ptsd Possible Rating Even With The Mess That Happened (See Prior Post)

[armyvet2010]

Hello everyone,I was finally able to copy my c&p notes from myhealthevet to get everyones opinion on a possible rating eventhough the exam was not done correctly.

I already posted about how my C&P exam went (see prior post) and since i wasn't able to scan a copy of my exam,i got it from myhealthevet.Can i get a possible rating opinion from you all?Just wanted to see where I might possibly get awarded or even get a denial...

SECTION I:

1. Diagnostic Summary

This section should be completed based on the current examination and clinical

findings.

Does the Veteran have a diagnosis of PTSD that conforms to DSM5 criteria based

on today's evaluation?

__Yes _X_ No

ICD code:

If no diagnosis of PTSD, check all that apply:

_X_ Veteran's symptoms do not meet the diagnostic criteria for PTSD under

DSM-5

criteria

__ Veteran does not have a mental disorder that conforms with DSM-5 criteria

_X_ Veteran has another mental disorder diagnosis. Continue to complete this

Questionnaire AND/OR the Eating Disorder Questionnaire:

2. Current Diagnoses

Mental Disorder Diagnosis #1: Major Depressive Disorder, with anxious distress

Comments, if any:_____________________

Mental Disorder Diagnosis #2: Alcohol Use Disorder

Comments, if any: __________________

Medical diagnoses relevant to the understanding or management of the Mental

Health Disorder (to include TBI): NA

3. Differentiation of symptoms

a. Does the Veteran have more than one Mental disorder diagnosed?

_X_ Yes __ No

If yes, complete the following question:

b. Is it possible to differentiate what symptom(s) is/are attributable to each

diagnosis?

_X_ Yes __ No __ (N/A)

If yes, list which symptoms are attributable to each diagnosis:

MDD with anxious distress: depressed mood, depressive ruminations which disrupt

sleep, poor energy, increased appetite with significant weight gain, guilt

feelings about past life decisions, diminished interest/pleasure

Alcohol use Disorder: increased consumption; increased tolerance; continued use

despite negative impact to mood.

c. Does the Veteran have a diagnosed traumatic brain injury (TBI)?

__ Yes __ No _X_ Not shown in records reviewed

d. Is it possible to differentiate what symptom(s) is/are attributable to each

diagnosis?

__ Yes __ No X__ (N/A)

4. Occupational and social impairment

a. Which of the following best summarizes the Veteran's level of

occupational

& social impairment with regards to all mental diagnoses? (Check/Retain

only

one and EXPLAIN RATIONALE)

__ No mental disorder diagnosis

__ A mental condition has been formally diagnosed, but symptoms are not severe

enough either to interfere with occupational and social functioning or to

require continuous medication

__ Occupational and social impairment due to mild or transient symptoms which

decrease work efficiency and ability to perform occupational tasks only during

periods of significant stress, or; symptoms controlled by medication

_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

__ Occupational and social impairment with reduced reliability and productivity

__ Occupational and social impairment with deficiencies in most areas, such as

work, school, family relations, judgment, thinking and/or mood

__ Total occupational and social impairment

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:

primarily impacted by depressive features.

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

If yes, list which portion of the indicated level of occupational and

social impairment is attributable to each diagnosis:

Section II: Clinical Findings

1. Evidence review

In order to provide an accurate medical opinion, the Veteran's claims

folder must be reviewed.

Medical record review

Was the Veteran's [paper] VA claims file reviewed? No

Was the Veteran's VA e-folder (VBMS or Virtual VA) reviewed? No - VBMS gave

error code

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

__X__ 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? No

2. History

a. Relevant Social/Marital/Family history (pre-military, military, and post-

military):

Veteran was born in Indianapolis, IN and raised in the St Louis, MO area until

the end of her 9th grade year. Veteran was raised by her mother and step-father

from the age of 5. She reports that her biological father lived in TN and she

had relatively frequent telephone contact and in-person every few mo

nths. She

has four half-siblings, two each from her biological parents. She was raised

with one half-sister in the home, 9 years her senior. She and her mother and

step-father moved to Cleveland, OH during her 9th grade year where she graduated

from high school. She returned to the St Louis area after graduation from high

school.

