ptsd C&P Exam for PTSD--What does this mean?

[bcnandprn]

I made my initial PTSD claim in March of 2009 and it was denied.  I then filed a NOD and it was received on 11/26/2013 and I just had my C&P exam for PTSD last week.  I am looking at the results online, but I really don't know what it means or how it translate to anything and I was hoping maybe you all could help clarify for me.  How will the VA rater view this?  S/C? Denied again?  Approved with any type of rating?  This is all so confusing to me and I'm so sick of fighting through all of this.  I'm just tired at this point.

1. Diagnostic Summary

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Does the Veteran have a diagnosis of PTSD that conforms to DSM-5 criteria based on today's evaluation?

[X] Yes [ ] No

 

2. Current Diagnoses

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a. Mental Disorder Diagnosis #1: PTSD

Mental Disorder Diagnosis #2: Major Depressive Disorder

 

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

Mental Health Disorder (to include TBI): headaches

 

3. Differentiation of symptoms

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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?

[ ] Yes [X] No [ ] Not applicable (N/A)

 

If no, provide reason that it is not possible to differentiate what portion of each symptom is attributable to each diagnosis and discuss whether there is any clinical association between these diagnoses:

Veteran's Major Depressive Disorder (MDD) is at least as likely as not related to or caused by her PTSD. Veteran's MDD shares many overlapping features of co-morbidity with PTSD and the two conditions are unable to be reliably separated.

 

c. Does the Veteran have a diagnosed traumatic brain injury (TBI)?

[ ] Yes [ ] No [X] Not shown in records reviewed

 

4. Occupational and social impairment

a. Which of the following best summarizes the Veteran's level of occupational and social impairment with regards to all and social impairment with regards to all mental diagnoses? (Check only one)

 

[X] Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation.

b. For the indicated level of occupational and social impairment, is it possible to differentiate what portion of the occupational and social impairment indicated above is caused by each mental disorder?

[ ] Yes [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:

Veteran's PTSD and MDD are too inter-related to be reliably separated and they both contribute to social and occupational impairment.

 

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:

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Clinical Findings:

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1. Evidence review

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In order to provide an accurate medical opinion, the Veteran's claims

Folder must be reviewed.

a. Medical record review:

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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?

[X] Yes [ ] No

If yes, list any records that were reviewed but were not included in the

Veteran's VA claims file:

VAMC and VBMS electronic record

If no, check all records reviewed:

[ ] Military service treatment records

[ ] Military service personnel records

[ ] Military enlistment examination

[ ] Military separation examination

[ ] Military post-deployment questionnaire

[ ] Department of Defense Form 214 Separation Documents

[ ] Veterans Health Administration medical records (VA treatment records)

[ ] Civilian medical records

[ ] Interviews with collateral witnesses (family and others who have known the Veteran before and after military service)

[ ] No records were reviewed

[ ] Other:

b. Was pertinent information from collateral sources reviewed?

[ ] Yes [X] No

2. History

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

Veteran reported that she was raised in a good household with her parents and her brother and sister. Veteran shared good relationships with her family while she was growing up but she has become distant from everyone over the years since the military including her family. Veteran denied childhood history of abuse or neglect. Veteran has been married to her first husband since 2010. Veteran has two children (ages 5 and 8). Veteran reported that she loses her patience with her children and she yells "way too much" which causes her to worry that she is "ruining their lives." Veteran stated that her children's normal youthful activities and noises cause irritability, tension and anxiety. Veteran's irritability, depression, anxiety and emotional detachment also interfere with her marital relationship.  Veteran stated that her best friend from 7th grade stopped talking to her about two years ago because veteran is "too negative."

Veteran stated that her husband complains about this as well.

 

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

Veteran's highest level of education is a bachelor's degree in psychology. Veteran served in the Army from 2000 to 2009, working as a radio operator. Veteran currently works for United States Citizenship and Immigration Services (US CIS) which falls under the umbrella of Department of Homeland Security. Veteran's job is to decide whether illegal immigrants meet requirements for "extreme hardship" waiver. Veteran stated that she is easily annoyed in the work place especially by noises. Veteran "feels like (she) is going to explode inside (but she is) able to control (her)self." Veteran later stated that she feels like a "bad person because (she) can control (her)self at work but not at home...that's horrible..."

