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Blesedell

Helpful input on MH C&P. Stressing wicked bad. Do not know who or where else to go for more information.

Question

My question is in regards to a recently completed C&P exam I had taken for MH. I am quite worried about the statements made by the examiner and a few other sections as well. I have tried to highlight the sections that worried me I am not sure if I had missed anything of importance. Normally I would take this issue up with my VSO but she is out sick. I do not know who else or where else to turn to for information about this. I am most worried about the statements made by the examiner in the final paragraph. I did as I was told by my VSO and others in the VA and are assisting me currently in matters of mental health. That was be honest and it will all be okay. Well turns out it might not be okay and I was completely honest with this examiner!!!

 

 

Date/Time:               21 Jan 2016 @ 1330
Note Title:              C&P MENTAL DISORDER
Location:                Chalmers P Wylie VA Outpatnt
Signed By:              
Co-signed By:           
Date/Time Signed:        21 Jan 2016 @ 1650
-------------------------------------------------------------------------

 LOCAL TITLE: C&P MENTAL DISORDER                               
STANDARD TITLE: MENTAL HEALTH C & P EXAMINATION CONSULT        
DATE OF NOTE: JAN 21, 2016@13:30     ENTRY DATE: JAN 21, 2016@16:50:27     
      AUTHOR:         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:  
   
                                   SECTION I:
                                   ----------
    1. Diagnostic Summary
    ---------------------
    Does the Veteran have a diagnosis of PTSD that conforms to DSM-5 criteria
    based on today's evaluation?
    [ ] Yes   [ ] No
   
    2. Current Diagnoses
    --------------------
    a. Mental Disorder Diagnosis #1: Diagnosis Deferred
           Comments, if any:

              The veteran was asked to be evaluated for PTSD, the stressor has
              been conceded as he has been awarded the Combat Infantry Badge.
              The diagnosis is deferred as the examiner is unable to offer a
              specific diagnosis with any level of scientific certainty. The veteran was
              administered the MMPI-2-RF, although it appears he understood and
              responded to the items in a consistent manner, the remainder of
              the profile is not able to be interpreted due to an over-reporting of
              symptomatology that is not common even in individuals with known
              severe psychopathology. There are a number of potential reasons
              for this profile to include it being a "plea for help", it may be a
              phenomenologic style to over report and to be traumatized (this
              pattern is frequently seen in Dependent and Histrionic Personality
              Disorders and Depressive Mood Disorders) or the individual is
              trying to look worse than they are for some secondary reason.
              Unfortunately it is impossible to determine the reason behind this
              pattern of responding in this case without resorting to
              speculation.

              His service treatment records suggest that he did not report PTSD
              symptoms while in the military. While he has been diagnosed and
              treated recently for PTSD, the requirements for a clinical
              diagnosis differ from the requirements for an independent/forensic
              evaluation. In the latter situation the examiner is required to
              consider other factors for an individual's complaints while a
              clinician takes their patient's report as being valid.


              Please note that the 2507 requested that the examiner complete
              both the mental disorder and Initial PTSD DBQ's, only the Initial PTSD
              DBQ will be completed as completing the Mental Disorder DBQ is
              redundant.


              In regards to the question as whether or not the veteran's sexual
              dysfunction is at least as likely as not approximately due to or
              the result of PTSD, while the veteran reports he has some
              difficulties sexually due to his prescriptions the veteran remains
              sexually active and furthermore there are other physical
              conditions as well as medications that may be negatively impacting his sexual
              dysfunction, as such the final decision is deferred to a physician.

              In regards to question whether the veteran's insomnia is at least
              as likely as not approximately due to are the result of PTSD; this
              would be a redundant opinion as chronic sleep difficulties are a
              symptom of PTSD (and depression), they are not a separate
              diagnosis/syndrome.
             

