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Absurd Ptsd C&p, Any Remedy?


kate7772
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Question

Finally figured out how to get this on here. This is the exam I posted about previously in another area. I am so angry about this exam. This examiner lied, half-truths and omitted many things in this exam. My husband was diagnosed by his PTSD therapy counselor and Clinical Psychological Nurse Practitioner with the diagnosis confirmed by the VA Clinical Psychologist and VA Psychiatrist. I did upload and fax a dispute letter as well as emailing a copy to the VA Secretary. Who knows if they will look at it and thoroughly review his treatment records.

LOCAL TITLE: C&P EXAMINATION NOTE

STANDARD TITLE: C & P EXAMINATION NOTE

DATE OF NOTE: NOV 05, 2014@13:00 ENTRY DATE: NOV 12, 2014@08:36:09

AUTHOR::

URGENCY: STATUS: COMPLETED

Initial Post Traumatic Stress Disorder (PTSD)

Disability Benefits Questionnaire

* Internal VA or DoD Use Only *

Name of patient/Veteran:

SECTION I:

----------

1. Diagnostic Summary

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

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 has another Mental Disorder diagnosis. Continue to complete

this Questionnaire and/or the Eating Disorder Questionnaire:

2. Current Diagnoses

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

a. Mental Disorder Diagnosis #1: adjustment disorder with mixed anxiety and

depressed mood

ICD code: 309.28

b. Medical diagnoses relevant to the understanding or management of the

Mental Health Disorder (to include TBI):

No response provided.

3. Differentiation of symptoms

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

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

[ ] Yes [X] No

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

occupational

and social impairment with regards to all mental diagnoses? (Check only

one)

[X] Occupational and social impairment with reduced reliability and

productivity

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 (hard copy paper C-file) reviewed?

[ ] Yes [X] 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 [ ] No

2. History

----------

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

post-military):

Veteran indicated that he was born and raised by both parents in a

intact family in. He was the youngest of 3 siblings

(all

brothers). He stated that he had a good childhood and did not incur

any

type of abuse growing up. Overall, he characterized childhood as a

"good time" and did not have any difficulties. He was

involved in

various activities including the band and reported having adequate

social support.

Veteran stated that he married his first wife while still serving

in

the Marines sometime in 1967. He indicated that the marriage ended in

divorce after 5 years of marriage. He reported being verbally abusive

towards his first wife. He stated that he has an adult son and

daughter

from the first marriage, indicating that his son is estranged from him

and that he has a difficult time showing his adult daughter his

emotions noting "hard time feeling emotions." He indicated

that he

remarried to his now second wife in 1972. They have 3 adult children,

2

daughters and 1 boy. He reported that his relationship with his wife

is

"tough" but noted that they both "trust each other"

and expressed love

for her "she knows I love her." He stated that he feels tough

to live

with and that he is irritable and often explodes easily over simple

things but could not provide any concrete examples of his behavior

toward his family. He noted that he was "regimented" with his

children

noting that his children "had to toe the line" but was not

abusive.

Again, he had difficulties providing specific examples of his

behavior

toward his children and when prompted for an example his wife noted

that Veteran was "probably too protective."

He provided examples of both but not included here.

Veteran noted that he has little relationship with his

grandchildren

noting "cant be emotionally attached to them." He indicated

that if the

grandchildren visit he usually will go to his room and lay down in

bed. Over the last year Veteran was diagnosed with a "kidney

This was 2-1/2 years ago, after first claim for anxiety, irritability was filed. Symptoms were there before the claim was filed so not likely the cause.

disease" that has resulted time off from work due to energy and

concentration . No, it resulted in time off due to leg swelling. Was already experiencing concentration problems that became worse after unable to work as much. He stated that he no longer participates in usual

activities such as "finishing jobs at home." He indicated

that over the

last year he has become more sedentary and usually does not leave the

house. He stated he spends most of his time watching television, web

searching, or playing video games.

Again, wrong; Husband said he does not play video games and cannot concentrate on TV shows.

He voiced having "guilt"

for not

being able to take the grandchildren to the zoo or the circus. He

voiced having little to no social network outside of his immediate

family.

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

and

post-military):

Veteran described himself as a "C" student. He was never

held back

any grades and graduated in 1963. He indicated that he did not hold

any

jobs during high school.

Upon graduating high school he stated that he immediately enlisted in

the Marine Corps. He served in the infantry and the postal division.

