I had my C&P exams for PTSD, osteoarthritis (right knee) and sinusitis. I will try to give the good, the bad and the ugly in my situation:
-Operational Experience:
OEF (Garmsir, 2008). 24 MEU. Cannon Cocker. Conducted combat patrols (was fired upon by the enemy, did not return fire due to non-combatants in the area). Indirect fire on the enemy resulting in 98 enemy casualties. We had 2 KIA in our battalion. Saw a child that had JUST been raped by a family member.
Operation Unified Response. Boots on the ground. Conducting security operations for Hattian citizens coming back from US Navy Hospital ships. Saw some very horrific things.
Received campaign medals and Navy and Marine Corps Achievement Medals for both operations (no “V” or CAR for OEF. Received HSM for Haiti).
Three other various deployments.
-Treatment in Service:
PTSD: 2 years of treatment prior to discharge, diagnosed at Naval Hospital Quantico, Behavioral Health
Treatment for knee throughout service diagnosed with osteoarthritis (right knee) in service.
Sinusitis treatment to include surgery (septoplasty and turbinoplasty). Diagnosed with sinusitis in service.
-VA claims process thus far.
Veteran’s Service Organization: DAV
PTSD, sinusitis and osteoarthritis on appeal, currently with DRO.
Stressor: Seeing small boy being raped in Afghanistan.
DRO had to gather records from the Marine Corps Archives (I am assuming to verify my stressor).
1. Diagnostic Summary
Does the Veteran have a diagnosis of PTSD that conforms to DMS-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
Mental Disorder Diagnosis #2: Major Depressive Disorder, Recurrent,
Severe
ICD code: 296.33
Comments, if any:
The diagnosis of major depressive disorder should be considered an inferred claim.
b. Medical diagnoses relevant to the understanding or management of the
Mental Health Disorder (to include TBI):
No response provided.
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?
[X] Yes [ ] No [ ] Not applicable (N/A)
If yes, list which symptoms are attributable to each diagnosis:
PTSD and depression are often co-occurring disorders with a great deal of shared symptomology. In general, the Veteran's PTSD accounts for his intrusive trauma memories, nightmares, flashbacks, avoidance behaviors, emotional numbness, hypervigilance,
hyperarousal, and related anxiety. His depression likely accounts for his chronic sad mood, feelings of worthlessness, tearfulness, lack of libido, self-criticalness, and change in appetite.
The following symptoms are found in both depression and PTSD and cannot be reliably distinguished without resorting to mere speculation: loss of interest in previously enjoyed activities, social isolation/withdrawal, sleeping disturbance (and associated fatigue), irritability, difficulty concentrating, distractibility, negative belief systems, restlessness, and feelings of guilt.
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 occupational
and social impairment with regards to all mental diagnoses? (Check only one)
[X] Occupational and social impairment with reduced reliability and productivity
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 extent to which symptoms of each psychiatric disorder are independently responsible for occupational and social impairment is impossible to delineate 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 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:
[X] Military service treatment records
[X] Military service personnel records
[ ] Military enlistment examination
[ ] Military separation examination
[X] Military post-deployment questionnaire
[ ] Department of Defense Form 214 Separation Documents
[ ] Veterans Health Administration medical records (VA treatment records)
[ ] Civilian medical records
[X] 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 [ ] No
2. History
a. Relevant Social/Marital/Family history (pre-military, military, and post-military):
Pre-military: was kind of a shy child, taking a while to warm up to people. Was able to trust others. Raised by grandparents because his mom was young, parents divorced when he was 5. No siblings. His childhood was good, lived in a small town as a child and then moved to
Seattle to live with Dad when 13. No abuse in childhood.
Military: He didn't stay in the same unit so moved around it was difficult to keep friendships. He still talks to some of his military friends. Only lets people in so far with the exception of his wife.
Has trouble trusting people. His wife stated that his overall attitude towards people was: "Get them before they get me." and that this was with everything including her.
