SECTION I
1. Diagnostic Summary
This section should be completed based on the currem examination and clinical findings.
Does the Veteran bave a diagnosis ofPTSD that conforolS to DSM-5 criteria based on today's evaluation?
[X] Yes 0 No
If no diagnosis ofPTSD. check all U1at apply:
(]Veteran's symptoms do not meet the diagnostic criteria for PTSD under DSM-5 criteria
0 Veteran does not have a mental disorder Ula t conforms with DSM-5 criteria
O Veteran has another Mental Disorder dia2nosis
Continue to complete this Questio1Dl3ire and/or the Eating Disorder Questionnaire.
2. Currrnt diagnosrs
a. Mental Disorder Diagnosis #1
PTSD
Comments. if any:
Mental Disorder Diagnosis #2:
I Alcohol Abuse. In Remission
Comments. if any:
Mental Disorder Diai!Ilosis #3:
I Attention-Deficit. Hyperactive Disorder. Inattentive Type
Counnents, if an :
Diai!Ilosed since childhood and medicated durin~ childhood.
Mental Disorder Diai!Ilosis #4:
Comments. if any:
If additional diai!Iloses. describe usin~ above format :
b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI):
Comments. if any:
3. Difff'reotiation of svmptoms
3. Difff'reotiation of svmptoms
a. Does the Veteran have more than one mental disorder diagnosed?
[X] Yes 0 No
If yes. complete the following question (3b):
b. Is it possible to differentiate what symptom(s) is/are attributable to each diagnosis?
[X] Yes 0 No 0 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 and
discuss whether there is any clinical association between these diagnoses:
Discuss whether there is an clinical association between those diaenoses:
If yes, list which symptoms are attributable to each diagnosis and discuss whether there is any clinical association between these
dia101oses:
The veteran's difficulties with Alcohol Abuse do not currently impact functioning. since he bas abstained from alcohol since 2012.
He presents with significant PTSD symptoms which in1pact current functioning. resulting in problems maintaining relationships
with others, agitation. and excessive anxiety. The history is significant for a diagnosis of ADHD which binders ability to
concentrate.
c. Does the Veteran have a diagnosed traUDlatic brain injury (TBI)?
0 Yes [X] No 0 Not shown in records reviewed
4. Occupational and social impairml'nt
tom is attributable to each dial!llosis:
a. Which of the following best summarizes the Veter311's level of occupational and social impairment with regards to all mental
diagnoses?
(Check only one)
0 No mental disorder diagnosis
0 A mental condition has been foJIDally diagnosed. but symptoms are not severe enough either to interfere with occupational and
social functioning or to require continuous medication
O Occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perfonn
occupational tas.ks only during periods of significant s tress. or: symptoms controlled by medication
0 Occupational and social impaiJIDent with occasional decrease in work efficiency and intennittent periods of inability to perfonn
occupational tasks. although generally fimctioning satisfactorily. wiUt nol1llal routine behavior. self-care and conversation
0 Occupational and social impairment with reduced reliability and productivity
[X) Occupational and social impairment with deficiencies in most areas. such as work. school. family relations. judgment. thinking
and/or mood
0 Total occupational and social impairment
b. For the indicated level of occupational and social impaimtent. is it possible to differentiate what portion of the occupational and
social impaimtent indicated above is caused by each mental disorder?
[X) Yes 0 No O 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 impaiJIDent
is attributable to each diagnosis:
If yes. list which portion of the indicated level of occupational and social impainnent is attributable to each dial!llosis:
Veteran's diagnosis of Alcohol Abuse. In Remission is no longer impacting functioning. However, he continues ro present with
severe PTSD symptoms resulting in excessive anxiety. startle response, hyper vigilance. agitation. and maintaining relations with
others.
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?
0 Yes [] No [X) No diagnosis ofTBI
If no. provide reason that it is not possible to differentiate what portion of the indicated level of occupational and social impaiJIDent
is attributable to each dial!.Dosis:
If yes. list which portion of the indicated level of occupational aud social i.mpairtnent is attributable to each diagnos is:
4. PTSD Diagnostic Ct·itc.•r·ia
Please cht rk crtte1ia used ror establisWng the CUJTt nt PTSD diagnosis. Do ~OT mark symptoms below that are clearly not
attributable to the criteria A stressor/PTSD. Instead, overlapping symptoms clearly aflributable to other things sbould 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. 5tb edition {DSM-5).
