Hello all. I would like to thank all of you for your work on this site. I am a long time lurker, first time poster. I received my C&P Results back and would appreciate any feedback. I understand that there is no way to be fully accurate when trying to guess a rating based off of this information. I am just under immense stress lately as I have watched my life fall apart piece by piece over the last few years. I had good rapport with the interviewer but don't know what to make of some of the things he wrote. Thanks in advance for your insights you all do great work here.
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: PTSD
ICD code: 309.81
Mental Disorder Diagnosis #2: Alcohol Abuse, in Remission
ICD code: 305.03
Mental Disorder Diagnosis #3: No response provided.
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 and
discuss whether there is any clinical association between these
diagnoses:
Currently, no symptoms are attributed to alcohol abuse, because
alcohol abuse is in remission. All symptoms are attributable to
PTSD.
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?
[X] Yes[ ] No[ ] No other mental disorder has been diagnosed
If yes, list which portion of the indicated level of occupational and
social impairment is attributable to each diagnosis:
Currently, no occupational or social impairment is attributed to
alcohol abuse, because alcohol abuse is in remission. All
occupational and social impairment is attributable to PTSD.
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:
[X] Military service treatment records
[ ] Military service personnel records
[ ] Military enlistment examination
[ ] Military separation examination
[ ] Military post-deployment questionnaire
[X] 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
[X] Other:
MTR - govt and nongovt, VA documents and forms,
b. Was pertinent information from collateral sources reviewed?
[X] Yes[ ] No
If yes, describe:
Buddy or lay statement from who was Veteran's
ex-girlfriend,
2. History
----------
a. Relevant Social/Marital/Family history (pre-military, military, and
post-military):
Relevant social history,
birthplace,
(mostly) happy childhood memories,
(-) homeless currently,
(-) rent currently,
(+) own currently,
(#0) of household occupants in addition to Veteran,
(-) close friends, Veteran states that he feels estangement from
others, he reached out to one of his military friends two weeks ago,
this was the first tome to do that for one year, Veteran used to be
active on Facebook, but he is no longer active on facebook, he began
experiencing the idea that his thoughts were being communicated in a
certain way by others,
(-) attend social activities,
(+) hobbies or interests, Video games, all kinds, grand theft auto,
mad
and football, wrestling, Veteran used to be an avid sports fan, he
used
to know the lines of college and professional football teams, he does
not do that anymore,
Relevant marital history,
(S) civil status, he used to have a girlfriend, they were together for
3 years, he used to yell and scream at her, he states that it took
everything within him to keep from hitting her, but he never hit her,
she left and she did not come back; Veteran states he never assaulted
his ex-girlfriend prior to their breakup; alternatively, he states
that
he choked his girlfriend in the heat of the moment 2 times, but she
did
not pass out,
(#0) number of marriages,
(#0) number of divorces,
(#1) number of childrren y/o son, Veteran's son's mother does not
allow Veteran's son to have unsupervised visits with Veteran,
Relevant family history,
(-) emotional or mental problems,
(+) heart disease, PGF has CAD and h/o CABG,
(+) both parents living,
(-) close to them, he rarely talks with them,
(#1) siblings living, 1 sister,
(-) close to her, they have not spoken for 2 years
Pre-military, Veteran states he killed his first animal at 10 y/o,
which was a deer, and he gutted and cleaned it at that age.
Post-military, Veteran states that he carries a gun wherever he goes.
He was closer to his family and other people pre-military and
military.
Post-military, he has become distant with family and friends. His
parents live inand have a home there
.
