
Disorder. His panic attacks are related to his diagnosis of Panic
Disorder.


3. 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, judgment, 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?
[X] Yes

If yes, list which portion of the indicated level of occupational and
social impairment is attributable to each diagnosis:
Based on the veteran's self-report and all available medical records,
the veteran's occupational and social impairment are linked primarily
to his Bipolar Disorder. He denied significant impact of his Panic
Disorder on his occupational and social impairment.


SECTION II:
-----------
Clinical Findings:
------------------
1. Evidence review
------------------

a. Medical record review:
-------------------------
Was the Veteran's VA e-folder (VBMS or Virtual VA) reviewed? Yes
Was the Veteran's VA claims file reviewed? Yes

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

Updated treatment records through Hampton VAMC. The veteran was previously
examined for "Bipolar Disorder" and "Anxiety Disorder." For this reason,
this
writer obtained information since his previous exam, dated in 2011. For
previous history, please refer back to his previous C&P report.

b. Was pertinent information from collateral sources reviewed? No


2. History
----------
a. Relevant Social/Marital/Family history (pre-military, military, and
post-military):
Since 2011, the veteran has reported increased social isolation and
interpersonal conflict in connection with his Bipolar Disorder. The
veteran reported that he has stopped talking to "everyone" except his
wife
and his brother. He reported detachment from family members with whom he
previously had positive relationships. According to the veteran, he
continues to be married and they have three children together. He
described his relationship with his wife as "good, I couldn't hold it
together without her." He noted dependence upon his wife for activities
of
daily living related to reported physical conditions. He reported that
his
Bipolar Disorder has prevented him from watching his children engage in
extracurricular activities, and feels that he is not as supportive as he
should be. He stated that he "can't tolerate" social situations, and
isolates in order to avoid conflict. According to the veteran, his "anger
and violence have gotten out of control." He reported continued physical
aggression since 2011. He estimated involvement in altercations twice per
week. He denied homicidal ideations, but rather impulsive reactions to
stressful situations. His medical record is consistent with this report.



b. Relevant Occupational and Educational history (pre-military, military,
and
post-military):
The veteran denied steady employment during this review period. He
reported that he attempted to continue working as a mechanic, but due to
a
combination of mental and physical problems, he has experienced an
unsuccessful series of attempts to obtain/maintain employment. He stated
that engages in verbal conflicts with others, and ultimately has lost his
jobs. "They never last long, one didn't event last a week." He stated
that
he has attempted to work in manual labor jobs, but is physically unable
to
do so. He also noted conflicts with customers. He reported that he "tried
the vocational rehabilitation program" and is currently on social
security/disability related to his mental illness.

Regarding the veteran's educational history, he reported that he began
classes at ECPI in February 2013, and was planning to obtain a degree in
Network Security. However, his grade declined shortly after enrolling due
to distractibility and confusion. He reported an altercation with his
academic advisor, resulting in physical aggression. He reported that he
has not been legally charged because his advisor started the conflict. He
reported that after that
situation, he experienced significant confusion
surrounding his class schedule. He was reportedly asked to leave a class,
because he was sitting in the wrong class. When asked for further
details,
the veteran responded that he still does not understand what happened,
and
he did not provide further clarification. However, he stated that he has
been unable to complete his class work, and recently dropped out of
classes.


c. Relevant Mental Health history, to include prescribed medications and
family mental health (pre-military, military, and post-military):
The veteran reported that since 2011, he has continued with medication
management through the Hampton VAMC (Virginia Beach CBOC). He is
currently
prescribed Lithium, Valium, Ziprazidone, and Diazepam. He reported that
he
has requested individual psychotherapy since 2011, but has not yet
started. He denied any history of psychiatric hospitalizations or
emergency room visits related to his mental health conditions in the
current review period. Record review reveals a significant verbal
altercation with another veteran in the Virginia Beach CBOC waiting room
in October 2013. According to that record, he had experienced significant
stress related to his daughter's health condition at the time, and he was
easily provoked.

The veteran's medical record also indicates a history of panic attacks
and
engaging in "cutting" within the past few weeks as a method of relieving
stress.


d. Relevant Legal and Behavioral history (pre-military, military, and
post-military):
Since 2011, he has continued to engage in physical fighting. However, he
denied legal charges related to his behavior. He received a speeding
ticket in December 2013, and got into a verbal altercation with the
police
officer. However, he was reportedly not charged for his behavior. "I
don't
know why; I clearly was in the wrong. But I feel like I can't control it.
It comes out of nowhere."


e. Relevant Substance abuse history (pre-military, military, and
post-military):
The veteran denied current use of alcohol or other substances since 2007.
He denied ever having a pattern of problematic or chronic use of
substances. He reported that he uses his medications as prescribed.