He

served in Vietnam from 1965-1966 for a t

otal of about 13 months. He was

discharged from the Marines in 1967. He stated that he held various

duties while stationed in Vietnam including "escort for fuel

tanks" and

a passenger on "earth movers." He indicated that immediately

prior to

leaving for Vietnam his mother passed away, making it much more

difficult for him to sent to Vietnam . He stated that prior to leaving

he and others outside of Camp Pendleton were called "baby

killers"

noting shock as he "loved my country" and thought he was

serving his

country. He initially was sent to Danang Viet Nam where he was

prepared to "fight" but was a dropping zone in a peaceful

city and then

immediately transported to the air base. He indicated that a few days

after being on land he was assigned to collect and "prepared"

bodies

in "bags" to be shipped back to the U.S. Veteran provided

additional

& numerous traumatic accounts that he experienced while in Viet

Nam. He

provided details of event where an Airman was killed in action along

with South Vietnamese. He stated that he continues to have recurrent

nightmares from these events where he sees "shapeless forms

running"

while feeling helpless to assist anyone in the dreams as they die. He

reported experiencing continuous mortar fire from the Viet Cong. He

provided accounts of witnessing a superior "bullwhip"

Vietnamese who

were trying to collect food out of the garbage that was being dumped.

He also provided accounts of being manipulated by a Vietnamese and

noted difficulties with trust afterwards.

After being discharged from the Marines he obtained work at a meat

packaging plant. He indicated that the job was align with his views

regarding other people and could work in isolation stating that other

people "annoyed me" and "didnt trust them." After

working at the meat

packaging plant he obtained a job doing dry wall for about 15 years

stating again he prefered this type of employment as he could complete

work without the presence of other people "I could be alone."

Veteran

indicated that he and his wife owned a restaurant for about 3 years.

He

stated that he ran the kitchen operations and noted that his employees

were often "afraid of me" and that he "was demanding and

I needed

perfection."

For about the last 8 years Veteran stated that he has been employed

as a television salesman. Petty I know, but also wrong. He sells furniture. Over the last year has been several years he noted that work

employment has become more difficult starting with his physical

problems as a result of kidney disease. He stated that his wife also

works at the same place of employment and that she often assists him

as

he apparently makes many "mistakes." He noted that he has

difficulties

with concentration and has "panic attacks" and is concerned

that he

will be let go from his job.

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

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

Veteran had no history of mental health treatment until his initial

encounter with PC-MHI in January 21, 2014. Review of the initial

encounter with mental indicated that patient was referred with

"c/o

depression, anxiety, and panic attacks." Veteran was started on

sertraline 50mg and was refered to psychotherapy for PTSD, anxiety,

and

depression. On February 12, 2014 he discontinued sertraline and

declined group treatment and evidence based treatments for PTSD

"Zoloft

secondary to "feeling like not me, like the Stepford wives."

Declines

group psychotherapy for PTSD, as well as making a decision on

evidence-based psycho-therapy for PTSD saying, "I have to think

about

that: I don't feel comfortable talking about it...my

stomach's

burning." On March 6th PC-MHI encounter that are concerns about

worsening work performance reporting constant "panic" and

making

continuos errors at work that the husband and wife perceive is

threatening job security. On March 20, 2014 there were accounts from

records that he had a verbal altercation at work over a sales

commission and hat he was held back by his wife. Also, in his records

and per his report today he had an altercation with his son-in law

where he almost no almost, it was real had a physical fight. Veteran was assessed by VA Psychologist

He was referred by his treating counselor to rule out other issues causing problems since the drugs were not offering much help..

in June 2014 with a summary of the results as follows

"This

score suggests that he may have some mild cognitive impairment,

however

not likely to the degree of significant impairment to his daily

functioning." "The veteran does report and demonstrate

significant

depressive and anxiety symptoms which appear to be the more

significant

contributors to his current functional difficulties, particularly in

regard to his reported sub-standard work performance. The veteran

reports that anxiety increases (including physical symptoms of nausea)

when he is on his way to work and that these symptoms subside once his

work shift is over. He stated that he has experienced anxiety

(i.e. symptoms of PTSD) since he returned from Vietnam. His wife

reported that he has been anxious and "edgy" for as long as

she has

known him. The severity of this veteran's depression and anxiety

are

probable reasons for the below average scores of the DRS and RBANS as

well. These scores can serve as baseline scores and it is recommended

that this veteran be re-evaluated in one year for comparison of

cognitive functioning. It is also recommended that the veteran remain

engaged in EBP for treatment of PTSD and on-going medication

management." Veteran completed EBT for PTSD in September 2014.

As of

the date of his C&P examination he is prescribed sertraline

(200mg) and

valproic acid (500mg). Over the course of treatment since January and

with EBT for PTSD Veterans mental health symptoms have not

appeared

to have improved and according to Veteran today feels that his

symptoms may have worsened after completion of EBT for PTSD.

