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
Question
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
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