3. Symptoms
-----------
For VA rating purposes, check all symptoms that apply to the Veteran's
diagnoses:

[X] Depressed mood
[X] Anxiety
[X] Panic attacks that occur weekly or less often
[X] Chronic sleep impairment
[X] Flattened affect
[X] Speech intermittently illogical, obscure, or irrelevant
[X] Impaired judgment
[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
[X] Impaired impulse control, such as unprovoked irritability with
periods
of violence
[X] Grossly inappropriate behavior
[X] Persistent danger of hurting self or others

Behavioral observations:
Please refer to the remarks section below.

5. Competency
-------------
Is the Veteran capable of managing his or her financial affairs?
[ ] Yes[X] No

If no, explain:
The veteran has reported that he cannot be trusted with finances. In
addition, he reports that his wife is the designated payee for his
social
security check. His prior history of shopping sprees also lends
additional evidence of this assertion. Overall, the symptoms of his mood
disorder would significantly interfere with his ability to appropriately
budget and spend his financial resources. He is at high risk for
misusing
such money, or falling victim to a predator (as he has routinely
displayed impaired judgment during episodes of mania).


6. Remarks (including any testing results), if any:
---------------------------------------------------
The veteran was notified of the limitations inherent in the present
interview. The examinee was made aware that the undersigned was functioning
solely in the role of an assessor, and not as a treatment provider. The
nature of the examination, with respect to the pending claim/request, was
made clear. Further, the limited confidentiality of the present results was
explained, and the veteran understood that the present results would be
shared with individuals attempting to adjudicate his compensation claim.
Additionally, the examinee was informed of this writer's affirmative
responsibility to prevent either the respondent or others from being placed
in danger of harm. Specifically, information related to ongoing elder/child
abuse would be related to an appropriate protective services agency.
Additionally, the veteran was instructed that if it is believed that he is
an
imminent threat to either himself or others, the limits placed upon
confidentiality, as previously explained, will no longer apply. The veteran
demonstrated an understanding of this material and provided verbal consent
to
continue with the scheduled assessment.

Mr. Mallette presented on time and in fair spirits. Rapport with this writer
appeared easily established and social skills were fairly intact. Personal
hygiene was fair. He was alert and aware throughout the present contact. He
was an active participant throughout the evaluation. He was oriented to all
spheres and understood the nature of the present assessment. Speech was
within normal limits for volume and rate. He demonstrated difficulty in
responding to specific questions, as his answers were initially on topic,
but
eventually derailed. However, he demonstrated awareness of this and
unsuccessfully attempted to correct himself.

Cognitive skills presented as grossly intact. He was able to complete
multi-step tasks without noticeable difficulty. The veteran reported "dull"
mood and this is congruent with his nonverbal behaviors, which were
indicative of depression. Performance was within expected limits on all
measures of memory. He was able to remember current and past president's
names, and he was able to recall all three target words after a 10 minute
interval without prompting or assistance. Additional screens of memory
functioning and attention did not suggest the presence of impairment in
memory or concentration. He was able to complete serial number tasks without
difficulty and he was able to correctly spell a 5 letter word forwards and
backwards.

Performance on a digit span type task was below expected limits, as he was
able to accurately recite five digits forward and four backward. Abstract
reasoning skills and general fund of information did not evidence noticeable
impairment. Intellectual dysfunction was not evident, nor suspected. No
symptoms of formal thought disorder were observed or reported. The veteran
also denied symptoms of psychosis, suicidal ideation, or homicidal ideation.


This compensation exam was conducted specifically to assess for the presence


of "Bipolar Disorder, Mixed." The veteran's medical record consisted of
many
diagnoses, including Bipolar Disorder, Bipolar II Disorder, ADHD, Anxiety
Disorder, Panic Disorder, and R/O Borderline Personality Disorder. His
C&P
exam in 2011 reveals a diagnosis of Bipolar Disorder, Mixed, and states that
his anxiety is attributed to his Bipolar Disorder. Most recent medical
documentation indicates Bipolar Disorder and Anxiety Disorder.