       Mental Disorder Diagnosis #2: Cluster B traits

       Mental Disorder Diagnosis #3: Alcohol Use Disorder - in self-reported
          remission

    b. Medical diagnoses relevant to the understanding or management of the
       Mental Health Disorder (to include TBI): see medical records

    3. Differentiation of symptoms
    ------------------------------
    a. Does the Veteran have more than one mental disorder diagnosed?
       No response provided
.
      
    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)
       No response provided.

      
    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?
       No response provided.

      
    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:
     
        [ ] 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
        [X] Other:
              The veteran's electronic medical records (CPRS & VistAWeb) were
              reviewed.

              The veteran was referred for a compensation and pension
              examination. The veteran was informed verbally of the nature and
              purpose of the examination and confidentiality limits. He appeared
              to have a basic understanding of the purpose of the examination
              and confidentiality limits. He was provided with a chance to ask
              questions about the evaluation procedures. All questions were
              answered to reasonable satisfaction or referred to other resources.
              He was informed that this examiner is not his treating clinician
              or the legal determiner of compensation or pension benefits. Instead,
              he was informed that this examiner is an independent provider of
              clinical information and expertise to assist those who review and
              make legal compensation and pension claim decisions and would not
              be participating in his healthcare. He was given information about
              the Veteran's 24 hour Crisis Line. The veteran indicated
              understanding of these terms and explicitly and freely consented
              to the evaluation. The judgments of symptoms and opinions in this
              evaluation report are offered to a reasonable degree of
              psychological certainty and are only based upon the information
              available at the time of the evaluation.

              The DSM 5 criteria have been considered in this evaluation.

              This report was dictated using Dragon Naturally Speaking dictation
              software, the report has been proofread however due to time
              constraints there still may be some typographical errors due to
              the nature of the dictation software.
             
    b. Was pertinent information from collateral sources reviewed?
    [ ] Yes   [X] No
   
       
    2. History
    ----------
    a. Relevant Social/Marital/Family history (pre-military, military, and
       post-military):

          The veteran is a 28-year-old single male, he is not currently in a
          relationship. He currently lives in a homeless shelter, he has one
          roommate in addition to 6 other veterans living in the house. He has
          no children. [Later during the interview the veteran reported having met
          a woman using a smart phone dating app (Tinder), although they are not
          in a relationship they still get together occasionally for sex].

          The veteran is the younger of 2 children, he does not get along with
          his sister saying "she had a rough time with drugs." The veteran says
          that he does not like "the way she treats my mother and my nephew."
          Apparently one of her 3 children is living with the veteran's mother
          and this causes difficulties in that relationship as well as the
          veteran's relationship with his sister.

          The veteran says his parents were never married saying "my father left
          prior to my birth." He would continue to see his father for a couple
          of weeks a year however. The veteran says his mother never remarried
          however she had several long-term boyfriends. The first long-term
          boyfriend entered the picture around the time of the veteran's birth,
          this gentleman died of a heroin overdose when the veteran was 6 years
          old. His mother then started another long-term relationship, they are
          still together, the veteran says he considers this man to be his
          stepfather/father figure. He maintains a good relationship with this
          man as well as then "outstanding" relationship with his mother. The
          veteran notes that his mother lives in Massachusetts and he has not
          been able to see her in the past 2-1/2 years although they talk
          several times a week. The veteran is hopeful that he will be able to buy a
          house and have his mother, her boyfriend and the veteran's nephew all
          moved to Ohio so that he can take care of them.

          The veteran says he has an "okay" relationship with his biological
          father although he said "we just don't talk very much, we don't have
          much in common."

          When asked to describe his childhood the veteran says it was "okay,
          there was a lot of issues. I had everything I needed and occasionally
          stuff I wanted." The veteran says at the time he thought his childhood
          was very good and that he was spoiled however he says looking back on
          the situation and comparing his childhood with the childhood of
          different people he has met over the years he realizes his childhood
          was not necessarily very good. The veteran says his mother was using
          drugs during his childhood although she stopped her drug use when the
          veteran was 14 years old.