He did indicate during the interview that the medications have

"calmed

me down" somewhat. He stated that after CPT his nightmares

increased

and that they increased from maybe once a month to once a night. He

stated that he avoids talking about events related to Vietnam and so

feels talking about it in psychotherapy he feels will only make things

worse. He noted long-term difficulties with anger, irritability, and

avoidance and only recently learning what PTSD is noting "just

learning

of this stuff," & "I didnt know what PTSD was when

they told me I had

it." He noted to often compare himself with others and that he no

longer is able to play golf or fish. He stated that

"compartmentalizes" I hope this guy isn't indicating my husband said that. He doesn't speak in those terms. He told him that he tries to lock those memories away.

his issues and noting difficulties with this ability recently. He

stated that he no longer goes inside to grocery shop with his wife

due

to anxiety and fear of being around other people.

It's a whole lot more than grocery shopping. He virtually goes nowhere. Talked him into a short vacation recently. First time in about 25 years. Went to the beach very early in the morning. Only one other couple on the boardwalk and my husband got about 25 feet from the car and had a panic attack and had to return to the car. I thought by going off-season and early when others were not around that it might be ok.

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

post-military):

He denied any history of legal or behavioral difficulties

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

post-military):

He denied any history of excessive alcohol use. He denied ever using

illicit substances.

f. Other, if any:

No response provided.

3. Stressors

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

No response provided

4. PTSD Diagnostic Criteria

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

No response provided

5. Symptoms

-----------

No response provided

6. Behavioral Observations

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

Veteran was accompanied by his wife during the evaluation. He provided

permission for his wife to be present. He appeared overly anxious and legs

were restless throughout the interview. He reported difficulties wieht

concentration but completed the MMPI-RF within a average time frame

suggesting average attention abilities. No SI/HI or abnormal thought

processes. He recounted events from Vietnam as they were scripted and

rehearsed while given the appearance of the importance that he not miss any

detail to this provider.

He did likely seems scripted. He has memory issues and was told it is very important to let the examiner know as many details as he can. So, he went over and over the things he needed to let the examiner know for several days before the exam. By the time he was done describing these stressors to the examiner, he was a mental mess; quivering, shaking and crying. Then he was taken in this state to take the MMPI-2 test.

7. Other symptoms

He didn't ask about symptoms. My husband has a history of suicidal thoughts, (I didn't even realize this until he began therapy) But, this guy never asked or pursued any other symptoms.

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

Does the Veteran have any other symptoms attributable to PTSD (and other

mental disorders) that are not listed above?

[ ] Yes [X] No

8. Competency

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

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

[X] Yes [ ] No

9. Remarks, (including any testing results) if any

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

Veteran completed the MMPI 2 RF, which is a empirically supported

objective test of psychopathology. Veteran did not randomly respond to

items nor did he respond in a fixed way to questions. From his validity

profile he minimized minor flaws such as virtuous qualities and moral

character while attempting to portray himself as having severe

psychopathology. Although medical conditions can elevate scores on the

index of infrequent somatic responses his unusually high responses likely

reflect symptom exaggeration and suggest overreporting of medical and

cognitive difficulties. Although MMPI-2-RF overreporting indicators do

not, in themselves, rule out the possibility of PTSD or other

psychological disorders. However, they do call into the veracity of

Veterans self-reported PTSD symptoms and thus I can only result to

mere

speculation of whether or not Veterans self-reported symptoms

reflect

PTSD as a result of his military services. Again, this is not to say that

Veteran does not have PTSD but that he presented himself a more

psychologically disturbed than most people in the context of a

compensation evaluation. He is indeed more psychologically disturbed. This is something his PTSD counselor is aware of. He calls it severe PTSD and major depressive disorder and his clinical Psychological Nurse Practitioner has really worked hard on trying to get the meds right to bring that under control. Unfortunately, it seems that the therapy made things worse recently.

To answer the specific question then. Does the Veteran have a diagnosis

of

(a)PTSD that is at least as likely as not (50 percent or greater

probability) incurred in or caused by (the) being in Vietnam during

service? I can only result to mere speculation whether or not his claimed

PTSD sx occurred during his Vietnam service based on his likely

overreporting of symptoms. The history and reviewed evidence suggests

that

his symptoms of PTSD are not as severe as his self-presentation given

that

he has been successfully employed since his discharge from the military,

no psychiatric hospitalizations, no history of any mental health

treatment

until very recently (January 2014), and in a stable and loving marriage

of

42 years.

True, been married for 42 years but stable is "overreporting" on this examiner's part. I just refused to leave.

True, has been employed for much of the time since leaving the military but at many jobs and often working long hours. We later were told by his counselor that this is a common occurrence in those suffering from PTSD and then when they are unable to work as much, everything comes to a head.

True, did not seek treatment until January 2014 and then only when I gave him an ultimatum.

