diabetes Opinion On Ptsd C&p Results

[Valen2384]

Hello i am new to these forums. I would like to say Hi to you all. I finally got C&P exam done on my claim. Some back story. i originally filed for ptsd back in 2008 and was diagnosed with ptsd but my claim got denied because i couldn't put my stressors down on paper took me almost 5 years of therapy to be able to get them down. sigh..Alot has happened but that's a story for another day. So, I Filed and appeal and somehow the RO lost it. So, i opened a new claim in 2013 for ptsd and left knee increase. It was stuck in RO limbo until my mother went behind my back and sent a letter to the White house. So, now the RO is working on my claim and they found the appeal and is reopening my claim from 2008 ( Took a letter from the White House for them to find it.....). Well, I was able to find my results for my ptsd C&P on myheathlyvet. any opinions? i was told to file for SSDI while my claim gets settled is that the right way to go or should i hold off? any idea's and or comments would be much appreciated. sorry for the broken thoughts and thank you in advance.

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: Post Traumatic Stress Disorder, chronic,

severe

ICD code: 309.81

Comments, if any:

Veteran reported that he has a depressed mood most of the day,

nearly every day. He stated that he has lost interest in almost

all

activities. He said that he has insomnia and a loss of energy. He

stated he wants to do things, but then he just doesn't have the

motivation to do it. He described feelings of uselessness, guilt,

hopelessness and helplessness. He reported that his attention and

concentration are poor. He said that he has difficulty making

decisions. He reported suicidal ideation without a plan or intent.

The Veteran stated that he has gained 50 pounds over a short

period

of time.

Veteran also reported that he has a great deal of anxiety and

worry; he said that he gets on edge and tense and irritable. He

worries about who he is; he is trying to find himself. He said

that he also worries about where he is going to be in the future.

He stated that when his anxiety becomes overwhelming, he will have

a panic attack that seems to come out of nowhere. He reported that

he has symptoms of an accelerated heart rate, sweating, shaking,

shortness of breath, chest pain, nausea, and chills and flushes.

Mental Disorder Diagnosis #2: Major Depressive Disorder, recurrent,

moderate with anxious distress

ICD code: 296.32

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

Mental Health Disorder (to include TBI): SEE COMMENTS SECTION

Comments, if any: Patellofemoral syndrome left knee, S/P meniscal tear;

elevated liver enzymes; tremor; diabetes; GERD; headaches; synovial

plica of knee; joint pain, left leg; two knee surgeries in less than

two

years

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 predominantly associated at this time with the diagnosis

of Major Depressive Disorder include low mood, low frustration

tolerance, increased appetite, anhedonia, and episodic suicidal

ideation. Symptoms predominantly associated at this time with the

diagnosis of PTSD include intrusive memories, sensory cues of his

reported military stressors, avoidance patterns, concentration

compromised when symptoms are most pronounced, and hypervigilance.

Symptoms of compromised sleep, isolation, and low energy are

associated with the impacts of both diagnosed conditions.

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

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

Comments, if any:

Veteran was evaluated in the polytrauma department for a head

injury, and results were inconclusive

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 deficiencies in most areas,

such as work, school, family relations, judgment, thinking and/or

mood

b. For the indicated level of occupational and social impairment, is it

possible to differentiate what portion of the occupational and social

impairment indicated above is caused by each mental disorder?

[ ] Yes [X] No [ ] No other mental disorder has been diagnosed

If no, provide reason that it is not possible to differentiate what

portion of the indicated level of occupational and social impairment

is attributable to each diagnosis:

Veteran is diagnosed with PTSD and with Major Depressive Disorder

with anxious distress. These diagnoses result in symptoms that are

active and interdependent. All symptoms work in conjunction to

impact social and occupational functioning. It is not possible to

fully differentiate what portion of impairments is attributable to

each diagnosis.

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:

[X] Military service treatment records

[ ] Military service personnel records

[ ] Military enlistment examination

[ ] Military separation examination

[ ] Military post-deployment questionnaire

[X] Department of Defense Form 214 Separation Documents

[X] 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

[X] Other:

CPRS electronic record; comprehensive clinical interview with the

Veteran and his mother

b. Was pertinent information from collateral sources reviewed?

