Review Post TraumaticStressDisorder (PTSD) Disability Benefits Questionnaire
SECTION I:
---------- 1 . D i a g n o s t i c Su m m a r y
--------------------- Does the Veteran now have or has he/ she ever been diagnosed with PTSD? [X] Yes[ ] No
2. Current Diagnoses -------------------- a. Mental Disorder Diagnosis #1: Post traumatic stress disorder, chronic and
currently severe.
Mental Disorder Diagnosis #2: Alcohol use disorder, comorbid with him secondary to PTSD, currently in early remission.
Mental Disorder Diagnosis #3: Opiate use disorder, comorbid with him secondary to PTSD, currently in early remission.
b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): This veteran has a history of a right heel injury.
3. Differentiation of symptoms ------------------------------ a. Does the Veteran have more than one mental disorder diagnosed?
[X] Yes[ ] No
b.Isit 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: The veteran's PTSD is characterized by a full syndrome
symptoms consistent with DSM5 criteria. These include hyperarousal episodes, avoidance symptoms, reexperiencing symptoms and negative cognitions.
The veteran's history of both alcohol and opiate abuse have been ongoing attempts to self medicate his PTSD symptoms are secondary to that condition. The veteran has not abused alcohol since September
2014. The veteran has recently completed a Suboxone treatment for
opiate abuse. He is currently abstinent from opiates.
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
occupat ional and social impairment with regards to all mental diagnoses? (Check only one)
[X] Total occupational and social impairment
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: The entirety ofwhat I assess to be ongoing and severe psychosocial and occupational impairment is the result of the veteran's posttraumatic stress disorder. His history secondary alcohol and opiate
abuse, which are both in early remission, had been ongoing attempts to self m e d i c a t e h i s P T SD s y m p t o m s .
c. If a diagnosis of TBI exists, is it possible to differentiate what port ion
the
of the occupational and social impairment indicated above is caused by
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 (VBMSor Virtual VA) reviewed? [X] Yes[ ] No
Was the Veteran's VA claims file (hard copy paper C-file) reviewed? [ ] Yes[X] No
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 [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 [ ] Other:
b. Was pertinent information from collateral sources reviewed? [ ] Yes[X] No0
2. Recent History (since prior exam) ------------------------------------ a.Relevant Social/Marital/Familyhistory:
There have been no significant changes in the veteran's psychosocial
to just
circumstances since he was last examined in July2014. He continues live by himself in a small house that he owns in a small community
outside of Binghamton NewYork.
b. Relevant Occupational and Educational history: There have been no changes in the veterans occupational status since
he
was last examined in July of 2014. When last seen he had been out of work and was awarded Social Security disability benefits because of a heel injury he suffered at his last job installing surveillance systems. . He currently supports himself on the 70% rating he currently gets for his posttraumatic stress disorder and money from a lawsuit related to his heel injury.
The veteran has had several jobs in the past. He has been fired from
lease 3 of them because of PTSD symptoms and his comorbid substance abuse.
c. Relevant Mental Health history, to include prescribed medications and family mental health:
This veteran continues to be in ongoing outpatient treatment for his
PTSD symptoms at the surgeon's VA Medical Center. He is part of a program that treats people with PTSD and related substance abuse issues so he does come up to Syracuse v.a as opposed to going to the clinic in Binghamton. He is seeing a social worker for psychotherapy on a regular basis. Whatever this treatment program is time limited and when it does end in several sessions of veteran likely seek treatment at the vet center in Binghamton.
The
The veteran also been seeing a psychiatrist at the Syracuse facility for his Suboxone treatment. He is no longer on the Suboxone and reports he we'll not continue to see the psychiatrist any longer.
veteran is currently not taking any psychotropic medications. In the past he has been on trazodone and venlafaxine but he did not like the side effects.
The veteran has been psychiatrically hospitalized at the Syracuse facility 3 times in the last 6 years. His most recent hospitalization occurred in September of 2014-2 and exacerbation of his PTSD symptoms and an intensification of his alcohol abuse.
The veteran has never made a suicide attempt. He does not currently present as an imminent suicidal or homicidal risk.
d. Relevant Legal and Behavioral history: This veteran has a past history of DWIs and a prison term and 2010. However he has not had any legal issues since he last exam. He is
not
on probation or parole.
e. Relevant Substance abuse history: As noted the veteran does have a history of alcohol and opiate abuse
as
away of self-medicating his PTSD symptoms. He is currently abstinent from alcohol since July2014. He has not used opiates for several months and is just gotten off the Suboxone he was taking to treat his opiate abuse. Both conditions are in early remission. He does occasionally attend AA or NA meetings.
f. Other, if any: No response provided.
