ptsd Ptsd Exam Anyone Know What I Would Get Thanks

[lilmatt1818]

Just got done with my exam and wanted to see what you guys think. I think between 50% and 70% but im not sure thanks.

----------
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 SEVERE
ICD code: 309.81
b. Medical diagnoses relevant to the understanding or management of the
Mental Health Disorder (to include TBI): NONE.
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 [X] No [ ] 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?
[X] Yes [ ] No
If yes, list any records that were reviewed but were not included in the
Veteran's VA claims file:
C-FILE/VBMS/VIRTUAL-VA; CPRS
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

History
----------
a. Relevant Social/Marital/Family history (pre-military, military, and
post-military):
This veteran reports an unremarkable childhood. Pre-Military, he
describes an active social life and engaging in many pleasurable
leisure time activities. Post-Military, the veteran describes:
Avoidance of People and Places, Social Isolation, Restricted Affect,
Anhedonia, Episodes of Uncontrolled Anger and Rage, Depressed Mood,
and
Feelings of Worthlessness and Guilt. He reports few friends, limited
leisure time activity, and a very limited social life.
b. Relevant Occupational and Educational history (pre-military, military,
and
post-military):
This veteran has been employed as an auto mechanic since 2013. He
reports that the following symptoms have had a detrimental impact upon
his ability to function in the workplace: Flashbacks, Episodes of
Anxiety and Panic, Social Isolation, Chronically Disturbed Sleep,
Episodes of Uncontrolled Anger and Rage, Difficulty Concentrating,
Obsessive Hypervigilance, Exaggerated Startle Response, and Depressed
Mood.
c. Relevant Mental Health history, to include prescribed medications and
family mental health (pre-military, military, and post-military):
This veteran reports working in psychotherapy which he finds
palliative. He reports taking medication at this time for these
symptoms which he finds palliative. He reports the following
psychological symptoms: Flashbacks, Nightmares, Episodes of Anxiety
and
Panic, Avoidance of People and Places, Social Isolation, Restricted
Affect, Anhedonia, Sense of Foreshortened Future, Chronically
Disturbed
Sleep, Episodes of Uncontrolled Anger and Rage, Difficulty
Concentrating, Obsessive Hypervigilance, Exaggerated Startle Response,
Depressed Mood, Fatigue, Psychomotor Sequelae, Passive Suicidal
Ideation, Feelings of Worthlessness and Guilt, Suppressed Appetite,
and
Avoiding Thinking of Traumatic Events.
d. Relevant Legal and Behavioral history (pre-military, military, and
post-military):
This veteran reports behavioral and/or legal difficulties prior to and
on leaving the military associated with the above noted psychiatric
symptoms.
e. Relevant Substance abuse history (pre-military, military, and
post-military):
No response provided.

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: The veteran's location was the target of mortar, rocket,
RPG
and/or small arms fire. During these experiences the veteran was
terrified for life and horrified by the aftermath of the experience.
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: This veteran was exposed to the carnage of war which the
veteran found terrifying and horrifying.
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: The veteran directly and/or indirectly experienced IED/Land
Mine attacks which were terrifying and horrifying.
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 militaryterrorist 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.
[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] Chronic sleep impairment
[X] Mild memory loss, such as forgetting names, directions or recent
events
[X] Impairment of short- and long-term memory, for example, retention of
only highly learned material, while forgetting to complete tasks
[X] Flattened affect
[X] Difficulty in understanding complex commands
[X] Impaired judgment
[X] Disturbances of motivation and mood
[X] Difficulty in establishing and maintaining effective work and social
relationships
[X] Difficulty in adapting to stressful circumstances, including work or
a
worklike setting
[X] Suicidal ideation
[X] Obsessional rituals which interfere with routine activities
[X] Impaired impulse control, such as unprovoked irritability with
periods
of violence
[X] Neglect of personal appearance and hygiene
6. Behavioral Observations
--------------------------
No response provided
7. Other symptomsntal 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
--------------------------------------------------
This veteran meets the criteria for a DSM-IV and DSM-V Diagnosis of PTSD
CHRONIC SEVERE. He reports the following psychological symptoms:
Flashbacks, Nightmares, Episodes of Anxiety and Panic, Avoidance of
People
and Places, Social Isolation, Restricted Affect, Anhedonia, Sense of
Foreshortened Future, Chronically Disturbed Sleep, Episodes of
Uncontrolled Anger and Rage, Difficulty Concentrating, Obsessive
Hypervigilance, Exaggerated Startle Response, Depressed Mood, Fatigue,
Psychomotor Sequelae, Passive Suicidal Ideation, Feelings of
Worthlessness
and Guilt, Suppressed Appetite, and Avoiding Thinking of Traumatic
Events.
This psychiatric condition was caused by the veteran's military
experience and/or combat exposure. The reported stressors are directly
related to the veteran's fear of hostile military and/or terrorist
activity. This veteran's GAF score represents Moderate symptoms
which
impact social, work and personal functioning. (GAF: 51)
NOTE: VA may request additional medical information, including additional
examinations if necessary to complete VA's review of the Veteran's
application.

[Oiler1995]

Can some one tell me how you get your report?Do they post it on ebenefits?Also I been looking for my gaf score.

[Philip Rogers]

I agree, 50-70%,is probable

pr

[georgiapapa]

lilmatt1818,

Google 38 CFR part 4.130 which is the Schedule of Ratings for Mental Health Disorders (including PTSD), review the General Rating Formula for Mental Disorders and compare your symptoms with the symptoms listed for each percentage level. This should give you a good idea as to the rating which should be awarded by the VA. If several of your symptoms appear in more than one level, the VA should award the percentage of the level where most of your symptoms appear.

Good luck to you and thank you for your service.

GP

[lilmatt1818]

Thanks guys yeah now I'm just playing the waiting game and see what I get. I'm not sure if it helps or not but I already pull 30 percent sc for anxiety so hopefully that will help my score

[Mikemmlj]

The GAF score of 51 I think indicates 50-70. There is a world of difference in VA thinking between a GAF of 49 and 51. Although I thought they weren't supposed to use GAF scores anymore.

[Navy04]

[X] Occupational and social impairment with reduced reliability and
productivity

The symptoms checked off do fit the 50-70% range, but the above statement carries a lot of weight when it comes to the raters, and if they go off that it could be 10-30%. Either way you made it thru the exam and I wish you the best. God Bless!!!