Post-military, after finishing his contract work in which he mostly
worked on military instillations for the federal government, he lived
with his parents for 2 months in He moved f
to to go to College in 2012. He did not start having problems
from symptoms of PTSD until after he finished his contract work, which
was more like being in, rather than out of, the military, and began
living more as a civilian.
b. Relevant Occupational and Educational history (pre-military, military,
and
post-military):
Relevant occupational history,
(-) currently working outside the home,
(2012) year last worked outside the home,
(F) P = part time, F = fulltime,
(security) type of work,
(nothing) current source of income, Veteran indicates that he has used
up his savings and now he is behind on many of his bills,
(+) emotional or mental symptoms associated with occupational
problems,
Veteran was fired from his last two jobs,
Relevant educational history,
(+) learning difficulties,
(-) learning disabilities,
(he has two years of college) level of education,
(+) emotional or mental symptoms associated with educational problems,
difficulty concentrating,
Veteran graduated from HS at 18 y/o. He went to college for one year.
He worked seasonal work, restaurant work, cabinet factory, met a
woman,
had a son, was in and out of legal troubles, and entered the USA at 23
y/o. He was discharged from the USA at 27 y/o. He worked for
as
a regional supervisor for 5 years.
. ;
Veteran
states he was a distinguished soldier during basic training. He became
the best mechanic while in stationed in Germanny. He was a
leader
and NCO in the Ranger battalion. He did not get DUIs and he did not
get
into fights. Veteran states that he laughed at the PTSD symptoms
checklist when he first came back from his deployment to Iraq. but now
he cannot get a job due to such symptoms. He has not been able to hold
down a job for the past 3 years.
c. Relevant Mental Health history, to include prescribed medications and
family mental health (pre-military, military, and post-military):
Relevant mental health history,
(-) mental health care before military service,
(-) mental health care during military service,
(+) mental health care after military service,
(#0) previous suicide attempt(s),
(#0) previous hospitalization on psychiatric ward(s),
(#0) previous court orders for involuntary treatment,
(+) currently seeing a provider for the purpose of medication
management,
(-) currently attending individual psychotherapy and/or group therapy,
he used to go to groups, he lost his driver's license, therefore he
has
not been going, because it is difficult getting there,
(+) h/o severe emotional trauma,
(-) h/o head trauma,
(-) h/o evaluation for TBI,
(+) current emotional or mental problems,
(+) mood often blue or sad,
(+) anger,
(+) h/o ever experiencing seven or more days of manic excitement
(i.e.,
abnormally, discretely, and persistently elevated, expansive, or
irritable mood), decreased need for sleep, racing thoughts, or
pressured speech, Veteran states that he has gone for many days
without
sleeping, he would keep busy because he was unable to sleep, he used
to
self-medicate insomnia by drinking alcohol to the point of blacking
out, he has h/o anxiety and paranoia, racing thoughts, increased goal
directed behavior (in terms of playing a video game), agitation (in
terms of pacing around the apartment), he was not talking faster or
more than usual, no significant change in self-esteem or grandiosity,
no significant distractability, (+) behavior for the purpose of
pleasure with potentially painful consequences (alcohol problem),
(+) h/o of hallucinations, he used to have these when he was drinking
alcohol, he used to have alcohol hallucinosis, he has been sober since
June 2015,
(+) h/o delusions, he has h/o delusions of reference,
Prescribed medications,
List, propranolol, sertraline, and trazodone; he was remotely taking
aripiprazole and valproate, he was taking quetiapine when going
through
inpatient treatment for alcohol abuse, he has h/o risperidone and
risperidone-associated akathisia,
(+) adverse events with one or more of these, his sleep is too deep
with trazodone, then he has disturbing dreams, then he cannot wake up
out of these disturbing dreams, because his sleep is too deep,
(-) beneficial effects with each of these, propranolol was previously
helpful while he was on risperidone to decrease the akathisia
associated with risperidone, sertraline is not yet producing a
beneficial effect,
Family mental health,
Please see above under "relevant family history."
d. Relevant Legal and Behavioral history (pre-military, military, and
post-military):
Relevant legal history,
(+) symptoms associated with legal problems,
(+) h/o arrests for assault, battery, or violence,
(+) h/o arrests, convictions, or sentencing (to jail or prison),
(-) currently on parole or probation,
(-) current conservator or guardian,
(+) h/o DUI, #1,
Relevant behavioral history,
(+) symptoms associated with behavioral problems, Veteran states that
he does not talk with anyone, he does not do anything, he enrolled in
school, he cannot deal with that anymore, he dropped out of College, he
cannot deal with the people there, he believes he is viewed by others
as a time bomb, after he was arrested for eluding an officer.