 

c. Relevant Mental Health history, to include prescribed medications and family mental health (pre-military, military, and post-military):

Veteran had no history of mental health diagnosis or treatment prior to the military. Veteran was diagnosed with PTSD (accompanied by severe depression) by KCVAMC Clinical Psychologist in August 2012. Veteran was unable to follow-up with therapy sessions because of the co-pay that would have been required of her at that time. Veteran instead sought treatment from private clinicians. For the past two years veteran has been working with a private counselor. Veteran is currently prescribed fluoxetine (mood) and phentermine (appetite) by private physicians.  Additionally, veteran stated that she recently started "Healing for Your Damaged Emotions", a class that her church is offering.  Veteran is nervous around people of certain heritage that resemble Middle Easterners in skin color, foreign language, etc. Veteran reported tearfully that "life sucks...I can't find happiness...I hate saying that because it makes me feel like a failure." Veteran stated that she frequently thinks about suicide but she would "never put (her) girls through that..."

 

d. Relevant Legal and Behavioral history (pre-military, military, and post-military): none

 

e. Relevant Substance abuse history (pre-military, military, and post-military): none

f. Other, if any: No response provided.

3. Stressors

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Describe one or more specific stressor event(s) the Veteran considers traumatic (may be pre-military, military, or post-military): a. Stressor #1: "...the RPGs that would come in and the whizzing of the rocket over your head...you would hear that siren and 'incoming, seek cover', the message would repeat..."

 

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

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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] Directly experiencing the traumatic event(s)

 

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] 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] 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 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] 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

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

Veteran's diagnoses:

[X] Depressed mood

[X] Anxiety

[X] Chronic sleep impairment

[X] Flattened affect

[X] Disturbances of motivation and mood

[X] Difficulty in establishing and maintaining effective work and social relationships

[X] Difficulty in adapting to stressful circumstances, including work or a work-like setting

[X] Suicidal ideation

6. Behavioral Observations

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Veteran presented with an anxious mood and restricted range of affect. Veteran's hygiene and grooming were good. Veteran was cooperative with the evaluation. Veteran's thoughts were centered around depressive themes throughout this evaluation and she was frequently tearful.

 

7. Other symptoms

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Does the Veteran have any other symptoms attributable to PTSD (and other mental disorders) that are not listed above?

[ ] Yes [X] No

 

8. Competency

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Is the Veteran capable of managing his or her financial affairs?

[X] Yes [ ] No

 

9. Remarks, (including any testing results) if any

Was Opinion Requested? - yes

NOTE: VA may request additional medical information, including additional examinations if necessary to complete VA's review of the Veteran's application.

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Medical Opinion

Disability Benefits Questionnaire

Indicate method used to obtain medical information to complete this document:

[ ] Review of available records (without in-person or video telehealth examination) using the Acceptable Clinical Evidence (ACE) process because the existing medical evidence provided sufficient information on which to prepare the DBQ and such an examination will likely provide no additional relevant evidence.

[ ] Review of available records in conjunction with a telephone interview with the Veteran (without in-person or telehealth examination) using the ACE process because the existing medical evidence supplemented with a telephone interview provided sufficient information on which to prepare the DBQ and such an examination would likely provide no additional relevant evidence.

