ptsd Ptsd C And P Exam Question

[Mbrown7621]

Hello everyone. I've been lurking on this page for quite awhile and decided to finally posy myself.

I had a PTSD C and P on 01/15/2015, I cannot post the whole report because I do not have access to myhealth.va.gov yet.

I picked up the paper copy today from the VA and this is what the final paragraph on the last page states:

Mr. Brown is a 30 year old, engaged, caucasian, NSC, male veteran of the Army National Guard who was seen on 01/15/2015 for an original PTSD C and P examination. Based on review of the veteran's medical records, VBMS record, interview, and objective testing, the results of this evaluation suggest that the veteran does presently meet diagnostic criteria for PTSD of very mild severity. He also meets criteria for alcohol use disorder, in remission. It is thought that the veterans diagnosis of PTSD is directly related to the veterans fear of hostile military or terrorist activity. The veterans psychiatric symptoms alone would not be expected to impede his ability to function well in a job environment. DSM-5 criteria was used for this evaluation.

Obviously I will post the full report when I gain't access to the website, however my question for now is, would this be considered a nexus statement from him?

The previous paragraphs stated high percentiles on all these different scales and suggested over reporting, which is what worried me. I felt I was honest on those evaluations and he suggested over reporting.

Any information would be grealty appreciated. Thank you kindly in advance.

[Pete53]

Welcome to Hadit.

[Mbrown7621]

Thank you glad to be here.

Forgot to mention. Yes there were three stressors listed and the criterion were met for all three, as I've mentioned before I will post the full report when I can.

[Mikemmlj]

The paragraph you quote seems to be different from other C and P examshere at hadit. From that paragraph alone I would say you're looking at a 0 or 10% but the full exam would give a clearer picture.

[Mbrown7621]

I have finally gotten my hands on the full report, I noticed the ending was different than a lot if not all of the other people's here as well, which is why I am seeking opinions. Any information appreciated. Thanks all.

SECTION I:

----------

1. Diagnostic Summary

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

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

based on today's evaluation?

[X] Yes [ ] No

ICD code: 309.81

2. Current Diagnoses

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

a. Mental Disorder Diagnosis #1: PTSD, chronic, mild

ICD code: 309.81

Comments, if any: Related to military service

Mental Disorder Diagnosis #2: ETOH use disorder, moderate, in remission

ICD code: 303.90

Comments, if any:

Unrelated to military service and not secondary to PTSD

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

Mental Health Disorder (to include TBI): Questionable TBI

Comments, if any: Upcoming TBI C&P will determine whether a

diagnosis of TBI is present. According to records at present, there appear to be no

medical conditions aggravating psychiatric 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:

Symptoms of intrusion, avoidance, hyperarousal, and negative

alterations in cognitions or mood are thought to be attributable

to PTSD, while minimal symptoms are likely attributable to alcohol

use disorder as it has been in remission for several years.

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

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

d. 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:

The effects of TBI that may have occurred are thought to be

minimal, based on a TBI assessment that was conducted in 2008. A

neuropsych C&P is scheduled and will be able to better delineate

which symptoms are attributable to the diagnosis of TBI, should

such a diagnosis be made.

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 due to mild or transient symptoms

which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by medication 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:

Very mild impairment in social and occupational functioning is

thought to be attributable to PTSD. Any additional impairment

above the very mild range is would be thought to be linked to other

diagnoses.

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?

[X] Yes [ ] No [ ] No diagnosis of TBI

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

social impairment is attributable to each diagnosis:

The effects of TBI on the veteran's functionality are thought

to be minimal, based on a TBI assessment that was conducted in 2008. A

neuropsych C&P is scheduled and will be able to better

delineate what degree of dysfunction is attributable to the diagnosis of

TBI, should such a diagnosis be made.

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 (hard copy paper C-file) reviewed?

[X] Yes [ ] 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 [X] No

2. History

----------

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

post-military):

The veteran was born in Ohio, but raised in (omitted for privacy). His father

died when the veteran was 3 years old. His mother remarried when the

veteran was about 13-years-old. The veteran was raised with 3 sisters

(he is the 3rd oldest) and several step-siblings. He reported good

relationships with his family while growing up. The veteran reported

that he made friends easily while growing up.