(yesterday) last time to be in a heated argument with another person,
(June, 2015) last time that to be in a physical altercation with
another person,
(poor) quality of sleep generally,
Pre-military: Veteran had reckless driving charges and assault with a
deadly weapon charges prior to USA service. He was charged with
reckless driving. He ended up doi of house arrest for
reckless driving. He took assault with a deadly weapon to a jury who
did not find him guilty as charged. It was determined that he was
defending himself, and he was absolved of any wrong doing. Military:
Veteran has one negative counseling statement for missing formation
one
morning due to oversleeping when they had a power outage, when his
roommate was on leave, but other than that he did not have any other
LOCs, no LORs, no Article 15s, and no other non-judicial or judicial
punishments.
Postmilitary: Veteran was arrested in 2013, and he was placed in a
mental health safe cell while in jail, because he drove off from a
traffic stop away from an officer. He was initially written up for
felony eluding, but the charges were plea bargained down to a
misdemeanor. Veteranhas pending charges. He has a warrant out for
his
arrest. This is for criminal speeding (99 mph in a 45 mph zone).
e. Relevant Substance abuse history (pre-military, military, and
post-military):
(+) tobacco during past 30 days,
(today) when last used,
(-) alcohol during past 30 days,
(July 2015) when last used, he got out of treatment June 8th, he
relapsed in July, for 2 days,
(+) h/o alcohol problem or alcohol abuse,
(-) illicit drugs during past 30 days,
(prior to March, 2014) when last used, he has not used spice
(synthetic
MJ since prior to his first inpatient treatment program,
(+) h/o inpatient or outpatient treatment for alcohol or illicit
substances, 2 times,
(+) currently attending AA, NA, or other support groups, Veteran does
not believe that he suffers from alcoholism,
Veteran smoked a joint of MJ when he graduated from HS, he did not
smoke MJ during the military, and he smoked MJ less than 6 times after
the military. He drank alcohol 2 times during HS, he was a social
drinker during college and the military, while in Germany, and he became
an alcoholic after the military. He was drinking a lot with his
friends, at the time of his deployment to Gerrmany, from dusk until dawn.
Other times, he could drink until 2 AM, go to sleep, wake up at 5 AM,
go to PT, and be fine, while in the regular Army battalion, but he was
not able to keep that lifestyle while in the Ranger battalion, because
they put him through too much. Veteran does not like talking with
anyone about anything, even the weather. Veteran feels uncomfortable
when in large groups of people. This triggers intense urges for
drinking alcohol. Living with his emotions and feelings is more
difficult without alcohol than with alcohol.
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 post-military):
a. Stressor #1: 1. Military Combat Trauma (Veteran observed traumatic events
as experienced by others, including seeing a person get his face shot
off, seeing people with their heads cut off, and seeing a dead body,
he
claims he saw a US missile hit a minivan carrying an entire family,)
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: No response provided.
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, 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 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] 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.
Criterion I: Which stressor(s) contributed to the Veteran's PTSD
diagnosis?:
[X] Stressor #1
5. Symptoms
-----------
For VA rating purposes, check all symptoms that actively apply to the
Veteran's diagnoses:
[X] Depressed mood
[X] Anxiety
[X] Suspiciousness
[X] Panic attacks that occur weekly or less often
[X] Chronic sleep impairment
[X] Difficulty in establishing and maintaining effective work and social
relationships
[X] Inability to establish and maintain effective relationships
6. Behavioral Observations
--------------------------
Appearance - attire is summertime casual, grooming is average, and
presently,
the veteran does not appear to intermittently be in distress as he
intermittently discusses his taaumas.
Behavior - eye contact is intermittent, and speech is of unremarkable rate,
rhythm, volume, prosody, and articulation. Speech contains profanity in many
sentences.
