Ok, so I got my C&P and I am pretty sure after reading a lot of your guys/gals responses that I had a favorable C&P, my question is it looks like the examiner places me at a 10%? Is he the person who decides? I've made a copy of it and it will be attached here to see what you guys think. I have read that at times the VA low balls their first rating, anybody else have experience with that? Thanks for your time!
LOCAL TITLE: C&P MENTAL DISORDER
STANDARD TITLE: MENTAL HEALTH C & P EXAMINATION CONSULT
DATE OF NOTE: JAN 13, 2016@10:00 ENTRY DATE: JAN 13, 2016@15:03:51
AUTHOR: RAY,CHRISTOPHER L EXP COSIGNER:
URGENCY: STATUS: COMPLETED
*** C&P MENTAL DISORDER Has ADDENDA ***
Initial Post Traumatic Stress Disorder (PTSD)
Disability Benefits Questionnaire
* Internal VA or DoD Use Only *
Name of patient/Veteran: Phillip Russell Barnett
SECTION I:
----------
1. Diagnostic Summary
---------------------
Does the Veteran have a diagnosis of PTSD that conforms to DSM-5 criteria
based on today's evaluation?
[X] Yes [ ] No
ICD code: 309.81
2. Current Diagnoses
--------------------
a. Mental Disorder Diagnosis #1: Posttraumatic stress disorder
CONFIDENTIAL Page 4 of 20
ICD code: 309.81
Comments, if any:
His clinical interview and test results are consistent with this
diagnosis.
Mental Disorder Diagnosis #2: Alcohol use disorder, severe
ICD code: 303.90
Comments, if any:
The veteran reported severe symptoms of this condition.
b. Medical diagnoses relevant to the understanding or management of the
Mental Health Disorder (to include TBI): None.
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?
[ ] 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:
When intoxicated he may exhibit mood lability and impaired social
functioning. Such symptoms are also characteristic of PTSD and it
is difficult to differentiate what portion of each symptom is
attributable to each condition.
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 mental diagnoses? (Check only
one)
[X] Occupational and social impairment due to mild or transient symptoms
which decrease work efficiency and ability to perform occupational
tasks only during periods of significant stress, or; symptoms
controlled by medication
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
BARNETT, PHILLIP RUSSELLCONFIDENTIAL Page 5 of 20
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:
Due to shared symptoms, it is difficult to reliably differentiate
what portion of the indicated level of occupational and social
impairment is attributable to each diagnosis.
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?
[X] Yes [ ] 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:
[ ] 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:
2. History
BARNETT, PHILLIP RUSSELL
BARNETT, PHILLIP RUSSELLCONFIDENTIAL Page 9 of 20
primary care physician and was seen in mental health (at the Columbus
VA)." He acknowledged that he received mental health treatment
after
the military. He reported that the treatment "helped. I don't
feel like
harming myself or anything." He said he is not currently
receiving
mental health treatment. He stated that he had been prescribed
citalopram "but I couldn't sleep on it at all."
The following information is derived from his CPRS records. These
records indicate that the veteran had contact in 2010 and 2011 with
Dr.
Minhas, a VA psychiatrist. The veteran indicated that he had taken
citalopram through a primary care physician but went off of it because
he felt he did not need it. During an appointment with Dr. Minhas on
2/28/11, he was experiencing bouts of depression and wanted to try the
medication again. He was diagnosed by Dr. Minhas with Depression NOS
and PTSD by history. He was prescribed citalopram.
His CPRS records suggest that the veteran previously had contact with
Dr. Haraburda, a VA psychologist. On 3/29/11 Dr. Haraburda provided
the
veteran with a diagnosis of PTSD.
d. Relevant Legal and Behavioral history (pre-military, military, and
post-military):
He denied any legal problems before the military. He stated that while
in the military "I lost my staff Sergeant stripe for fighting
with
another NCO." He stated that this incident took place after his
Iraq
deployment. He denied receiving any criminal charges since leaving the
military.
e. Relevant Substance abuse history (pre-military, military, and
post-military):
Before the military he reported that he "smoked weed (marijuana)
maybe
twice." He added that he used "minimal" amounts of
alcohol prior to the
service. While in the military he did not report consuming illegal
drugs. He acknowledged that while in the military he drank alcohol
"maybe once a month when going out with friends." After the
military he
said two years ago "I smoked marijuana twice." Since the
military, he
reported that he has consumed alcohol. He said he drinks "maybe a
BARNETT, PHILLIP RUSSELLCONFIDENTIAL Page 10 of 20
case
of beer every three days. My wife and I will have a bottle of wine
every few weeks or so." He noted that he has experienced
increased
tolerance to alcohol. He stated that at times he consumes more alcohol
than expected. He reported that he has made some attempts to cut down
on using alcohol. He said in the past his use of alcohol has
negatively
impacted relationships like with his first wife. He denied any
negative
impact of his alcohol use on his work. He added, "sometimes my
wife
(current) gets angry when I drink." He said he has driven his car
shortly after consuming alcohol.
f. Other, if any:
He did not report any medical problems "other than obesity."