It appears from reviewing his history that Veteran began to

experience difficulties at work and with finances after being diagnosed

with significant kidney disease. His kidney disease has caused him to

reduce significant amount of time at work due to the result of fatigue

and

lower leg edema and thus limiting his finances, which could be the cause

of his psychological distress. Sure, this doesn't help but symptoms and original claim of symptoms were filed before the kidney issues.

Therefore, a diagnosis of adjustment disorder with mixed and anxiety and

depressed mood was opined as the result of his current medical situation

and not incurring or result of his military history.

NOTE: VA may request additional medical information, including additional

examinations if necessary to complete VA's review of the Veteran's

application.

PSYCHOLOGIST

Signed: 11/12/2014 08:36

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This is not a favorable C&P exam for PTSD or any MH disorder in my opinion...When I had my C&P Exam the examiner did not believe I met the criteria for PTSD under the DSM-5 however did indicate I had "other mental disorders"... I will say this my MH therapist I was seeing saw her C&P exam and disagreed with her findings about PTSD - I was able to submit that visit/notes to the rater prior to my rating - I knew I was going to be rated for MH but wasn't sure how they would rate me - I got s/c for PTSD/MST 30% and I believe it was due to both the C&P exam and my current therapist.....

In the beginning the Occupational description warrants 50% however reading this C&P exam the examiner doesn't feel any of his issues are related to his service.

Towards the end is what also concerns me b/c the examiner gave no respond for:

3) Stressors - NONE? that is not good - I had several

4) PTSD Diagnosis Criteria - NONE? that is not good - I had multiple criterion's mentioned

5) Symptoms - NONE? that is not good - I had several symptoms mentioned.

The examiner for your husband feels he may or may not have PTSD but doesn't feel it is attributed to the military...

Do you have an independent doctor that would attest to your husband's PTSD being linked to his active duty?

Edited by Navy4life
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Don't have an independent doctor but all the symptoms and stressors are recorded in his VA treatment records as well as the diagnosis and treatment. He also submitted a stressor statement when the claim was filed.

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When you state "stressors" do you have any VA exams to show his diagnosis of the stressors? I am concerned that the Examiner stated NONE for the stressors....His statement of stressors is irrelevant to this entire process. He needs to get the "stressors" connected to Active Duty and then continuity of treatment for the stressors.....

I would review all the VA notes on MyhealthyVets ASAP and see what you can find out from his therapist he is seeing....Has he seen anyone prior to this year for his MH issues?

He has to prove to the VA that his stressors are related to his active duty - does that make since?

Also the C&P Examiner really feels his MH issues are stemming from his kidney issues.....

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He did send info in with the stressor statement pertaining to the events, news articles, etc. and his paperwork shows he was there. He has been working with the PTSD counselor on dealing with the stressors. They are mentioned on Myhealthevet.

The fact that the kidney disease was diagnosed a year after he filed the original claim with the same symptoms should help to dispute that the kidney disease is causing them.

The symptoms did become worse after he was diagnosed and he had to work less but they were there before.

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The fact that he has the "stressors" is fine but has the PTSD counselor specifically stated they are related to his Active Duty service? You have to have the "link" to get the service connection. Anyone can have PTSD from events in their lives but connecting it to Active Duty is what needs to be proven.....

The kidney disease is that related to his active duty?

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Kate: That C&P is a killer. You and your husband have your work cut out for the 2 of you. Appeal time is here, be prepaired for the long haul 3++ yrs depending on any New & Material Evidence that you can obtain from a Private Psychiatrist with Heavy PTSD credentials. You can't rely on your VA Mental Health treating clinicians to be a great deal of help. The Drs are required to hand off your PTSD DBQ request to another Psychiatrist or Psychologist PHD that isn't one of your treating clinicians. The VA doesn't want to jeopardize what ever trust issues you have built with your treating clinicians, if they go against you. If you can even find a VA Psychiatrist that's willing to complete a PTSD DBQ, you have to be careful. Another Negative DBQ completed by a VA Psychiatrist and placed in your medical records and C-File, could be the old nail in the coffin.

Consider getting a couple FREE legal consults from VA Accredited Appeals Attorneys. It certainly couldn't hurt at this point. You might even be able to pick up a plan of attack. At the very least, your appeal will keep your claim alive for another 3-5 yrs. A high power PTSD DBQ submitted as New & Material Evidence might get a VARO Review of your claim and a possible local reversal of the denial. The Vet is supposed to get the benefit of doubt if it's a jump ball situation. Two Psychiatrists of equal credentials with apposing diagnoses, the Vet is suppose to get the award.

Was your husband awarded a USMC Combat Action Ribbon, see his DD-214? If you haven't already done so, file a FOIA claim requesting his complete C-File and while your at it, request his complete USMC Personnel File.

Semper Fi

Gastone

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