          When asked about physical or sexual abuse the veteran says "just small
          (stuff), hitting and stuff."
         
         
    b. Relevant Occupational and Educational history (pre-military, military,
and post-military):

          The veteran says that he graduated from high school in 2008, when
          asked how he did in school he says "not good", he says his grades were
          "roughly D's and C's. I had pretty severe anger issues. I just wanted
          to fight everybody." He did not repeat any grades although he had to
          take night school the last semester of classes for English and math so
          he could graduate. He did not participate in any special education
          services. The veteran did not participate in any extracurricular
          activities. While in high school the veteran worked for Sears as a
          mechanic.

          The veteran says that after graduating from high school he decided to
          join the military because "there was nothing there." The veteran felt
          that if he stayed at home he would "be deeper into drugs."

          The veteran served in the Army from 2008 until 2014, his MOS was 11B,
          the veteran received a general discharge with a final rank of E-5. The
          veteran says he was administratively discharged for misconduct, he had
          received a felony conviction. The veteran was deployed to Iraq in
          2010/2011 into Afghanistan in 2012.

          The veteran says that he moved to Ohio to move in with one of his
          friend's family. The veteran says he was on probation for the felony
          conviction in Hawaii and in order to relocate from Hawaii he had to be
          able to prove he had a job and a place to live. He worked for his
          friend's father for 2 or 3 months doing interior paining until he got
          a better job. The veteran worked for 2 months at Columbus Castings, he
          stopped working after a failed suicide attempt in 2015. The veteran
          says he has recently appealed a Social Security Disability denial, he
          is hopeful he will eventually qualify for these benefits.
         
         
    c. Relevant Mental Health history, to include prescribed medications and
       family mental health (pre-military, military, and post-military):

          The veteran says he currently sees Dr. McGill for psychotherapy
          although he notes she is on maternity leave currently. The veteran
          says that therapy was "going great", and he is hopeful he will be able to
          return to therapy upon her return.

          The veteran currently sees Dr. Schwartz for psychiatric services, he
          is prescribed Zoloft, prazosin and quetiapine. When asked how the
          medications are working for him the veteran says "I haven't seen much
          of a difference."

          The veteran says that in April 2015 he had tied a rope to a guard
          rail, he tied the other in to his neck he then drove away in his truck the
          rope apparently broke however he sustained significant internal
          scarring to his neck and currently has a tracheotomy and feeding tube.

          While in the military the veteran completed the ASAP program twice
          (following DUIs), he also recently completed the SATP program through
          Chillicothe.
         
         
    d. Relevant Legal and Behavioral history (pre-military, military, and
       post-military):

          The veteran says he was frequently suspended while in school for
          fighting or misconduct towards teachers.

          While in the Army the veteran received one article 15 in 2011 for DUI,


          he says they did not pursue the second article 15 proceedings
          following his second DUI because being separated from the military.

          The veteran reported being arrested in 2011 for DUI, in 2013 he was
          arrested and convicted of a felony for unauthorized entry into a
          vehicle. He received his second DUI in 2014 however he says his lawyer
          was eventually able to get the charges dropped. The veteran is
          currently on probation for 3-1/2 years for the felony conviction.
         
         
    e. Relevant Substance abuse history (pre-military, military, and
       post-military):

          When asked about his current alcohol use the veteran says that
          "currently I'm trying to do the sober thing" the veteran says he last
          drank "just after Christmas", he says he had 3 L of Mad Dog 20/20. The
          veteran says he would have to mix the liquor with ice so that he could
          drink it. In the past the veteran says he has poured alcohol straight
          into his feeding tube.