Veteran denies childhood history of trauma or maltreatment.

Veteran married in May, 2008 during leave from her deployment. They separated

while veteran was still on active duty, in July 2009, and the divorce was

finalized in Feb, 2012.

Veteran has one daughter, born Sept 2010. Veteran does not have contact with

the child's father.

Veteran has lived with her mother and daughter since her discharge in Sept,

2010. She and her mother and daughter moved to NC from May 2013 until Jan 2014

which veteran reports was so that her mother could assist with the care of her

grandmother.

Veteran denies that she has maintained contact with her friends. She states

that her friends began "acting weird" toward her and she perceives that

she was

being judged for her "PTSD." She states that she does not keep up with

her

friends any longer and spends her time at home in her room if she is not at

work. She describes that limited finances restrict her activities and she and

her daughter primarily watch movies at home. She states that her limited

finances interfere with her prioritizing her own interests (i.e., keeping up her

hairstyle, clothing). She describes that she would like to have friends, go to

the movies, go to the mall but most days "I don't want to be

bothered."

b. Relevant Occupational, Educational, & Military history (pre-military,

military, and post-military):

Veteran graduated high school in 2005. She denies academic or behavior problems

during her school years. She describes that she had a wide social network but

did not participate in school-sponsored sports/activities.

Veteran states that her biological parents, step-father, two elder siblings had

served in the military which contributed to her decision to enlist in the USA in Nov, 2006. She completed basic training and AIT at Ft Jackson, SC. She was trained as a human resources specialist and her job included postal operations.

She was stationed at Ft Hood, TX. Veteran deployed to Afghanistan from Jan,

2008 to April, 2009 where her duties were strictly related to postal operations.

Veteran received a Chapter 8 discharge for "pregnancy and childbirth"

in Sept,

2010. She achieved the rank of E4 at the time of discharge. She denies

administrative or disciplinary action during her military career.

Veteran moved to the Belleville, IL area after her military discharge. Veteran

has attended SWIC and recently transferred to UMSL. She states that she

primarily takes online courses and is presently enrolled in 5 classes (summer

semester). She is expected to graduate in Spring, 2014 with a degree in

criminal justice. She describes that her concentration is "off" and

she is

attaining mostly a "C" average.

She was employed, briefly, in 2012 as a housekeeper at the St Louis VAMC but

"I

left on my own...I felt the supervisor was picking on me...she knew I was on

medication and had appointments in this building...I just left before I did

something I did not want." She recently became employed 30 hours per week

with

USAREC as an administrative assistant (June, 2014). She denies any other

employment since Sept, 2009.

She receives some income from the GI bill and child support.

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

mental health (pre-military, military, and post-military):

Veteran denies mental health treatment prior to military service.

Veteran describes that she had "suicidal thoughts" prior to deployment.

She

states that somehow "it got around to the whole company" and she states

that she

felt stigmatized by the other soldiers. She describes that she had problems

with leadership "they always seemed to pick on me a lot...it was always

favoritism, they always picked me to do details...and they had their favorites

in the company...always put me on CQ...it just got to me where I was having

suicidal thoughts." She denies that she actually had plan or intent for

harm.

She was taken to the R&R on post and she was referred off-post to see a

psychologist. She recalls that this occurred 6-7 months prior to deployment.

Although veteran denies any mental health distress prior to service, this

examiner is in agreement with Dr O'Connor's assessment that, "it

would be

unusual for such stressors to lead to SI in persons with no MH history."She reports that she experienced "suicidal thoughts" during her deployment. She states that she spoke with a chaplain during her deployment and did notparticipate in further mental health treatment at that time.Veteran completed a thorough mental health diagnostic interview, focused on her desire for treatment of PTSD, at the PTSD clinic at Jefferson Barracks VAMC in Jan, 2013. Dr Shawn O'Connor completed the interview and identified, "The veteran reported that she has a long history of significant depressive symptoms dating back to 2007, prior to her deployment, for which she received treatment in the service, both stateside prior to deployment, and then immediately after arriving in OEF. The veteran reported that she wanted to 'get medications and get someone to fill out my disability benefits questionnaire.'"Veteran was determined not meet criteria for PTSD at that time. Dr O'Connor specifically noted that the veteran's complaints were related to interpersonal functioning rather than specific to her deployment/combat experiences.