First marriage lasted for 8 years they did not have children. She cheated on him. "I was not the best husband." He was distant. No contact with her. Married second time in 2003, they have two children. He stated that the marital relationship was "not bad", she reported "it has
its moments". In the beginning it was very good, first four years. She stated that
"my husband went to Afghanistan and didn’t come back." Not the same at all, not the same with wife and kids. Before he would get mad at normal things now he blows up over everything. Was drinking everyday for about 3 years after he got back and got a DUI. He still drinks and states that he does this to stop the continuous loop of horror in his head.
She does not feel as close or connected to him, doesn't talk about what
happened while he was deployed or how he feels.
b. Relevant Occupational and Educational history (pre-military, military, and post-military):
Pre-military: he stated that towards the beginning of school was below average but toward the end was above average. No attention or learning problems in childhood. Played soccer and swam.
Military: Graduated from HS early and joined the Marines at 18. The veteran served in the Marine Corps from August 17, 1994 to May 31,
2013. Jobs in the military: started in amphibious assault then went to artillery. Has had 5 deployments with 4 combat operations, 1)
(70 days); 3) OEF - (8 months); 4) OEF - (classified); 5 Operation disaster relief in Haiti (10 days). No difficulties on the job in the military. He retired early because of downsizing.
Post-military: work for the county does public service. It requires Him to have a lot of interactions with people. He goes from being very angry to being very happy and this happens daily. The anger builds like a bubble and then pops. Difficulty with co workers, I want to believe
that it is not their fault. Co-workers are frustrating and irritating, it is hard for me to function and smile. Not sure how much longer he will be able to work there, He has been written up several times at work for his behavior, he gets asked to leave the office, he has been told he acts crazy. Working since August of 2013, he snaps at people, sometimes he will think that is really stupid and have to apologize. He feels that he could be able to work alone.
Currently in school full-time for criminal intelligence degree. He is in a traditional classroom and is doing okay.
c. Relevant Mental Health history, to include prescribed medications and
family mental health (pre-military, military, and post-military):
Pre-military: no psychiatric diagnosis or treatement.
Military: While at Quantico he was diagnosed with PTSD November 2010
after returning from a deployment to Haiti, Jordan and Oman. He was
followed from that time by psychiatrist and social work. He was tried
on multiple medications for, celexa, zoloft, ambien. Since 2010 he had
been diagnosed with Depression, Chronic PTSD, Anxiety NOS. and alcohol
abuse. Has had TBI testing (last incident 2010) have had irregular
imaging. Still has problems with attention and memory.
Post-military: He stated "I just lost himself. I don't even
know who I am anymore. All of this consumes me" Symptoms started in 2008 but
he is not sure. Depression, anxiety, panic once a week.
Sleep: maybe 3 hours of sleep a night, "I beat the shit out of my
wife", sweats, bought a bigger bed trying to help, thrashes around, having nightmares, sleep talking, Irritable, angry outbursts, easily starteled. Auditory hallucinations,
weird things, like a high pitched squeak, squealing every so often driving down the road. This has just started. It is unclear whether this is related to auditory dysfunction or a hallucination. Has visual anomalies, seeing movement out of the corner of his eye. If he sees trash on the side of the road he has to swerve around it. NO problem driving small distances but can't drive a long distance or "will lose my mind."
Suicidal and homicidal ideation denied.
Ritualistic behavior before bed, "have to get clothes ready they have to be in certain spot, if they are not in the right spot I go ape shit." If he can't do it it is very stressful he has to do it. "I am not me anymore. It happened after Afghanistan, like I don't have
A soul, like I am hollow every day." He has certain rituals during
morning and during the day. If he doesn't do these things he would be
completely lost. He doesn't know how he is going to function the
rest of his life. "I am a xxxxxxx horrible husband and father." He
reported that he feels close to his children. He stated that his yougest
daughter who is 10 "keeps me together."
d. Relevant Legal and Behavioral history (pre-military, military, and
post-military):
Had a DWI in October 10, 2010 which is why he had to start seeing
psychiatrist until he retired. Is not seeing a psychiatrist now or
therapist. Had the conviction set aside, his wife did all the work.