Clittiion A: Exposure to actual or tbreatened a) death. b) serious injury. c) sexual violation. in one or more of tbe following ways:
[X) Directly experiencing the traumatic event(s)
O Witnessing. in person. tbe traumatic event(s) as they occurred to otbers
O Learning tbat the traumatic event(s) occurred to a close family member or close friend: cases of actual or threatened death must
bave been violent or accidental: or. experiencing repeated or extreme exposure to aversive details oftbe tramuatic event(s} (e.g ..
first responders collecting human remains: police officers repeatedly exposed to details of cbild abuse): Ulis does not apply to
exposure through electronic media. television. movies. or picrures. unless this exposure is work related
Cliterion B: Presence of (one or more) oftbe following intrusion symptorus associated with the traumatic event(s). beginning after
U1e traumatic event(s) occurred:
[X] Recurrent. involuntary. and intrusive distressing memories of tbe traumatic event(s).
[X} Recurrent disil-essing dreams in which tbe content and/or affect of tbe dreant are related to the traumatic event(s).
O Dissociative reactions (e.g .. flashbacks) in wh.icb Ute individual feels or acts as if the tramnatic e\·ent(s) were recurring. (Snell
reactions may occur on a continuum. witb the most extreme expression being a complete loss of awareness of present
stUTOimdings.)
0 Intense or prolonged psychological distress at exposure to internal or external cues tbat symbolize or resemble an aspect of tbe
traumatic event(s).
O Marked physiological reactions to internal or eJo.iernal cues tbat symbolize or resemble an aspect of tbe traumatic event(s).
Ctituion C: Persistent avoidance of stimuli associated witb tbe tramnatic evem(s). beginning after tbe traumatic event(s) occurred. as
evidenced by one or both of tbe following:
O Avoidance of or efforts to avoid distressing memories. tboughts. or feelings about or closely associated witb tbe traumatic event(s).
[X] Avoidance of or efforts to avoid external reminders (people. places, conversations, activities, objects, situations) tbat arouse
diStressing memories. thoughts. or feelings abom or closely associated with tbe rratmlatic event(s).
Clituion D: Negative alterations in cognitions and mood associated with tbe traumatic event(s), beginning or worsening after the
traumatic e\·em(s) occurred, as evidenced by two (or more) of Ute following:
0 Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative anmesia and not to other factors
such as bead injury. alcohol. or drugs).
O Persistent and exaggerated negative beliefs or expectations about oneselt albers. or tbe world (e.g .. "I am bad." "No one can be
trus ted." ·'The world is completely dangerous." "My whole nervous system is pennanently ruined").
O Persistent, distorted cognitions about the cause or consequences of tbe tramnatic event(s) tbat lead to the individual to blame
himself/herself or others.
O 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.
O Persistent inability to experience positive emotions (e.g., inability to experience happiness. satisfaction, or loving feelings.)
Ctiterlon E: Marked alterations in arousal and reactivity associated v,itllthe 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 (witb little or no provocation) typically expressed as verbal or physical aggression toward
people or objects.
[X} Reckless or self-destructh·e behavior.
[X} Hypervigilance
[X] Exaggerated startle response.
[X] Problems with concentration.
(X) Sleep disrurbance (e.g .. difficulty fallin!! or staying asleep or restless sleep).
Ctitt tion F:
[X} Duration of the disrurbance (Criteria B. C. D. and E) is more than 1 month.
Q·Herioo G:
(X) The disttu·bance causes clinically significant distress or impairment in social, occupational. or other imporrant areas of
functioning.
Ctiterioo 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 raring purposes. check all symptoms Uta! actiYely apply to lhe Veterans diagnoses. Text boxes after the symptoms can contain
information for addressing frequency. severity, duration. as well as additional pertinent comments.