[ ] Examination via approved video telehealth

[X] In-person examination

 

Evidence review

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

Was the Veteran's VA claims file reviewed? Yes

If yes, list any records that were reviewed but were not included in the

Veteran's VA claims file:

VAMC and VBMS electronic record

MEDICAL OPINION SUMMARY

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RESTATEMENT OF REQUESTED OPINION:

a. Opinion from general remarks: Does the Veteran have a diagnosis of (a) PTSD that is at least as likely as not (50 percent or greater probability) incurred in or caused by (the) confirmed Iraq service during service?

b. Indicate type of exam for which opinion has been requested: PTSD TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR DIRECT SERVICE CONNECTION ]

a. The condition claimed was at least as likely as not (50% or greater probability) incurred in or caused by the claimed in-service injury, event or illness.

c. Rationale: Veteran had no history of mental health diagnosis or treatment prior to the military. Veteran developed PTSD after exposure to traumatic events in Iraq and the PTSD symptoms continue to date (e.g. severe depression, anxiety, sleep disturbance, irritability, distressing recollections of trauma, avoidance of trauma reminders, mood and motivation disturbances, negative alterations of cognitions and mood, hypervigilance, exaggerated startle response).

[flores97]

Bcnandprn, it looks like you have a guaranteed rating from what your c&p examiner put in the report.  I am by no means an expert on PTSD, and I'm certain more knowledgeable members will comment, but I would say looks like a 30-50% rating, leaning toward 30 since you are able to work, jmo. Of course its all up to the rater but looks very promising for you, Good luck to you and your family!!

[Buck52]

I'm not an expert on rating  but from your symptoms I would say 70% to100% But becareful of the Back pay. if you first filed for this  condition in 3 -9-09 & Denied  and never filed NOD within a year  and later filed  in 11-26-2013  They will probably want to say your retro will be last week when you had your RECENT C&P an or not the 11-26 2013 date...BUT if you filed your NOD back from 2009 within the one year limit  that is the or should be your retro date   in other words if you filed NOD after you were denied for this same condition within the one year limit  that should be your EED...So watch this very carefully.

 

jmo

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

[bcnandprn]

Thank you both for your thoughts.  I messed up and said I filed in March 2009; however, I actually filed on March 9, 2012 and got denied on December 3, 2012.  I'm sorry for the confusion, but that's a good point to know about since I wasn't aware of that.  

I an an such a newbie to all of this, but I thought it may be a 30% too (if anything) because of what the C&P lady said under item #4.  But then I noticed she also marked 3 items in the symptoms that fall in the 30% level, 3 that fall in the 50% level, and 2 that fall in the 70% level, so that's very confusing to me.  I guess I'm more screwed up than I thought.  I really just want to get better and be happy again. 

[Gastone]

Aren't we all? I thought I was a Lock on 30, slight chance of a 50 and ended up with a 70. All PTSD ratings build on one another. You look like a 70, with a possible IU claim either inferred or available when you can no-longer work at any or all jobs, including Sedentary work. The ability or lack thereof to earn the Substantially Gainful Income (SGI) $12,400, comes into play with an IU rating.

The VA Group Sessions won't necessarily cure your PTSD but will help you understand and cope with it, to a certain degree. Good chance a PTSD Vet's spouse will begin displaying PTSD symptoms acquired by living with the Vet. None of the guys in my group ever gave that any consideration. 2 people living in the same house, with PTSD really sucks. 

PTSD is the gift that keeps on giving. Your young and early intervention may help take the edge off. Can't say I've talked to any PTSD Vets, mostly old Dogs, that think they've "gotten better." Their understanding and coping skills have improved but all the issues are still there.

Semper Fi

[flores97]

I would definitely give more weight to Buck's and Gastone's answers, they are absolutely right, the rater is supposed to rate according to symptoms, not just whatever box the c&p examiner checks off on reduced reliability. I apologize, this was the last post I read before bed and my brain wasn't firing on all cylinders.  I sincerely hope you get the highest rating possible.  Gastone also gave great advice, my father who is also a disabled veteran who has severe PTSD as well as bipolar disorder lived with me for five years, during which time my symptoms went off the charts, it was not a good situation, my lupus also began flaring more severely and often. The VA should consider the toll on family members living with vets that have PTSD.

[Buck52]

flores97

your post is fine brother and you could be absolutely correct Buddy.

when we ''think'' we have a fairly good C&P the VA can blow that out of the water and we get lowballed.

at least if the veteran stays on his/her claim&gets the Big D (DENIED)  we have the NOD but some times that just puts us in the appeal line.

it happens a lot.

 

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