ptsd Should I claim PTSD?

[DevilDog12]

I am 30% SC for Major Depression.  I called VA to schedule an appointment with a Psychologist because of ongoing Depression.  Had a Mental health representative from VA call me, and she conducted several Q&A's over phone.  One was a PCL-5 Questionnaire for PTSD.  I scored a 52 out of possible 80.  VA notes say it is above cutoff.  Also conducted other questions over phone, and got moderately Severe, and Severe.  Not sure if I should file increase for Major Depression or new claim for PTSD?  Thoughts?

[DevilDog12]

Here are results of phone consultation.  Wondering if I should claim PTSD, or an increase for Major Depression?

LOCAL TITLE: CONSULTATION REPORT

STANDARD TITLE: CONSULT

DATE OF NOTE: DEC 29, 2015@11:57 ENTRY DATE: DEC 29, 2015@11:57:58

AUTHOR: ROPER,LISA A EXP COSIGNER:

URGENCY: STATUS: COMPLETED

BEHAVIORAL HEALTH CONSULTATION LIASON TEAM (BHCLT) - TELEPHONE ENCOUNTER

 

DATE: Dec 29,2015@11:58

 

CONFIDENTIAL 

TYPE: Telephone

DURATION: 30 minutes

BHP'S ROLE AND INFORMED CONSENT EXPLAINED: Yes

VETERAN is a 39 year old MALE.

REASON FOR REFERRAL/CHIEF COMPLAINT: Depression.

REFERRED BY: PCP., PA

 

SCREENING: PCL-5 (Post Traumatic Stress Disorder Checklist), PHQ-9 (Patient

Health Questionnaire - 9 Symptom Checklist), AUDIT-C (Alcohol Use Disorders

Identification Test), Suicide Risk Screening, GAD-7 (Generalized Anxiety

Disorder), Other Tests

 

SESSION FOCUS: The Veteran was contacted for baseline assessment screenings by

our health technician for an evidence based structured interview.

Baseline remarkable for depression, generalized anxiety, and elevated posttrauma

Symptoms

 

Veteran recently establishing VA services. Reported a history of depression with

a MDD diagnosis in the past. Veteran, during baseline, described a traumatic

event in 1995 in which a military vehicle in the convoy he was in, lost brakes, and 

went off road, flipped over, and a fellow Marine died during baseline assessment 

and another regarding a bomb evacuation from his ship. Experiencing pain from migraines.

Veteran is employed as correctional counselor at a Federal prison and provided his

daytime office phone at. Veteran receptive to Behavioral Healthout-patient treatment options.

 

FUNCTIONAL ASSESSMENT:

S/O of depression: Yes PHQ-9 score = 18 moderately severe symptoms

S/O of generalized anxiety: Yes GAD-7 score = 18 severe symptoms

S/O of traumatic stress: Yes PCL-5 score = 52 above cutoff

 

Trauma reported: Convoy accident killing a fellow Marine

Trauma Date: 2/1995

 

Alcohol: No

Patient reports drinking in the past year, but did not report any drinking in

the past week or binges in the past 3 months.

Patient was screened but did not meet criteria for an alcohol use disorder

within the last 12 months.

 

Psychiatric/pain meds: Yes Citalopram 10/29/2015

Cognitive Screening: The patient reported never experiencing a

significant head injury in the past.

Tobacco: No

Illicit drug use: No

S/O of Mania/hypomania: No

Delusions/hallucinations: No

 

Pain: No Patient reported daily or near daily pain. The patient rated

average pain as 8 on a scale from 0-10, with 10 being the worst pain.

The patient rated interference in daily activities from the pain as a 7 on a

scale from 0-10, with 10 being complete interference.

Current marital status: Married/Partnered

Current employment status: Employed full time

 

CONFIDENTIAL 

Self-reported financial situation: Has just enough to get along

 

SERVICE CONNECTED % - 60

HYPERTENSIVE VASCULAR DISEASE 0% SC

NERVOUS TIC 0% SC

MAJOR DEPRESSIVE DISORDER 30% SC

MIGRAINE HEADACHES 30% SC

SINUSITIS,MAXILLARY,CHRONIC 10% SC

 

INTERVENTION: Screening assessment & psychoeducation

PATIENT EDUCATION: Verbal

DIAGNOSTIC IMPRESSIONS:

-Deferred

-Please see medical diagnoses in problem list which were

reviewed by this provider

LETHALITY: Suicidal/homicidal ideations denied

RISK LEVEL IMPRESSION:

[x] Low risk: presence of risk minimal. Veteran NOT at imminent

risk, but recommend reassessment if changes in situational

stressors or presentation are observed at follow-up appointments.

PLAN FOR MANAGEMENT OF LETHALITY CONCERNS: No treatment indicated at present

VETERAN PROVIDED WITH:

[X] Contact info and next step details

[X] Veterans crisis hotline information

[X] Managing risks/seeking help information and literature

FOLLOW-UP: BHCLT telephone f/u to determine the most appropriate level of

care given veteran's concerns.

[X]: Veteran expressed agreement & understanding of the plan.

REFERRAL SOURCE PROVIDED WITH FEEDBACK: View alert/Additional signer

CARE MANAGER

Signed: 12/29/2015 12:23

Receipt Acknowledged By:

12/29/2015 13:13 /es/, PHD

CLINICAL PSYCHOLOGIST

[PCW]

I would go over you symptoms with your Psychologist and see if he/she comes up with a PTSD diagnosis. Has your depression increased? Did you let your Psychologist know? Treatment is the best thing you can do to help yourself.     

Edited January 5, 2016 by PCW

[DevilDog12]

Yes, depression has increased.  I did go over it with psycologist, and have another appointment with him at end of month.  I want to do therapy, so hopefully they start me on it

[Buck52]

You need a VA  PTSD Diagnoses 

And seek treatment with VA MH.

 if you file a claim only for PTSD Only file a FDC Claim  you need your in service strssor's and a nexus to put the two together from your prior military service.

Request your C-File and all your military records ASAP.

because a lot of other events can cause PTSD you need it Service Connected.

your STR's & ISR's you need to prove your where abouts and what you did  MOS plays a big part, as well as your DD-214

if you have  CIB then the stressor's are not necessary but I would send in any  that you have & Medical Records.

The Claims Intake Center will send you a letter  telling you what all they need form you after you file your claim usually  in about 4 weeks.

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

[DevilDog12]

Great info!  Thanks Buck!

[DevilDog12]

I was just curious because of what they noted on this phone consultation.  I recently filed for an increase for my Major Depression rating, so I take it I will have tonwait until they send me a NOD to fill out?