He added
that he takes no medications.
3. Stressors
------------
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 #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] 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).
BARNETT, PHILLIP RUSSELLCONFIDENTIAL Page 12 of 20
[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] Reckless or self-destructive behavior.
[X] Hypervigilance.
[X] Exaggerated startle response.
[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.
BARNETT, PHILLIP RUSSELLCONFIDENTIAL Page 13 of 20
Criterion I: Which stressor(s) contributed to the Veteran's PTSD
diagnosis?:
[X] Stressor #1
[X] Stressor #2
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] Chronic sleep impairment
6. Behavioral Observations
--------------------------
The veteran was alert and oriented to person, place, the date, time, and
situation. The veteran's clothing was appropriate to the situation and
weather. He maintained appropriate eye contact. The veteran exhibited
acceptable hygiene. His speech was within normal limits with regard to rate,
rhythm and volume. He walked with a normal gait. The veteran was cooperative
and actively participated in the evaluation procedures. His affect was
appropriate to discussion. The veteran described his mood as "like
crap." He
noted that the anticipation of the current examination and "the
Christmas
season" tends to bother him. He added, "I associate that
(Christmas) with
going to the mall." He did not report thoughts of suicide or of harming
others. He did not report nor were there clear indications of obsessions,
compulsions, panic attacks, or manic symptoms.
Regarding his mental content, the veteran's thought processes were
linear.
His associations were goal-directed. Although he is suspicious of crowds,
there were no indications of delusions or hallucinations. Regarding ADLs, he
reported that he keeps up with his personal hygiene. He stated that he is
able to cook, clean, and complete other basic household chores. He said he
does not feel like he does well in keeping up with chores, but he feels
capable of doing them. He reported that he has a bank account and
driver's license.
His judgment in hypothetical situations is intact. He exhibits adequate
abstract reasoning and comprehension. He was able to remember events from
the past indicating no significant long term memory issues. He did not report
concentration deficits and none were apparent in session. His intellectual
functioning appears to be in the high average range based upon his
BARNETT, PHILLIP RUSSELLCONFIDENTIAL Page 14 of 20
educational attainment and vocabulary.
DSM-5 ASSESSMENT OF PTSD:
CRITERIA A: EXPOSURE TO ACTUAL OR THREATENED DEATH, SERIOUS INJURY, OR
SEXUAL VIOLENCE IN ONE (OR MORE) OF THE FOLLOWING WAYS:
1. DIRECTLY EXPERIENCING THE TRAUMATIC EVENT(S)
2. WITNESSING, IN PERSON, THE EVENT(S) AS IT OCCURRED TO OTHERS
3. LEARNING THAT THE TRUAMATIC EVENT(S) OCCURRED TO A CLOSE FAMILY MEMBER OR
CLOSE FRIEND, IN CASES OF ACTUAL OR THREATENED DEATH OF A FAMILY MEMBER OR
FRIEND, THE EVENT(S) MUST HAVE BEEN VIOLENT OR ACCIDENTAL.
4. EXPERIENCING REPEATED OR EXTREME EXPOSURE TO AVERSIVE DETAILS OF THE
TRAUMATIC EVENT(S) (e.g., first responders collecting human remains; police
officers repeatedly exposed to details of child abuse).
These reports of traumatic stress would fulfill the requirement for Criteria
A for
a diagnosis of PTSD.
SET OF DIAGNOSTIC CRITERIA B: PRESENCE OF ONE (OR MORE) OF THE FOLLOWING
INTRUSION SYMPTOMS ASSOICATED WITH THE TRAUMATIC EVENT(S), BEGINNING AFTER
THE TRAUMATIC EVENT(S) OCCURRED:
CRITERIA B-1: RECURRENT, INVOLUNTARY AND INTRUSIVE DISTRESSING MEMORIES OF
THE TRAUMATIC EVENT(S).
He acknowledged unwanted thoughts about the trauma stressors "very
often." He
said such thoughts are intrusive.