          When asked about current drug use the veteran denied any. Veteran says
          he last had any drugs in late 2014, at the time he was using cocaine.
          The veteran says he stopped his drug use because he is on probation.
         
         
    f. Other, if any:

          =====================================================================

          **IMPORTANT NOTE** ---> There is a glitch in the DBQ reporting
          software such that if the examiner does not check off any of the boxes in
          Section II, Number 4 ("PTSD Diagnostic Criteria") [below], because the
          Veteran does not exhibit those symptoms, the software will produce "No
          response provided", which makes it sound as if the examiner simply
          forgot to answer those items, which is not the case. In this instance
          the software should, instead, produce something like, "No PTSD
          diagnostic criteria were found during this exam."

          =====================================================================


          =====================================================================

          **IMPORTANT NOTE** ---> There is a glitch in the DBQ reporting
          software such that if the examiner does not check off any of the boxes in
          Section II, Number 5 ("Symptoms") [below], because the Veteran does
          not exhibit those symptoms, the software will produce "No response
          provided", which makes it sound as if the examiner simply forgot to
          answer those items, which is not the case. In this instance the
          software should, instead, produce something like, "None of the listed
          symptoms were found during this exam."

          =====================================================================
         
         
    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: Only one stressor was elicited from the veteran, he was
          rather uncomfortable during this portion of the evaluation and since
          the stressors are being conceded the examiner chose not to
          inconvenience the veteran by forcing him to recall more than 1
          stressor. The veteran says while he was in the convoy the vehicle in
          front of them was hit by an IED and flipped over. The veteran says he
          was afraid that all of the occupants were dead, fortunately they were
          able to survive.
         
          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
    ---------------------------
    No response provided

    5. Symptoms
    -----------
    No response provided

   
    6. Behavioral Observations
    --------------------------
    No response provided

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

       On a brief mental status exam he was able to freely recall 2 of 3 words
       presented after a brief delay, he was able to recall the final word after
       being provided with a simple verbal prompt. He was able to recall 6
       digits forward and 4 digits backward. He was able to complete a serial 7
       subtraction task with no errors to 7 places. He was able to spell the   
       word WORLD forwards and backwards. He was able to complete simple 2 digit
       addition and subtraction. His responses to proverbs were good.


       Although the veteran denied current suicidal ideation saying "I don't
      want my mom to bury me", however he says that "if my mom died ..." (He would
       seriously consider making another suicide attempt). The veteran denied
       any homicidal ideation.

       He denied hallucinatory experiences.

       When asked to describe his mood on most days the veteran says he is
       "depressed and anxious." The veteran reports significant episodes of
       anxiety says he has "never had one where I'm frozen." Based on his report
       of symptoms he would appear to be depressed, anxious and suspicious.

       The veteran says he forgets "simple things", he has never been diagnosed
       with a head injury although he claims he suffered a concussion in the
       military where he was momentarily disoriented. The veteran says he knew
       that if he sought medical attention he would be taken off admission
       status and he felt he could not do that to the soldiers under his command so he
       convinced the medic to not report this incident. While the veteran
       complains of memory problems he did not display significant memory
       problems during the evaluation today.

       The veteran says he has significant problems motivating himself saying
       that occasionally he still will stay in bed all day. He says this occurs
       about 2-3 times a week.

       Socially the veteran described himself as being isolated saying "I have a
       hard time connecting with people." The veteran says "I don't talk to
       anyone."

       The veteran says the only activities he engages in is to go to the gym
       2-3 times a week "if I can." He describes his energy level is "awful" saying
       "other than the gym I can't exert too much." The veteran says that
       occasionally he may go over to his female friend's house while she is at
       work and spend time with her dogs.

       The veteran says that he averages 4-5 hours of sleep "lately, he feels
       that the weeks leading up to the different C&P examinations have been
       hard on him prior to this he was getting "around 6" hours of sleep per night.
       The veteran says he has difficulty falling and staying asleep. The
       veteran says he has dreams/nightmares "at least 3 times a week." The veteran says
       although he may try to take a nap "it's just more me laying there."

