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    When a Veteran starts considering whether or not to file a VA Disability Claim, there are a lot of questions that he or she tends to ask. Over the last 10 years, the following are the 14 most common basic questions I am asked about ...
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  • Can a 100 percent Disabled Veteran Work and Earn an Income?

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    You’ve just been rated 100% disabled by the Veterans Affairs. After the excitement of finally having the rating you deserve wears off, you start asking questions. One of the first questions that you might ask is this: It’s a legitimate question – rare is the Veteran that finds themselves sitting on the couch eating bon-bons … Continue reading

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Navy04

Ptsd Increase C&p Exam Report. What % Will I Get?

Question

I am Currently 30%SC for PTSD. I was Medically Retired Feb 25,2013 from the Navy. What do you guys think that I will get? Also if you look at bottom of report Psych C&P Examiner states that when I had my C&P in 2012, I met the Criteria for 70% PTSD, yet the VA low balled me at 30%. What can I do to let the VA know that I was screwed in 2012 by the VA and try to get back pay, or is it not worth fighting. Going by my recent 6 C&Ps, it looks like I will be 100% when this FDC is settled. I have 4 or 5 conditions that I am going to submit another C&P when this claim is complete. I want to make sure that I keep my 100% Schedular if I get it, and not deal with IU down the road. That is such a headache. Thanks again guys for your help.

Review Post Traumatic Stress Disorder (PTSD)

Disability Benefits Questionnaire

SECTION I:

----------

1. Diagnostic Summary

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

Does the Veteran now have or has he/she ever been diagnosed with PTSD?

[X] Yes[ ] No

2. Current Diagnoses

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

a. Mental Disorder Diagnosis #1: Posttraumatic Stress Disorder (PTSD)

Mental Disorder Diagnosis #2: Obsessive Compulsive Disorder (OCD)

Mental Disorder Diagnosis #3: Major Depressive Disorder (MDD)

b. Medical diagnoses relevant to the understanding or management of the

Mental Health Disorder (to include TBI):

No response provided.

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: Current

symptoms overlap and are attributable to all three diagnoses, PTSD,

OCD, and MDD.

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 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[ ] 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: Current

impairment is attributable to all three diagnoses, PTSD, OCD, and

MDD.

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?

[ ] Yes[X] 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:

VA medical records via CPRS

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[X] No

If yes, describe:

2. Recent History (since prior exam)

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

a. Relevant Social/Marital/Family history:

Currently lives in Emory, Tx, about 100 miles from Bonham VA,

that's

where he does treatment. Lives with wife, married 10 years, today is

there anniversary, and 2 daughters, ages 8 and 5. Overall, getting

along with wife ok. Gets frustrated easily, helping with homework,

wife

does all that. Separated from wife for 6-7 months in 2012, related to

his mental health at the time.

On a typical day, does not sleep much, wife handles all his meds, wife

cooks him breakfast, she works 6:30-10:30am, watches the cooking

channel on tv, used to play sports, cars, not interested anymore. Does

not trust anybody.

Only leaves house for dr. appointments. Used to go to church, sports.

Now does not leave the house very often. No stores, restaurants. Goes

to trauma treatment.

Father does not believe in his emotional problems, not supportive.

Wife

is generally supportive but frustrated. No close friends nearby.

Does not use computers, rarely uses the phone. Does not have much

family. Brother has problems with drugs. Has an identical twin

brother,

does not talk to him.

b. Relevant Occupational and Educational history:

Active duty 9 years, separated from Navy in Feb. 2013, one year ago.

Deployments to Iraq, Afghanistan, went in went people got hurt.

Post:

Was working for the state as an agent, tracking sex offenders

Resigned

due to physical and mental issues, couldn't handle it. Has a

Bachelor's

in Criminal Justice and homeland security. Was working on

Master's

classes, dropped out in fall due to dropping grades. Has a few classes

left to finish MA. Started MA August 2012, completed 6 classes. Also

has BA in teaching.

Currently has SS disability claim. Not looking for work right now. No

school.

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

family mental health:

Individual therapy weekly. Psychiatrist every 3 months.

2012, 3 months in mental hospital, River Oaks mental hospital in New

Orleans, in the navy was sent there for suicidality. No psychiatric

hospital since then. 2 suicide attempts, first time overdosed on

Xanax,

stomach pumped. Pulled out in front of cement truck on a bridge, then

sent to hospital. MPs took him to hospital.

In 2012, was seeing faces of dead bodies.

Veteran describes current mood as "depressed." Crying spells

most days.