CRITERIA B-2: RECURRENT DISTRESSING DREAMS IN WHICH THE CONTENT AND/OR
AFFECT OF THE DREAM ARE RELATED TO THE TRAUMATIC EVENT(S).
He endorsed this symptom. He noted that the dreams have been "every
night
this past week." However, since he cannot recall the content of the
dreams it
is unclear if criteria for this symptom is met.
CRITERIA B-3: 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.)
He denied this symptom.
CRITERIA B-4: INTENSE OR PROLONGED PSYCHOLOGICAL DISTRESS AT EXPOSURE TO
INTERNAL OR EXTERNAL CUES THAT SYMBOLIZE OR RESEMBLE AN ASPECT OF THE
TRAUMATIC EVENT(S).
He reported that car doors slamming remind him of his trauma stressors. He
stated that he gets bothered by large crowds.
BARNETT, PHILLIP RUSSELLCONFIDENTIAL Page 15 of 20
CRITERIA B-5: MARKED PHYSIOLOGICAL REACTIONS TO INTERNAL OR EXTERNAL CUES
THAT SYMBOLIZE OR RESEMBLE AN ASPECT OF THE TRAUMATIC EVENT(S).
He said he wakes up from his dreams "covered in sweat." He added
that his
palms sweat when he is in large crowds.
These descriptions of re-experiencing symptoms meet the requirement for
Criteria B for PTSD.
SET OF DIAGNOSTIC CRITERIA C: PERSISTENT AVOIDANCE OF STIMULI ASSOCIATED
WITH THE TRAUMATIC EVENT(S), BEGINNING AFTER THE TRAUMATIC EVENT(S)
OCCURRED,
AS EVIDENCED BY ONE OR BOTH OF THE FOLLOWING:
CRITERIA C-1: AVOIDANCE OF OR EFFORTS TO AVOID DISTRESSING MEMORIES,
THOUGHTS, OR FEELINGS ABOUT OR CLOSELY ASSOCIATED WITH THE TRAUMATIC
EVENT(S).
He noted that he avoids conversations, memories, and thoughts about the
trauma stressors. He stated, for example, that he avoids conversations with
his wife about what happened.
CRITERIA C-2: AVOIDANCE OF OR EFFORTS TO AVOID EXTERNAL REMINDERS (PEOPLE,
PLACES, CONVERSATOINS, ACTIVITIES, OBJECTS, SITUATIONS) THAT AROUSE
DISTRESSING MEMORIES, THOUGHTS, OR FEELINGS ABOUT OR CLOSELY ASSOCIATED WITH
THE TRAUMATIC EVENT(S).
He reported avoiding large crowds of people. He added that he does not
"go to
fireworks" or "loud bars."
The veteran does report avoidance symptoms that would fulfill the
requirement
for Criteria C for PTSD.
SET OF DIAGNOSTIC CRITERIA 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:
CRITERIA D-1: 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).
He can remember well what happened, so criteria is not met.
CRITERIA D-2: 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
BARNETT, PHILLIP RUSSELLCONFIDENTIAL Page 16 of 20
whole nervous system is
permanently ruined.")
He stated that he feels like "I can't trust anyone at all."
CRITERIA D-3: PERSISTENT, DISTORTED COGNITIONS ABOUT THE CAUSE OR
CONSEQUENCES OF THE TRAUMATIC EVENT(S) THAT LEAD THE INDIVIDUAL TO BLAME
HIMSELF/HERSELF OR OTHERS.
He denied this symptom.
CRITERIA D-4: PERSISTENT NEGATIVE EMOTIONAL STATE (e.g., fear, horror,
anger, guilt, or shame).
He stated that he feels guilty "that I wasn't doing more
at the time of the trauma stressors. He added that he
has
persistent fears of crowds.
CRITERIA D-5: MARKEDLY DIMINISHED INTEREST OR PARTICIPATION IN SIGNIFICANT
ACTIVITIES.
He reported that he does some lifting but does not engage in many
activities.
He noted a lack of interest in engaging in other activities.
CRITERIA D-6: FEELINGS OF DETACHMENT OR EXTRANGEMENT FROM OTHERS.
He reported that he does not talk to "anybody from the military
anymore."
However, he stated that he talks to people at work. His test results are
suggestive of a tendency to avoid social interactions with others. Criteria
is considered met.
CRITERIA D-7: PERSISTENT INABILITY TO EXPERIENCE POSITIVE EMOTIONS (e.g.,
inability to experience happiness, satisfaction, or loving feelings).
