Hello I was wondering if you guys can help me, and let me know what you think about my C&P exam. If you think that I will get a rating then what you think it might be. Thank you all.
SECTION I:
----------
1. Diagnostic Summary
---------------------
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: PTSD, chronic
Comments, if any:
The veteran also has depressive moods, but they are as likely as
not related to his PTSD.
b. Medical diagnoses relevant to the understanding or management of the
Mental Health Disorder (to include TBI): Migraine headaches; back pain
3. Differentiation of symptoms
------------------------------
a. Does the Veteran have more than one mental disorder diagnosed?
[ ] Yes [X] No
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 conversation
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 [ ] No [X] No other mental disorder has been diagnosed
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 [X] No
2. History
----------
a. Relevant Social/Marital/Family history (pre-military, military, and
post-military):
Pre-Military - The veteran was born in the Dominican Republic, but his
family came to the U.S. when he was approximately 3 years old. He grew
up in Lynn, MA, in an intact family until age 13 when his parents
divorced. After the divorce, the veteran stayed with his mother who
did
not re-marry. He has one sister and two half-sisters (on his father's
side). There was no physical abuse during his childhood. He felt that
both of his parents were caring to him. His father stayed in contact
with him after he divorced the veteran's mother. The veteran also
reports that he had many aunts in the area and thus he had a big
extended family. He further notes that there were many children in his
neighborhood with whom he could play. The family also stayed in touch
with their relatives in the Dominican Republic.
Military - The veteran was in the Army from 1999-2002. He then was in
the Army Reserves and his unit was called up to serve in Iraq. He
served in Iraq for 12 months in 2003-4. In Iraq, he worked as a
petroleum supply specialist. He was first sent to Korea where he
states
that he got the difficult details. He was to change a tire but he was
called to another detail. He had a friend who was then asked to change
the tire. The tire exploded in his friend's face and he was killed.
This man had a newborn child at home whom he had never seen. The
veteran felt that this loss was heartbreaking. It was also a situation
where he could have been the victim. In another incident in Iraq, he
had gotten back from working security and he heard a big bang. He and
a
friend rushed to see what had happened. An Iraqi enemy group had
rammed
the barrier of an Italian military Police station with a truck. Then
they drove a car throught the breach and blew up the Police station.
The veteran found people who had beeen blown in half and many other
body parts. Over 30 people died in the explosion. It was a horrifying
event. The veteran also experienced alerts that signified possible
danger. He feels that he adapted to these alerts.
Post-Military - The veteran has never married, but he has a girlfriend
whom he met after his military service and they have an 8 year old
son.
They live in Lynn in a rented apartment. When the veteran first got
out
of the military, he moved to Florida to attend Valencia Community
College in computer technology. He met his girlfriend there. He
reports
that, after his war experience, he was somewhat withdrawn and did not
like to go out. He feels that this affected his girlfriend and,
although they had a child, they broke up for 4-5 years. They decided
to
give it another try about 2 years ago. During the separation, he
maintained contact with his son. The veteran moved to MA in 2010 to be
closer to his family. His girlfriend and his son then moved up here to
be with him in 2012. For the past 2 and 1/2 years, he has worked in IT
for Draeger Company which makes medical equipment. He states that he
and his girlfriend have matured and are able to tolerate each other's
differences better. He reports that he is still easily irritated,
however, and he sometimes feels that he has trouble with the demands
that an 8 year old son can make on him. He denies using any physical
pu
nishment with his son. The veteran states that his mother has
encouraged him to seek mental health care. He feels that she has done
this in a supportive way.
b. Relevant Occupational and Educational history (pre-military, military,
and
post-military):
Pre-Military - The veteran graduated from high school and joined the
Army. He reports that he was a B to C type student. He was never held
back a grade. He had no known learning problems. He states that he
played football in high school. In the summers, he worked in summer
camps that were sponsored by the city and he also worked at a
MacDonald's.
Military - As noted above, in Iraq, the veteran worked as a petroleum
supply specialist. He reports that he frequently inhaled fumes on his
job.
Post-Military - Immediately after his military service, the veteran
did
some contract IT work and one of his contracts was with Draeger
Company. Draeger then decided to hire him into a full time position.
