ptsd Ptsd C&p Exam Results

[mjenlou]

I am a little confused about my C&P exam results. For one thing, I have already been diagnosed and currently being treated for PTSD by my VA MHP, but the C&P examiner says I dont have PTSD. Another thing I noted is how she left out some of the things I told her and switched a few things on a couple of my answers. Anyway this is part of my exam results. Can anyone tell me what it means?

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

based on today's evaluation?

[ ] Yes [X] No

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

[X] Veteran has another Mental Disorder diagnosis. Continue to complete

this Questionnaire and/or the Eating Disorder Questionnaire:

Mental Disorder Diagnosis #2: Other Specified Trauma or Stressor Related

Disorder

Comments, if any:

The Veteran reports traumatic stressors related to his time in

Iraq

(see below)that meet criterion A of PTSD. He endorses many

symptoms

of PTSD but does not meet Criterion C, avoidance symptoms

specifically related to the trauma.

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?

[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:

It is likely that some symptoms of PTSD were present soon after

the

Veteran's deployment. However, these were not reported as being

significantly distressing until 2014. It is the opinion of this

writer that the GAD developed within the past few years and that

is

when symptoms became less manageable. Based on this, it is

estimated that the GAD/Depressive symptoms combination and the

OSTSRD contribute equally (50/50) to the Veteran's level of social

and occupatonal impairment.

RESTATEMENT OF REQUESTED OPINION:

a. Opinion from general remarks: MEDICAL OPINION REQUEST

TYPE OF MEDICAL OPINION REQUESTED: Direct service connection

OPINION : Direct service connection

b. Indicate type of exam for which opinion has been requested: Initial PTSD

TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR DIRECT SERVICE

CONNECTION ]

a. The condition claimed was at least as likely as not (50% or greater

probability) incurred in or caused by the claimed in-service injury, event

or

illness.

c. Rationale: The OSTSRD is based on symptoms related to the Veteran's

reported military trauma and is thought to be directly service connected

because the intrusive symptoms are about the military experiences.

However, it seems that additional Depressive Disorder seems to have become a

significant problem more in the past few years. Some general anxiety seems

to

have been present over the years, but reaching the level of need for

treatment appears to be just recently. General anxiety symptoms and

depressive symptoms were apparently not reported in the military and are

less

likely than not directly connected to military service.

[lcurle]

"less likely than not" means there is a less than 50% chance the disability or condition is service connected. Good luck, sounds like it will be denied.

[JoeyAnderson]

No, what she said about your Other Specified Trauma or Stressor Related Disorder (also called "partial PTSD", "subthreshold PTSD", or "subsyndromal posttraumatic stress syndrome") was:

The condition claimed was at least as likely as not (50% or greater probability)

The legal wording required for these medical opinions is confusing. The part in parentheses is usually easier to understand, i.e., "50% or greater probability" in your case. So, she's saying several things:

1. Your current posttraumatic stress symptoms don't quite meet full criteria for PTSD, but they do meet the criteria for subthreshold PTSD, which in DSM-5 terminology is called Other Specified Trauma or Stressor Related Disorder. (DSM-5 is the diagnostic guide mental health professionals must use in C&P exam reports.)
   
2. She essentially said "Yes" to the question, "Was the veteran's Other Specified Trauma or Stressor Related Disorder incurred during military service?"
   
3. She said she does not think your more recent depressive and generalized anxiety symptoms are related to your subthreshold PTSD, i.e., only the amount of social and occupational impairment caused by your subthreshold PTSD is compensable. She estimated that half your problems are caused by subthreshold PTSD, and half are caused by whatever she put for Diagnosis #1 (you did not include that part of your report in your post, so I don't know what that diagnosis is).
   
4. She checked off the summary statement ("Occupational and social impairment with occasional decrease in work efficiency...") that corresponds with a 30% disability rating.
   
5. You did not include which items she checked off on the "Symptoms List" (Section II, Number 5 of the report). The VBA Raters focus on that more than the summary statement.
   
