C & P Results From Ptsd

[wysiwyg1965]

Hi All,

I just had a C & P recently and found the below in the blue button on Myhealthevet. I would really appreciate it if somebody could tell me what all of this means. It doesn't make sense to me when it comes to the bottom whereas the examiner puts her opinion. I just supplied a PTSD Nexus letter from my personal doctor stating my PTSD is likely as not a result of military service.

Initial Post Traumatic Stress Disorder (PTSD)

----------

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

2. Current Diagnoses

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

a. Mental Disorder Diagnosis #1: Anxiety disorder unspecified

Mental Disorder Diagnosis #2: None

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

Mental Health Disorder (to include TBI): OSA, HTN

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 [ ] 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] A mental condition has been formally diagnosed, but symptoms are not

severe enough either to interfere with occupational and social

functioning or to require continuous medication

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?

[ ] 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:

[ ] Military service treatment records

[X] 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?

[X] Yes [ ] No

If yes, describe:

VBMS

2. History

----------

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

post-military):

xxx

her.

b. Relevant Occupational and Educational history (pre-military, military,

and

post-military):

xxx

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

the dream are related to 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:

No response provided.

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:

No response provided.

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:

No response provided.

Criterion F:

No response provided.

Criterion G:

No response provided.

Criterion H:

No response provided.

Criterion I: Which stressor(s) contributed to the Veteran's PTSD

diagnosis?:

No response provided.

5. Symptoms

-----------

For VA rating purposes, check all symptoms that actively apply to the

Veteran's diagnoses:

[X] Anxiety

6. Behavioral Observations

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

pleasant and cooperative

7. Other symptoms

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

Does the Veteran have any other symptoms attributable to PTSD (and other

mental 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

n/a

[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:

cprs

MEDICAL OPINION SUMMARY

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

RESTATEMENT OF REQUESTED OPINION:

a. Opinion from general remarks: CLAIMS FILE BEING SENT FOR REVIEW BY THE

EXAMINER.

Date of claim: 10/08/2013

Days pending: 632

An in-person examination is required for the following exam(s). ACE process

must not be used to complete the DBQ.

DBQ General Medical Gulf War

DBQ PSYCH Mental disorders

____________________________________________________________________________

The following contentions need to be examined:

PTSD

TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR DIRECT SERVICE

CONNECTION ]

b. The condition claimed was less likely than not (less than 50%

probability) incurred in or caused by the claimed in-service injury, event

or illness.

c. Rationale: BASED ON REVIEW OF MEDICAL RECORDS AND HISTORY PROVIDED BY

VETERAN, HE DOES NOT MEET DSM-5 CRITERIA FOR PTSD AT PRESENT. HIS ANXIETY IS

AT LEAST AS LIKELY AS NOT SECONDARY TO HIS FAMILY AND LEGAL ISSUES.

[USMC_VET]

There were a lot of criterion that were strangely marked "no response provided". when asked questions by the examiner, was there any point where you refused to answer or say "i dont want to talk about it". If not then i would be readying your NOD.

Your private psych are they a board certified psychologist and did they say as likely as not or more likely than not? shouldnt matter since both are 50% or greater, however i would ask that your private psych redo his report to read "more likely than not" since this gets you above the 50/50 that as likely as not can be interpreted as.

I would also go and find a great, experienced, board certified, specialist and get a IMO/IME. Have them conduct the interview and do a DBQ and also give them a copy of this exam and tell them that wherever there is a difference between their report and this exam to go into more detail. basically so that they have a detailed refutation of every bs part of this exam.

im sorry this is going on.

[wysiwyg1965]

Hi, Thank you for your post! I appreciate it!

My personal Dr. is a MD, PC and Psychotherapist is a MA, LLP, LPC, CAAC. They wrote likely as not instead of more likely than not unfortunately because I don't think she may of understood the importance between the two.

I took all kinds of tests and exams so I've just submitted as evidence.

The C & P examiner did not really ask me anything, I came prepared and told her what I thought she needed to know. I can't believe that in the beginning of the exam she had marked YES for DSM-5 criteria:

Does the Veteran have a diagnosis of PTSD that conforms to DSM-5 criteria

based on today's evaluation?

[X] Yes [ ] No

But at the end of the report she writes that I do not meet DSM-5 criteria?

Rationale: BASED ON REVIEW OF MEDICAL RECORDS AND HISTORY PROVIDED BY

VETERAN, HE DOES NOT MEET DSM-5 CRITERIA FOR PTSD AT PRESENT

I think I'm getting hood winked here?? Will the rater ask for another C & P since she did not ask me those specific questions? I answered everything she ask me!

Thank you for your help and advise!!