He
has been employed by Draeger for 2 and 1/2 years. He feels that they
are satisfied with his performance. There are times when he gets
irritated and needs to take a break and get outside. He states that
his
supervisors have been tolerant of these needs. The veteran is also
taking college classes on-line. His objective is to get a bachelor's
degree in IT. He feels that he is doing well in his courses. He is
about 20 credits away from getting his bachelor's degree.
c. Relevant Mental Health history, to include prescribed medications and
family mental health (pre-military, military, and post-military):
Pre-Military - The veteran did not need and was not referred for
mental
health care prior to entry into the Army.
Military - The veetran was not referred to and did not seek mental
health care while in the Army or the Army Reserves.
Post-Military - When living in Florida after his Iraq War experience,
the veteran felt very frustrated and sought care at the VA Clinic in
Kissemmee, FL. He was seen there for a few sessions but he felt
embarrassed to be seeking psychological care and he dropped out. In
Massachusetts, he has sought treatment at the VA Clinic in Lynn. He
sees Dr. Dennis O'Neil, a psychiatrist, about once every 2 months. Dr.
O'Neil is treating him for PTSD and depression and he prescribes
zoloft
and trazadone. The veteran feels that the medication has helped with
his mood and it seems to allow him to get out socially a bit more.
d. Relevant Legal and Behavioral history (pre-military, military, and
post-military):
Pre-Military - The veteran did not have legal or disciplinary problems
prior to entry into the Army.
Military - The veteran did not have any disciplinary problems while in
the Army or the Army Reserves.
Post-Military - The vetran has not had any legal or disciplinary
problems since leaving military service.
e. Relevant Substance abuse history (pre-military, military, and
post-military):
Pre-Military - The veteran did not have a problem with alcohol or
drugs
prior to his military service.
Military - The veteran drank on the weekends while in the Army. He
became drunk on some occasions, but he denies that his drinking then
created any problems for him in regard to carrying out his military
duties. He did not abuse other drugs.
Post-Military - The veteran reports that when he first got out of the
military, the only way he could be happy was to drink alcohol. He
drank
every other day and he would drink to intoxication. He feels that he
drank to improve his mood. Currently, the veteran has about 1-2 drinks
on a weekend and that's about all. He does not abuse drugs.
f. Other, if any:
No response provided.
3. Stressors
------------
a. Stressor #1: While stationed in Korea, the veteran was to change a tire
but he was called to another detail. He had a friend who was then
asked
to change the tire. The tire exploded in his friend's face and he was
killed. This man had a newborn child at home whom he had never seen.
The veteran felt that this loss was heartbreaking. It was also a
situation where he could have been the victim.
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?
[ ] Yes [X] No
Is the stressor related to personal assault, e.g. military sexual
trauma?
[ ] Yes [X] No
b. Stressor #2: In an incident in Iraq, the veetran had gotten back from
working security and he heard a big bang. He and a friend rushed to
see
what had happened. An Iraqi enemy group had rammed the barrier of an
Italian Military Police station with a truck. Then they drove a car
through the breach and blew up the Police station. The veteran found
people who had beeen blown in half and many other body parts. Over 30
people died in the explosion. It was a horrifying event.
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
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] Intense or prolonged psychological distress at exposure 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).
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] 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] Suspiciousness
[X] Chronic sleep impairment
[X] Mild memory loss, such as forgetting names, directions or recent
events
[X] Disturbances of motivation and mood
[X] Difficulty in establishing and maintaining effective work and social
relationships
[X] Obsessional rituals which interfere with routine activities
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?
[X] Yes [ ] No
If yes, describe:
The veetran has survivor guilt in regard to the event in Korea
when
his friend was killed attempting to change a tire that exploded.
8. Competency
-------------
Is the Veteran capable of managing his or her financial affairs?
[X] Yes [ ] No
9. Remarks, if any
------------------
This veteran meets criteria for a DSM-5 diagnosis of PTSD with associated
depressive feelings. His PTSD has clearly had an effect on his
relationships with his significant other and with his son. At work, when
suffering from PTSD-related frustration and irritability, he is able to
take a time out and stabilize himself. he has also been able to take
college courses on-line. His disability is as likely as not
mild-moderate.
NOTE: VA may request additional medical information, including additional
examinations if necessary to complete VA's review of the Veteran's
Question
gmankd
Hello I was wondering if you guys can help me, and let me know what you think about my C&P exam. If you think that I will get a rating then what you think it might be. Thank you all.
SECTION I:
----------
1. Diagnostic Summary
---------------------
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: PTSD, chronic
Comments, if any:
The veteran also has depressive moods, but they are as likely as
not related to his PTSD.
b. Medical diagnoses relevant to the understanding or management of the
Mental Health Disorder (to include TBI): Migraine headaches; back pain
3. Differentiation of symptoms
------------------------------
a. Does the Veteran have more than one mental disorder diagnosed?