This was rough on both of them.
Trouble with drinking began in Marine Corps. Now he is not drinking
much at all, his wife stated one or two, once a week. Went a couple of
years without drinking.
No substance use
e. Relevant Substance abuse history (pre-military, military, and
post-military):
See legal history
No current problem with alcohol or substance use.
f. Other, if any:
No response provided.
3. Stressors
a. Stressor #1: I saw a boy 9 to 10 years old get raped by one of his family
member and not being able to do anything about it. Happened in
afghanistan.
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 #6 - 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 (DMS-5).
Criterion A: Exposure to actual or threatened a) death, b) serious
injury,
c) sexual violatrion, in one or more of the following ways:
[X] Directly experiencing the tramuatic 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
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).
[X] Recurrent distressing dreams in which the content and/or affect of
the dream are related to the traumatic event(s).
[X] Dissociative reactions (e.g., flashbacks) in which the individual
feels or acts as if the traumatic event(s) were recurring. (Such
reactions may occur on a continuum, with the most extreme
expression being a complete loss of awareness of present
surroundings).
[X] Intense or prolonged psychological distress at exposure to
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 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 traumatic event(s), beginning or worsening after the
traumatic event(s) occurred, as evidenced by two (or more)
of
the following:
[X] Inability to remember an important aspect of the traumatic
event(s)
(typically due to dissociative amnesia and not to other factors
such as head injury, alcohol, or drugs).
[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] Persistent, distorted cognitions about the cause or consequences
of
the traumatic event(s) that lead to the individual to blame
himself/herself or others.
[X] Persistent negative emotional state (e.g., fear, horror, anger,
guilt, or shame).
[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, or 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)
of
the following:
[X] Irritable behavior and angry outbursts (with little or no
provocation) typically expressed as verbal or physical aggression
toward people or objects.
[X] Reckless or self-destructive behavior.
[X] Hypervigilance.
[X] Exaggerated startle response.
[X] Problems with concentration.
[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.
5. Symptoms
For VA rating purposes, check all symptoms that apply to the Veterans
diagnoses:
[X] Depressed mood
[X] Anxiety
[X] Suspiciousness
[X] Panic attacks that occur weekly or less often
[X] Near-continuous panic or depression affecting the ability to function
independently, appropriately and effectively
[X] Chronic sleep impairment
[X] Mild memory loss, such as forgetting names, directions or recent
events
[X] Difficulty in understanding complex commands
[X] Disturbances of motivation and mood
[X] Difficulty in adapting to stressful circumstances, including work or
A worklike setting
[X] Inability to establish and maintain effective relationships
[X] Obsessional rituals which interfere with routine activities
[X] Impaired impulse control, such as unprovoked irritability with
Periods of violence
6. Behavioral Observations
The veteran and his wife arrived on time for his scheduled evaluation. He
Was appropriately dressed and groomed. Gait appeared normal, with no gross motor
deficits observed. He was alert and attentive. He shows no significant impairment of communication. Thought processes were normal and goal-directed,
with no signs of hallucinations or delusions. Eye contact was appropriate.