He reported that he is able to have positive feelings toward his children.
However, his wife has told him "I'm the most emotionally
unavailable person
she's met." He said he thinks this was different prior to his
Iraqi
deployment. Criteria is met.
The veteran reported symptoms that meet Criteria D for PTSD.
SET OF DIAGNOSTIC CRITERIA 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:
BARNETT, PHILLIP RUSSELLCONFIDENTIAL Page 17 of 20
CRITERIA E-1: IRRITABLE BEHAVIOR AND ANGRY OUTBURSTS (WITH LITTLE OR NO
PROVOCATION) TYPICALLY EXPRESSED AS VERBAL OR PHYSICAL AGGRESSION TOWARD
PEOPLE OR OBJECTS).
He said he is doing better in controlling his anger.
CRITERIA E-2: RECKLESS OR SELF-DESTRUCTIVE BEHAVIOR
He stated that he has engaged in some drinking and driving.
CRITERIA E-3: HYPERVIGILANCE
He endorsed this symptom. He reported, "I always look at people's
eyes and
hands. I have also checked window locks and door locks twice a night."
CRITERIA E-4: EXAGGERATED STARTLE RESPONSE
He reported that he gets easily startled by sudden noises like fireworks. He
added that sudden movements bother him.
CRITERIA E-5: PROBLEMS WITH CONCENTRATION
He denied having concentration deficits.
CRITERIA E-6: SLEEP DISTURBANCE (e.g., difficulty falling or staying asleep
or restless sleep).
He reported that he has been experiencing sleep deficits and has only been
getting 4-5 hours of sleep at night. He noted that he has problems with
getting to and staying asleep.
The veteran reported symptoms that meet Criteria E for PTSD.
CRITERIA F: DURATION OF THE DISTURBANCE (CRITERIA B, C, D, AND E) IS MORE
THAN ONE MONTH
Criteria is met.
CRITERIA G: THE DISTURBANCE CAUSES CLINICALLY SIGNIFICANT DISTRESS OR
IMPAIRMENT IN SOCIAL, OCCUPATIONAL, OR OTHER IMPORTANT AREAS OF FUNCTIONING.
The veteran endorsed significant distress. The veteran reported social
impairment associated with his mental health symptoms. The veteran did not
report recent occupational impairment related to his mental health symptoms.
CRITERIA H: THE DISTURBANCE IS NOT ATTRIBUTABLE TO THE PHYSIOLOGICAL
EFFECTS
OF A SUBSTANCE (e.g., medication, alcohol) OR ANOTHER MEDICAL CONDITION.
The disturbance is not attributable to the physiological effects of a
BARNETT, PHILLIP RUSSELLCONFIDENTIAL Page 18 of 20
substance or another medical condition. He indicated that he has experienced
PTSD symptoms even in the absence of using alcohol or recovering from its
effects.
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
SSGTBarnett
Ok, so I got my C&P and I am pretty sure after reading a lot of your guys/gals responses that I had a favorable C&P, my question is it looks like the examiner places me at a 10%? Is he the person who decides? I've made a copy of it and it will be attached here to see what you guys think. I have read that at times the VA low balls their first rating, anybody else have experience with that? Thanks for your time!
LOCAL TITLE: C&P MENTAL DISORDER
STANDARD TITLE: MENTAL HEALTH C & P EXAMINATION CONSULT
DATE OF NOTE: JAN 13, 2016@10:00 ENTRY DATE: JAN 13, 2016@15:03:51
AUTHOR: RAY,CHRISTOPHER L EXP COSIGNER:
URGENCY: STATUS: COMPLETED
*** C&P MENTAL DISORDER Has ADDENDA ***
Initial Post Traumatic Stress Disorder (PTSD)
Disability Benefits Questionnaire
* Internal VA or DoD Use Only *
Name of patient/Veteran: Phillip Russell Barnett
SECTION I:
----------
1. Diagnostic Summary
---------------------
Does the Veteran have a diagnosis of PTSD that conforms to DSM-5 criteria
based on today's evaluation?
[X] Yes [ ] No
ICD code: 309.81
2. Current Diagnoses
--------------------
a. Mental Disorder Diagnosis #1: Posttraumatic stress disorder
CONFIDENTIAL Page 4 of 20
ICD code: 309.81
Comments, if any:
His clinical interview and test results are consistent with this
diagnosis.
Mental Disorder Diagnosis #2: Alcohol use disorder, severe
ICD code: 303.90
Comments, if any:
The veteran reported severe symptoms of this condition.
b. Medical diagnoses relevant to the understanding or management of the
Mental Health Disorder (to include TBI): None.