[X} Depressed mood
[X) Anxiety
0 Suspiciousness
O Panic attacks rhar occur weekly or less often
0 Panic attacks more than once a week
0 Near<ontinuous panic or depression affecting the ability to function independently. appropriately and effectively
(X) Chronic sleep impairment
0 Mild memory loss. such as forgetting names. directioJlS or recent events
O Impairment of shorr· and long-rerm memory. for exatllple. retention of only highly learned material. while forgetting to complete
tasks
O Memory loss for names of close relatives. own occupation. or own name
(X) Flattened affect
0 Circumstantial, circumlocutory or stereotyped speech
O Speech intermittently illogical, obscure. or irrelevant
0 Difficulty in understanding complex coD1lllands
0 Impaired judgment
0 Impaired absn·act thinking
O Gross impairment in thought processes or communication
[X} Disturbances of motivation and mood
[X] Difficulty in establishing and maintaining effecti,·e work and social relationships
0 Difficulty in adapting to stressful circumstances. including work or a work like setting
0 Inability ro establish and maintain effective relatioliShips
0 Suicidal ideation
O Obsessional rituals which interfere with routine activities
O Impaired impulse control. such as unprovoked irritability with periods of violence
0 Spatial disorientation
O Persistent delusions or hallnciuatio.ns
0 Grossly inappropriate behavior
0 Persistent danger of hurting self or others
O Neglect of personal appearance and hygiene
O intermittent inability ro perform activities of daily li\·ing. including mainrenance of minimal personal hygiene
0 Disorientation to time or place
Behavioral Observations:
Vereran presented as alert and well oriented. He presented as casually dressed. with marginal grooming and adequate hygiene. He
required no assistive devices and presenred with normal motor functioning. He reporred dyshphoric mood. frustration related to
ongoing concentration difficulties impacting his ability to succeed in school. poor sleep. excessive anxiety. starrle response. hyper
vigilance. difficulty maintaining relationships. He appeared uncomfortable and anxious during !be interview. with a soft and
trembling voice. He denied self-injurious ideation. plan. and intent. He did nor present as a danger to self or ollters.
DBQ lnitial Post· Traumatic Stress Disorder (PTSD)-DSM V
Sorry for the twerked words here and there, had trouble converting the scanned pdf document into something readable.
I'm already in with a private provider for EMDR therapy and start next week. Any thoughts on my rating level would be appreciated.
Question
mbl22885
SECTION I
1. Diagnostic Summary
This section should be completed based on the currem examination and clinical findings.
Does the Veteran bave a diagnosis ofPTSD that conforolS to DSM-5 criteria based on today's evaluation?
[X] Yes 0 No
If no diagnosis ofPTSD. check all U1at apply:
(]Veteran's symptoms do not meet the diagnostic criteria for PTSD under DSM-5 criteria
0 Veteran does not have a mental disorder Ula t conforms with DSM-5 criteria
O Veteran has another Mental Disorder dia2nosis
Continue to complete this Questio1Dl3ire and/or the Eating Disorder Questionnaire.
2. Currrnt diagnosrs
a. Mental Disorder Diagnosis #1
PTSD
Comments. if any:
Mental Disorder Diagnosis #2:
I Alcohol Abuse. In Remission
Comments. if any:
Mental Disorder Diai!Ilosis #3:
I Attention-Deficit. Hyperactive Disorder. Inattentive Type
Counnents, if an :
Diai!Ilosed since childhood and medicated durin~ childhood.
Mental Disorder Diai!Ilosis #4:
Comments. if any:
If additional diai!Iloses. describe usin~ above format :
b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI):
Comments. if any:
3. Difff'reotiation of svmptoms
3. Difff'reotiation of svmptoms
a. Does the Veteran have more than one mental disorder diagnosed?
[X] Yes 0 No
If yes. complete the following question (3b):
b. Is it possible to differentiate what symptom(s) is/are attributable to each diagnosis?
[X] Yes 0 No 0 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 and
discuss whether there is any clinical association between these diagnoses:
Discuss whether there is an clinical association between those diaenoses:
If yes, list which symptoms are attributable to each diagnosis and discuss whether there is any clinical association between these
dia101oses:
The veteran's difficulties with Alcohol Abuse do not currently impact functioning. since he bas abstained from alcohol since 2012.
He presents with significant PTSD symptoms which in1pact current functioning. resulting in problems maintaining relationships
with others, agitation. and excessive anxiety. The history is significant for a diagnosis of ADHD which binders ability to
concentrate.
c. Does the Veteran have a diagnosed traUDlatic brain injury (TBI)?
0 Yes [X] No 0 Not shown in records reviewed
4. Occupational and social impairml'nt
tom is attributable to each dial!llosis:
a. Which of the following best summarizes the Veter311's level of occupational and social impairment with regards to all mental
diagnoses?