Hard to stop crying when he stops. Sometimes laughs during serious

conversations, can't control it.

DEPRESSION SX:

__x___Depressed mood daily

__x___Diminished interest/pleasure

in activities

__x___Weight loss/gain (sometimes gains/loses 20 lbs, has

Chrohn's

disease)

__x___Insomnia or hypersomnia

__x___Psychomotor agitation/retardation

__x___Fatigue/loss of energy

__x___Feelings of worthlessness/guilt (feels wo

rthless)

__x___Poor concentration/indecisiveness

__x___SI, plan or attempt (passive thoughts, denied plan or intent)

*Thinks about hurting people. Wants to hurt bad guys, going back

overseas and hurting people to feel better.

Sleep:

3-4 hours per night. On sleep meds, help him fall asleep, don't

help

him stay asleep. Wife says he's having nightmares, cries and

screams in

sleep. Has sleep apnea. Sometimes wakes up under beds and in closets.

Has hit his wife in sleep. Wakes up scared, trying to help people,

dreams of being wounded, paralyzed, related to deployments. Has TENS

unit and Alpha-Stim.

Trauma Treatment:

Started Sept. 2013, once per week, PTSD tx, nurse practitioner for

meds, counselor is Karen Davisson-Gerleman. Has psych meds, takes

every

day, prazosin for sleep and nightmares, alprazolam for anxiety,

temazepam for sleep, vanlafaxine for depression. Started meds in

Afghanistan in 2010, prescribed by Marine doctor, was taking a lot of

Xanax at the time.

Anxiety:

Counts stuff all the time, mind never stops. Thinks that he's in

multiple battles. Anxiety throughout day, muscle tension, tired a lot.

Panic attacks at least once per week, seems random. Anxiety during

day,

restlessness at night, checking the house a lot. Installed alarm

system, has not reduced anxiety. Diagnosed with OCD 3/2012, counting

rituals, touching rituals, tries to touch things in even numbers.

Don't

like people on the left side of his body. Paranoid, does not trust his

family.

AVH.

6-8 months ago, faces of dead children, they talk to him, criticizing

him for not doing enough. On a daily basis, on a bad day throughout

the

day, good day 2-3 times.

Anger:

Broke all the mirrors in the house, 6-7 mirrors, broke them with his

cane. He sees somebody he does not like. 3-4 times per month, feels

angry and aggressive, hits walls, throws something. Hits the dog.

Medical:

Chrohn's disease, erectile dysfunction

d. Relevant Legal and Behavioral history:

Denied.

e. Relevant Substance abuse history:

Denied current alcohol use. Denied any drug or alcohol use.

f. Other, if any:

No response provided.

3. PTSD Diagnostic Criteria

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

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

diagnostic criteria for PTSD, are from the Diagnostic and Statistical Manual

of Mental Disorders, 5th edition (DSM-5). The stressful event can be due to

combat, personal trauma, other life threatening situations (non-combat

related stressors.) 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 #5 - "Other

symptoms".

Criterion A: Exposure to actual or threatened a) death, b) serious

injury,

c) sexual violation, in on 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] 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, distorted cognitions about the cause or

consequences of the traumatic event(s) that lead to the

individual to blame himself/herself or others.

[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] The duration of the symptoms described above in Criteria

B, C, and D are more than 1 month.

Criterion G:

[X] The PTSD symptoms described above cause clinically

significant distress or impairment in social,

occupational, or other important areas of functioning.

Criterion H:

No response provided.

4. Symptoms

-----------

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

diagnoses:

[X] Depressed mood

[X] Anxiety

[X] Suspiciousness

[X] Near-continuous panic or depression affecting the ability to function

independently, appropriately and effectively

[X] Chronic sleep impairment

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

events

[X] Circumstantial, circumlocutory or stereotyped speech

[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] Suicidal ideation

[X] Obsessional rituals which interfere with routine activities

[X] Impaired impulse control, such as unprovoked irritability with

periods

of violence

5. Behavioral Observations:

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

This veteran is a 31 year old, married Hispanic male. Veteran appeared on

time, was well nourished and dressed in casual clothing. Veteran walked

with two knee braces and a cane, and was emotionally distressed

throughout

the exam, with frequent tearfulness. Veteran was alert and oriented x3.

Intellectual functioning estimated above average. Veteran was cooperative

and eye contact was appropriate. Thought processes were somewhat

circumstantial, yet he was easily redirected. Speech was within normal

limits regarding rate, rhythm, and volume. Mood was extremely depressed

and affect was congruent with depressed mood. Veteran's ability to

maintain minimal personal hygiene and other basic ADL's appeared

intact.