He is able to maintain his personal hygiene and perform other activities of
daily living independently. He endorses obsessive, ruminative thoughts as
well as mild compulsive behaviors. Suicidal and homicidal ideation were
denied. Remote and recent memory was grossly intact. Affectively, he was
noticeably anxious and labile throughout the examination; affect and mood
were congruent. His speech was logical and goal-directed, rate was at times
pressured, rhythm and flow were within normal limits. Throughout the
interview and assessment the veteran was fully compliant 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, if any
Testing battery was completed including: Insomnia Severity Index (ISI),
Question
Jar Head 0811
Good Afternoon All,
I had my C&P exams for PTSD, osteoarthritis (right knee) and sinusitis. I will try to give the good, the bad and the ugly in my situation:
-Operational Experience:
OEF (Garmsir, 2008). 24 MEU. Cannon Cocker. Conducted combat patrols (was fired upon by the enemy, did not return fire due to non-combatants in the area). Indirect fire on the enemy resulting in 98 enemy casualties. We had 2 KIA in our battalion. Saw a child that had JUST been raped by a family member.
Operation Unified Response. Boots on the ground. Conducting security operations for Hattian citizens coming back from US Navy Hospital ships. Saw some very horrific things.
Received campaign medals and Navy and Marine Corps Achievement Medals for both operations (no “V” or CAR for OEF. Received HSM for Haiti).
Three other various deployments.
-Treatment in Service:
PTSD: 2 years of treatment prior to discharge, diagnosed at Naval Hospital Quantico, Behavioral Health
Treatment for knee throughout service diagnosed with osteoarthritis (right knee) in service.
Sinusitis treatment to include surgery (septoplasty and turbinoplasty). Diagnosed with sinusitis in service.
-VA claims process thus far.
Veteran’s Service Organization: DAV
PTSD, sinusitis and osteoarthritis on appeal, currently with DRO.
Stressor: Seeing small boy being raped in Afghanistan.
DRO had to gather records from the Marine Corps Archives (I am assuming to verify my stressor).
1. Diagnostic Summary
Does the Veteran have a diagnosis of PTSD that conforms to DMS-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
Mental Disorder Diagnosis #2: Major Depressive Disorder, Recurrent,
Severe
ICD code: 296.33
Comments, if any:
The diagnosis of major depressive disorder should be considered an inferred claim.
b. Medical diagnoses relevant to the understanding or management of the
Mental Health Disorder (to include TBI):
No response provided.
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?
[X] Yes [ ] No [ ] Not applicable (N/A)
If yes, list which symptoms are attributable to each diagnosis:
PTSD and depression are often co-occurring disorders with a great deal of shared symptomology. In general, the Veteran's PTSD accounts for his intrusive trauma memories, nightmares, flashbacks, avoidance behaviors, emotional numbness, hypervigilance,
hyperarousal, and related anxiety. His depression likely accounts for his chronic sad mood, feelings of worthlessness, tearfulness, lack of libido, self-criticalness, and change in appetite.
The following symptoms are found in both depression and PTSD and cannot be reliably distinguished without resorting to mere speculation: loss of interest in previously enjoyed activities, social isolation/withdrawal, sleeping disturbance (and associated fatigue), irritability, difficulty concentrating, distractibility, negative belief systems, restlessness, and feelings of guilt.
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 occupational
and social impairment with regards to all mental diagnoses? (Check only one)
[X] Occupational and social impairment with reduced reliability and productivity
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 extent to which symptoms of each psychiatric disorder are independently responsible for occupational and social impairment is impossible to delineate 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 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:
[X] Military service treatment records
[X] Military service personnel records
[ ] Military enlistment examination
[ ] Military separation examination
[X] Military post-deployment questionnaire
[ ] Department of Defense Form 214 Separation Documents
[ ] Veterans Health Administration medical records (VA treatment records)
[ ] Civilian medical records
[X] 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 [ ] No
2. History
a. Relevant Social/Marital/Family history (pre-military, military, and post-military):
Pre-military: was kind of a shy child, taking a while to warm up to people. Was able to trust others. Raised by grandparents because his mom was young, parents divorced when he was 5. No siblings. His childhood was good, lived in a small town as a child and then moved to
Seattle to live with Dad when 13. No abuse in childhood.
Military: He didn't stay in the same unit so moved around it was difficult to keep friendships. He still talks to some of his military friends. Only lets people in so far with the exception of his wife.