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?
[ ] 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:
When intoxicated he may exhibit mood lability and impaired social
functioning. Such symptoms are also characteristic of PTSD and it
is difficult to differentiate what portion of each symptom is
attributable to each condition.
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 mental diagnoses? (Check only
one)
[X] Occupational and social impairment due to mild or transient symptoms
which decrease work efficiency and ability to perform occupational
tasks only during periods of significant stress, or; symptoms
controlled by medication
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
BARNETT, PHILLIP RUSSELL CONFIDENTIAL Page 5 of 20
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:
Due to shared symptoms, it is difficult to reliably differentiate
what portion of the indicated level of occupational and social
impairment is attributable to each diagnosis.
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?
[X] Yes [ ] 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:
[ ] 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:
2. History
BARNETT, PHILLIP RUSSELL
BARNETT, PHILLIP RUSSELL CONFIDENTIAL Page 9 of 20
primary care physician and was seen in mental health (at the Columbus
VA)." He acknowledged that he received mental health treatment
after
the military. He reported that the treatment "helped. I don't
feel like
harming myself or anything." He said he is not currently
receiving
mental health treatment. He stated that he had been prescribed
citalopram "but I couldn't sleep on it at all."
The following information is derived from his CPRS records. These
records indicate that the veteran had contact in 2010 and 2011 with
Dr.
Minhas, a VA psychiatrist. The veteran indicated that he had taken
citalopram through a primary care physician but went off of it because
he felt he did not need it. During an appointment with Dr. Minhas on
2/28/11, he was experiencing bouts of depression and wanted to try the
medication again. He was diagnosed by Dr. Minhas with Depression NOS
and PTSD by history. He was prescribed citalopram.
His CPRS records suggest that the veteran previously had contact with
Dr. Haraburda, a VA psychologist. On 3/29/11 Dr. Haraburda provided
the
veteran with a diagnosis of PTSD.
d. Relevant Legal and Behavioral history (pre-military, military, and
post-military):
He denied any legal problems before the military. He stated that while
in the military "I lost my staff Sergeant stripe for fighting
with
another NCO." He stated that this incident took place after his
Iraq
deployment. He denied receiving any criminal charges since leaving the
military.
e. Relevant Substance abuse history (pre-military, military, and
post-military):
Before the military he reported that he "smoked weed (marijuana)
maybe
twice." He added that he used "minimal" amounts of
alcohol prior to the
service. While in the military he did not report consuming illegal
drugs. He acknowledged that while in the military he drank alcohol
"maybe once a month when going out with friends." After the
military he
said two years ago "I smoked marijuana twice." Since the
military, he
reported that he has consumed alcohol. He said he drinks "maybe a
BARNETT, PHILLIP RUSSELL CONFIDENTIAL Page 10 of 20
case
of beer every three days. My wife and I will have a bottle of wine
every few weeks or so." He noted that he has experienced
increased
tolerance to alcohol. He stated that at times he consumes more alcohol
than expected. He reported that he has made some attempts to cut down
on using alcohol. He said in the past his use of alcohol has
negatively
impacted relationships like with his first wife. He denied any
negative
impact of his alcohol use on his work. He added, "sometimes my
wife
(current) gets angry when I drink." He said he has driven his car
shortly after consuming alcohol.
f. Other, if any:
He did not report any medical problems "other than obesity."
He added
that he takes no medications.
3. Stressors
------------
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 #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] 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).
BARNETT, PHILLIP RUSSELL CONFIDENTIAL Page 12 of 20
[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] Reckless or self-destructive behavior.
[X] Hypervigilance.
[X] Exaggerated startle response.
[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.
BARNETT, PHILLIP RUSSELL CONFIDENTIAL Page 13 of 20
Criterion I: Which stressor(s) contributed to the Veteran's PTSD
diagnosis?:
[X] Stressor #1
[X] Stressor #2
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] Chronic sleep impairment
6. Behavioral Observations
--------------------------
The veteran was alert and oriented to person, place, the date, time, and
situation. The veteran's clothing was appropriate to the situation and
weather. He maintained appropriate eye contact. The veteran exhibited
acceptable hygiene. His speech was within normal limits with regard to rate,
rhythm and volume. He walked with a normal gait. The veteran was cooperative
and actively participated in the evaluation procedures. His affect was
appropriate to discussion. The veteran described his mood as "like
crap." He
noted that the anticipation of the current examination and "the
Christmas
season" tends to bother him. He added, "I associate that
(Christmas) with
going to the mall." He did not report thoughts of suicide or of harming
others. He did not report nor were there clear indications of obsessions,
compulsions, panic attacks, or manic symptoms.
