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Ptsd C&p Concerns


Jb21

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Hello all. Longtime lurker, first time poster. I have a few concerns about my recent C&P results. I am currently in the Ides process so I understand there are going to be differences. Any insight is appreciated though. I am trying to format it and remove PII, but I can not figure out how to get it spaced out so I will attempt to post and then edit. I have addressed a few concerns I have. Thank you for your time.


Does the Veteran have a diagnosis of PTSD that conforms to DMS-5

criteria based on today's evaluation?

[x ] Yes [ ] No

If no diagnosis of PTSD, check all that apply:

[ ] 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

[ ] Veteran has another Mental Disorder diagnosis. Continue

to complete

this Questionnaire and/or the Eating Disorder

Questionnaire

ICD code:



2. Current Diagnoses

a. Mental Disorder Diagnosis #1: None

ICD code:

Comments, if any: see Remarks section of this report for

additional information

b. Medical diagnoses relevant to the understanding or management

of

the Mental Health Disorder (to include TBI): hypertension,

migraines, GERD, IBS, chronic fatigue, fibromyalgia

ICD code: unknown

Comments, if any: See med chart and Gen Med eval



3. Differentiation of symptoms

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

[ ] Yes [x ] No

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

attributable to

each diagnosis?

[ ] Yes [ ] No [x ] 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:

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

[ ] Yes [ ] No [x ] Not shown in records reviewed

Comments, if any:

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

attributable to

each diagnosis?

[ ] Yes [ ] No [x ] 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:

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 reduced reliability

and productivity. The all-powerful 50% social and occupation mark. The rest of this report along with my treatment notes seems to support deficiencies on most areas. I feel I should have been at the 70% mark.

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

If no, provide reason that it is not possible to differentiate

what

portion of the indicated level of occupational and social

impairment is attributable to each diagnosis:

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

and

social impairment is attributable to each diagnosis:

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 no, provide reason that it is not possible to differentiate

what

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.

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:

SM is active duty, thus does not have a VA file. Current

active duty

records (Ahlta) were reviewed. Narsum was reviewed:

Dr. Kaye; 8-1-14; SM's typed statement reviewed

If no, check all records reviewed:

[x] Military service treatment records

[ ] Military service personnel records

[ ] Military enlistment examination

[ ] Military separation examination

[ ] Mi

litary 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?

[X] Yes [ ] No

If yes, describe:

see body of report

2. History

----------

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

military, and

post-military):

raised by both parents after

divorce; 2 siblings. SM was close to family growing up. SM is

not

close to family currently. SM denied any history of child abuse.

SM had good friends while he was growing up and played many

sports.

SM doesn't have any current friends. SM has been married 1.5

years.

In free time, SM plays with dogs, spends time with wife, watches

TV, chips golf balls in back yard. SM socializes daily at work,

but has no friends and has infrequent contact with family. This makes me seem like I live a happy go lucky life, which I do not. If I was doing well I would not be in this process. My entire life revolves around survial, treatments and trying to rationalize thoughts of impending doom. This was the exact response I had when asked how I was doing.

b. Relevant Occupational and Educational history (pre-military,

military, and

post-military):

Highest level of education: some college classes; HS gpa 3.8

Prior to the military, SM worked in construction and fast food

SM has been in the Navy for 9 years.

Rate/MOS is FC; rank is E6.

SM is currently on Limdu/PEB, not working in rate and is working

as

communications monitor. SM reported that performance on current

job has been at least satisfactory. SM wants to farm*** after he

gets out of the military if he is able. NMA describes I am not doing satisfactory. ***If I can recover enough, I would eventually like to live on a small farm for animal therapy, Isolation and mental challenge.

c. Relevant Mental Health history, to include prescribed

medications and

family mental health (pre-military, military, and

post-military):

SM denied any mental health problems or treatment prior to the

military. SM first began psychiatric treatment in 2011. SM has

been in treatment on and off since that time

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

military, and

post-military):

Legal/behavioral problems while growing up: SM denied

Legal/behavioral problems while in the military: SM denied

Disciplinary action while in the military: --- NJP for DUI;

referred to tx

e. Relevant Substance abuse history (pre-military, military,

and

post-military):

Substance abuse problems/treatment prior to the military: SM

denied

Substance abuse problems/treatment during the military: --- DUI;

SARP level 1; drank a lot after first tour

Current alcohol consumption: last drink was July 2013

f. Other, if any:

3. Stressors

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



a. Stressor #1: SM was exposed to a total of 17 months of

combat SM served

in

Iraq in support of OIF from 2007-2008 and GWOT from 2010-2011.

Exposure was to frequent rocket and mortar attacks, small arms

fire

and casualties. During one particular incident in 2007. SM yada yada stressor yada …SM reported that he feels he was

changed from that moment forward.

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

If no, explain:

Is the stressor related to personal assault, e.g.

military sexual

trauma?

[x ]Yes [ ]No

If yes, please describe the markers that may

substantiate the

stressor. SM's 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 (DMS-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 tramuatic event(s)

[x ] Witnessing, in person, the traumatic event(s) as

they occurred to

Others

[x ] 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:

[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 ] 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).

[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] 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 ] Anxiety

[x ] Panic attacks more than once a week

[x ] Chronic sleep impairment



Both my treatment records and this DBQ show significantly more symptoms. Should I be worried about this?