Has trouble trusting people. His wife stated that his overall attitude towards people was: "Get them before they get me." and that this was with everything including her.
First marriage lasted for 8 years they did not have children. She cheated on him. "I was not the best husband." He was distant. No contact with her. Married second time in 2003, they have two children. He stated that the marital relationship was "not bad", she reported "it has
its moments". In the beginning it was very good, first four years. She stated that
"my husband went to Afghanistan and didn’t come back." Not the same at all, not the same with wife and kids. Before he would get mad at normal things now he blows up over everything. Was drinking everyday for about 3 years after he got back and got a DUI. He still drinks and states that he does this to stop the continuous loop of horror in his head.
She does not feel as close or connected to him, doesn't talk about what
happened while he was deployed or how he feels.
b. Relevant Occupational and Educational history (pre-military, military, and post-military):
Pre-military: he stated that towards the beginning of school was below average but toward the end was above average. No attention or learning problems in childhood. Played soccer and swam.
Military: Graduated from HS early and joined the Marines at 18. The veteran served in the Marine Corps from August 17, 1994 to May 31,
2013. Jobs in the military: started in amphibious assault then went to artillery. Has had 5 deployments with 4 combat operations, 1)
Operation Southern Watch - Kuwait (2 months); 2) Operation Silent Lance - Serbia
(70 days); 3) OEF - (8 months); 4) OEF - (classified); 5 Operation disaster relief in Haiti (10 days). No difficulties on the job in the military. He retired early because of downsizing.
Post-military: work for the county does public service. It requires Him to have a lot of interactions with people. He goes from being very angry to being very happy and this happens daily. The anger builds like a bubble and then pops. Difficulty with co workers, I want to believe
that it is not their fault. Co-workers are frustrating and irritating, it is hard for me to function and smile. Not sure how much longer he will be able to work there, He has been written up several times at work for his behavior, he gets asked to leave the office, he has been told he acts crazy. Working since August of 2013, he snaps at people, sometimes he will think that is really stupid and have to apologize. He feels that he could be able to work alone.
Currently in school full-time for criminal intelligence degree. He is in a traditional classroom and is doing okay.
c. Relevant Mental Health history, to include prescribed medications and
family mental health (pre-military, military, and post-military):
Pre-military: no psychiatric diagnosis or treatement.
Military: While at Quantico he was diagnosed with PTSD November 2010
after returning from a deployment to Haiti, Jordan and Oman. He was
followed from that time by psychiatrist and social work. He was tried
on multiple medications for, celexa, zoloft, ambien. Since 2010 he had
been diagnosed with Depression, Chronic PTSD, Anxiety NOS. and alcohol
abuse. Has had TBI testing (last incident 2010) have had irregular
imaging. Still has problems with attention and memory.
Post-military: He stated "I just lost himself. I don't even
know who I am anymore. All of this consumes me" Symptoms started in 2008 but
he is not sure. Depression, anxiety, panic once a week.
Sleep: maybe 3 hours of sleep a night, "I beat the shit out of my
wife", sweats, bought a bigger bed trying to help, thrashes around, having nightmares, sleep talking, Irritable, angry outbursts, easily starteled. Auditory hallucinations,
weird things, like a high pitched squeak, squealing every so often driving down the road. This has just started. It is unclear whether this is related to auditory dysfunction or a hallucination. Has visual anomalies, seeing movement out of the corner of his eye. If he sees trash on the side of the road he has to swerve around it. NO problem driving small distances but can't drive a long distance or "will lose my mind."
Suicidal and homicidal ideation denied.