According to the veteran, he did not have any adjustment problems

during his time in training. He was able to befriend other soldiers

during training and maintained good relationships when his unit was

activated. Upon his return from Iraq and subsequent

deactivation of his unit, the veteran continued to socialize with his friends. He denied the

emergence of social problems until around 2010, at which point he

started to become more socially isolated. He reported that although he

has not had falling-outs with any family members, he isolates himself

and tries to avoid attending or minimize the time he spends at family

events. He stated that he only maintains two friendships and reported

having no interests outside of his work and spending time with his

family. Regarding his family, the veteran reported that he started dating his

now fianc?e in about 2009. They have been engaged since July 2013.

They have a three-year-old daughter together. They live together in a

Duplex they rent. He stated that he loves his wife and daughter, but they

"bear the brunt" of his symptoms as he often becomes verbally

Upset over what he considers to be small issues. He denied physical

violence.

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

and post-military):

According to the veteran, he was in honor's classes until 6th or

7^th grade before his academic performance started to decline. Records

indicate that he started hanging out with a "bad crowd." He

reported that he became the "class clown" and was suspended on

occasion for disrupting class. He denied engaging in behavior that is indicative of

serious misconduct. He worked summers for his uncle's painting

company before dropping out of school after completing the 11th grade to work

full time. He denied any problems at work. He dropped out because he

"wanted to make money" and "knew I wanted to join the

Army." The veteran enlisted in the Army National Guard in 2003. He completed SWOT

at Ft. Benning, GA, and was assigned the MOS of 11B infantry. His unit

was activated and deployed to Iraq (Anbar Province).

When queried about his duties in Iraq, the veteran replied,

"I did the Lieutenant's job," noting that he carried the radio,

Wrote reports, gave briefings, dealt with the interpreter, and dealt with

The public. He reported that he was exposed to small arms fire,

IED's, suicide bombers, and mortars "damn near every day." He

reported that he routinely outside of the wire and discharged his weapon on several

different occasions. He was awarded the CIB.

He eventually got a job at the unemployment office

taking claims, but left that job after a year as he found the work too

boring. He then worked for four years for in real estate as a

property manager before leaving to take his current job with

a fracking company. He stated he

changed jobs as this one offers him more money. He has held this job

for just shy of a year. Across his post-military employment history,

the veteran denied problems getting along with coworkers (though he

stated that he is not close with any of them), absenteeism, tardiness,

or performance issues.

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

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

The veteran denied any family history of psychiatric problems or

substance abuse problems. He denied a childhood history of abuse. He

denied receiving psychiatric treatment during his premilitary history.

He denied any suicide attempts. The veteran denied receiving any

psychiatric or substance abuse treatment while in the military. He

denied attempting suicide while in the military. The veteran has not

sought treatment since his discharge, though he did seek a

second-level TBI evaluation in 2008 which concluded that he was likely not

experiencing lingering symptoms of a TBI and offered a diagnosis of

adjustment disorder with anxiety and depressed mood.

When queried about information in his military and VA records

indicating that he largely denied the presence of trauma-related

symptoms, the veteran responded that he was avoiding acknowledging

that they exist. He stated that it has only been recently, and at the

strong behest of his wife, that he has sought treatment. Per his report, he

has not been seen, but has contacted a therapist in the community for

an appointment. He is not currently prescribed psychotropic medications.

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

post-military):

The veteran denied any legal problems prior to joining the military.

He denied post-military legal problems, though

records indicate that his license was suspended. When directly asked

about this, the veteran reported that he received a speeding ticket in

Ohio while on his way to a concert, but failed to pay the ticket. When

pulled over in PA, they saw that his license was suspended in Ohio

(reportedly without his knowledge), so they also suspended it in PA.

There was not legal history reported outside of this incident. Besides

an isolated instance or two of fighting as a youth, there is not

pre-military, military, or post-military history of assaultive

behavior.

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

post-military):

The veteran reported that he drank on occasional weekends while in

high

school and started smoking about 1 ppd cigarettes. While in the military, he

largely followed this pattern. He denied drug use prior to joining the

military. According to the veteran,

he drank very heavily for the two years following his discharge,

frequently drinking to the point of blacking out and experiencing

hangovers. He denied that it impacted his work and he also denied

developing withdrawal symptoms. He reported that he reduced his

drinking once meeting his fiance. He currently drinks socially and

continues to smoke about 1ppd of cigarettes.

f. Other, if any:

No response provided.

3. Stressors

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

Describe one or more specific stressor event(s) the Veteran considers

traumatic (may be pre-military, military, or post-military):

a. Stressor #1: (Omitted for privacy)

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

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

trauma?