Rob

[Navy04]

It sounds like you may be granted SC for Anxiety Disorder at the 0-10% range, but not PTSD. As stated above you may need a Stressor Letter or IMO. Good luck and keep us posted, God Bless

[USMC_VET]

Hi, Thank you for your post! I appreciate it!

My personal Dr. is a MD, PC and Psychotherapist is a MA, LLP, LPC, CAAC. They wrote likely as not instead of more likely than not unfortunately because I don't think she may of understood the importance between the two.

You may want to ask them, and explain why its important, that if they feel comfortable rewriting their report to reflect that wording to do so. tell the difference in the VA's viewing and if they do feel it is "more likely than not" then to write that.

I took all kinds of tests and exams so I've just submitted as evidence.

The C & P examiner did not really ask me anything, I came prepared and told her what I thought she needed to know. I can't believe that in the beginning of the exam she had marked YES for DSM-5 criteria:

Does the Veteran have a diagnosis of PTSD that conforms to DSM-5 criteria

based on today's evaluation?

[X] Yes [ ] No

But at the end of the report she writes that I do not meet DSM-5 criteria?

Rationale: BASED ON REVIEW OF MEDICAL RECORDS AND HISTORY PROVIDED BY

VETERAN, HE DOES NOT MEET DSM-5 CRITERIA FOR PTSD AT PRESENT

I think I'm getting hood winked here?? Will the rater ask for another C & P since she did not ask me those specific questions? I answered everything she ask me!

Thank you for your help and advise!!

Rob

That is strange to say that you meet it, but then opine you dont. I wouldnt bet the farm or even a penny that they will ask for a new C&P exam.

Since the decision hasnt been made yet you cant file an NOD, but be ready to from the looks of this.

I would file a sworn declaration as evidence, do all the appropriate mailing and submissions (see the post in my signature line). In that declaration state that you have seen the C&P exam online and you disagree with the way the exam was conducted. That you take offense with so many sections noted "no response provided" as you were not asked questions relating to that criterion and in fact were not asked all that much regarding your condition. Then request that a new C&P exam be conducted with a new examiner.

The problem is that for a NEW claim for PTSD that has not been diagnosed by the VA prior your private doc notes cannot be used to diagnose the issue or provide a nexus (ie connect the ptsd to inservice) they can be used to provide a scope of how it affects you. I would say it wouldnt hurt to have them fill out a dbq for you, but it wont help. your best option is to request a new C&P exam.

here is the new DBQ for PTSD

If i were you I would put together a file of all your treatment notes from your private doctor and write up a sworn declaration talking about the incident (stressor) that caused the PTSD. go into detail (if you can, if not i get it) about what happened and when you first started to be affected and how it made you feel as well as how it makes you feel now and how it affects you. have family/friends/coworkers do these as well as to how it hurts you, relationships, etc.

make copies of those hand them into the doc when you go into a C&P exam. Then get his/her name, then after the C&P exam write on the evidence cover page that this was presented in full to Dr. So and so on DATE. then send that into the claims intake center as evidence. get certified/return receipt all that stuff.

NOW

If they wont grant you a new exam all you can do is wait for the decision. once the decision comes out IF its not what you feel is correct then send in the NOD.

So since it looks like this may not be going your way I would prepare the following.

Notice of Disagreement

-Private psych records/exams

-Private Psych reprot

-Sworn declarations

- FROM YOU regarding old C&P exam as stated above

- FROM YOUR regarding incident, and how you are now

- FROM FAMILY/FRIENDS about how it affects your relationships, work, etc.

- FROM old military buddies, etc. anyone who was there when it happened, direct witness best, friends who were in that heard about it, aware of it, heard you talk about it, etc.

Have them talk about the incident, basically confirming that they KNOW it happened to you.

-List of medications you are on for the ptsd if any

-days of work you have missed because you were depressed couldnt come to work.

-Unit records, news stories, etc that may have been about the incident.

However what it sounds like is that they are not having an issue as much that something happened to you, more of a is this ptsd vs something else.

In your sworn declaration dont talk about "my ptsd causes me to...." just say my illness, or my issues, etc. you are not a doctor. it may in fact not be ptsd and something else.

Edited August 10, 2015 by USMC_VET

[Buck52]

I would CUE them...

jmo

..............Buck

[USMC_VET]

I would CUE them...

jmo

..............Buck

Buck i a mnot a expert on CUE, however from what i understand that did pop into my head however i have heard that NOD is far better than CUE as far as time and PIA (pain in ass) is concerned.

I also think that the decision on CUE might not go your way either and at best result in a new C&P since i believe the actually remarks and opine on their opinion of the condition would carry more weight than just a box being checked when trying to "figure out" what the examiner meant to write.