3. PTSD Diagnostic Criteria --------------------------- Please check criteria used for establishing the current PTSD diagnosis. The diagnostic criteria for PTSD, are from the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5). The stressful event can be due to combat, personal trauma, other life threatening situations (non-combat relatedstressors.)DoNOTmarksymptomsbelowthat areclearlynot attributable to the Criteria A stressor/ PTSD. Instead, overlapping symptoms clearly attributable to other things should be noted under #6 - "Other symptoms" .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 sympt oms
memories
event (s).
were with
to
t r au m at i c
associated with the traumatic event(s), beginning after the traumatic event(s) occurred:
[X] Recurrent, involuntary, and intrusive distressing
of the traumatic event(s). [X] Recurrent distressingdreamsinwhichthecontent and/or
affect of the dream are related to the traumatic
[X] Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s)
recurring. (Suchreactionsmayoccuronacontinuum,
the most extreme expression being a complete loss of
awareness of present surroundings). [X] Intense or prolonged psychological distress at exposure
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
event (s).
Criterion C: Persistent avoidance of stimuli associated with the t r au m at i c
the
or
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
traumatic event(s). [X] Avoidance of or efforts to avoid external reminders
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 theCONFIDENTIALPage 23 of 418
of
or
of
thefollowing:
[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,
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)
thefollowing:
[X] Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects.
[X] Hypervigilance. [X] Exaggerated startle response. [X] Problems with concentration. [X] Sleep disturbance (e.g., difficulty falling or staying
asleep or restlesssleep).
Criterion F: [X] The duration of the symptoms described above in Criteria
The veteran is a well-nourished white male of average height who looks some what younger than his stated age. His attire was casual,neat and appropriate. His hygiene and grooming were good. He was cooperative to the exam. He made good eye contact. His sensorium was in tact. The veteran's speech wasr elevant,coherent and productive. His thought process was rational and goal-directed. There was no evidence of a thought disorder. There was no evidence of hallucinations or delusions. During the exam the veteran was orientedx3. During the exam the veteran's basic cognitive functioning presented as grossly intact
interview and observational data. I would estimate the veterans
per
relat ionships
intellectual skills to be in the average range. The veteran's mood was
tense and anxious during the exam overtly he was pleasant. His affect was
appropriate with a full range noted.
6. Other symptoms ----------------- Does the Veteran have any other symptoms attributable to PTSD (and other mental disorders) that are not listed above? [ ] Yes[X] No
7. Competency ------------- Is the Veteran capable of managing his or her financial affairs? [X] Yes[ ] No
8. Remarks, (including any testing results) if any: ---------------------------------------------------
When compared to when the veteran was last examined for compensation and p e n s i o n p u r p o s e s i n Ju l y 2 0 1 4 t h e r e i s e v i d e n c e o f an i n c r e a s e i n t h e severity of his PTSD symptoms. When last seen they presented, per my interpretation of the report,as moderate to severe. They are now fully severe.
It is noted that the veteran is applying for individual unemployability secondarytohisposttraumaticstressdisorder. Withregardtoother veterans PTSD symptoms impact upon his occupational functioning I
rendered the following opinion based on my exam today:
Based on all the evidence available it is my opinion that the veteran does
present as totally and permanently disabled in terms of his occupational functioning secondary to his PTSDsymptoms. The chronicity Mark severity of the symptoms would preclude any capacity on this veteran's part whatsoever for maintaining even a marginal semblance of behavioral or emotional stability in any type of work setting, even a low stress 1, and the was sedentary or non-sedentary. His symptoms also severely impaired his capacity to carry out even simple work-related activities and a reliable and consistent manner.
The veteran psychosocial functioning is also quite severely impaired. He continues to have nightmares and flashbacks. He continues to be socially avoidant and hypervigilant in crowds or public situations. He continues to have irritability. A severe sleep disturbance is noted. The veteran is also severely isolated and withdrawn. Except for the ongoing contact with his father he essentially has no social support system were no other supportive social contacts. His ability to enjoy any daily activity with
her social or solitary is severely impaired.
The veteran should continue with his current treatment at discharge he is VA Medical Center until it and says it is time limited. After that the veteran does plan to seek treatment at either the VA clinic in Binghamton where he gets his primary care or the vet center in Binghamton.
Question
Oiler1995
COMP AND PEN NOTE STANDARDTITLE: C& PEXAMINATIONNOTE DATEOFNOTE: FEB25, 2015@10:00 ENTRYDATE: FEB25, 2015@10:39:50: URGENCY: STATUS: COMPLETED
Review Post TraumaticStressDisorder (PTSD) Disability Benefits Questionnaire
SECTION I:
---------- 1 . D i a g n o s t i c Su m m a r y
--------------------- Does the Veteran now have or has he/ she ever been diagnosed with PTSD? [X] Yes[ ] No
2. Current Diagnoses -------------------- a. Mental Disorder Diagnosis #1: Post traumatic stress disorder, chronic and
currently severe.