[ ] Yes [X] No
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 conversation
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 [ ] No [X] No other mental disorder has been diagnosed
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 [X] No
2. History
----------
a. Relevant Social/Marital/Family history (pre-military, military, and
post-military):
Pre-Military - The veteran was born in the Dominican Republic, but his
family came to the U.S. when he was approximately 3 years old. He grew
up in Lynn, MA, in an intact family until age 13 when his parents
divorced. After the divorce, the veteran stayed with his mother who
did
not re-marry. He has one sister and two half-sisters (on his father's
side). There was no physical abuse during his childhood. He felt that
both of his parents were caring to him. His father stayed in contact
with him after he divorced the veteran's mother. The veteran also
reports that he had many aunts in the area and thus he had a big
extended family. He further notes that there were many children in his
neighborhood with whom he could play. The family also stayed in touch
with their relatives in the Dominican Republic.
Military - The veteran was in the Army from 1999-2002. He then was in
the Army Reserves and his unit was called up to serve in Iraq. He
served in Iraq for 12 months in 2003-4. In Iraq, he worked as a
petroleum supply specialist. He was first sent to Korea where he
states
that he got the difficult details. He was to change a tire but he was
called to another detail. He had a friend who was then asked to change
the tire. The tire exploded in his friend's face and he was killed.
This man had a newborn child at home whom he had never seen. The
veteran felt that this loss was heartbreaking. It was also a situation
where he could have been the victim. In another incident in Iraq, he
had gotten back from working security and he heard a big bang. He and
a
friend rushed to see what had happened. An Iraqi enemy group had
rammed
the barrier of an Italian military Police station with a truck. Then
they drove a car throught the breach and blew up the Police station.
The veteran found people who had beeen blown in half and many other
body parts. Over 30 people died in the explosion. It was a horrifying
event. The veteran also experienced alerts that signified possible
danger. He feels that he adapted to these alerts.
Post-Military - The veteran has never married, but he has a girlfriend
whom he met after his military service and they have an 8 year old
son.
They live in Lynn in a rented apartment. When the veteran first got
out
of the military, he moved to Florida to attend Valencia Community
College in computer technology. He met his girlfriend there. He
reports
that, after his war experience, he was somewhat withdrawn and did not
like to go out. He feels that this affected his girlfriend and,
although they had a child, they broke up for 4-5 years. They decided
to
give it another try about 2 years ago. During the separation, he
maintained contact with his son. The veteran moved to MA in 2010 to be
closer to his family. His girlfriend and his son then moved up here to
be with him in 2012. For the past 2 and 1/2 years, he has worked in IT
for Draeger Company which makes medical equipment. He states that he
and his girlfriend have matured and are able to tolerate each other's
differences better. He reports that he is still easily irritated,
however, and he sometimes feels that he has trouble with the demands
that an 8 year old son can make on him. He denies using any physical
pu
nishment with his son. The veteran states that his mother has
encouraged him to seek mental health care. He feels that she has done
this in a supportive way.
b. Relevant Occupational and Educational history (pre-military, military,
and
post-military):
Pre-Military - The veteran graduated from high school and joined the
Army. He reports that he was a B to C type student. He was never held
back a grade. He had no known learning problems. He states that he
played football in high school. In the summers, he worked in summer
camps that were sponsored by the city and he also worked at a
MacDonald's.
Military - As noted above, in Iraq, the veteran worked as a petroleum
supply specialist. He reports that he frequently inhaled fumes on his
job.
Post-Military - Immediately after his military service, the veteran
did
some contract IT work and one of his contracts was with Draeger
Company. Draeger then decided to hire him into a full time position.
He
has been employed by Draeger for 2 and 1/2 years. He feels that they
are satisfied with his performance. There are times when he gets
irritated and needs to take a break and get outside. He states that
his
supervisors have been tolerant of these needs. The veteran is also
taking college classes on-line. His objective is to get a bachelor's
degree in IT. He feels that he is doing well in his courses. He is
about 20 credits away from getting his bachelor's degree.
c. Relevant Mental Health history, to include prescribed medications and
family mental health (pre-military, military, and post-military):
Pre-Military - The veteran did not need and was not referred for
mental
health care prior to entry into the Army.