Veteran moved to NC, briefly, in 2013 wherein she continued mental health

treatment. She was provided a diagnosis of PTSD, however, a full diagnostic

interview during which specific symptoms were detailed was not completed. Thus,

this diagnosis is not viewed as particularly accurate.

Veteran resumed treatment at the St Louis VAMC in April, 2014 with psychiatry

services only. She was provided diagnoses of Dysthymic Disorder and Rule out

Axis II (personality disorder). She is prescribed Fluoxetine and Trazodone

which she reports taking daily, as directed.

Veteran describes that she has become increasingly irritable and uncomfortable,

particularly around men. She describes that she experiences

"outbursts" and has

been known to throw objects or walk away from the situation. She describes that

she experiences "panic attacks" with SOB, increased heart rate and

"I feel real

nervous", which she states occurs 3-4 times per week lasting 5-10 minutes

per

occasion. She states that this typically happens while she is at home, alone,

in her room "my mind wanders off...thinking about different things that

happened

to me...and that is when it happens." She describes that she becomes

distracted

while watching television thinking about "how I am now...the personal

assault

and everything with the military period...why is this happening to me, is it my

fault. Things just haven't been right since I joined the military."

She reports that she has nightmares about being physically assaulted or "the

deployment...bombs going off..." 4-5 times per week. She reports that the

dreams awaken her and she is unable to return to sleep. She describes that she

initially retires to bed at 10/1030pm, watches TV in bed but turns the TV off to

go to sleep. She reports sleep onset delay of 30-60 minutes and awakens 3-4

hours later. She states that she blames herself for joining the military

"that

is when my life started going downhill...feeling bad that I can't provide

for

my daughter...I always have that guilt." She states that if she is able to

return to sleep after waking, she is only able to remain asleep for one hour.

She is typically awake for the day at 0500.

Veteran goes to work from 0830-1530, rides the metro link to and from work, and

comes straight home after work. She spends her at-home time watching

television, completing school work and looking at the internet. She denies that

she is involved in any activities outside of work and school assignments.

Veteran's mother cares for her daughter while she is at work.

She describes that her mood is such that "I don't like being around

people."

She states that "I feel like people will judge me for what I have been going

through. I am afraid I might have my outbursts or say things I don't need

to be

saying...any little thing a person does will bother me." She states that

she

had to inform her employer (USAREC) that she had a C&P appointment today

"they

don't think I have PTSD..." She states that she feels that the active

duty

members with whom she works judge her negatively and do not believe that she has

PTSD which makes her feel uncomfortable around them.

Veteran endorsed depressive rumination, low energy, diminished interest,

appetite increased "I overeat" and she reports that her typical weight

was 145-

155 and "now I am at 240" which she states is her highest weight and

that it has

steadily increased since 2010. She attributes the weight gain to over-eating

and increased alcohol consumption. She also endorses guilt and poor

concentration. She denies actual SI, plan or intent but endorses occasional

thoughts of "what would it be like if I weren't here."

d. Relevant Legal & Behavioral history (pre-military, military, and

post-

military):

Veteran reports that her spouse was verbally abusive and "very

controlling."

She relates an incident in July 2009 during which her spouse pushed her down and

began to physically assault her about the face and arms. She states that he

became destructive to property in their home. Veteran filed charges against her

spouse and requested an order of protection.

e. Relevant Substance abuse history (pre-military, military, and post-military):

Veteran reports that during her military service she typically consumed alcohol

3 times per week. She reports that consumption over the past 3 years has been 5

times per week, 2-3 "cups" of wine cooler, or "straight"

tequila or Smirnoff

which, per veteran, equates to a fifth of alcohol, twice per week.

"When I drink, it is to help me feel better...about myself in a lot of

ways..."