Mental Disorder Diagnosis #2: Alcohol use disorder, comorbid with him secondary to PTSD, currently in early remission.
Mental Disorder Diagnosis #3: Opiate use disorder, comorbid with him secondary to PTSD, currently in early remission.
b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): This veteran has a history of a right heel injury.
3. Differentiation of symptoms ------------------------------ a. Does the Veteran have more than one mental disorder diagnosed?
[X] Yes[ ] No
b.Isit 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: The veteran's PTSD is characterized by a full syndrome
symptoms consistent with DSM5 criteria. These include hyperarousal episodes, avoidance symptoms, reexperiencing symptoms and negative cognitions.
The veteran's history of both alcohol and opiate abuse have been ongoing attempts to self medicate his PTSD symptoms are secondary to that condition. The veteran has not abused alcohol since September
2014. The veteran has recently completed a Suboxone treatment for
opiate abuse. He is currently abstinent from opiates.
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
occupat ional and social impairment with regards to all mental diagnoses? (Check only one)
[X] Total occupational and social impairment
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: The entirety ofwhat I assess to be ongoing and severe psychosocial and occupational impairment is the result of the veteran's posttraumatic stress disorder. His history secondary alcohol and opiate
abuse, which are both in early remission, had been ongoing attempts to self m e d i c a t e h i s P T SD s y m p t o m s .
c. If a diagnosis of TBI exists, is it possible to differentiate what port ion
the
of the occupational and social impairment indicated above is caused by
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 (VBMSor Virtual VA) reviewed? [X] Yes[ ] No
Was the Veteran's VA claims file (hard copy paper C-file) reviewed? [ ] Yes[X] No
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 [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 [ ] Other:
b. Was pertinent information from collateral sources reviewed? [ ] Yes[X] No0
2. Recent History (since prior exam) ------------------------------------ a.Relevant Social/Marital/Familyhistory:
There have been no significant changes in the veteran's psychosocial
to just
circumstances since he was last examined in July2014. He continues live by himself in a small house that he owns in a small community
outside of Binghamton NewYork.
b. Relevant Occupational and Educational history: There have been no changes in the veterans occupational status since
he
was last examined in July of 2014. When last seen he had been out of work and was awarded Social Security disability benefits because of a heel injury he suffered at his last job installing surveillance systems. . He currently supports himself on the 70% rating he currently gets for his posttraumatic stress disorder and money from a lawsuit related to his heel injury.
The veteran has had several jobs in the past. He has been fired from
lease 3 of them because of PTSD symptoms and his comorbid substance abuse.
c. Relevant Mental Health history, to include prescribed medications and family mental health:
This veteran continues to be in ongoing outpatient treatment for his
PTSD symptoms at the surgeon's VA Medical Center. He is part of a program that treats people with PTSD and related substance abuse issues so he does come up to Syracuse v.a as opposed to going to the clinic in Binghamton. He is seeing a social worker for psychotherapy on a regular basis. Whatever this treatment program is time limited and when it does end in several sessions of veteran likely seek treatment at the vet center in Binghamton.
The
The veteran also been seeing a psychiatrist at the Syracuse facility for his Suboxone treatment. He is no longer on the Suboxone and reports he we'll not continue to see the psychiatrist any longer.
veteran is currently not taking any psychotropic medications. In the past he has been on trazodone and venlafaxine but he did not like the side effects.
The veteran has been psychiatrically hospitalized at the Syracuse facility 3 times in the last 6 years. His most recent hospitalization occurred in September of 2014-2 and exacerbation of his PTSD symptoms and an intensification of his alcohol abuse.
The veteran has never made a suicide attempt. He does not currently present as an imminent suicidal or homicidal risk.
d. Relevant Legal and Behavioral history: This veteran has a past history of DWIs and a prison term and 2010. However he has not had any legal issues since he last exam. He is
not
on probation or parole.
e. Relevant Substance abuse history: As noted the veteran does have a history of alcohol and opiate abuse
as
away of self-medicating his PTSD symptoms. He is currently abstinent from alcohol since July2014. He has not used opiates for several months and is just gotten off the Suboxone he was taking to treat his opiate abuse. Both conditions are in early remission. He does occasionally attend AA or NA meetings.
f. Other, if any: No response provided.