       The veteran says he tends to avoid situations involving a lot of noise. He

      also attempts to avoid talking about his traumatic stresses. He appeared
       to be particularly relieved when the examiner said it was only necessary
       to focus on one traumatic event. Based on his self-report veteran reports
       exaggerated negative beliefs about himself and the world, he tends to
       blame himself scribed traumatic stressor saying that he was too
       complacent.

       The veteran describes his temper control is being currently "fairly
       good", historically prior to the military he appears to have had very poor temper control.

       The veteran was administered the MMPI-2-RF, although it appears he
       understood and responded to the items in a somewhat consistent manner
       remainder of the profile is not able to be interpreted due to an
       over-reporting of symptomatology that is not common even in individuals
       with known severe psychopathology. There are a number of potential
       reasons for this profile to include it being a "plea for help", it may be a
       phenomenologic style to over report and to be traumatized (this pattern
       is frequently seen in Dependent and Histrionic Personality Disorders and
       Depressive Mood Disorders) or the individual is trying to look worse than
       they are for some secondary reason. Unfortunately it is impossible to
       determine the reason behind this pattern of responding in this case
       without resorting to speculation.

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

 

Clinical Psychologist
Signed: 01/21/2016 16:50

01/21/2016 ADDENDUM                      STATUS: COMPLETED
C&P Exam completed in Capri by PhD; procedure code 99456.
 
/es/PhD
Clinical Psychologist
Signed: 01/21/2016 17:28

Any assistance or opinions on this matter are greatly appreciated!!! Thank you for your time and for reading this as well!

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I need to preface this with a statement that I am not a licensed psychological practitioner, am not providing legal or professional advice and cannot act on anyone's behalf in providing professional services.

IN MY OPINION (only my opinion):

It appears as though you were administered an instrument (the MMPI - Minnesota Multiphasic Personality Inventory - a personality instrument) and then interviewed. According to test results from the National Institutes for Health (http://www.ncbi.nlm.nih.gov/pubmed/20207423, 2010), the instrument was evaluated for effective detection on those feigning PTSD. Results:

"Diagnostic-specific MMPI-2 validity indicators, such as the Infrequency-PSTD scales and Malingered Depression scale, were not effective at detecting participants instructed to feign those conditions. For the PAI, the most accurate validity indicator was the MAL index; however, the detection rate using this validity indicator was modest at best. The MMPI-2 validity indicators were clearly superior to those on the PAI at identifying feigned versus honest responding in this sample."

This means that the clinician relied on an instrument not designed to indicate PTSD and that is not valid for detecting those pretending to have PTSD. It sounds like (from the text above) they interviewed you then administered the instrument. Is this true? If they conducted an interview, then used an instrument to back up their perception they violated the American Psychological Association (APA) Ethical principles of psychologists and code of conduct (http://www.apa.org/ethics/code/principles.pdf) Code of Standards and Ethical Conduct and the American Mental Health Counselors Association (AMHCA) code of ethics (https://www.amhca.org/assets/news/AMHCA_Code_of_Ethics_2010_w_pagination_cxd_51110.pdf) by relying on the inappropriate use for an instrument beyond its designed intent to reach a biased conclusion. With some research, you could quote the sections. I don't  have time to look at each code to find the specific section numbers, but look for those that discuss what I've told you in this paragraph.

I'm a PhD candidate in psychology with a focus on tests and measures (like the one they used to diagnose you). Copy the above text and add it to your response to the C&P exam and request a new exam. There is no way an instrument can indicate PTSD from a clinical perspective. If the instrument was administered before you were interviewed, the results were biased and therefore invalid and a violation of several ethical codes. The person that conducted the review should be reported to his or her state certification board for this violation and for creating harm (there is a provision for non-malfeasance in the codes as well) as a result of this action. Nail them to the wall for it, then get another evaluation.