Comportment suggests that the veteran gets along adequately with this writer.
Affect is neutral.
Thought processes are logical, linear, and goal-oriented. Presently, the
veteran does not have a formal thought disorder.
Thought content is without homicidal ideation or suicidal ideation.
Perceptions - the veteran presently does not appear to be responding to
internal stimuli.
Insight is fair. Judgment is fair.
Psychomotor activity - Veteran becomes agitated when talking about his
experiences in Iraq.
Muscular observation shows absence of focal motor deficits.
Cognitions are grossly intact.
Abstractions demonstrate at least average capacity for logical reasoning and
systematic thought.
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
Question
HankChinaski
Hello all. I would like to thank all of you for your work on this site. I am a long time lurker, first time poster. I received my C&P Results back and would appreciate any feedback. I understand that there is no way to be fully accurate when trying to guess a rating based off of this information. I am just under immense stress lately as I have watched my life fall apart piece by piece over the last few years. I had good rapport with the interviewer but don't know what to make of some of the things he wrote. Thanks in advance for your insights you all do great work here.
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: PTSD
ICD code: 309.81
Mental Disorder Diagnosis #2: Alcohol Abuse, in Remission
ICD code: 305.03
Mental Disorder Diagnosis #3: No response provided.
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 and
discuss whether there is any clinical association between these
diagnoses:
Currently, no symptoms are attributed to alcohol abuse, because
alcohol abuse is in remission. All symptoms are attributable to
PTSD.
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?
[X] Yes [ ] No [ ] No other mental disorder has been diagnosed
If yes, list which portion of the indicated level of occupational and
social impairment is attributable to each diagnosis:
Currently, no occupational or social impairment is attributed to
alcohol abuse, because alcohol abuse is in remission. All
occupational and social impairment is attributable to PTSD.
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:
[X] Military service treatment records
[ ] Military service personnel records
[ ] Military enlistment examination
[ ] Military separation examination
[ ] Military post-deployment questionnaire
[X] 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
[X] Other:
MTR - govt and nongovt, VA documents and forms,
b. Was pertinent information from collateral sources reviewed?
[X] Yes [ ] No
If yes, describe:
Buddy or lay statement from who was Veteran's
ex-girlfriend,
2. History
----------
a. Relevant Social/Marital/Family history (pre-military, military, and
post-military):
Relevant social history,
birthplace,
(mostly) happy childhood memories,
(-) homeless currently,
(-) rent currently,
(+) own currently,
(#0) of household occupants in addition to Veteran,
(-) close friends, Veteran states that he feels estangement from
others, he reached out to one of his military friends two weeks ago,
this was the first tome to do that for one year, Veteran used to be
active on Facebook, but he is no longer active on facebook, he began
experiencing the idea that his thoughts were being communicated in a
certain way by others,
(-) attend social activities,
(+) hobbies or interests, Video games, all kinds, grand theft auto,
mad
and football, wrestling, Veteran used to be an avid sports fan, he
used
to know the lines of college and professional football teams, he does
not do that anymore,
Relevant marital history,
(S) civil status, he used to have a girlfriend, they were together for
3 years, he used to yell and scream at her, he states that it took
everything within him to keep from hitting her, but he never hit her,
she left and she did not come back; Veteran states he never assaulted
his ex-girlfriend prior to their breakup; alternatively, he states
that
he choked his girlfriend in the heat of the moment 2 times, but she
did
not pass out,
(#0) number of marriages,
(#0) number of divorces,
(#1) number of childrren y/o son, Veteran's son's mother does not
allow Veteran's son to have unsupervised visits with Veteran,
Relevant family history,
(-) emotional or mental problems,
(+) heart disease, PGF has CAD and h/o CABG,
(+) both parents living,
(-) close to them, he rarely talks with them,
(#1) siblings living, 1 sister,
(-) close to her, they have not spoken for 2 years
Pre-military, Veteran states he killed his first animal at 10 y/o,
which was a deer, and he gutted and cleaned it at that age.
Post-military, Veteran states that he carries a gun wherever he goes.