Ritualistic behavior before bed, "have to get clothes ready they have to be in certain spot, if they are not in the right spot I go ape shit." If he can't do it it is very stressful he has to do it. "I am not me anymore. It happened after Afghanistan, like I don't have
A soul, like I am hollow every day." He has certain rituals during
morning and during the day. If he doesn't do these things he would be
completely lost. He doesn't know how he is going to function the
rest of his life. "I am a xxxxxxx horrible husband and father." He
reported that he feels close to his children. He stated that his yougest
daughter who is 10 "keeps me together."
d. Relevant Legal and Behavioral history (pre-military, military, and
post-military):
Had a DWI in October 10, 2010 which is why he had to start seeing
psychiatrist until he retired. Is not seeing a psychiatrist now or
therapist. Had the conviction set aside, his wife did all the work.
This was rough on both of them.
Trouble with drinking began in Marine Corps. Now he is not drinking
much at all, his wife stated one or two, once a week. Went a couple of
years without drinking.
No substance use
e. Relevant Substance abuse history (pre-military, military, and
post-military):
See legal history
No current problem with alcohol or substance use.
f. Other, if any:
No response provided.
3. Stressors
a. Stressor #1: I saw a boy 9 to 10 years old get raped by one of his family
member and not being able to do anything about it. Happened in
afghanistan.
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 #6 - 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 (DMS-5).
Criterion A: Exposure to actual or threatened a) death, b) serious
injury,
c) sexual violatrion, in one or more of the following ways:
[X] Directly experiencing the tramuatic 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
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).
[X] Recurrent distressing dreams in which the content and/or affect of
the dream are related to the traumatic event(s).
[X] Dissociative reactions (e.g., flashbacks) in which the individual
feels or acts as if the traumatic event(s) were recurring. (Such
reactions may occur on a continuum, with the most extreme
expression being a complete loss of awareness of present
surroundings).
[X] Intense or prolonged psychological distress at exposure to
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 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 traumatic event(s), beginning or worsening after the
traumatic event(s) occurred, as evidenced by two (or more)
of
the following:
[X] Inability to remember an important aspect of the traumatic
event(s)
(typically due to dissociative amnesia and not to other factors
such as head injury, alcohol, or drugs).
[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] Persistent, distorted cognitions about the cause or consequences
of
the traumatic event(s) that lead to the individual to blame
himself/herself or others.
[X] Persistent negative emotional state (e.g., fear, horror, anger,
guilt, or shame).
[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, or 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)
of
the following:
[X] Irritable behavior and angry outbursts (with little or no
provocation) typically expressed as verbal or physical aggression
toward people or objects.
[X] Reckless or self-destructive behavior.
[X] Hypervigilance.
[X] Exaggerated startle response.
[X] Problems with concentration.
[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.
5. Symptoms
For VA rating purposes, check all symptoms that apply to the Veterans
diagnoses:
[X] Depressed mood
[X] Anxiety
[X] Suspiciousness
[X] Panic attacks that occur weekly or less often
[X] Near-continuous panic or depression affecting the ability to function
independently, appropriately and effectively
[X] Chronic sleep impairment
[X] Mild memory loss, such as forgetting names, directions or recent
events
[X] Difficulty in understanding complex commands
[X] Disturbances of motivation and mood
[X] Difficulty in adapting to stressful circumstances, including work or
A worklike setting
[X] Inability to establish and maintain effective relationships
[X] Obsessional rituals which interfere with routine activities
[X] Impaired impulse control, such as unprovoked irritability with
Periods of violence
6. Behavioral Observations
The veteran and his wife arrived on time for his scheduled evaluation. He
Was appropriately dressed and groomed. Gait appeared normal, with no gross motor
deficits observed. He was alert and attentive. He shows no significant impairment of communication. Thought processes were normal and goal-directed,
with no signs of hallucinations or delusions. Eye contact was appropriate.