[X] Yes [ ] No

If yes, describe:

Veteran brought a copy of a letter from his therapist. The

letter was dated 12/4/2014 and described some of the Veteran's stressors

and some of his PTSD symptoms.

2. History

----------

removed personal information.

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

post-military):

There are no relevant legal issues at this time.

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

post-military):

The Veteran reported that he has never smoked cigarettes or used

illegal substances. He said that he did not drink alcohol prior to

entering the military. During the military, he stated that he drank

heavily when he returned from deployment. He said that he was binge

drinking every day. He drank beer. He said that he drank with many

of

his peers from the military. He stated that, at present, he only

drinks occassionally.

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:

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:

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:

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, involuntary, and intrusive distressing memories of the

traumatic event(s).

[X] Recurrent distressing dreams in which the content and/or affect of

the dream are related to the traumatic event(s).

[X] Dissociative reactions (e.g., flashbacks) in which the individual

feels or acts as if the traumatic event(s) were recurring. (Such

reactions may occur on a continuum, with the most extreme

expression being a complete loss of awareness of present

surroundings).

[X] Intense or prolonged psychological distress at exposure to

internal

or external cues that symbolize or resemble an aspect of the

traumatic event(s).

[X] Marked physiological reactions to internal or external cues that

symbolize or resemble an aspect of the 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] Inability to remember an important aspect of the traumatic

event(s)

(typically due to dissociative amnesia and not to other factors

such as head injury, alcohol, or drugs).

[X] Persistent and exaggerated negative beliefs or expectations about

oneself, others, or the world (e.g., "I am bad,: "No one can be

trusted,: "The world is completely dangerous,: "My whole nervous

system is permanently ruined").

[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] Persistent negative emotional state (e.g., fear, horror, anger,

guilt, or shame).

[X] Markedly diminished interest or participation in significant

activities.

[X] Feelings of detachment or estrangement from others.

[X] Persistent inability to experience positive emotions (e.g.,

inability to experience happiness, satisfaction, or loving

feelings.)

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)

of

the following:

[X] Irritable behavior and angry outbursts (with little or no

provocation) typically expressed as verbal or physical aggression

toward people or objects.

[X] Reckless or self-destructive behavior.

[X] Hypervigilance.

[X] Exaggerated startle response.

[X] Problems with concentration.

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

restless sleep).

Criterion F:

[X] Duration of the disturbance (Criteria B, C, D, and E) is more than

1 month.

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] Depressed mood

[X] Anxiety

[X] Suspiciousness

[X] Panic attacks more than once a week

[X] Near-continuous panic or depression affecting the ability to function

independently, appropriately and effectively

[X] Chronic sleep impairment

[X] Mild memory loss, such as forgetting names, directions or recent

events

[X] Flattened affect

[X] Impaired judgment

[X] Disturbances of motivation and mood

[X] Difficulty in establishing and maintaining effective work and social

relationships

[X] Inability to establish and maintain effective relationships

[X] Suicidal ideation

[X] Impaired impulse control, such as unprovoked irritability with

periods

of violence

6. Behavioral Observations

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

Mental Status:

Veteran was casually dressed and used a cane. He was accompanied to the

evaluation by his mother. He was alert and oriented to person, place, and

time. He maintained sporadic eye contact. The purposes and procedures of

the

evaluation as well as the limits of confidentiality were reviewed with the

Veteran. He consented to the evaluation and expressed an understanding of

its purpose and of the limits of confidentiality. He was anxious but

cooperative.

His mood was depressed and anxious at different points in the evaluation.

He

was very anxious when discussing his military stressors. He stated that it

took him many sessions in his individual therapy to be able to talk about

even one stressor. His affect was flat. His thought processes were logical

and goal-directed. The thought content was appropriate to the evaluation.

There was no evidence of hallucinations or delusions. The rate of his

speech

was slow; the rhythm and volume were within the normal range. His judgment

is impaired. He acknowledges that he has suicidal ideation without a plan

or

intent. He denies homicidal ideation. His ADLs are good.

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:

The Veteran reported that his flashbacks are frequent, and they

have caused him to have a car accident because he was not paying

attention to his driving. He said that he does not drive now

because of his flashbacks. He also stated that driving causes him

to have a panic attack because it reminds him of driving in Iraq

and always being watchful for IEDs or hazards on the road that

could hold an IED. The Veteran and his mother stated that he

stays

home in his room and does not participate in any activities. He

even avoids people in the home because he can have a flashback

that

triggers a rage reaction that he is not even aware that he is

having. The Veteran has difficulty falling and staying asleep. He

said that he is afraid that he will wake up and find that he is

still in Iraq.