Military - The veetran was not referred to and did not seek mental
health care while in the Army or the Army Reserves.
Post-Military - When living in Florida after his Iraq War experience,
the veteran felt very frustrated and sought care at the VA Clinic in
Kissemmee, FL. He was seen there for a few sessions but he felt
embarrassed to be seeking psychological care and he dropped out. In
Massachusetts, he has sought treatment at the VA Clinic in Lynn. He
sees Dr. Dennis O'Neil, a psychiatrist, about once every 2 months. Dr.
O'Neil is treating him for PTSD and depression and he prescribes
zoloft
and trazadone. The veteran feels that the medication has helped with
his mood and it seems to allow him to get out socially a bit more.
d. Relevant Legal and Behavioral history (pre-military, military, and
post-military):
Pre-Military - The veteran did not have legal or disciplinary problems
prior to entry into the Army.
Military - The veteran did not have any disciplinary problems while in
the Army or the Army Reserves.
Post-Military - The vetran has not had any legal or disciplinary
problems since leaving military service.
e. Relevant Substance abuse history (pre-military, military, and
post-military):
Pre-Military - The veteran did not have a problem with alcohol or
drugs
prior to his military service.
Military - The veteran drank on the weekends while in the Army. He
became drunk on some occasions, but he denies that his drinking then
created any problems for him in regard to carrying out his military
duties. He did not abuse other drugs.
Post-Military - The veteran reports that when he first got out of the
military, the only way he could be happy was to drink alcohol. He
drank
every other day and he would drink to intoxication. He feels that he
drank to improve his mood. Currently, the veteran has about 1-2 drinks
on a weekend and that's about all. He does not abuse drugs.
f. Other, if any:
No response provided.
3. Stressors
------------
a. Stressor #1: While stationed in Korea, the veteran was to change a tire
but he was called to another detail. He had a friend who was then
asked
to change the tire. The tire exploded in his friend's face and he was
killed. This man had a newborn child at home whom he had never seen.
The veteran felt that this loss was heartbreaking. It was also a
situation where he could have been the victim.
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?
[ ] Yes [X] No
Is the stressor related to personal assault, e.g. military sexual
trauma?
[ ] Yes [X] No
b. Stressor #2: In an incident in Iraq, the veetran had gotten back from
working security and he heard a big bang. He and a friend rushed to
see
what had happened. An Iraqi enemy group had rammed the barrier of an
Italian Military Police station with a truck. Then they drove a car
through the breach and blew up the Police station. The veteran found
people who had beeen blown in half and many other body parts. Over 30
people died in the explosion. It was a horrifying event.
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
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] Intense or prolonged psychological distress at exposure 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).
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] 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] Suspiciousness
[X] Chronic sleep impairment
[X] Mild memory loss, such as forgetting names, directions or recent
events
[X] Disturbances of motivation and mood
[X] Difficulty in establishing and maintaining effective work and social
relationships
[X] Obsessional rituals which interfere with routine activities
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?
[X] Yes [ ] No
If yes, describe:
The veetran has survivor guilt in regard to the event in Korea
when
his friend was killed attempting to change a tire that exploded.
8. Competency
-------------
Is the Veteran capable of managing his or her financial affairs?
[X] Yes [ ] No
9. Remarks, if any
------------------
This veteran meets criteria for a DSM-5 diagnosis of PTSD with associated
depressive feelings. His PTSD has clearly had an effect on his
relationships with his significant other and with his son. At work, when
suffering from PTSD-related frustration and irritability, he is able to
take a time out and stabilize himself. he has also been able to take
college courses on-line. His disability is as likely as not
mild-moderate.
NOTE: VA may request additional medical information, including additional
examinations if necessary to complete VA's review of the Veteran's
application.
Link to comment
Share on other sites
Top Posters For This Question
3
1
1
1
Popular Days
Jun 20
6
Top Posters For This Question
gmankd 3 posts
Berta 1 post
USMC_HVEQ 1 post
Navy04 1 post
Popular Days
Jun 20 2014
6 posts
Popular Posts
Navy04
Occupational impairment in some areas usually awards 10% or if you are lucky 30%. Good luck and keep us posted. I was low balled 30% PTSD when I retired last year, and now I am 70%. So you can alway
5 answers to this question
Recommended Posts
Create an account or sign in to comment
You need to be a member in order to leave a comment
Create an account
Sign up for a new account in our community. It's easy!
Register a new accountSign in
Already have an account? Sign in here.
Sign In Now