She denies use of illicit substances.

f. Other, if any:

3. Stressors

The stressful event can be due to combat, personal trauma, other life

threatening situations (non-combat related stressors).

NOTE: For VA purposes, "fear of hostile military or terrorist activity"

means

that a veteran experienced, witnessed, or was confronted with an event or

circumstance that involved actual or threatened death or serious injury, or a

threat to the physical integrity of the veteran or others, such as from an

actual or potential improvised explosive device; vehicle-imbedded explosive

device; incoming artillery, rocket, or mortar fire; grenade; small arms fire,

including suspected sniper fire; or attack upon friendly military aircraft.

Describe one or more specific stressor event (s) the Veteran considers

traumatic (may be pre-military, military, or post-military):

a. Stressor #1:

Veteran reports that their FOB was attacked several times per day, and during

the night, by rockets and mortars. She describes that her postal mission

included having to travel by convoy to complete the postal mission. She

describes that she was aware of others being injured killed on convoy missions

and she was "always scared" while on convoys which she states occurred

3 times

per week, "just the thought of, 'what if I get killed'".

Does this stressor meet Criterion A (i.e., is it adequate to support the

diagnosis of PTSD)? Yes

Is the stressor related to the Veteran's fear of hostile military or

terrorist activity? Yes

Is the stressor related to personal assault, e.g. military sexual trauma? No

b. Stressor #2:

July 2009 - assault by former spouse

Does this stressor meet Criterion A (i.e., is it adequate to support the

diagnosis of PTSD)? Yes

Is the stressor related to the Veteran's fear of hostile military or

terrorist activity? No

If no, explain: not military

Is the stressor related to personal assault, e.g. military sexual trauma? Yes

If yes, please describe the markers that may substantiate the stressor:

police report

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 (DSM-5).

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

sexual violation, in one or more of the following ways:

_X_ Directly experiencing the traumatic event(s)

_X_ Witnessing, in person, the traumatic event(s) as they occurred to others

__ Learning that the traumatic event(s) occurred to a close family

member or close friend; cases of actual or threatened death must have been

violent or accidental; or, experiencing repeated or extreme exposure to

aversive details of the traumatic events(s) (e.g., first responders collecting

human remains; police officers repeatedly exposed to details of child abuse);

this does not apply to exposure through electronic media, television, movies,

or pictures, unless this exposure is work-related.

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:

__ Recurrent, involuntary, and intrusive distressing memories of the

traumatic event(s).

_X_ Recurrent distressing dreams in which the content and/or effect of

the dream are related to the traumatic event(s).

__ Dissociative reactions (e.g., flashbacks) in which the individual

feels or acts as if the traumatic event(s) were recurring. (Such reactions may

occur on a continuum, with the most extreme expression being a complete loss of

awareness of present surroundings).

__ Intense or prolonged psychological distress at exposure to internal

or external cues that symbolize or resemble an aspect of the traumatic event(s).

__ 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:

__ Avoidance of or efforts to avoid distressing memories, thoughts, or

feelings about or closely associated with the traumatic event(s).

__ 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:

__ Inability to remember an important aspect of the traumatic event(s)

(typically due to dissociative amnesia and not to other factors such as head

injury, alcohol, or drugs).

__ 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").

__ Persistent, distorted cognitions about the cause or consequences of the

traumatic event(s) that lead to the individual to blame himself/herself or

others.

__ Persistent negative emotional state (e.g., fear, horror, anger, guilt, or

shame).

__ Markedly diminished interest or participation in significant activities.

__ Feelings of detachment or estrangement from others.

__ 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:

__ Irritable behavior and angry outbursts (with little or no provocation)

typically expressed as verbal or physical aggression toward people or object




__ Reckless or self-destructive behavior.
__ Hypervigilance.

__ Exaggerated startle response.

__ Problems with concentration.

_X_ Sleep disturbance (e.g., difficulty falling or staying asleep or restless

sleep).

Criterion F:

__ Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month.

Criterion G:

__ The disturbance causes clinically significant distress or impairment in

social, occupational, or other important areas of functioning.