8. Competency

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

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

[X] Yes [ ] No

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

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

Summary:

The Veteran meets the DSM 5 diagnostic criteria for PTSD, chronic, severe

based on the number, frequency and severity of his symptoms. His

stressors are related to his fear of hostile military and terrorist

attacks. It is likely that his PTSD is related to his military service in

Iraq. The Veteran also meets the DSM 5 diagnostic criteria for Major

Depressive Disorder, recurrent, moderate with anxious distress. He

mentioned several times throughout the evaluation how he is depressed

with

his life, and he does not know who he is anymore. He stated that he made

some poor decisions in Iraq that cost people their lives. He stated

that his attention and concentration are very poor. He stated that he

feels useless out of the military. He said that in the military he at

least had a purpose to his life. It is at least as likely as not that

his

Major Depressive Disorder is secondary to his PTSD.

Unemployability:

The Veteran has outbursts of anger and rage that he could not control

when

he did work. He even tried to strangle a customer who had stolen from the

store. His flashbacks and his panic attacks occur frequently and they

abruptly remove him from an interaction with another person. His

anhedonia

removes his desire to connect with others. His mistrust of others

impedes

his ability to form good working relationships to a severe extent. The

overall effects of these symptoms is to impair the Veteran's ability to

work cooperatively with co-workers, supervisors, and the public to a

severe extent.

The Veteran has difficulty concentrating, and when he has a flashback, he

is not paying attention to the task at hand. His hypervigilance and his

intense psychological distress at exposure to internal or external cues

that remind him of his stressors interfere with attention and

concentration and impede the encoding of information into memory. These

symptoms impair the Veteran's ability to understand and follow directions

and to retain instructions to a severe extent.

The Veteran experiences anhedonia and apathy which decrease his

motivation

to do a task. His flashbacks and his panic attacks sap his energy and

distract him from his objectives. These symptoms impair the Veteran's

ability to maintain task persistence to a moderate extent. They impair

his ability to arrive at work on time to a moderate extent. They impair

his ability to work a regular schedule without excessive absences to a

severe extent.

NOTE: VA may request additional medical information, including additional

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

application.

[Berta]

If this is for a TDIU claim, I feel it will support that claim.

"i originally filed for ptsd back in 2008 and was diagnosed with ptsd but my claim got denied because i couldn't put my stressors down on paper took me almost 5 years of therapy to be able to get them down. sigh..Alot has happened but that's a story for another...."

Did you have the PH, CIB, or CAR on your DD 215?

If so they should have conceded the stressors.

For many combat vets it is a horrible, dejavu experience to have to explain them to the VA.

Edited February 14, 2015 by Berta

[Navy04]

Welcome aboard bud, and it looks like you will be granted service connection at the 50-70% range. God Bless and good luck

[Valen2384]

If this is for a TDIU claim, I feel it will support that claim.

"i originally filed for ptsd back in 2008 and was diagnosed with ptsd but my claim got denied because i couldn't put my stressors down on paper took me almost 5 years of therapy to be able to get them down. sigh..Alot has happened but that's a story for another...."

Did you have the PH, CIB, or CAR on your DD 215?

If so they should have conceded the stressors.

For many combat vets it is a horrible, dejavu experience to have to explain them to the VA.

Hello Berta,

No i have not filled out for TDUI yet. waiting for the claim to get finished or should i fill out for it now? I still have not gotten SC for PTSD. Another reason for my Denial of benifts was because my DD 2-14 was not up to date with my current awards. Perfect example my airbone badge and arcom from iraq were not listed. Since the denial i got Help at a Vet center where they helped me get my dd 2-14 updated. That took me 2 years because my unit records for me and a couple battle buddies had us as we did not exist but luckly i saved all my orders (awards) and deployment orders that stated otherwise. I submitted a copy of my DD2-15 on ebenifits in september 2014 but my battle now is for my CAB. Since i ETS a couple months before the CAB award was created. I have asked Army HR for info on how to go about getting the award last year and i have not gotten a written responce from them. Thanks again for your time.