ptsd Ptsd Claims Question

[John87]

Hey Everybody,

I just that other day had my first PTSD one-on-one session with a psychologist. He wasn't pushy, seemed nice and actually listened to what I had to say instead of feeding me what he thought I should feel. It was difficult and I hated it but he really thinks I should continue to better stabilize my emotions and deal with my conditions. So that reason I'm writing all this is I have a question: I'm rated at 30% anxiety was curious if filing for a reconsideration for PTSD is worth it and if so what percentage would I be at? I was diagnosed with PTSD by a VA psychologist in 2012 when I was getting treatment in 2012 that wasn't very "fun". I had to move to a new area since. Below is my initial session with my new VA psychologist:

• -Referral: Veteran was referred by his primary care provider. Met with veteran by phone for 50 minutes to clarify his treatment needs.
• -Demographic Information: Veteran is a 27 year old male living in XXXXXXXX with his wife and four children. He is currently not employed and is the primary caregiver for their children during the day.
• -Description of the Problem(s): PTSD/Depression - veteran is currently 30% service connected for an anxiety disorder. He reported having a long history of depression and anxiety going back to when he was in the military after he returned from a deployment to Iraq. Relationship problems – Strained marriage based on anxiety and trust issues Stress -- the veteran reported that he easily becomes overwhelmed with stress. He rated his average level of stress as 9.5-10/10 with 10 being overwhelming levels of stress most days. He describes that small tasks such as getting his children ready for school can overwhelm him and lead him to shut down.
• -Current Symptoms: the symptoms currently causing the patient the most difficulty include high levels of anxiety, intrusive thoughts from his experiences in Iraq, low levels of energy and motivation. His wife works nights and he feels particularly anxious when she is working. He has difficulty sleeping because of nightmares and "weird dreams."
• -Functional Impairment: He is having difficulties initiating and persisting in routine tasks of daily living. The veteran reported experiencing a depression and anxiety on a daily basis, but he reported that if his surroundings are quiet and he is able to spend time with his wife he does not feel anxious or depressed; these times occur infrequently.
• SIGNIFICANT HEALTH & PSYCHIATRIC HISTORY The veteran was deployed to Kirkuk, Iraq in 2009. He was a medical technician in the Air Force, and when he was in Iraq he worked in the ER. He witnessed numerous severely injured soldiers being brought into the emergency room. He still wonders if he "did enough" to help them. The veteran reported he engaged in counseling in the military and also in 2013 while he was at Eglin AFB in Florida with his wife. The veteran reported that he is currently taking Prozac. He was on a different medication prior to the prozac that he could not recall the name of, but the medication made his stomach ache he reported taking his medication on a daily basis as directed. He estimated he has been on the prozac for 4 months. He does not believe it is having a significant impact on his depression or anxiety.
• RELEVANT DEVELOPMENTAL/PSYCHOSOCIAL/OCCUPATIONAL The veteran was married in 2012. She is a nurse and is currently in the military
• ALCOHOL AND OTHER SUBSTANCE USE The veteran reported that he stopped drinking a couple of years ago when he was first having problems with his wife because his heavy alcohol consumption had been an issue in the relationship. He stated it has not been difficult for him to maintain his sobriety. He denied other substance use both in the past as well as currently.
• ASSESSMENT Sensorium: AlertOrientation: Oriented to person, place, time & situationAttitude During Intake: CooperativeSpeech Quantity: Normal/UnremarkableSpeech Quality: Normal/UnremarkableReported Mood: Anxious & DepressedRange of Affect: RestrictedThought Processes: Logical & CoherentThought Content -- Preoccupations: Presenting Problem(s)Thought Content -- Delusions: None EvidentObsessions: NoneConcentration: Mildly Impaired Memory Functions: Immediate Memory Deficit (forgetting things lately)Impulse Control: SufficientJudgment: GoodSelf-Care: Good Self-CareHallucinations: Denied Because this was a phone session, this provider was unable to assess his physical appearance or personal hygiene.
• SUICIDE RISK SCREENING QUESTIONS: Are you feeling hopeless about the present or future? YESHave you had thoughts of taking your life? YESWhen did you have these thoughts? several times a week Do you have a plan to take your life? NOHave you ever had a suicide attempt? YES Description\Dates: 2011 tried overdosing, made himself throw them up. Paying close attention to previous questions: Full Suicide Risk Assessment
• OTHER CURRENT RISK FACTORS: patient (suicidal ideation and/or recent/past attempts), mental health diagnoses, sleep disturbances (unable to sleep or sleeping all the time), anxiety/agitation SOCIAL/DEMOGRAPHIC RISK FACTORS: -white -male
  
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• CURRENT PSYCHOSOCIAL STRESSORS/RECENT LOSSES: marriage difficulties
  
• PROTECTIVE FACTORS: positive social support, sense of responsibility to(children/significant other), life satisfaction, positive coping skills, positive problem-solving skills Given the veteran's presentation at the time of this assessment and considering the above noted risk and protective factors, in my clinical judgment the veteran's current risk potential for suicidal behavior is: LOW RISK. Patient judged NOT to be at significant risk for self harm.
• SUICIDE RISK ASSESSMENT PLAN OF CARE: Veteran given the National Suicide Hotline (1-800-273-TALK), 911, and contact info for Veteran's provider. Veteran told how to access the Boise VA Emergency Department 24 hours a day. Recommend reassessment for suicide risk after any significant change in situational stressors or patient presentation. The veteran reported having suicidal ideation a couple of times a month when "things get bad," typically when he is having conflict with his wife. He has never attempted suicide. During these times he does not seriously contemplate suicide nor plan suicide. He reported that at approximately 2011 he tried to commit suicide by taking pills but then made himself throw up. After reported that during the time he and his wife were going through their difficulties, he tried to swim out into the bay in Florida, but his wife went after him and he returned to shore. He reported that he cut on himself one time during a period that he was having problems in his relationship with his wife. He denied engaging in other forms of self-harm since that point in time. He stated that he has called the crisis line a couple of times in the past few years and that it has been helpful to him. He reported that he would call the number again if needed or go to the emergency room as needed.
• CLINICAL IMPRESSIONS -Conceptualization: The veteran reported having a history of depression starting after his deployment to Iraq that has likely been exacerbated by his experiences in Iraq as well as the disruption in his relationship caused by his viewing pornography. He reported that his sleep is significantly disrupted making it difficult for him to feel rested. The combination of the depression and the chronic sleep problems are leading to his reduced motivation and energy levels. He has a chronic sense of guilt and shame around his experiences Iraq, and this are likely a significant part of his depression. At this point, it is not possible to determine if his dependence on his wife relates to personality issues, or if she has been a source of stability for him and he therefore feels anxious when she is not around.
• -Diagnostic Impressions: anxiety nos; PTSD by self-report; depression; r/o PD
• INITIAL TREATMENT PLAN We'll work on emotionally stabilizing the veteran and reducing his anxiety. Will discuss and clarify his treatment plan during our next session likely focusing on improving his coping skills, managing his reported traumatic symptoms, and working through feelings of guilt regarding his experiences in Iraq.