6. Behavioral Observations

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

see Remarks section



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: see Remarks section

8. Competency

Is the Veteran capable of managing his or her financial

affairs?

[x ] Yes [ ] No

If no explain:

9. Remarks, if any

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

VBA 2507 INDICATES THAT SM IS UNDERGOING PEB FOR THE FOLLOWING

REFERRED PSYCHIATRIC CONDITIONS: ---- Anxiety Disorder NOS, PTSD

VBA 2507 INDICATES THAT SM HAS FILED C&P CLAIM FOR THE

FOLLOWING

PSYCHIATRIC CONDITIONS: ---- sleep disorder, TBI,

Per Ahlta note on 28May2014; Dr: "?The sailor

reports

that following IA deployment to Baghdad in 2007-2008, he developed

symptoms found later to be consistent with a diagnosis of PTSD:

nightmares of traumatic events, avoidance of discussing details of

trauma except in treatment, avoidance of and discomfort in crowded

spaces like large stores this hospital, reduced sense of a

positive

future, emotional numbing in relationships that led to the

break-up

of his engagement, increased startle response to loud noises like

fireworks, a few fistfights in those first couple of years which

was out of character for him, and trouble sleeping (delayed onset,

nightmares, thrashing about or acting out while asleep). He began

to drink for the first time and rapidly became a very heavy user,

reporting that he consumed the equivalent of 18-24 beers daily on

at least 6 days per week, beginning in 2008 and continuing through

2012. He had a DUI in 20009 which led to NJP and to a Level 1

SARP

referral, but he says that he did not apply himself to that

program

and did not attempt to cut back until 2012 when his now-wife asked

him to. He tapered his usage over several months and now reports

that his last drink was in SEP13. As a result of the self-taper

he

denies any physical withdrawal symptoms but began to have

re-emergence of the more distressing emotional/behavioral

symptoms,

and for that reason brought himself to treatment in Sigonella. To

his knowledge neither his alcohol use nor his PTSD symptoms led to

any noticeable impairment of work function. If this was true my NMA would have said that, but it doesn’t. Should this worry me?

He reports that treatment has been helpful, and that the most

important factor in his semi-recovery has been learning better how

to communicate what he is thinking and feeling with his wife, with

his treaters, and with his peers. He believes that he has made

good progress (he declines to try to quantify this) but wants to

continue that work.

The patient denies any history of suicidal attempts or generally

destructive behaviors. However, he admits to a period of cutting

on his arms and legs from about the time of alcohol tapering to

the

time that he began CPT treatment in Germany in SEP13. He also

admits to occasional suicidal thoughts of "maybe my wife would

be

better off without me", but denies any history of intent to

die or

plan to die. He admits to violence in fistfights as noted above

during the 2008-2010 period?."

MSE: SM was appropriately dressed and neatly groomed. SM was

alert and oriented in all spheres and pleasant, cooperative and

polite. Speech was spontaneous with normal rate, rhythm, tone,

and

volume. The patient's mood was anxious with WNL affect.

Significant psychomotor abnormalities at present interview were :

rapid gait, hand and leg shaking. Thought process was linear and

logical; thoughts were goal-directed. Thought content was

unremarkable for obsessions, compulsions or persecutory/grandiose

delusions. The patient denied any auditory or visual

hallucinations. Memory and cognition were grossly intact, however

SM reported mild diffuse memory problems; no neuropsychological

testing available in records at the time of current evaluation.

SM

denied any current or recent homicidal/suicidal ideation.

Judgment

was deemed good to fair. Insight was fair. Impulse control was

fair. Intelligence was estimated to be at least in the average

range. SM has disturbed sleep nightly. SM reported that he had a

sleep study that indicated he had numerous abnormalities which

included frequent awakenings, limb movements and should be

referred

to a neurologist, but that has not yet occurred. No diagnosis of

any other anxiety disorder at the time of current evaluation as

SM's symptoms are consistent with PTSD. R/o Substance Use

Disorder, in Remission.

SM denied any significant problems with Activities of Daily Living

(e.g., shopping, self-feeding, bathing) due to mental health

issues.

I was asked if I could go get myself bread for a sandwich if I absolutely had to. I replied if it was a good day and no one there and I absolutely had to, I would attempt in those conditions. I have not been able to venture out alone, and my spouse has to both get groceries and cook dinner. I explained this to the doc but it has been left out. Another should I worry/get changed.

Discussed purpose of the evaluation and limits of confidentiality

with SM. SM was given the opportunity to ask questions and

indicated understanding of these limits. SM consented to

participation in this interview. Medical history and C-file were

reviewed with a focus on psychiatric symptoms. Advised that SM

can

obtain a copy of the report from the VA at their discretion.

Reader is referred to body of report where symptoms are

delineated.

SM is now on active duty and therefore has no "post

military"

stressors or post military employment history. Note: GAF is no

longer applicable when diagnosing under DSM V criteria.

Due to template restrictions, the remainder of this form is blank,

there is no further information contained.



My questions are what should I do in this situation? I feel this DBQ does not properly reflect my treatment and symptoms as I am unable to independently function, have no friends and simply cannot adapt to stressful circumstances.

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