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 yearhas 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
Question
kate7772
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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saints13
I had the same exact type of c&p but she didn't ask me many questions. I tried to give her evidence and she said no thanks I have everything here. I stared at the walls for 45 mins while she typed
Navy4life
Here is what I would suggest: 1) Take the C&P Exam to your husband's next MH appointment and let his current therapist review it and give his/her opinion 2) Request on a VA21-4138 that he wo
NavyWife
The part where the examiner says they would "have to resort to mere speculation" regarding the nexus, is reason enough to have the C&P thrown out as " inadequate".
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