Regarding his mental content, the veteran's thought processes were
linear.
His associations were goal-directed. Although he is suspicious of crowds,
there were no indications of delusions or hallucinations. Regarding ADLs, he
reported that he keeps up with his personal hygiene. He stated that he is
able to cook, clean, and complete other basic household chores. He said he
does not feel like he does well in keeping up with chores, but he feels
capable of doing them. He reported that he has a bank account and
driver's license.
His judgment in hypothetical situations is intact. He exhibits adequate
abstract reasoning and comprehension. He was able to remember events from
the past indicating no significant long term memory issues. He did not report
concentration deficits and none were apparent in session. His intellectual
functioning appears to be in the high average range based upon his
BARNETT, PHILLIP RUSSELL CONFIDENTIAL Page 14 of 20
educational attainment and vocabulary.
DSM-5 ASSESSMENT OF PTSD:
CRITERIA A: EXPOSURE TO ACTUAL OR THREATENED DEATH, SERIOUS INJURY, OR
SEXUAL VIOLENCE IN ONE (OR MORE) OF THE FOLLOWING WAYS:
1. DIRECTLY EXPERIENCING THE TRAUMATIC EVENT(S)
2. WITNESSING, IN PERSON, THE EVENT(S) AS IT OCCURRED TO OTHERS
3. LEARNING THAT THE TRUAMATIC EVENT(S) OCCURRED TO A CLOSE FAMILY MEMBER OR
CLOSE FRIEND, IN CASES OF ACTUAL OR THREATENED DEATH OF A FAMILY MEMBER OR
FRIEND, THE EVENT(S) MUST HAVE BEEN VIOLENT OR ACCIDENTAL.
4. EXPERIENCING REPEATED OR EXTREME EXPOSURE TO AVERSIVE DETAILS OF THE
TRAUMATIC EVENT(S) (e.g., first responders collecting human remains; police
officers repeatedly exposed to details of child abuse).
These reports of traumatic stress would fulfill the requirement for Criteria
A for
a diagnosis of PTSD.
SET OF DIAGNOSTIC CRITERIA B: PRESENCE OF ONE (OR MORE) OF THE FOLLOWING
INTRUSION SYMPTOMS ASSOICATED WITH THE TRAUMATIC EVENT(S), BEGINNING AFTER
THE TRAUMATIC EVENT(S) OCCURRED:
CRITERIA B-1: RECURRENT, INVOLUNTARY AND INTRUSIVE DISTRESSING MEMORIES OF
THE TRAUMATIC EVENT(S).
He acknowledged unwanted thoughts about the trauma stressors "very
often." He
said such thoughts are intrusive.
CRITERIA B-2: RECURRENT DISTRESSING DREAMS IN WHICH THE CONTENT AND/OR
AFFECT OF THE DREAM ARE RELATED TO THE TRAUMATIC EVENT(S).
He endorsed this symptom. He noted that the dreams have been "every
night
this past week." However, since he cannot recall the content of the
dreams it
is unclear if criteria for this symptom is met.
CRITERIA B-3: 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.)
He denied this symptom.
CRITERIA B-4: INTENSE OR PROLONGED PSYCHOLOGICAL DISTRESS AT EXPOSURE TO
INTERNAL OR EXTERNAL CUES THAT SYMBOLIZE OR RESEMBLE AN ASPECT OF THE
TRAUMATIC EVENT(S).
He reported that car doors slamming remind him of his trauma stressors. He
stated that he gets bothered by large crowds.
BARNETT, PHILLIP RUSSELL CONFIDENTIAL Page 15 of 20
CRITERIA B-5: MARKED PHYSIOLOGICAL REACTIONS TO INTERNAL OR EXTERNAL CUES
THAT SYMBOLIZE OR RESEMBLE AN ASPECT OF THE TRAUMATIC EVENT(S).
He said he wakes up from his dreams "covered in sweat." He added
that his
palms sweat when he is in large crowds.
These descriptions of re-experiencing symptoms meet the requirement for
Criteria B for PTSD.