3. PTSD Diagnostic Criteria --------------------------- Please check criteria used for establishing the current PTSD diagnosis. The diagnostic criteria for PTSD, are from the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5). The stressful event can be due to combat, personal trauma, other life threatening situations (non-combat relatedstressors.)DoNOTmarksymptomsbelowthat areclearlynot attributable to the Criteria A stressor/ PTSD. Instead, overlapping symptoms clearly attributable to other things should be noted under #6 - "Other symptoms" .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 sympt oms
memories
event (s).
were with
to
t r au m at i c
associated with the traumatic event(s), beginning after the traumatic event(s) occurred:
[X] Recurrent, involuntary, and intrusive distressing
of the traumatic event(s). [X] Recurrent distressingdreamsinwhichthecontent and/or
affect of the dream are related to the traumatic
[X] Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s)
recurring. (Suchreactionsmayoccuronacontinuum,
the most extreme expression being a complete loss of
awareness of present surroundings). [X] Intense or prolonged psychological distress at exposure
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
event (s).
Criterion C: Persistent avoidance of stimuli associated with the t r au m at i c
the
or
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
traumatic event(s). [X] Avoidance of or efforts to avoid external reminders
(people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts,
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 theCONFIDENTIAL Page 23 of 418
of
or
of
thefollowing:
[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,
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)
thefollowing:
[X] Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects.
[X] Hypervigilance. [X] Exaggerated startle response. [X] Problems with concentration. [X] Sleep disturbance (e.g., difficulty falling or staying
asleep or restlesssleep).
Criterion F: [X] The duration of the symptoms described above in Criteria
B,C,andDaremorethan1month.
Criterion G: [X] ThePTSDsymptomsdescribedabovecauseclinically
significant distress or impairment in social, occupational, or other important areas of functioning.
Criterion H: No response provided.
4. Symptoms ----------- For VA rating purposes, check all symptoms that actively apply to the
Veteran's diagnoses:
[X] Depressed mood [X] Anxiety [X] Suspiciousness [X] Chronic sleep impairment [X] Mild memory loss, such as forgetting names, directions or recent
event s [X] Disturbances of motivation and mood [X] Difficulty in establishing and maintaining effective work and social
traumatic event(s) occurred, as evidenced by two (or more[X] Difficulty in adapting to stressful circumstances, including work or
worklike setting [X] Inability to establish and maintain effective relationships
5. Behavioral Observations: ---------------------------
The veteran is a well-nourished white male of average height who looks some what younger than his stated age. His attire was casual,neat and appropriate. His hygiene and grooming were good. He was cooperative to the exam. He made good eye contact. His sensorium was in tact. The veteran's speech wasr elevant,coherent and productive. His thought process was rational and goal-directed. There was no evidence of a thought disorder. There was no evidence of hallucinations or delusions. During the exam the veteran was orientedx3. During the exam the veteran's basic cognitive functioning presented as grossly intact
interview and observational data. I would estimate the veterans
per
relat ionships
intellectual skills to be in the average range. The veteran's mood was
tense and anxious during the exam overtly he was pleasant. His affect was
appropriate with a full range noted.
6. Other symptoms ----------------- Does the Veteran have any other symptoms attributable to PTSD (and other mental disorders) that are not listed above? [ ] Yes[X] No
7. Competency ------------- Is the Veteran capable of managing his or her financial affairs? [X] Yes[ ] No
8. Remarks, (including any testing results) if any: ---------------------------------------------------
When compared to when the veteran was last examined for compensation and p e n s i o n p u r p o s e s i n Ju l y 2 0 1 4 t h e r e i s e v i d e n c e o f an i n c r e a s e i n t h e severity of his PTSD symptoms. When last seen they presented, per my interpretation of the report,as moderate to severe. They are now fully severe.
It is noted that the veteran is applying for individual unemployability secondarytohisposttraumaticstressdisorder. Withregardtoother veterans PTSD symptoms impact upon his occupational functioning I
rendered the following opinion based on my exam today:
Based on all the evidence available it is my opinion that the veteran does
present as totally and permanently disabled in terms of his occupational functioning secondary to his PTSDsymptoms. The chronicity Mark severity of the symptoms would preclude any capacity on this veteran's part whatsoever for maintaining even a marginal semblance of behavioral or emotional stability in any type of work setting, even a low stress 1, and the was sedentary or non-sedentary. His symptoms also severely impaired his capacity to carry out even simple work-related activities and a reliable and consistent manner.
The veteran psychosocial functioning is also quite severely impaired. He continues to have nightmares and flashbacks. He continues to be socially avoidant and hypervigilant in crowds or public situations. He continues to have irritability. A severe sleep disturbance is noted. The veteran is also severely isolated and withdrawn. Except for the ongoing contact with his father he essentially has no social support system were no other supportive social contacts. His ability to enjoy any daily activity with
her social or solitary is severely impaired.
The veteran should continue with his current treatment at discharge he is VA Medical Center until it and says it is time limited. After that the veteran does plan to seek treatment at either the VA clinic in Binghamton where he gets his primary care or the vet center in Binghamton.
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Navy04
No retro, as this will be approved for an increase. I just went thru this bud, and it looks like we have a lot of bad in common. You will definitely get 100% PTSD, or the 70% PTSD and IU. Either way y
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