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C & P Opinions: Yese's - Ptsd Combat, And Ptsd Mst; Service Connection


fatheryabueloDE9

Question

I recently had my C & P exam by a VA psychologist, and downloaded it

from My healthevet.

Note: For over 40 years, I kept to myself most of the traumatic Vietnam combat related experiences, especially the MST. I never reported the MST while in the RVN to Military, later to the VA, nor any civilian doctors. I kept the MST violations internally, never informing my wife until 2014 when seeking VA mental health treatment. I am still continuing MH counseling from the VA.

It appears the Opinions (NEXUS) by the C & P examiner are favorable, yese's for both PTSD Combat and MST, and Service Connected.

However, I do not agree with the Rating given for

"Occupational and social impairment " (30%)

I realize that other factors beside the C & P are use for the overall ratings.

Any educated guesses on what Rating might be given by the Rating person based on the C & P below? Combined Ratings ?

Below is about 98% of the actual C & P Report by the VA psychologist. Slight edits were made to the for clarity or anominity.

_______

Initial Post Traumatic Stress Disorder (PTSD)

Disability Benefits Questionnaire

* Internal VA or DoD Use Only *

Name of patient/Veteran: XXXXX

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 (F43.10)

2. Current Diagnoses

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

a. Mental Disorder Diagnosis #1: Posttraumatic Stress

Disorder ICD code: 309.81 (F43.10)

Mental Disorder Diagnosis #2: Alcohol Use Disorder

ICD code: 305.00 (F10.10)

b. Medical diagnoses relevant to the understanding or

management of the Mental Health Disorder (to include TBI):

deferred to medical providers

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?

[ ] Yes [X] No [ ] Not applicable (N/A)

If no, provide reason that it is not possible to

differentiate what portion of each symptom is attributable to each

diagnosis and discuss

whether there is any clinical association between

these diagnoses:

The symptoms of each disorder overlap and occur

in a concurrent and

reciprocal relationship. It is not possible to

accurately separate

them without resorting to mere speculation.

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

[ ] Yes [ ] No [X] 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 occasional

decrease in work

efficiency and intermittent periods of inability to

perform

occupational tasks, although generally functioning

satisfactorily,

with normal routine behavior, self-care and conversation

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:

The symptoms of each disorder overlap and occur

in a concurrent and

reciprocal relationship. It is not possible to

accurately separate

the impairments without resorting to mere

speculation.

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: recent medical records

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?

[X] Yes [ ] No

If yes, describe:

cfile, medical records

2. History

----------

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

military, and post-military):

He lives with his wife of 35 + years. He reports

their relationship has

had discord but he states they are currently getting

along "fine." He

reports increased agitation at home. He reports he

prefers to stay

around the house but they eventually enjoy going out

to organized

activities together at their senior community. They

attend dances. He

reports he also enjoys watching television and going

for walks. He

also enjoys running

He reports his relationship with his children is

"pretty good." He has a

friend from his community. He enjoys playing a

dominos game with

another couple once a week.

b. Relevant Occupational and Educational history (premilitary,

military, and post-military):

He last worked in 2002. He reports he applied for

social security

disability during 2002.(when 54 years old.)

He had been working for a college in CA as an administrator. He had been working for them for 2 years. He states he was

terminated related to

budget cuts. He states he perceives he was fired

for whistle blowing

on the President of the School who he states had

misapropriated funds.

Prior to that he was unemployed for 3 years. Prior

to working for another university as an assistant finance

controller for 3.5 years.

He states he was terminated due to poor performance.

He states he percieves he was terminated again related to whistle

blowing. He states he had reports to management that another

employee had not completed their job correctly and he perceives the

administration was

more loyal to the other employee. He attended

college and obtained a bachelors degree in business in 197x.

He served IN … from JUN of 1968 until MAR of 1970. His job was ….

He was honorably discharged at the rank of E4.

c. Relevant Mental Health history, to include prescribed medications and family mental health (pre-military, military, and postmilitary):

He sought treatment at the ….CBOC during FEB of 2014. His diagnosis

at that time was Major Depressive Disorder, Anxiety

Disorder NOS, ADHD, and rule out PTSD.

He continued to received treatment.

During 2014 the diagnoses of PTSD and Alcohol Use Disorder were added. He is prescribed bupropion for psych symptoms.

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

military, and post-military): denied

e. Relevant Substance abuse history (pre-military,

military, and post-military):

He reports he uses alcohol 2 days/week and drinks 4

drinks per sitting.

He states he has a history of excessive alcohol use

but in 2003 he

quit drinking alcohol after attending an alcohol

rehab program. He began drinking again in 2009 and has been moderation drinking. He

reports prior to 2003 he was drinking 10 beers per

day for 30 years.