Also, from reading the interview notes it appears you've had a history of issues leading up to your present state. The interviewer is giving a whole person picture that doesn't look good for indicating that PTSD was caused by the incident in the military alone. If the interviewer was not using the Clinician-Administered PTSD Scale (CAPS) (generally accepted for use in detecting PTSD by structured interview), they appear to have used an instrument they were familiar with or trained to use. They used a hammer to drive a screw because it was the only tool in the toolbox.

This is all I have time to provide, but should give you an argument to get another C&P.

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12 hours ago, Blesedell said:

I realize this is not what you we're expecting to come out of your C&P exam, but this exam really doesn't hurt you at all. You have a diagnosis of PTSD in your medical record. Since this examiner has differed an opinion on virtually every question, he has neither helped nor hurt your claim for service connection. Since this examiner failed to respond regarding symptoms, level of impairment, etc.... This exam is "inadequate" for VA rating purposes and, regardless of all of his babble and insinuation, he really has not stated that you are feigning. He acknowledges that you do have a diagnosis of PTSD and says nothing to the contrary. He simply differed. Long story short, since you have a  diagnosis and a Combat Infantry Badge, there is no way they can deny service connection for PTSD. Since this exam is inadequate for rating purposes, the VA should order a new C&P exam.

 

Edited by bluevet
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justrluk - I was interviewed first and then completed this instrument afterwards to my knowledge. I believe the one you are speaking of is the one that was 200+ questions with true or false answers. If it is, then yes I completed this paperwork post C&P exam. I am going to bring this information in with me to my VSO upon her return to work and see if we can get all this squared away.

bluevet -  Definitely not what I had expected to come out of the exam. Everyone else I have spoke with have had good things to say about the VA here. I have had four so far this month and the other three have seemed to go well. They seemed to actually listen to the me and my concerns/worries. It is a relief to see that you do not believe it is a negative or positive outcome. I was quite concerned about this negatively effecting my claim.

 

To both of you, I thank you and appreciate you taking the time to read and comment on my concerns and situation. Your responses have definitely put my mind in a bit less of a worried state. Now just have to get over to my VSO and figure out what the process is for the appeal of the exam or the request for another examination.

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Blesedell, I am so sorry for what you had to go through during that obviously incompetent examiners exam. Some very good, excellent advice from the members above. I wish you success in obtaining your service connection and please keep us updated.

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Thank you Flores97! I agree great advice provided!

Here is the most recent update.... I am now 40% service connected according to the individual I spoke to in Cleveland, OH yesterday not to include PTSD. It has not showed up yet on my ebenefits though so hopefully he wasn't blowing smoke. As for the PTSD they ended up not service connecting it because they said I do not have it due to time in service and that I have it due to my childhood. We are going to be fighting this of course. By we I mean myself and my VSO. She has been unbelievably helpful throughout all this. So now I just have to do a bit of running around for letters from a few VA workers stating that my PTSD diagnosis stems from my military service and my VSO is going to review my file to make sure they seen all the supporting documents in the claim to be sure we do not need to resubmit anything. I will continue to post with any questions or updates as they arise.

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    • Yes 

      After a PTSD/Unspecific MDD Diagnose From the VA Dr's

      The gold standard for diagnosing PTSD is a structured clinical interview such as the Clinician-Administered PTSD Scale (CAPS-5). When necessary, the PCL-5 can be scored to provide a provisional PTSD DSM 5 diagnosis.

      Any clinical clinician such as MD ,Psychiatrist even a L.C.S.W. (Certified)can perform the Diagnostics Evaluation Employed by the the VA

      ...They just need to figure out your symptoms and put together a list of your symptom's that you possess or show from the evaluation...I am not 100% Sure just how they do this ?

      being I am not a Dr or clinical clinician 

      Once a Diagnoses of PTSD is given they try to set you up with a Therapist to help with your New dx And how to adjust or cope with the Anxiety and Depression the PTSD can cause.

        you learn the tools to cope with and depending how severe your symptoms are ? 

       They test /screen you with phychoeducational type therapy treatment usually at first.