He is able to maintain his personal hygiene and perform other activities of
daily living independently. He endorses obsessive, ruminative thoughts as
well as mild compulsive behaviors. Suicidal and homicidal ideation were
denied. Remote and recent memory was grossly intact. Affectively, he was
noticeably anxious and labile throughout the examination; affect and mood
were congruent. His speech was logical and goal-directed, rate was at times
pressured, rhythm and flow were within normal limits. Throughout the
interview and assessment the veteran was fully compliant 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, if any
Testing battery was completed including: Insomnia Severity Index (ISI),
Beck Depression Inventory-II (BDI-II), Beck Hopelessness Scale (BHS),
Beck
Anxiety Inventory (BAI), Posttraumatic Stress Disorder Checklist-Military
Version for the DSM-IV (PCL-M), the Mississippi Scale (MISS) and the
Combat Exposure Scale (CES).
The ISI is a self-report measure which provides a global measure of
perceived insomnia severity. The first item includes 3 scored responses,
and items 2-5 provide a total of 4 additional responses, for a total of 7
scored items for the questionnaire. Question 6 is not scored, but rather
provides a subjective assessment of daytime symptoms which allows one to
determine if the respondent meets full diagnostic criteria for an
insomnia diagnosis, which requires a deficit in daytime functioning. Each of the
scored items are rated on a 5-point Likert scale for a total score
ranging from 0-28. The ISI has adequate psychometric properties, has been
validated against diary and polysomnographic measures of sleep, and has
been shown sensitive to therapeutic changes in a pilot study for veterans
with PTSD. Veteran scored 26/28 on the ISI which indicates a severe
level of insomnia. The daytime affects of poor sleep that were endorsed
by veteran included: daytime fatigue (tired, exhausted, washed out,
sleepy), difficulty functioning (performance impairment at work/daily
chores, difficulty concentrating, memory problems), mood problems
(irritable, tense, nervous, groggy, depressed, anxious, grouchy, hostile,
angry, confused), and physical symptoms (muscle aches/pain, light-headed,
headache, nausea, heartburn, muscle tension).
The Beck Depression Inventory (BDI-II) was administered to determine the
degree to which specific depressive symptoms are experienced by the
Veteran. Scores on the BDI-II range from 0 to 63, with higher scores
indicating more severe depression. Today, the veteran scored a 45 on the
BDI-II which indicates a severe level of depression. The interpretation
Of the BDI-II is based on normative data and is consistent with self report
of severe depressive symptoms and behavioral observation during the
clinical interview. The Beck Anxiety Inventory (BAI) is a 21 item self-report measure used to
assess anxiety symptom severity as well as to assist in the diagnosis of
anxiety. The veteran is asked to rate each item on a scale from 0 to 3
with 0 being "Not at all" and 3 being "Severely" to indicate the degree to
which they have been bothered by symptoms of anxiety during the past week
including today. Each of the 21 items is then added to provide a total
score, with higher scores indicating greater anxiety. Today, the veteran
scored a 30 on the BAI which indicates a severe level of anxiety. The
interpretation of the BAI is based on normative data and is consistent
with self report and behavioral observations of anxiety symptoms during
the clinical interview.
The Beck Hopelessness Scale (BHS) was used to measure attitudes about
hopelessness, feelings about the veteran's future, loss of motivation
and expectations. The BHS has been shown to predict suicidal ideation and
intent. Today the veteran scored 18/20 indicating a severe level of
hopelessness. The veteran denied suicidal ideation. The scores from the
BHS indicated that he has negative feelings about his future, loss of
motivation and negative expectations of what his future holds.
The PCL-M was used to asses PTSD symptom severity as well as to assist in
diagnosis. The 17 item self-report measure has three subscales following
the DSM-IV criteria; re-experiencing subscale, avoidance/numbing
subscale, hyperarousal subscale. The Veteran rates each item on a scale from 1 to 5
with 1 being "not at all" and 5 "extremely" to indicate the degree to
which they have been bothered by the symptom over the past month. This
instrument provides a total score which can range from 17 to 85.
Veteran’s score indicated that he has experienced severe to
Extreme symptoms of PTSD over the past month. It appears that veteran has had
difficulties with re-experiencing, avoidance behaviors and hyperarousal.