Criterion H:

__ 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 Veteran's

diagnoses:

The veteran was advised to present to the JC ER should he experience

any active suicidal or homicidal ideation; he readily agreed to do so, should

the need arise. The veteran was also given multiple 24-hour crisis hotline

numbers. Given that the veteran denied current SI/HI, plan, or intent, was

futuristic in his thinking, and contracted to access emergency services, should

the need arise, he is considered sustainable as an outpatient at this time.

_X_ Depressed mood

_X_ Anxiety

__ Suspiciousness

__ Panic attacks that occur weekly or less often

__ Panic attacks more than once a week

__ Near-continuous panic or depression affecting the ability to function

independently, appropriately and effectively

_X_ Chronic sleep impairment

__ Mild memory loss, such as forgetting names, directions or recent events

__ Impairment of short- and long-term memory, for example, retention of only

highly learned material, while forgetting to complete tasks

__ Memory loss for names of close relatives, own occupation, or own name

__ Flattened affect

__ Circumstantial, circumlocutory or stereotyped speech

__ Speech intermittently illogical, obscure, or irrelevant

__ Difficulty in understanding complex commands

__ Impaired judgment

__ Impaired abstract thinking

__ Gross impairment in thought processes or communication

__ Disturbances of motivation and mood

__ Difficulty in establishing and maintaining effective work and social

relationships

__ Difficulty in adapting to stressful circumstances, including work or a work-

like setting

__ Inability to establish and maintain effective relationships

__ Suicidal ideation

__ Obsessional rituals which interfere with routine activities

__ Impaired impulse control, such as unprovoked irritability with periods of

violence

__ Spatial disorientation

__ Persistent delusions or hallucinations

__ Grossly inappropriate behavior

__ Persistent danger of hurting self or others

__ Neglect of personal appearance and hygiene

__ Intermittent inability to perform ADLs, including maintaining minimal

personal hygiene

__ Disorientation to time or place

Behavioral Observations:

Veteran arrived on time, appropriately dressed and responded appropriately

throughout the examination. No obvious difficulties with speech,

concentration, gait, orientation or fund of knowledge were observed.

Veteran appeared to provide an accurate representation of his current

mental health status.

6. 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: increased alcohol consumption

7. Competency

Is the Veteran capable of managing his or her financial affairs?

_X_ Yes __ No

8. Remarks, if any:

Per VA mandate, all C&P examinations conducted after 12/1/2013 should

utilize

DSM-5 diagnostic criteria, but should also note in the remarks whether the

veteran's diagnostic status would differ if DSM-IV TR diagnostic criteria

were utilized. These guidelines were adhered to for today's evaluation. Please

see below. Based on today's report of symptoms and a review of the veteran's

medical records it is the opinion of this examiner that the veteran does NOT meet

criteria for a diagnosis of PTSD. Although she identifies Criterion A stressor

and symptoms of re-experiencing the event(s), she does not identify sufficient

symptoms from the remaining criteria to warrant a diagnosis of PTSD. Her

symptoms appear to be more depressive in nature rather than a specific response to trauma.

Veteran is provided a diagnosis of Major Depressive Disorder with anxious distress. Her symptoms appear to be related to current psychosocial stressors and ruminative depressive thoughts of self-blame related to her military service, (i.e., that she blames herself for joining the military "that is when my life started going downhill...feeling bad that I can't provide for my daughter...I always have that guilt."). Thus, it is opined that her current diagnosis is as likely as not related to her military service, however is perpetuated by ongoing psychosocial stressors unrelated to service. Veteran has not yet engaged in appropriate mental health treatment for her depressive symptoms (i.e., evidence based psychotherapy) which she is encouraged to consider. Veteran is also provided a diagnosis of Alcohol Use Disorder which appears to be secondary to her depressive conditions.

[Navy04]

Sorry to hear of your misfortunes. It looks to be 10% for sure, or 30% for MDD if you are lucky. The Doc all together disregarded a diagnoses of PTSD so you might need to get an IMO. If you are diagnosed thru the VA with PTSD, or are currently seeking treatment for PTSD, continue the treatment and then submit a new FDC claim for PTSD. Good luck and keep us posted

[Mikemmlj]

What were the results?