       Warning  some of this therapy can be very rough on a Veteran  from holding on to guilt  from the trauma its self or you maybe in a  ''stuck point''from memories and guilt or from the stressor's or anything that reminds you of the trauma you endured.

      The therapy works  even if we think it don't,  I recommend Therapy for all PTSD Veterans  it could very well save your life once the correct therapy is in place and the Veteran makes all his Clinical Appointments.

      I still have Combat PTSD it probably will never be cured completely but we can learn the tools it takes to cope with this horrible diseases 

      even learning breathing techniques  Helps tremendously during a panic attact.

      I have guilt from the war in Vietnam  ( I ask my self what could I have done to make a better outcome/difference?..and also I am in what the therapist calls stuck points. working on that at present once a week for 90 minutes.  I am very fortunate to have the help the VA gives me and I am lucky I have not turned to alcohol or drugs to mask my problem.

      But I have put my family through a living hell with my angers of burst.and they all stood by me the whole time years and years of my family life was disrupted because of me and my children &spouse  never deserved it one bit.

      That's all I want to say about that.

      At least I am still around. and plan to be tell my old age dying day.
    • No timeframe gotta love that answer it’s even better when you ask 1800 people or call the board directly they’ll say you’ll know sooner then later. I had mine advanced and it was about 2 months later until I had the decision in my hand which seems forever but in the present system in 2016 lightning fast...
        • Thanks
    • I am serviced connected for ankylosing spondylitis back in 1985. I had a C&P exam on 7-7-19 since I am asking for an increase in my cervical, thoracic, and lumbosacral ratings. After speaking with the DAV to find out progress and info on my exam, the Rep. noted sort of what I expected. Radiculopathy was noted and ROM was 0-15 for cervical, and 0-25 for back. I am currently rated as Cervical 30%, Thoracic 10%, and Lumbosacral 40%. The main question that I have is relating to the thoracic 10% and lumbosacral 40%. I am confused on these two. Is Lumbosacral separate from the thoracic/others ? Since my back ROM is at 0-25, does this mean that my thoracic might increase from the 10% to a higher rating ? I am confused how they break down my ratings from cervical at 30%, Thoracic at 10%, and Lumbosacral at 40%. Also, with the radiculopathy, is this something that they will rate also ? I am currently at 90% total combined for all my disabilities. I hope this helps for someone to give me advice/answers.
      • 4 replies
    • Thank you @GeekySquid for your reply. 

       

      I have redacted personal information for my documents listed below. 

      I look forward to your reply. 

      HEADACHE STR 2006 copy_Redacted.pdf

      HEADACHE-DBQ.pdf

      Pages from Original Denial-Grant Reasons_Redacted.pdf
    • Hello Defenders of freedom!

      I have a question pertaining to this denial for headaches. The decision letter is quoted below. 

       

      3. Service connection for headaches.

      "We may grant service connection for a disability which began in military service or was caused by some event or experience in service.

      Your STRs are negative for any treatment of or diagnosis of headaches. On your post-deployment exam in 2005 you denied any headaches. On separation, you denied any headaches. VA treatment records are negative for any treatment of or diagnosis of headaches. On VA exam, the examiner stated there was no evidence of any residuals of a traumatic brain injury.

      We have denied service connection for headaches because the evidence of record fails to show this disability was incurred in or caused by military service."

      From my understanding these 3 points must be overturned to successfully win a CUE case:

       (1) either the correct facts, as they were known at the time, were not before the adjudicator or the statutory or regulatory provisions in existence at that time were incorrectly applied; 

      (2) the error must be undebatable and of the sort which, had it not been made, would have manifestly changed the outcome at the time of the prior determination

      and (3) a determination that there was CUE must be based on the record and law that existed at the time of the prior adjudication in question.  

      @Berta, or veterans out here who have knowledge/experience, tell me what facts you think would be needed to prove this denial for headaches was an error? 
      • 14 replies
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