He reports during his military service he used

amphetamine, alcohol,

and cannabis. He states he has not used cannabis or

amphetamine for 40 years.

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 postmilitary):

a. Stressor #1: He served in Vietnam. He witnessed a

plane crash with loss of life. There were episodes of incoming rounds.

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: He reports two incidents of MST. One of

suspected sodomy

while he was passed out and another of non-

consensual oral sex.

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?

[ ] Yes [X] No

If no, explain:

it is related to MST

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

military sexual trauma?

[X] Yes [ ] No

If yes, please describe the markers that may

substantiate the stressor.

Service treatment records confirm service in Chu Lai from 68-69;

Complaints of "thinking bad" and feeling tense, thoughts of

going UA; c/o frequent

trouble sleeping and nervous trouble after 16

months of service.

Military Personnel File notes a decrease in

performance scores in March of 1969 and contains letter

from veteran noting that he does not

feel proud to

be in the uniform after his tour in RVN.

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)

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).

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

the traumatic event(s), beginning or

worsening after the

traumatic event(s) occurred, as evidenced by

two (or more) of the following:

[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] Markedly diminished interest or participation in

Significant activities.

X] Feelings of detachment or estrangement from others.

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] Hypervigilance.

[X] Exaggerated startle response.

[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

5. Symptoms

-----------

For VA rating purposes, check all symptoms that actively

apply to the Veteran's diagnoses:

[X] Depressed mood

[X] Anxiety

[X] Chronic sleep impairment

[X] Disturbances of motivation and mood

6. Behavioral Observations

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

Patient is oriented to all spheres. Patient's affect is

congruent with

stated mood and symptoms. Veteran was relatively calm

and responsive.

Speech is of normal rhythm and content. Veteran

maintained focus on topics

and responded appropriately to questions. There is no

evidence of a formal

thought disorder. Insight and judgment were grossly

intact. Active suicidal

ideation, planning, and intent was denied. Protective

factors were identified.

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: there is agitation without behavioral aggression.

8. Competency

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

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

[X] Yes [ ] No

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

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

No remarks provided.

NOTE: VA may request additional medical information,

including additional

examinations if necessary to complete VA's review of the

Veteran's

application.

**************************************************************************

**

Medical Opinion

Disability Benefits Questionnaire

Name of patient/Veteran: xxxxx

Indicate method used to obtain medical information to

complete this document:

[ ] Review of available records (without in-person or video telehealth

examination) using the Acceptable Clinical Evidence

(ACE) process because

the existing medical evidence provided sufficient

information on which to

prepare the DBQ and such an examination will likely

provide no additional

relevant evidence.

[ ] Review of available records in conjunction with a

telephone interview

with the Veteran (without in-person or telehealth

examination) using the

ACE process because the existing medical evidence

supplemented with a

telephone interview provided sufficient information on

which to prepare

the DBQ and such an examination would likely provide

no additional

relevant evidence.

[ ] Examination via approved video telehealth

[X] In-person examination

Evidence review

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

Was the Veteran's VA claims file reviewed? Yes

If yes, list any records that were reviewed but were not

included in the

Veteran's VA claims file: recent medical records

MEDICAL OPINION SUMMARY

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

RESTATEMENT OF REQUESTED OPINION:

a. Opinion from general remarks: The Veteran is claiming

service connection for PTSD.

Please evaluate and

provide an opinion as to whether or not the veteran has a

current diagnosis of posttraumatic stress disorder that is related to his

conceded stressor of fear of hostile military activity.

If a diagnosis of PTSD is made, the examiner needs to

determine if the

Veteran's claimed stressor is related to the Veteran's

fear of in-service

hostile military or terrorist activity. The current

worksheet/template is

otherwise adequate to encompass the new regulation. The

initial PTSD

examination is to be conducted by a VA psychiatrist or psychologist.

"Fear of hostile military or terrorist activity" means

that a Veteran

experienced, witnessed, or was confronted with an event

or circumstances

that involved actual or threatened death or serious

injury, or a threat to

the physical integrity of the Veteran or others and the

Veteran's response

to the event or circumstances involved a psychological or

psychophysiological

state of fear, helplessness, or horror. The

event or

circumstances include, but are not limited to, the

following:

(1) Actual or potential improvised explosive device;

(2) Vehicle-embedded explosive device;

(3) Incoming artillery, rocket, or mortar fire;

(4) Small arms fire, including suspected sniper fire; or

(5) Attack upon friendly aircraft.