Regarding his mood disturbance, the veteran reported a "dull" mood most
days.
However, he reported distinct episodes of mania and depression, with each
lasting anywhere from 2-3 weeks. He reported that during a manic phase, he
achieves approximately 3 hours of sleep per night with adequate energy.
However, when in a depressive phase, "I feel like crap" and "sleep all day."
During his manic phase, he experiences elevated sense of self-esteem,
decreased need for sleep, talkativeness, racing thoughts, distractibility,
increase in goal-directed activity, and involvement in risky behaviors
(including losing up to $3000 within 4 hours of gambling, which caused
financial problems for the family; and increased sex drive with prior sexual
indiscretions, although his current medications provide complications
related
to sex drive). He reported that his spending became such a problem that his
wife has been designated as his payee for Social Security, and she handles
all of the household finances. Regarding depressive symptoms, the veteran
reported episodes of sad mood, markedly diminished interest in previously
enjoyed activities, significant weight fluctuations due to variable
appetite,
hypersomnia, fatigue, concentration difficulties, and psychomotor agitation.
The veteran meets criteria for Bipolar I Disorder, Severe, Most Recent
Episode Depressed. The veteran's reported symptoms are not suggestive of
mixed features, as he describes them as distinct episodes.

The veteran also reported many symptoms of anxiety, including panic attacks
beginning in 2007. He described these as including chest pain, difficulty
breathing, sweating, shaking, abdominal distress, dizziness, chills,
depersonalization, fear of losing control, and fear of dying. He stated that
these panic attacks are usually unexpected. He reported persistent concern
about having another attack. He also reported that when he first notices an
attack beginning, he tries to calm himself down. The veteran reported that
panic attacks occur in multiple settings. However, as a result of panic
attacks on the highway, he has begun to avoid highways when possible. He
reported that he can tolerate highways when his wife is driving, although he
experiences significant tension. Although he reported prior motorcycle
accidents, he denied direct correlation of symptoms to these accidents. He
denied intrusive or other PTSD symptoms related to his accidents. The
veteran's previous C&P report attributed the veteran's anxiety symptoms
to
his Bipolar Disorder. Although Bipolar Disorder with anxious distress
encompasses some feelings of restlessness and fear that something awful may
happen (DSM-5, p. 149), the veteran's reported symptoms are more reflective
of Panic Disorder, without Agoraphobia. He denied additional anxiety
symptoms
that would warrant an additional anxiety diagnosis.

According to the veteran's medical record, prior test results reveal
responses congruent with Antisocial Personality Disorder. However, the
veteran was never diagnosed with Antisocial Personality Disorder. He denied
symptoms of conduct disorder during his childhood, and there is no evidence
of such in his medical record. In addition, he reported feeling remorse for
his actions until recently. "I'm concerned because I've started not to care
anymore. It's like I'm numb and I don't like that." In addition, the DSM-5
states that Antisocial Personality Disorder should not be diagnosed when
antisocial behavior occurs exclusively during the course of a bipolar
disorder (p. 662). The veteran also denied symptoms related to Borderline
Personality Disorder.

The veteran reported that his primary problems are related to his mood
disturbance, particularly his agitation, irritability, and lack of
concentration. He reported that they have contributed to significant
impairment in interpersonal relationships and his ability to obtain and
maintain employment. It is believed that the veteran experiences significant
impairment in judgment, motivation, and mood, resulting in significant
difficulties in occupational and social functioning.

As a mental health professional, I recognize that the determination on this
individuals claim is properly a matter for the VBA and/or the court to
decide. Therefore, the clinical opinions provided in this report in regard
to
these issues are of an advisory nature only. The medical of record in this
case was reviewed and considered in the overall assessment of the veteran.
He
appeared to freely acknowledge prior events and behaviors that may reflect
poorly upon him. As such, the results of the present clinical interview are
considered to be an accurate reflection of his current functioning. I will
be
glad to provide the referral source with any further information, records,
or
testimony that it may require. Please note that all diagnoses reflect DSM 5
criteria.

(In short is there any hope. The VA requested my info from SSDI on the 7th which will show i recieved for SC injuries and that i am unemployable.

My othere C&P for my shoulders she cleared me for seditary work but she didnt take in concideration my MH) Please help

Thank You)

It seems as if she is with me then she falls off the wagon so to speak but then comes back really strong on some points. She requested i need further intensive followup with my provider before i left.

[Rx7mike]

VSO stated SDI award is requested as evidence only to as the SC injuries make me unemployable. She stated that the fact that i did recieve them while still on AD almost states in itself that it is all SC disabilities. it is by no means a gaurentee but backing information just like a Voch Rehab letter would apparently. fingers crossed