He was closer to his family and other people pre-military and
military.
Post-military, he has become distant with family and friends. His
parents live inand have a home there
.
Post-military, after finishing his contract work in which he mostly
worked on military instillations for the federal government, he lived
with his parents for 2 months in He moved f
to to go to College in 2012. He did not start having problems
from symptoms of PTSD until after he finished his contract work, which
was more like being in, rather than out of, the military, and began
living more as a civilian.
b. Relevant Occupational and Educational history (pre-military, military,
and
post-military):
Relevant occupational history,
(-) currently working outside the home,
(2012) year last worked outside the home,
(F) P = part time, F = fulltime,
(security) type of work,
(nothing) current source of income, Veteran indicates that he has used
up his savings and now he is behind on many of his bills,
(+) emotional or mental symptoms associated with occupational
problems,
Veteran was fired from his last two jobs,
Relevant educational history,
(+) learning difficulties,
(-) learning disabilities,
(he has two years of college) level of education,
(+) emotional or mental symptoms associated with educational problems,
difficulty concentrating,
Veteran graduated from HS at 18 y/o. He went to college for one year.
He worked seasonal work, restaurant work, cabinet factory, met a
woman,
had a son, was in and out of legal troubles, and entered the USA at 23
y/o. He was discharged from the USA at 27 y/o. He worked for
as
a regional supervisor for 5 years.
. ;
Veteran
states he was a distinguished soldier during basic training. He became
the best mechanic while in stationed in Germanny. He was a
leader
and NCO in the Ranger battalion. He did not get DUIs and he did not
get
into fights. Veteran states that he laughed at the PTSD symptoms
checklist when he first came back from his deployment to Iraq. but now
he cannot get a job due to such symptoms. He has not been able to hold
down a job for the past 3 years.
c. Relevant Mental Health history, to include prescribed medications and
family mental health (pre-military, military, and post-military):
Relevant mental health history,
(-) mental health care before military service,
(-) mental health care during military service,
(+) mental health care after military service,
(#0) previous suicide attempt(s),
(#0) previous hospitalization on psychiatric ward(s),
(#0) previous court orders for involuntary treatment,
(+) currently seeing a provider for the purpose of medication
management,
(-) currently attending individual psychotherapy and/or group therapy,
he used to go to groups, he lost his driver's license, therefore he
has
not been going, because it is difficult getting there,
(+) h/o severe emotional trauma,
(-) h/o head trauma,
(-) h/o evaluation for TBI,
(+) current emotional or mental problems,
(+) mood often blue or sad,
(+) anger,
(+) h/o ever experiencing seven or more days of manic excitement
(i.e.,
abnormally, discretely, and persistently elevated, expansive, or
irritable mood), decreased need for sleep, racing thoughts, or
pressured speech, Veteran states that he has gone for many days
without
sleeping, he would keep busy because he was unable to sleep, he used
to
self-medicate insomnia by drinking alcohol to the point of blacking
out, he has h/o anxiety and paranoia, racing thoughts, increased goal
directed behavior (in terms of playing a video game), agitation (in
terms of pacing around the apartment), he was not talking faster or
more than usual, no significant change in self-esteem or grandiosity,
no significant distractability, (+) behavior for the purpose of
pleasure with potentially painful consequences (alcohol problem),
(+) h/o of hallucinations, he used to have these when he was drinking
alcohol, he used to have alcohol hallucinosis, he has been sober since
June 2015,
(+) h/o delusions, he has h/o delusions of reference,
Prescribed medications,
List, propranolol, sertraline, and trazodone; he was remotely taking
aripiprazole and valproate, he was taking quetiapine when going
through
inpatient treatment for alcohol abuse, he has h/o risperidone and
risperidone-associated akathisia,
(+) adverse events with one or more of these, his sleep is too deep
with trazodone, then he has disturbing dreams, then he cannot wake up
out of these disturbing dreams, because his sleep is too deep,
(-) beneficial effects with each of these, propranolol was previously
helpful while he was on risperidone to decrease the akathisia
associated with risperidone, sertraline is not yet producing a
beneficial effect,
Family mental health,
Please see above under "relevant family history."