SET OF DIAGNOSTIC CRITERIA C: PERSISTENT AVOIDANCE OF STIMULI ASSOCIATED
WITH THE TRAUMATIC EVENT(S), BEGINNING AFTER THE TRAUMATIC EVENT(S)
OCCURRED,
AS EVIDENCED BY ONE OR BOTH OF THE FOLLOWING:
CRITERIA C-1: AVOIDANCE OF OR EFFORTS TO AVOID DISTRESSING MEMORIES,
THOUGHTS, OR FEELINGS ABOUT OR CLOSELY ASSOCIATED WITH THE TRAUMATIC
EVENT(S).
He noted that he avoids conversations, memories, and thoughts about the
trauma stressors. He stated, for example, that he avoids conversations with
his wife about what happened.
CRITERIA C-2: AVOIDANCE OF OR EFFORTS TO AVOID EXTERNAL REMINDERS (PEOPLE,
PLACES, CONVERSATOINS, ACTIVITIES, OBJECTS, SITUATIONS) THAT AROUSE
DISTRESSING MEMORIES, THOUGHTS, OR FEELINGS ABOUT OR CLOSELY ASSOCIATED WITH
THE TRAUMATIC EVENT(S).
He reported avoiding large crowds of people. He added that he does not
"go to
fireworks" or "loud bars."
The veteran does report avoidance symptoms that would fulfill the
requirement
for Criteria C for PTSD.
SET OF DIAGNOSTIC CRITERIA 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:
CRITERIA D-1: 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).
He can remember well what happened, so criteria is not met.
CRITERIA D-2: 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
BARNETT, PHILLIP RUSSELL CONFIDENTIAL Page 16 of 20
whole nervous system is
permanently ruined.")
He stated that he feels like "I can't trust anyone at all."
CRITERIA D-3: PERSISTENT, DISTORTED COGNITIONS ABOUT THE CAUSE OR
CONSEQUENCES OF THE TRAUMATIC EVENT(S) THAT LEAD THE INDIVIDUAL TO BLAME
HIMSELF/HERSELF OR OTHERS.
He denied this symptom.
CRITERIA D-4: PERSISTENT NEGATIVE EMOTIONAL STATE (e.g., fear, horror,
anger, guilt, or shame).
He stated that he feels guilty "that I wasn't doing more
at the time of the trauma stressors. He added that he
has
persistent fears of crowds.
CRITERIA D-5: MARKEDLY DIMINISHED INTEREST OR PARTICIPATION IN SIGNIFICANT
ACTIVITIES.
He reported that he does some lifting but does not engage in many
activities.
He noted a lack of interest in engaging in other activities.
CRITERIA D-6: FEELINGS OF DETACHMENT OR EXTRANGEMENT FROM OTHERS.
He reported that he does not talk to "anybody from the military
anymore."
However, he stated that he talks to people at work. His test results are
suggestive of a tendency to avoid social interactions with others. Criteria
is considered met.
CRITERIA D-7: PERSISTENT INABILITY TO EXPERIENCE POSITIVE EMOTIONS (e.g.,
inability to experience happiness, satisfaction, or loving feelings).
He reported that he is able to have positive feelings toward his children.
However, his wife has told him "I'm the most emotionally
unavailable person
she's met." He said he thinks this was different prior to his
Iraqi
deployment. Criteria is met.
The veteran reported symptoms that meet Criteria D for PTSD.
SET OF DIAGNOSTIC CRITERIA 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:
BARNETT, PHILLIP RUSSELL CONFIDENTIAL Page 17 of 20
CRITERIA E-1: IRRITABLE BEHAVIOR AND ANGRY OUTBURSTS (WITH LITTLE OR NO
PROVOCATION) TYPICALLY EXPRESSED AS VERBAL OR PHYSICAL AGGRESSION TOWARD
PEOPLE OR OBJECTS).
He said he is doing better in controlling his anger.
CRITERIA E-2: RECKLESS OR SELF-DESTRUCTIVE BEHAVIOR
He stated that he has engaged in some drinking and driving.
CRITERIA E-3: HYPERVIGILANCE
He endorsed this symptom. He reported, "I always look at people's
eyes and
hands. I have also checked window locks and door locks twice a night."
CRITERIA E-4: EXAGGERATED STARTLE RESPONSE
He reported that he gets easily startled by sudden noises like fireworks. He
added that sudden movements bother him.
CRITERIA E-5: PROBLEMS WITH CONCENTRATION
He denied having concentration deficits.
CRITERIA E-6: SLEEP DISTURBANCE (e.g., difficulty falling or staying asleep
or restless sleep).
He reported that he has been experiencing sleep deficits and has only been
getting 4-5 hours of sleep at night. He noted that he has problems with
getting to and staying asleep.
