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Civilian Ptsd Exam Notes....not Normal Format. Thoughts On Rating?


Squad227

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Had my C&P and the civilian doc didn't follow the format I usually see posted on here......hard to interpret. I'm thinking it seems to fit a 50% rating...but maybe 70%? Any advice or thoughts?

He does stay depressed on a daily basis with sad mood and crying spells, the

insomnia as noted, poor appetite with a 25 pound weight loss, the

irritability and rage, anhedonia, lethargy and fatigue, some chronic

headaches and passive thoughts about death but no active suicidal

ideation. No psychotic symptoms.

Section V additional symptoms to PTSD: Depressed mood, anxiety,

suspiciousness, chronic sleep impairment, disturbances of motivation and

mood, difficulty establishing and maintaining work and social

relationships, difficulty adapting to stressful circumstances, inability

to establish and maintain effective relationships, and passive thoughts

about suicide without active plan. There seem to be no other symptoms

related to a mental disorder that have not been listed.

The effect of the PTSD and depression on his occupational and social functioning would be causing

deficiencies in all of these areas in that he has been fired from one job

both due to theft and it sounds like to his rage and irritability and

pushing a supervisor through a wall which would definitely not be a good

way to stay on a job. He has also had significant interpersonal problems

in that he has had a divorce and breakup of a fairly long-term

relationship all due to his irritability and his distancing of himself

emotionally from these women and he has been unable to have other

relationships since then other than with his daughter.

Axis I: Posttraumatic stress disorder, chronic, 309.81; major

depressive disorder, recurrent, severe, 296.33.

Axis II: Deferred.

Axis III: As noted above.

Axis IV: Level IV stressors with his ongoing severe depression,

anxiety, inability to interact with others and find social

contacts as well not having a job or financial support.

Axis V: GAF as noted above.

Edited by Squad227
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