d. Relevant Legal and Behavioral history (pre-military, military, and
post-military):
Relevant legal history,
(+) symptoms associated with legal problems,
(+) h/o arrests for assault, battery, or violence,
(+) h/o arrests, convictions, or sentencing (to jail or prison),
(-) currently on parole or probation,
(-) current conservator or guardian,
(+) h/o DUI, #1,
Relevant behavioral history,
(+) symptoms associated with behavioral problems, Veteran states that
he does not talk with anyone, he does not do anything, he enrolled in
school, he cannot deal with that anymore, he dropped out of College, he
cannot deal with the people there, he believes he is viewed by others
as a time bomb, after he was arrested for eluding an officer.
(yesterday) last time to be in a heated argument with another person,
(June, 2015) last time that to be in a physical altercation with
another person,
(poor) quality of sleep generally,
Pre-military: Veteran had reckless driving charges and assault with a
deadly weapon charges prior to USA service. He was charged with
reckless driving. He ended up doi of house arrest for
reckless driving. He took assault with a deadly weapon to a jury who
did not find him guilty as charged. It was determined that he was
defending himself, and he was absolved of any wrong doing. Military:
Veteran has one negative counseling statement for missing formation
one
morning due to oversleeping when they had a power outage, when his
roommate was on leave, but other than that he did not have any other
LOCs, no LORs, no Article 15s, and no other non-judicial or judicial
punishments.
Postmilitary: Veteran was arrested in 2013, and he was placed in a
mental health safe cell while in jail, because he drove off from a
traffic stop away from an officer. He was initially written up for
felony eluding, but the charges were plea bargained down to a
misdemeanor. Veteran has pending charges. He has a warrant out for
his
arrest. This is for criminal speeding (99 mph in a 45 mph zone).
e. Relevant Substance abuse history (pre-military, military, and
post-military):
(+) tobacco during past 30 days,
(today) when last used,
(-) alcohol during past 30 days,
(July 2015) when last used, he got out of treatment June 8th, he
relapsed in July, for 2 days,
(+) h/o alcohol problem or alcohol abuse,
(-) illicit drugs during past 30 days,
(prior to March, 2014) when last used, he has not used spice
(synthetic
MJ since prior to his first inpatient treatment program,
(+) h/o inpatient or outpatient treatment for alcohol or illicit
substances, 2 times,
(+) currently attending AA, NA, or other support groups, Veteran does
not believe that he suffers from alcoholism,
Veteran smoked a joint of MJ when he graduated from HS, he did not
smoke MJ during the military, and he smoked MJ less than 6 times after
the military. He drank alcohol 2 times during HS, he was a social
drinker during college and the military, while in Germany, and he became
an alcoholic after the military. He was drinking a lot with his
friends, at the time of his deployment to Gerrmany, from dusk until dawn.
Other times, he could drink until 2 AM, go to sleep, wake up at 5 AM,
go to PT, and be fine, while in the regular Army battalion, but he was
not able to keep that lifestyle while in the Ranger battalion, because
they put him through too much. Veteran does not like talking with
anyone about anything, even the weather. Veteran feels uncomfortable
when in large groups of people. This triggers intense urges for
drinking alcohol. Living with his emotions and feelings is more
difficult without alcohol than with alcohol.
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 post-military):
a. Stressor #1: 1. Military Combat Trauma (Veteran observed traumatic events
as experienced by others, including seeing a person get his face shot
off, seeing people with their heads cut off, and seeing a dead body,
he
claims he saw a US missile hit a minivan carrying an entire family,)
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: No response provided.
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, 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 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] 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.