The veteran reported symptoms that meet Criteria E for PTSD.
CRITERIA F: DURATION OF THE DISTURBANCE (CRITERIA B, C, D, AND E) IS MORE
THAN ONE MONTH
Criteria is met.
CRITERIA G: THE DISTURBANCE CAUSES CLINICALLY SIGNIFICANT DISTRESS OR
IMPAIRMENT IN SOCIAL, OCCUPATIONAL, OR OTHER IMPORTANT AREAS OF FUNCTIONING.
The veteran endorsed significant distress. The veteran reported social
impairment associated with his mental health symptoms. The veteran did not
report recent occupational impairment related to his mental health symptoms.
CRITERIA H: THE DISTURBANCE IS NOT ATTRIBUTABLE TO THE PHYSIOLOGICAL
EFFECTS
OF A SUBSTANCE (e.g., medication, alcohol) OR ANOTHER MEDICAL CONDITION.
The disturbance is not attributable to the physiological effects of a
BARNETT, PHILLIP RUSSELL CONFIDENTIAL Page 18 of 20
substance or another medical condition. He indicated that he has experienced
PTSD symptoms even in the absence of using alcohol or recovering from its
effects.
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
--------------------------------------------------
Assessment Results:
The MMPI-2-RF was administered to measure symptom patterns associated
with
particular classes of psychopathology and as a measure of feigning. The
veteran's profile is valid and interpretable.
His MMPI-2-RF profile is similar to individuals who report feeling
anxious. Such individuals tend to experience intrusive ideation, sleep
difficulties including nightmares, significant anxiety, and PTSD.
The veteran reported a lack of emotional experiences. Such individuals
tend to experience significant problems with anhedonia, lack interests,
are pessimistic, and complain about depression.
According to his test results, he reported significant past and current
substance abuse. Such individuals have a history of problematic use of
alcohol or drugs and engage in sensation-seeking. They also may have had
legal problems as a result of substance abuse.
Interpersonally, he reported not enjoying social events and avoiding
social situations. He also indicated disliking people and being around
them. Such individuals tend to be asocial, introverted, emotionally
restricted, and have difficulty forming close relationships.
His MMPI-2?2?RF results suggest that he should be evaluated for cluster C
personality disorders, disorders associated with social avoidance such as
avoidant personality disorder, schizoid personality disorder, substance
use-related disorders and anxiety-related disorders, including PTSD.
Opinion & Rationale:
It is my opinion, with reasonable psychological certainty, that it is
more
likely than not (greater than a 50% probability) that his Posttraumatic
stress disorder with secondary depressive symptoms resulted from his
Iraqi
BARNETT, PHILLIP RUSSELL CONFIDENTIAL Page 19 of 20
trauma stressors. My opinion is based upon my clinical experience and
expertise, a review of the veteran's CPRS records, a review of his
VBMS
records, the results of a clinical interview, and the veteran's test
results. The veteran showed no signs of significant exaggeration or
feigning of mental disorder symptoms on objective testing, during the
interview, or when comparing his self-report to the evidence of record.
There are no known major traumatic stressors other than what happened
during his military service that could explain his PTSD symptoms. There
appears to be a direct link between his PTSD symptoms and his trauma
stressors experienced in Iraq. Of note is that the veteran is
experiencing
anhedonia and mild sadness, which are considered secondary to his PTSD
because of the temporal relationship between the onset of the symptoms
and
his trauma stressors. Also, a persistent negative mood state is
considered
to be consistent with a diagnosis of PTSD. The veteran's CPRS
records
suggest that a prior mental health treatment provider has diagnosed him
with PTSD. His social avoidance found in his testing is likely associated
with his PTSD condition rather than a personality disorder.
NOTE: VA may request additional medical information, including additional
examinations if necessary to complete VA's review of the Veteran's
application.
/es/ CHRISTOPHER RAY PHD ABPP
Psychologist, C&P
Signed: 01/13/2016 15:03
01/13/2016 ADDENDUM STATUS: COMPLETED
The veteran's C&P exam was completed in CAPRI. The procedure codes are
99456 and
96101.
/es/ CHRISTOPHER RAY PHD ABPP
Psychologist, C&P
Signed: 01/13/2016 15:04
END OF MY HEALTHEVET PERSONAL INFORMATION REPORT
Edited by SSGTBarnettLink to comment
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pwrslm
C&P examiner does not determine what your rating is. The Regional Office assigned a trained rater who does that. All the C&P exam is, is a tool for the rater to use to determine what th
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Looks a lot like my C&P. I got 30%
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