Veteran denied suicidal ideation, endorsed ideation of violence toward

enemies, yet denied plan or intent to harm himself or others. Veteran

endorsed daily auditory and visual hallucinations related to combat

stressors.

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, (including any testing results) if any:

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

Claims File was reviewed by examiner.

Mr. Kiefer is a 31-year-old, 80% Service Connected for various

conditions,

married Hispanic male evaluated for a PTSD review exam. The veteran's

VA

medical records, self-reports during the examination, and claims file

data

were reviewed in forming an opinion.

Veteran continues to meet both DSM-IV-TR and DSM-5 criteria for three

mental health disorders, Posttraumatic Stress Disorder (PTSD), Obsessive

Compulsive Disorder (OCD), and Major Depressive Disorder (MDD). Veteran

was orginally service-connected 30% for PTSD in the spring of 2012. Per

report in Claims File, prior C&P Initial Evaluation for PTSD dated

5/22/12

noted dx of PTSD, OCD, and Depressive Disorder with symptoms which are

associated with 70% impairment and a GAF score of 53. Veteran continues

to

have social and occupational impairment with deficiencies in most areas

such as work, school, family relations, judgment, thinking or mood due to

the combination of PTSD, OCD, and MDD. Veteran is currently treated with

weekly appointments at the trauma team at the Bonham VA, with counseling

and medication.

Upon direct questioning about whether he had any other comments or

information not covered in the interview, the veteran stated he had

nothing to add to any part of this report.

From 2507:

CLAIMS FILE BEING SENT FOR REVIEW BY THE EXAMINER.

***** OCR - One Year Initiative -EXPEDITE BY VA DIRECTIVE ***********

CLINICIAN: IF USING THE ACE PROCESS TO COMPLETE THE DBQ, PLEASE:

-EXPLAIN THE BASIS FOR THE DECSION NOT TO EXAMINE THE VETERAN AND

-IDENTIFY THE SPECIFIC MATERIALS REVIEWED TO COMPLETE THE DBQ

FULLY DEVELOPED CLAIM

C-FILE BEING SENT FOR REVIEW

MEDICAL OPINION: STATE C-FILE WAS REVIEWED

"Examiner, please note for this examination to be sufficient, a

review of

the claims

file, to include documentation that review was completed, is

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Did your 2012 decision become final? If not and you got 70% on appeal I would file a NOD and point out the fact that you met the criteria for 70% in 2012.

You have one year after your 70% rating to file the NOD. This may slow down your other claims.

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The 2012 was final as of April 2013, as I was Medically Retired in Feb 2013, and pay kicked in May 2013. I have until Tuesday to submit an NOD. I don't know what to do. If I submit the NOD this week, I know that the VA will grant the 70% PTSD to May 2013 for pay purposes. By my calculation it would be around $2500. I know that once the VA completes my FDC claim I have now in the next few months, they are going to give me 70% or better for PTSD, and along with my other conditions, they will bump me up to 100%. I don't want to slow this claim down at all, just want to get back at the VA, since they actually admitted to themselves that they screwed me with my original PTSD, when they only gave me 30%, WTH!. John, thanks for the info.

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Marine Doctor? lol

I wish you good luck, I know how much of a pain this VA stuff is. Keep your head up.

Remember to do your calming down breathing exercises.

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I have a 70% rating already for anxiety disorder and I put in for an increase during my C&P examine the examiner told me that I should add a physiologist to my treatment team because I have developed more symptoms than the anxiety disorder I already have a psychiatrist who I see after the C&P examine my claim went from gathering information to pending decision I want to know if that is a good sign or not...Thank you in advance for your answer....

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The 2012 was final as of April 2013, as I was Medically Retired in Feb 2013, and pay kicked in May 2013. I have until Tuesday to submit an NOD. I don't know what to do. If I submit the NOD this week, I know that the VA will grant the 70% PTSD to May 2013 for pay purposes. By my calculation it would be around $2500. I know that once the VA completes my FDC claim I have now in the next few months, they are going to give me 70% or better for PTSD, and along with my other conditions, they will bump me up to 100%. I don't want to slow this claim down at all, just want to get back at the VA, since they actually admitted to themselves that they screwed me with my original PTSD, when they only gave me 30%, WTH!. John, thanks for the info.

Navy in the document review it says you do not use a computer where did that come from?

First time out I was PTSD at 50% with a gaf of 50 and I actually thought I was more like 30% if anything, and while not a social butterfly I do get out especially when my wife wants to go somewhere of course I never have a good time though!

Stillhee

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