Criterion I: Which stressor(s) contributed to the Veteran's PTSD
diagnosis?:
[X] Stressor #1
5. Symptoms
-----------
For VA rating purposes, check all symptoms that actively apply to the
Veteran's diagnoses:
[X] Depressed mood
[X] Anxiety
[X] Suspiciousness
[X] Panic attacks that occur weekly or less often
[X] Chronic sleep impairment
[X] Difficulty in establishing and maintaining effective work and social
relationships
[X] Inability to establish and maintain effective relationships
6. Behavioral Observations
--------------------------
Appearance - attire is summertime casual, grooming is average, and
presently,
the veteran does not appear to intermittently be in distress as he
intermittently discusses his taaumas.
Behavior - eye contact is intermittent, and speech is of unremarkable rate,
rhythm, volume, prosody, and articulation. Speech contains profanity in many
sentences.
Comportment suggests that the veteran gets along adequately with this writer.
Affect is neutral.
Thought processes are logical, linear, and goal-oriented. Presently, the
veteran does not have a formal thought disorder.
Thought content is without homicidal ideation or suicidal ideation.
Perceptions - the veteran presently does not appear to be responding to
internal stimuli.
Insight is fair. Judgment is fair.
Psychomotor activity - Veteran becomes agitated when talking about his
experiences in Iraq.
Muscular observation shows absence of focal motor deficits.
Cognitions are grossly intact.
Abstractions demonstrate at least average capacity for logical reasoning and
systematic thought.
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
--------------------------------------------------
REQUESTS AND FINDINGS
A. CLAIM TYPE - ORIGINAL, DBQ PSYCH PTSD Initial, the following
contentions need to be examined - PTSD, The VARO has verified the
veteran's combat service and the veteran has the following combat medals
Combat Action Badge,
Veteran is a y/o divorced, unemployed EA who served in a Ranger
battalion while serving in the USA and experienced military combat while
serving in Iraq. Veteran served in the USA from 2003 to 2007.
He was in the motor pool division of the Ranger battalion. He observed
traumatic events as experienced by others, including seeing a person get
his face shot off, seeing people with their heads cut off, and seeing a
dead body. He claims he saw a US missile hit a minivan carrying an entire
family, because the US forces wanted to kill one enemy combatant inside
the minivan. Veteran saw a VAMC on
10/01/2014, who diagnosed him with and treated him for PTSD. Veteran
experienced military combat stressors. Currently, at night he has dreams,
in which he cannot get his gun to shoot, because it will not fire. During
the day, he has uncontrollable thoughts. He visions someone getting shot.
Either he is shooting at the person getting shot or groups of people are
shooting at the person getting shot. He hears someone getting shot. He
states that it makes a very distinct sound. Thunderstorms, trigger he to
"lose it," whereby he becomes diaphoretic, comes to, and finds himself on
the floor in the prone position, after he has pulled his ex-girlfriend to
the floor with him. He has trouble sleeping for one week following such
events. Firecrackers on the 4th of July trigger he to "lose it," whereby
he finds he has pulled his son to the ground with him, causing abrasions
to his son's B/L knees. Veteran states that he avoids people, because
when
they find out that he is an Iraq War veteran, then they have a tendency
to
talk with him and ask him questions about his experiences. He states that
he hates it when they state that they understand, and he states that they
do not understand, because they were not there. Veteran voices his
suspiciousness and states that as soon as groups of people at AZU, where
he was in school, and groups of people where he has been employed find
out
that he has issues, then people talk about him and he is talked about.
Veteran states that people make jokes as to when would he be going postal
and start shooting up the office. He states that he knows that others are
talking about him, because when he goes into a room, then everyone stops
talking. Veteran states that once people become uncomfortable with
someone, then they plot and scheme. Veteran used to be a baseball player,
where he learned that being calm and controlled worked to his advantage,
but he states that he has lost the ability of being calm and controlled
in
order to work to his advantage. He recognizes that he has a "short fuse"
and can suddenly go from neutral to angry, agitated, and combative with
the right cue, as in someone older bossing him around and telling him
what
to do. He states "[he] wants to punch out a window over nothing." Veteran
states that if he applies for a supervisor position, then he is offered
an
entry level position instead. He states in the past he was able to deal
with supervisors, but now he cannot deal with supervisors. One of his
supervisors was talking to him as though he was a child, then Veteran
took
his left hand, placed it across his supervisors neck, and pushed him
against the wall. His supervisor "flipped out," talked about suing him,
and talked about pressing charges. Then Veteran was immediately let go.