***IF NO TO OPINION ABOVE, PLEASE PROVIDE AN OPINION

REGARDING PSTD DUE TO MST BELOW - THANK YOU***

MST OPINION - Please review the veteran's entire claims

file and medical

records and provide an opinion as to whether it is at

least as likely as not

that the VETERAN'S RECORDS SUPPORT THE OCCURRENCE of a

military sexual assault.

Please do not provide opinion #2, unless you have

provided opinion #1.

Opinion #2

If YES to opinion #1, please provide an opinion as to

whether the veteran's

current mental health condition is at least as likely as

not related to the

military sexual assault.

Opinion #3

If NO to opinion #1, please provide an opinion as to

whether it is at least

as likely as not that the veteran's current mental health

condition had its

onset in military service. If you find that this

condition pre-existed the

veteran's military service, please indicate if the

treatment during service

shows this condition was aggravated beyond it's normal

level of progression

by military service.

Rationale must be provided in the appropriate section.

If more than one mental disorder is diagnosed please

comment on their

relationship to one another and, if possible, please

state which symptoms are attributed to each disorder.

b. Indicate type of exam for which opinion has been

requested: Initial PTSD

TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR

DIRECT SERVICE CONNECTION ]

a. The condition claimed was at least as likely as not

(50% or greater probability) incurred in or caused by the claimed inservice injury, event or illness.

c. Rationale: To reiterate, the veterans PTSD is MOST

LIKELY related to both his fear of hostile military and terrorist activity as

well as to MST.

The record MOST LIKELY supports the occurance of MST.

Finally, the veterans symptoms did MOST LIKELY have onset while in

the military.

Opinion is based on clinical experience and research, clinical interview data, DSM5 criteria,

behavioral observation, and supporting service and

medical records.

*********************************************************

****************

xxxxxxx, PSY.D.

STAFF PSYCHOLOGIST, C&P

Signed: 03/xx/2015 07:36

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5 answers to this question

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  • 0

What do you get the SSDI for?

If it is solely for what you are getting SCed for, then the 30% is WAY too low.

Does VA have your SSDI records?

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What do you get the SSDI for?

If it is solely for what you are getting SCed for, then the 30% is WAY too low.

Does VA have your SSDI records?

Hi I appreciate your reply.

re SSDI: In 2002, about the same time, I applied for CA workmens comp And SSDI primarily

for carpal tunnel syndrome. But I was also having depression etc, dealing with authorities.

I am now about 68 and of course the SSDI in now regular SS retirement income.

In 2002, my WC lawyer was a very experienced WC atty; did not expect me to win SSDI. He even offered to "help" my appeal for SSDI upon being denied by S.Sec.

When awarded SSDI ( approved in 4 months) Lawyer said approval had to be for something other than Carpel T. For several years, I had been getting rx's for depression, etc.

I do not know if the VA has my SSDI records.

In my VA claim I mentioned the SSDI started at 55 years of age. In my claim were my statements about having job issues (loss of jobs, etc.

Looks like 30% but possibly 50% due to the amount of Symptoms the Doc checked off. Good luck and God Bless!!!

thanks for reply.

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  • HadIt.com Elder

If they give you a 30% rating, you should appeal it. My initial award was 30% and I appealed, appealed and appealed some more. It took 10yrs and 5 months but I got my 100% rating, retro to day one of my claim. They always lowball claimants! Neve give up!!!

pr

VN 9/65-9/67, 11B4P

1st Cav.

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If they give you a 30% rating, you should appeal it. My initial award was 30% and I appealed, appealed and appealed some more. It took 10yrs and 5 months but I got my 100% rating, retro to day one of my claim. They always lowball claimants! Neve give up!!!

pr

VN 9/65-9/67, 11B4P

1st Cav.

Hello PR,

Well, it is now a month since your post above.

My Claim closed yesterday at 30%- a BIG disappointment. But I am happy I got in the door.

I saw the rating & $ amount on eBenefits- my stomach sank! (I just signed up for Ebenefits in early April.

I spoke briefly with my FL. VSO. Of course we both disagree.

We will be filing an NOD, appeal. But, I have to await the BBE /package from the Rating people.

I do need to find out WHAT is going on with the effective date.

My eBenefits Dashboard, Disabilities has 05/29/2015 as effective date. I saw and printed my AB8.

But the AB8 letter of yesterday has the effective date of Dec. 1, 2014. a 6 month difference ??

The Dashborad Disabilities sounds correct or at least more accuate than the letter.

My Notice to file was May 28, 2014, the VA Claim shows my Claim received 06/04/2014.

Back in May 2014, and yesterday, my understanding confirmed by VSO that my effective Claim

date is June 2014.

Now the struggle. I am confused. Somewhere on this forum I thought reading

that one can ask for a review of the C & P and Rater?

Well this became a long reply. I do appreciate your post of Mar 23rd.

XNam Vet

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