(Check only one)
0 No mental disorder diagnosis
0 A mental condition has been foJIDally diagnosed. but symptoms are not severe enough either to interfere with occupational and
social functioning or to require continuous medication
O Occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perfonn
occupational tas.ks only during periods of significant s tress. or: symptoms controlled by medication
0 Occupational and social impaiJIDent with occasional decrease in work efficiency and intennittent periods of inability to perfonn
occupational tasks. although generally fimctioning satisfactorily. wiUt nol1llal routine behavior. self-care and conversation
0 Occupational and social impairment with reduced reliability and productivity
[X) Occupational and social impairment with deficiencies in most areas. such as work. school. family relations. judgment. thinking
and/or mood
0 Total occupational and social impairment
b. For the indicated level of occupational and social impaimtent. is it possible to differentiate what portion of the occupational and
social impaimtent indicated above is caused by each mental disorder?
[X) Yes 0 No O 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 impaiJIDent
is attributable to each diagnosis:
If yes. list which portion of the indicated level of occupational and social impainnent is attributable to each dial!llosis:
Veteran's diagnosis of Alcohol Abuse. In Remission is no longer impacting functioning. However, he continues ro present with
severe PTSD symptoms resulting in excessive anxiety. startle response, hyper vigilance. agitation. and maintaining relations with
others.
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?
0 Yes [] No [X) No diagnosis ofTBI
If no. provide reason that it is not possible to differentiate what portion of the indicated level of occupational and social impaiJIDent
is attributable to each dial!.Dosis:
If yes. list which portion of the indicated level of occupational aud social i.mpairtnent is attributable to each diagnos is:
_______________________________________________________________________
Leaving some stuff out.
________________________________________________________________________
4. PTSD Diagnostic Ct·itc.•r·ia
Please cht rk crtte1ia used ror establisWng the CUJTt nt PTSD diagnosis. Do ~OT mark symptoms below that are clearly not
attributable to the criteria A stressor/PTSD. Instead, overlapping symptoms clearly aflributable to other things sbould 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. 5tb edition {DSM-5).
Clittiion A: Exposure to actual or tbreatened a) death. b) serious injury. c) sexual violation. in one or more of tbe following ways:
[X) Directly experiencing the traumatic event(s)
O Witnessing. in person. tbe traumatic event(s) as they occurred to otbers
O Learning tbat the traumatic event(s) occurred to a close family member or close friend: cases of actual or threatened death must
bave been violent or accidental: or. experiencing repeated or extreme exposure to aversive details oftbe tramuatic event(s} (e.g ..
first responders collecting human remains: police officers repeatedly exposed to details of cbild abuse): Ulis does not apply to
exposure through electronic media. television. movies. or picrures. unless this exposure is work related
Cliterion B: Presence of (one or more) oftbe following intrusion symptorus associated with the traumatic event(s). beginning after
U1e traumatic event(s) occurred:
[X] Recurrent. involuntary. and intrusive distressing memories of tbe traumatic event(s).
[X} Recurrent disil-essing dreams in which tbe content and/or affect of tbe dreant are related to the traumatic event(s).
O Dissociative reactions (e.g .. flashbacks) in wh.icb Ute individual feels or acts as if the tramnatic e\·ent(s) were recurring. (Snell
reactions may occur on a continuum. witb the most extreme expression being a complete loss of awareness of present
stUTOimdings.)
0 Intense or prolonged psychological distress at exposure to internal or external cues tbat symbolize or resemble an aspect of tbe
traumatic event(s).
O Marked physiological reactions to internal or eJo.iernal cues tbat symbolize or resemble an aspect of tbe traumatic event(s).
Ctituion C: Persistent avoidance of stimuli associated witb tbe tramnatic evem(s). beginning after tbe traumatic event(s) occurred. as
evidenced by one or both of tbe following:
O Avoidance of or efforts to avoid distressing memories. tboughts. or feelings about or closely associated witb tbe traumatic event(s).
[X] Avoidance of or efforts to avoid external reminders (people. places, conversations, activities, objects, situations) tbat arouse
diStressing memories. thoughts. or feelings abom or closely associated with tbe rratmlatic event(s).
Clituion D: Negative alterations in cognitions and mood associated with tbe traumatic event(s), beginning or worsening after the
traumatic e\·em(s) occurred, as evidenced by two (or more) of Ute following:
0 Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative anmesia and not to other factors
such as bead injury. alcohol. or drugs).