He
was told that they were going to consider it as though he was never
hired.
Veteran admits to being high strung and states that he used to be able to
filter out supervisors telling him what to do kinds of stressors, but he
is no longer able to do that. He states that yesterday when he took a
urine drug test for a job that he would like to get, after waiting for 20
minutes and watching the receptionist doing one thing or another on the
computer, he became irate and confrontational. Veteran denies suicidal
ideation. He states his father's sister's husband killed himself.
Veteran states that he would never do that. He would not do it on
account of his mother and his son. Work impairments include being up for
3
nights at a time without sleeping, then he falls asleep while he is doing
something routine, such as tying his shoes. He states that he has missed
a
few jobs on account of this problem. Veteran meets the following DSM 5
criteria for PTSD.
1.) Trauma,
(+) Directly experiencing the events,
(+) Witnessing the events as they occurred to others,
(-) Learning that the traumatic events occurred to someone close,
2.) re-experiencing,
(+) dreams or nightmares,
(+) flashbacks,
(-) illusions or hallucinations,
(+) images, perceptions, or thoughts,
(+) triggers cause emotional and mental distress,
3.) avoidance,
(-) activities, he enjoyed American Sniper immensely, but he states that
this stirred up emotions and feelings,
(+) conversations, he avoids conversations with his Ranger friends,
(-) feelings,
(+) people, he avoids seeing his Ranger friends,
(+) places, he states he does not like the VA, people came back without
eyes and limbs, he came back with emotional and mental symptoms,
(-) thoughts,
4. negative feelings or thoughts,
(+) anhedonia,
(+) decreased interest or participation in activities,
(+) distorted cognitions about the cause or consequences of the events,
he
states that the entire Gulf War was "&$,"
(+) feeling detached and estranged,
(-) forgetting details about the events,
(+) negative beliefs about himself, others, or the world, he states that
the US federal government is "&$,"
(+) negative emotions,
5.) Altered arousal and reactivity
(+) angry outbursts,
(+) irritable behavior,
(+) hypervigilance,
(+) exaggerated startle,
(+) recklessness,
(+) self-destructiveness,
(-) concentration problem, if interested, then he can concentrate really
well, if not interested, then he cannot concentrate very well,
(+) sleep disturbance,
6.) (+) long-term duration,
7.) (+) dysfunction,
8.) (+) not due to a medical illness or substance,
Veteran has decreased productivity at work, because he has emotional and
mental symptoms affecting his ability to work, interpersonal problems
affecting his ability to get along well with others, and authority and
submission problems affecting his ability to get along well with
supervisors. These problems are secondary to symptoms of PTDS. They
occasionally, but not continuously, affect reliability. Otherwise, his
ability to adapt to change, maintain a regular work schedule, pay
attention, concentrate, and reason, show up for the job, maintain himself
on the job, and complete the job are not impaired. Alcohol abuse is in
remission. Functional limitations include working under a less than
supportive supervisor, working around any more than 2 or 3 other people,
and working indoors.
B. ELECTRONIC CLAIMS FOLDER AVAILABLE, review Veteran's electronic folder
in VBMS and state that it was reviewed.
Veteran's electronic folder in VBMS and was reviewed.
C. If more than one mental disorder is diagnosed, comment on their
relationship to one another.
Alcohol abuse is secondary to insomnia, which is secondary to PTSD.
Alcohol abuse is in remission.
D. If more than one mental disorder is diagnosed, state which symptoms
are
attributed to each disorder.
Currently, no symptoms are attributed to alcohol abuse, because alcohol
abuse is in remission.
NOTE: VA may request additional medical information, including additional
examinations if necessary to complete VA's review of the Veteran's
application.
Edited by HankChinaskiIdentifiers, tags
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