ptsd opinions on the probability of a service connection

[willidx4]

Below are some of the examiners notes from my PTSD C&P. I would like get opinions on the probability of a service connection. I will say (with limited knowledge) that it looks like 30% but who knows what the rater will do.

My name and Doctors Names removed
 

Name of patient/Veteran:

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: Posttraumatic Stress Disorder

ICD code: 309.81

Comments, if any:

During the present MH C&P exam, the veteran described stressors

meeting criterion A for a diagnosis of PTSD based on his report of

combat-related stressors related to fear of hostile military or

terrorist activity during his deployment in Operation Desert

Shield/Desert Storm. Mr.xxxx described intrusion symptoms

(primarily distress and physical reactions to cues/triggers of

traumatic events as well as nightmares), avoidance symptoms,

xxxxxxxxxx CONFIDENTIAL Page 5 of 101

negative alterations in cognitions and mood associated with

traumatic events, and arousal / reactivity associated with

traumatic events. Therefore, full criteria were met for a

diagnosis of PTSD at this time.Of note, the veteran was recently administered the Clinician

Administered PTSD Scale for DSM-5 (CAPS) during an individual

therapy appointment on 08/06/2015 at the xxxx II CBOC. Mr.

xxxxxx denied experiencing trauma other than combat-related and

was assessed for combat-related PTSD. Dr.xxxxxx, the provider,

wrote that "Results from administration of the CAPS indicate that

Mr.xxxxx currently meets criteria for PTSD, chronic. Mr.

xxxxx appears to experience more generalized anxiety than is

typical of PTSD diagnosis. This generalized anxiety may become an

additional or supplemented focus of treatment." Mr.xxxx is

also receiving mental health treatment from psychiatrist Dr.xxxxxx

at the xxxx II CBOC and is prescribed psychotropic

medications to treat sleep problems, anxiety, and depressive

symptoms. Recent treatment notes document that his current

medication regimen is effective. A diagnosis of rule out PTSD has

been given by Dr.xxx, as well as Unspecified Anxiety Disorder

and MDD, recurrent, in remission on meds.

Due to the fact there are no records to suggest the veteran had

symptoms of Posttraumatic Stress Disorder prior to his military

service (presumption of soundness), as well as the veteran's

self-report that his symptoms started in reaction to his

experiences while deployed to Desert Shield/Desert Storm, it is

this examiner's opinion it is at least as likely not (50/50

probability) that symptoms of Posttraumatic Stress Disorder were

caused by or the result of combat related activities during his military service.

Although treatment records document a history of problems related

to alcohol use and Mr.xxxxxx has, at times, acknowledged having

alcohol-related problems per records, the veteran denied current

use of alcohol since starting psychiatric medications. He denied

recent excessive alcohol use with the exception of one night after

his wife left in 2013. Thus, there is no current evidence that

criteria have been met for an Alcohol Use Disorder at this time.

Past treatment records also document a history of other mental

disorder diagnoses, including major depression, posttraumatic

stress disorder, anxiety disorder, and personality disorder. At

the time of the present MH C&P exam, the veteran did not report or

describe mental health symptoms consistent with any other mental

disorder diagnosis besides PTSD.

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 [ ] 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 diag

[pwrslm]

"it is this examiner's opinion it is at least as likely not (50/50 probability) that symptoms of Posttraumatic Stress Disorder were caused by or the result of combat related activities during his military service."

 

That is a pretty good shot.  50/50 means the Vet wins.

[broncovet]

The exam you posted sounds like this exam is favorable to a service connection for PTSD.  You need to check other exams, tho, to see if they conflate with this one...VA will.  

Assuming you get service connected (that exam is no guarntee...VA still loves to deny even when we have all three:  Diagnosis, stressor, nexus, by making stuff up.   For me, the VA made up a "new" criteria:  time since military service.  I called them on that and BVA reversed them.    Then they countered with a lowball.  

What one guy does is write down the symptoms the doc says you have.  Then compare those with the rating criteria, and see which one is the closest to yours.  

[willidx4]

broncovet I was afraid of that my  treating VA Psychologist diagnosed me with PTSD, and the Psychologist doing the c&p diagnosed me with PTSD. Two private Psychiatrist treated and diagnosed me with PTSD in the past,  my VA Psychiatrist diagnosed me with  major depression/anxiety R/O ptsd he did however cosign the dx of ptsd by my current VA Psychologist. However as you stated you never know what the VA will pull out of thin air to use as an excuse. If they were forced to follow there own rules things would run so much smoother.

below is  what she listed which if I get rated points to 30%

[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

   

[Fat]

I wish you luck...........

Hopefully the RO will decide n your favor.

[willidx4]

30% granted for PTSD