O Persistent and exaggerated negative beliefs or expectations about oneselt albers. or tbe world (e.g .. "I am bad." "No one can be
trus ted." ·'The world is completely dangerous." "My whole nervous system is pennanently ruined").
O Persistent, distorted cognitions about the cause or consequences of tbe tramnatic event(s) tbat lead to the individual to blame
himself/herself or others.
O 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.
O Persistent inability to experience positive emotions (e.g., inability to experience happiness. satisfaction, or loving feelings.)
Ctiterlon E: Marked alterations in arousal and reactivity associated v,itllthe 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 (witb little or no provocation) typically expressed as verbal or physical aggression toward
people or objects.
[X} Reckless or self-destructh·e behavior.
[X} Hypervigilance
[X] Exaggerated startle response.
[X] Problems with concentration.
(X) Sleep disrurbance (e.g .. difficulty fallin!! or staying asleep or restless sleep).
Ctitt tion F:
[X} Duration of the disrurbance (Criteria B. C. D. and E) is more than 1 month.
Q·Herioo G:
(X) The disttu·bance causes clinically significant distress or impairment in social, occupational. or other imporrant areas of
functioning.
Ctiterioo 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 raring purposes. check all symptoms Uta! actiYely apply to lhe Veterans diagnoses. Text boxes after the symptoms can contain
information for addressing frequency. severity, duration. as well as additional pertinent comments.
[X} Depressed mood
[X) Anxiety
0 Suspiciousness
O Panic attacks rhar occur weekly or less often
0 Panic attacks more than once a week
0 Near<ontinuous panic or depression affecting the ability to function independently. appropriately and effectively
(X) Chronic sleep impairment
0 Mild memory loss. such as forgetting names. directioJlS or recent events
O Impairment of shorr· and long-rerm memory. for exatllple. retention of only highly learned material. while forgetting to complete
tasks
O Memory loss for names of close relatives. own occupation. or own name
(X) Flattened affect
0 Circumstantial, circumlocutory or stereotyped speech
O Speech intermittently illogical, obscure. or irrelevant
0 Difficulty in understanding complex coD1lllands
0 Impaired judgment
0 Impaired absn·act thinking
O Gross impairment in thought processes or communication
[X} Disturbances of motivation and mood
[X] Difficulty in establishing and maintaining effecti,·e work and social relationships
0 Difficulty in adapting to stressful circumstances. including work or a work like setting
0 Inability ro establish and maintain effective relatioliShips
0 Suicidal ideation
O Obsessional rituals which interfere with routine activities
O Impaired impulse control. such as unprovoked irritability with periods of violence
0 Spatial disorientation
O Persistent delusions or hallnciuatio.ns
0 Grossly inappropriate behavior
0 Persistent danger of hurting self or others
O Neglect of personal appearance and hygiene
O intermittent inability ro perform activities of daily li\·ing. including mainrenance of minimal personal hygiene
0 Disorientation to time or place
Behavioral Observations:
Vereran presented as alert and well oriented. He presented as casually dressed. with marginal grooming and adequate hygiene. He
required no assistive devices and presenred with normal motor functioning. He reporred dyshphoric mood. frustration related to
ongoing concentration difficulties impacting his ability to succeed in school. poor sleep. excessive anxiety. starrle response. hyper
vigilance. difficulty maintaining relationships. He appeared uncomfortable and anxious during !be interview. with a soft and
trembling voice. He denied self-injurious ideation. plan. and intent. He did nor present as a danger to self or ollters.
DBQ lnitial Post· Traumatic Stress Disorder (PTSD)-DSM V
Sorry for the twerked words here and there, had trouble converting the scanned pdf document into something readable.
I'm already in with a private provider for EMDR therapy and start next week. Any thoughts on my rating level would be appreciated.
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Navy04
I am with NavyWIfe and John999 on this one. Too many Vets want to talk about their Alcohol or Drug Addiction. I am not down playing those two conditions as they are very serious. I always tell Vets ge
11cvolley
Luckily they didn't use my habit of missing school to hangout with friends against me. I agree with John, DO NOT disclose more than you need to, keep it short and simple, and tell the truth.
Navy04
Larry good luck on your appeal bud. MBL, sorry to hear of your troubles, but remember that you can always put in for an increase. When I was Medically Retired last year the VA only gave me 30% for PTS
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