[ ] Yes [X] No

b. Stressor #2: (Omitted for Privacy)

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

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

trauma?

[ ] Yes [X] No

c. Stressor #3: (Omitted for Privacy)

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

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

trauma?

[ ] Yes [X] No

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 #7 - 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 (DSM-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 traumatic event(s)

[X] Witnessing, in person, the traumatic event(s) as they occurred to

Others

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 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).

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] 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] Markedly diminished interest or participation in significant

activities.

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)

ofthe following:

[X] Hypervigilance.

[X] Exaggerated startle response.

[X] Sleep disturbance (e.g., difficulty falling or staying asleep or

restless sleep).

Criterion F:

No response provided.

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.

Criterion I: Which stressor(s) contributed to the Veteran's PTSD

diagnosis?:

[X] Stressor #1

[X] Stressor #2

[X] Stressor #3

5. Symptoms

-----------

For VA rating purposes, check all symptoms that actively apply to the

Veteran's diagnoses:

[X] Anxiety

[X] Chronic sleep impairment

6. Behavioral Observations

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

The veteran arrived on time to his appointment and was unaccompanied. The

veteran ambulated with a slow gait without assistive devices. The veteran

was dressed casually and is of average height and build; he looked to be about

his stated age. Grooming and hygiene were good. Speech was of normal rate

and volume, but was without prosody for much of the interview. Response

latencies were unremarkable. His attitude was cooperative, though he

provided terse responses. Eye contact was poor as the veteran averted his gaze for

much of the interview. Significant psychomotor agitation was noted

throughout the interview in both the veteran's upper and lower extremities.

Thought processes were clear, logical, and goal directed. No evidence of delusions,

hallucinations, paranoia, or mania was evident during this evaluation.

Attention and concentration appeared grossly intact during this interview,

though not formally tested. Mood was dysphoric, though he reported it as

good in general. Affect was constricted, though he became tearful while

describing his stressors. Insight and judgment appeared good. Intelligence appeared to

fall in the average range. He denied SI/HI.

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:

Faintness; dizziness

8. Competency

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

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

[X] Yes [ ] No

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

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

At the current examination, the veteran completed the Beck Depression

Scale, 2nd Edition (BDI), the Brief Symptom Inventory (BSI), the

Mississippi Scale for Combat-Related PTSD (MSC), and the PTSD Checklist

(PCL). The veteran was administered the BDI, on which he scored a 27,

which is suggestive of the moderate range of depressive symptoms. This is

inconsistent with the veteran's reported mood and his reported level

of functioning. The veteran was also administered the Brief Symptom

Inventory, on which he endorsed 43 of a possible 53 possible symptoms.

His Global Severity Index score fell at the 95th percentile, his Positive

Symptom Distress Index score also fell at the 95th percentile, and his

Positive Symptom Total score fell at the 88th percentile compared to a

sample of male psychiatric outpatients. Clinically significant elevations

were evident on the somatic subscale (99th percentile), the

Obsessive-Compulsive subscale (95th percentile), and on the anxiety

subscale (97th percentile). On the MSC, the veteran scored a 132, which

falls over the cutoff suggestive of PTSD symptoms, but may reflect

overreporting. Finally, on the PCL-5, the veteran scored a 69, which

falls well above the suggested cutoff for PTSD, but likely reflects

overreporting. Overall, the symptoms endorsed on testing seem to be

consistent with symptoms of depression, anxiety, and PTSD, though

self-report measures appear to be inflated across the board when aspects

of the veteran's psychosocial history are considered (e.g., has

never sought past treatment, has performed relatively well at his jobs over a

long period of time, etc.).

Mr. Brown is a 30-year-old, engaged, Caucasian, NSC, male

veteran of the Army National Guard who was seen on 1/15/2014 for an

original PTSD C&P examination. Based on review of the

veteran's medical records, VBMS record, interview, and objective testing, the results of

this evaluation suggest that the veteran does presently meet diagnostic

criteria for PTSD of very mild severity. He also meets criteria for

alcohol use disorder, in remission. It is thought that the veteran's

diagnosis of PTSD is directly related to the veteran's fear of

hostile military or terrorist activity. The veteran's psychiatric symptoms

alone would not be expected to impede his ability to function well in a job

environment. DSM-5 criteria were used for this evaluation.

NOTE: VA may request additional medical information, including additional

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

application

[Mikemmlj]

I would say 10% but the examiners statement of over reeporting may be a concern.