The total score is well above the suggested cutoff for combat veterans.
Total Score (cutoff = 50, Veteran's score = 82)
The Mississippi Scale (MISS) was used to assess the presence of symptoms
reflecting the three main DSM-IV criteria for PTSD: re-experiencing,
avoidance and numbing, and hyperarousal along with associated features
such as depression and substance abuse. The 35 items are rated on a
five-point scale asking respondents to rate their symptoms over time
"since the event." Symptom severity can range from 35-175. The
Cutoff score of 107 was suggested for combat related PTSD (Vietnam).
Veteran’s score of 155 is well above the suggested cutoff.
Total Score (cutoff = 107, Veteran's score = 155)
The Combat Exposure Scale (CES) was used to assess wartime stressors
experienced by the examinee. The 7-item self-report measure is rated on a
5-point frequency (1 = "no" or "never" to 5 = "more than 50 times"),
5-point duration (1 = "never" to 5 = "more than 6 months"), 4-point
frequency (1 = "no" to 4 = "more than 12 times") or 4-point degree of loss
(1 = "no one" to 4 = "more than 50%") scale.
Respondents are asked to answer based on their exposure to various combat situations, such as
firing rounds at the enemy and being on dangerous duty. The total CES
score (ranging from 0 to 41) is calculated by using a sum of weighted
scores, which can be classified into 1 of 5 categories of combat exposure
ranging from "light" to "heavy." The CES was developed to be easily administered and scored.
The veteran's total score is 24 indicating a moderate level of
Combat exposure. Combat experiences endorsed by the veteran included: combat
patrols or other dangerous duty, was under enemy fire, was surrounded by
the enemy, had soldiers in his unit that were KIA, wounded or MIA, fired
rounds at the enemy, saw someone hit by incoming or outgoing rounds and
was in danger of being injured or killed.
Based on DSM-IV and DSM-5 criteria, current interview with veteran and
his wife, review of the VA and VBMS electronic record, as well as scores
on the ISI, BDI-II, BAI, BHS, PCL-M, MISS and CES, the Veteran has
symptoms consistent with Post Traumatic Stress Disorder and Major
Depressive Disorder, Recurrent, Severe. THE DIAGNOSIS OF MAJOR DEPRESSIVE
DISORDER SHOULD BE CONSIDERED AN INFERRED CLAIM (Veteran was diagnosed in
service). Overall, chronic psychiatric symptoms have resulted in very
severe disruptions in family, social, leisure, occupational and
psychological domains of functioning. He is having great difficulty in
his job which requires him to interact with co-workers and the public
appropriately when there is evidence of significant irritability, low
frustration tolerance, and angry outbursts. This has resulted in
reprimands and being written up for inappropriate behavior in the office
which threatens his job. His symptoms create an incredible burden for the
veteran and his family. The veteran and his wife are unable to have any
social experiences. He was diagnosed and treated in 2010 for PTSD and
depression while he was in the Marines. There is no record or report of
psychiatric diagnosis or treatment before the military. He is currently
prescribed lexapro by a private primary care physician for PTSD and
depressive symptoms which is not effective. Severe symptoms of PTSD and
depression which began during his service is at least as likely as not
due to the cumulative effects of daily, multiple exposures to war and fear of hostile military or terrorist activity.
Any help or insight with this would be great. Thank you again.
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Berta
Does VA have that info? Have they ever mentioned this in any decision under Evidence? I would consider that as prime facie, bonafide , undisputable proof, beyond the git go, that you have PTSD from S
Jar Head 0811
The amount of information I've received and the fact that people ACTUALLY care to read my post is priceless.....Thank you all so very much...
Vync
Welcome to Hadit! Thank you for your service. I don't really see a specific question other than help or insight, so I'll provide my nonprofessional opinion. With details about your knee and sinus issu
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