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Thoughts On C&p Exam? Currently 30% Ptsd

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1. Diagnostic Summary
Does the Veteran now have or has he/she ever been diagnosed with PTSD?
[X] Yes[ ] No
ICD Code: 309.81

2. Current Diagnoses
a. Mental Disorder Diagnosis #1: PTSD
ICD Code: 309.81
Comments, if any: Previously service connected

Mental Disorder Diagnosis #2: Alcohol use disorder
ICD Code: 303.90
Comments, if any: Previously diagnosed as alcohol dependence. Diagnosis
updated for DSM-5. Secondary to PTSD

b. Medical diagnoses relevant to the understanding or management of the
Mental Health Disorder (to include TBI): No relevant diagnoses

3. 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?
[X] Yes[ ] No[ ] Not applicable (N/A)

If yes, list which symptoms are attributable to each diagnosis and
discuss whether there is any clinical association between these
diagnoses: PTSD
Intrusive memories, nightmares, distress in response to triggers,
Avoidance of thoughts and discussions related to the trauma,
of reminders
Decreased participation in activities, disconnection from other
people, lack of positive emotions
Irritability, hypervigilance, insomnia, anxiety attacks

Alcohol use disorder: Currently, 2-3 days a week, up to a bottle of
wine, sometimes beer and liquor as well

c. Does the Veteran have a diagnosed traumatic brain injury (TBI)?
[ ] Yes[ ] No[X] Not shown in records reviewed

4. Occupational and social impairment
a. Which of the following best summarizes the Veteran's level of
and social impairment with regards to all mental diagnoses? (Check only

[X] Occupational and social impairment with deficiencies in most areas,
such as work, school, family relations, judgment, thinking and/or
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[X] No[ ] 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: Due to overlap and the interaction
effects between symptoms, it is not possible to apportion the source
of occupational/social impairment.

c. If a diagnosis of TBI exists, is it possible to differentiate what
of the occupational and social impairment indicated above is caused by
[ ] Yes[ ] No[X] No diagnosis of TBI
3. PTSD Diagnostic Criteria
Please check criteria used for establishing the current PTSD diagnosis. The
diagnostic criteria for PTSD, are from the Diagnostic and Statistical Manual
of Mental Disorders, 5th edition (DSM-5). The stressful event can be due to
combat, personal trauma, other life threatening situations (non-combat
related stressors.) 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

Criterion A: Exposure to actual or threatened a) death, b) serious
c) sexual violation, in one or more of the following ways:
[X] Directly experiencing the traumatic event(s)

Criterion B: Presence of (one or more) of the following intrusion
associated with the traumatic event(s), beginning after the
traumatic event(s) occurred:

[X] Recurrent, involuntary, and intrusive distressing
of the traumatic event(s).
[X] Recurrent distressing dreams in which the content and/or
affect of the dream are related to the traumatic
[X] Dissociative reactions (e.g., flashbacks) in which the
individual feels or acts as if the traumatic event(s)
recurring. (Such reactions may occur on a continuum,
the most extreme expression being a complete loss of
awareness of present surroundings).
[X] Intense or prolonged psychological distress at exposure
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

Criterion C: Persistent avoidance of stimuli associated with the
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
traumatic event(s).
[X] Avoidance of or efforts to avoid external reminders
(people, places, conversations, activities, objects,
situations) that arouse distressing memories, thoughts,
feelings about or closely associated with the traumatic

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)
the following:

[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.

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)
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] The duration of the symptoms described above in Criteria
B, C, and D are more than 1 month.

Criterion G:
[X] The PTSD symptoms described above cause 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.

4. Symptoms
For VA rating purposes, check all symptoms that actively apply to the
Veteran's diagnoses:

[X] Depressed mood
[X] Anxiety
[X] Suspiciousness
[X] Panic attacks more than once a week
[X] Chronic sleep impairment
[X] Impairment of short- and long-term memory, for example, retention of
only highly learned material, while forgetting to complete tasks
[X] Flattened affect
[X] Impaired judgment
[X] Disturbances of motivation and mood
[X] Difficulty in establishing and maintaining effective work and social
[X] Difficulty in adapting to stressful circumstances, including work or
worklike setting

5. Behavioral Observations:
The veteran arrives on time to his appointment. His
grooming and hygiene are fair and he dresses casually in a black
hoodie and jeans. He has several days of facial hair. He carries a
large can of Red Bull with him. He is very polite but seems to be
emotionally disengaged. Eye contact is appropriate. Mood appears
to be apathetic and depressed and affect is constricted. He does
not exhibit any psychomotor abnormalities. Speech is soft and rapid
and sometimes his words run together. Process of thought is
organized and linear with no suggestions of thought disorder. He
does not describe any delusional thinking, hallucinations, or other
psychotic symptoms. Level of insight and judgment appear to be
fair. He is a reasonable historian for past events. The veteran
endorses passive suicidal ideation at baseline. He has had 2
previous suicidal threats, most recently in December 2013. Risk
factors for suicide include the veteran's male gender, Caucasian
race, history of attempts, severity of PTSD, and social isolation.
He is considered a moderate to high risk for suicide and should be
PHQ-9 depression screen is a 22 and reflects severe depression.
Performance on cognitive screening is within the normal range (26/30 on
the MoCA). The veteran misses 4/5 words on delayed recall. His
performance is otherwise intact.

6. Other symptoms
Does the Veteran have any other symptoms attributable to PTSD (and other
mental disorders) that are not listed above?
[ ] Yes[X] No

7. Competency
Is the Veteran capable of managing his or her financial affairs?
[X] Yes[ ] No

8. Remarks, (including any testing results) if any:
SUMMARY: The veteran continues to exhibit intrusion, hyperarousal,
avoidance, negative cognition and mood symptoms consistent with
PTSD. He describes a history of problems with alcohol use,
nightmares, severe insomnia, hypervigilance, anger, irritability
with physical aggression, and emotional numbing. The veteran
initiated treatment through the VA, but has been told that he needs
to complete substance abuse treatment before he can connect with
general mental health services. Other than the diagnoses listed, no
other mental conditions were apparent. The veteran is able to
maintain activities of daily living including personal hygiene.
There has been inappropriate behavior in terms of aggression in bars
that has resulted in fights. He also inadvertently hit his wife
when she woke him up from a dream. There has not been any
significant trauma since Afghanistan. Thought processes and
communication are not impaired. Social functioning is
impacted by irritability resulting in conflict in his marriage,
general dislike of people, emotional withdrawal, and depressed mood.
Employment is primarily impacted by irritability and poor response
to authority. He also describes memory and concentration problems,
anhedonia, and low frustration tolerance. He is not currently in
treatment. Symptoms are continuous and could benefit from
continuous medication. There have been no remissions in the past
year. He was sober for 4-1/2 years, but then relapsed and is now
drinking moderately per his report. Prognosis for improvement is
estimated to be guarded based on the severity of symptoms and

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50% is my guess although 70 seems reasonable.

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