6. If the items she checked off on the Symptoms List also correspond with the 30% disability rating (you can find which symptoms correspond with which disability rating levels in the General Rating Formula for Mental Disorders - search the board, I know it's posted in at least one or two places on this site), then overall that's your level, BUT she said that your service-related condition (subthreshold PTSD) causes half of that impairment and the other half is not service-related. So, theoretically, you would qualify for a 15% disability rating, except that there is no such rating for mental disorders (it's 0%, 10%, 30%, 50%, 70%, or 100% only).
   
7. In most cases like this that I've seen the VBA Rater gives the benefit of the doubt to the veteran and would rate at 30%. But if you want more precise guesstimates regarding your probable disability rating, you need to post that Symptoms List because if she checked off a whole bunch of symptoms than you're likely to receive a higher disability rating.
   
8. Also remember that the C&P exam report is important, but it is not the only basis for your disabilitiy rating. The VBA Rater will also review your medical records, especially mental health treatment notes and primary care notes; any statements you or family members or friends submitted; your service medical records; and any other relevant evidence. For example, the VBA Rater might decide that there is solid evidence that all your mental disorders are service connected, i.e., the Rater disagrees with the C&P examiner's opinion on that point. The Rater makes the decision.

Good luck!

All the Best,

Joey

Edited November 14, 2014 by JoeyAnderson

[And we all survived]

So I reopened my case for major depression disorder with psychosis/anxiety and the VA instead of using the DBQ provided my psychologist, they rather asked me to go in for another QTC appointment for evaluation (second time- 2012/2014). I have already been diagnosed and currently being treated for Major Depression Disorder with psychosis/schizophrenia by the VA. Can someone tell me what the DBQ from QTC means? Am trying to figure out the possible rating decision if am even going to get a positive one. Thanks

SECTION I

1. Diagnosis

1. Does the Veteran now have or has he/she ever been diagnosed with a mental disorder?

[X] Yes [] No

Mental Disorder Diagnosis #1: Major Depression Disorder, recurrent

1. Medical condition relevant to the understanding or management of the Mental Health disorder (to include TBI): Sleep Apnea

2. Differentiation of symptoms

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

[X] Yes [] No

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

[] Yes [] No [X] Not applicable (N/A)

c. Does the veteran have diagnose traumatic brain injury TBI?

[] Yes [X] No

3. 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

SECTION II

Clinical Findings

1. Evidence review

Medical Record Review

a. Was the veteran’s VA claims file reviewed?

[X] Yes [] No

b. Was the pertinent information from collateral sources reviewed?

[] Yes [X] No

1. History
2. Symptoms

For VA rating purposes, check all that apply to the veteran’s 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] Impaired judgment

[X] Disturbances of motivation and mood

[X] Difficulty in establishing and maintaining effective work and social relationships

[X] Difficulty in adapting to stressful circumstances, including work or a work like setting

[X] Inability to establish and maintain effective relationships

[X] Suicidal ideation

1. Other symptoms

Does the veteran have any other symptoms attributable to mental disorders that are no listed above?

[] Yes [X] No

1. Competency

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

[X] Yes [] No

6. Remarks

MEDICAL OPINION

(To be completed by the examiner)

1. Definitions
2. Restatement of requested opinion

1. Insert request opinion …
2. Indicate type of exam for which opinion has been requested (e.g. Skin Disease):

PTSD

1. Evidence review
2. Medical opinion for direct service connection
   
   a. Direct service connection OPINION: The claimed condition was at least as likely as not (50 percent or greater probability) incurred in or caused by the claimed in-service injury, event, or illness. Provide rational in section c.

c. Rationale: Based on the records provided, it is at least as likely as not that claimant’s major depression disorder was incurred during his military service. Furthermore, it was caused by consistent harassment during his military service. The medical records reviewed which include in service treatment records.

Am not too sure why she said the indicated exam used was PTSD and MDD was the Axis 1. Also, I was told by the VA (regional office) that my case was closed accidently without rating decision given and that they are reviewing it again for a decision.

[carlie]

It would be best for you to repost this as a NEW POST please.

Thanks

[tdubya82]

[deleted]

Edited July 21, 2016 by tdubya82

[And we all survived]

Ok thanks.