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Question
Closure
What are your thoughts? I am already SC for anxiety & depression rated at 70%. I filed for TDIU and receive SSD for the same. C&P listed below.
Thanks,
------------
a. Does the Veteran now have or has he/she ever been diagnosed
with a mental
disorder(s)?
[X] Yes[ ] No
ICD code: 309.81
If the Veteran currently has one or more mental disorders
that conform to
DSM-5 criteria, provide all diagnoses:
Mental Disorder Diagnosis #1: PTSD
ICD code: 309.81
and Related
Disorder
ICD code: 296.80
Comments, if any:
Bipolar I-II have been diagnosed previously
ICD code: 303.90
#4 Cocaine Use Disorder 304.23
b. Medical diagnoses relevant to the understanding or management
of the
Mental Health Disorder (to include TBI): Lung disease
------------------------------
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:
diagnoses
with the symptoms overlapping. Some of the specific
symptoms,
relayed to this examiner specifically
re-experiencing/flashbacks/nightmares are more specific
to PTSD.
c. Does the Veteran have a diagnosed traumatic brain injury
(TBI)?
[ ] Yes[ ] No[X] Not shown in records reviewed
3. 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] Total occupational and social impairment
impairment, is it
possible to differentiate what portion of the occupational
and social
impairment indicated above is caused by each mental disorder?
[ ] Yes[X] No[ ] No other mental disorder has been diagnosed
If no, provide reason that it is not possible to
differentiate what
portion of the indicated level of occupational and social
impairment
is attributable to each diagnosis:
diagnoses
with the symptoms overlapping. Some of the specific
symptoms,
relayed to this examiner specifically
re-experiencing/flashbacks/nightmares are more specific
to PTSD.
c. If a diagnosis of TBI exists, is it possible to differentiate
what portion
of the occupational and social impairment indicated above is
caused by the
TBI?
No response provided.
SECTION II:
-----------
Clinical Findings:
------------------
1. Evidence review
------------------
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 no, check all records reviewed:
[ ] Military service treatment records
[ ] Military service personnel records
[ ] Military enlistment examination
[ ] Military separation examination
[ ] Military post-deployment questionnaire
[X] Department of Defense Form 214 Separation Documents
[X] Veterans Health Administration medical records (VA
treatment records)
[ ] Civilian medical records
[ ] Interviews with collateral witnesses (family and others
who have
known the Veteran before and after military service)
[ ] No records were reviewed
[X] Other:
VBMS
b. Was pertinent information from collateral sources reviewed?
[X] Yes[ ] No
If yes, describe:
Appeal info
2. History
----------
a. Relevant Social/Marital/Family history (pre-military,
military, and
post-military):
see remarks
b. Relevant Occupational and Educational history (pre-military,
military, and
post-military):
see remarks
c. Relevant Mental Health history, to include prescribed
medications and
family mental health (pre-military, military, and post-
military):
see remarks
d. Relevant Legal and Behavioral history (pre-military,
military, and
post-military):
see remarks
e. Relevant Substance abuse history (pre-military, military, and
post-military):
see remarks
f. Other, if any:
No response provided.
3. Symptoms
-----------
For VA rating purposes, check all symptoms that actively apply
to the
Veteran's diagnoses:
[X] Depressed mood
[X] Anxiety
[X] Suspiciousness
[X] Panic attacks more than once a week
[X] Near-continuous panic or depression affecting the ability
to function
independently, appropriately and effectively
[X] Chronic sleep impairment
[X] Mild memory loss, such as forgetting names, directions or
recent
events
[X] Impairment of short- and long-term memory, for example,
retention of
only highly learned material, while forgetting to
complete tasks
[X] Flattened affect
[X] Impaired judgment
[X] Impaired abstract thinking
[X] Disturbances of motivation and mood
[X] Difficulty in establishing and maintaining effective work
and social
relationships
[X] Difficulty in adapting to stressful circumstances,
including work or a
worklike setting
[X] Inability to establish and maintain effective
relationships
[X] Suicidal ideation
[X] Impaired impulse control, such as unprovoked irritability
with periods
of violence
[X] Persistent danger of hurting self or others
Behavioral observations:
see remarks
4. Other symptoms
-----------------
Does the Veteran have any other symptoms attributable to mental
disorders
that are not listed above?
[X] Yes[ ] No
If yes, describe:
PTSD symptoms
5. Competency
-------------
Is the Veteran capable of managing his or her financial affairs?
[X] Yes[ ] No
6. Remarks (including any testing results), if any:
---------------------------------------------------
Veteran reports to C&P for the Mental Health DBQ on FEb. 24,
2016 after
being evaluated during his last C&P evaluation on 3-16-15.
compensation
related disability assessment. Do not construe it as a thorough
evaluation of
other unrelated issues. It should not be used for clinical,
diagnostic, or
treatment planning purposes as we are specifically directed not
to treat
patients in the C&P setting.
Behavioral Observations
Veteran presented to the C&P area for the Mental Health DBQ
Evaluation
ambulatory and unaccompanied. Veteran was explained the limits
of
confidentiality and reported an understanding of the contents
verbally
provided and Veteran verbally consents to the evaluation.
Veteran was
considered a reliable historian.
Veteran is a 44 year old African American male who appears the
stated age.
Veteran appears to be of average height and weight. Veteran's
adhered to
civilian social conventions. Veteran's grooming was adequate and
Veteran was
appropriately dressed for the interview and climate. Veteran
related to the
examiner with ease in an open/candid manner after rapport was
developed.
Social/Family History: Veteran currently resides in Jackson, MS
in the
homeless program.
Social support: mom
Highest Level of Education/Degrees /Special Services:No changes
since his
last C&P evaluation on 3-16-15.
Military: No changes since his last C&P evaluation on 3-16-15.
3-16-15.
Legal: Arrested for domestic violence in January 2016, in jail
x4 days,
called 20 times
Mental Health Treatment:
Veteran reports receiving all of his mental health treatment
under the
direction of the Jackson VA. He indicates he has been receiving
mental
treatment at the Jackson VA.
mental health
treatment.
Alcohol/Drug Use History: Drug Treatment Programs:currently in
drug
treatment at VA. 30 day program-then to TRP
Head Injury-No changes since his last C&P evaluation on 3-16-15.
Current Medical Issues-Lung disease
Surgeries-No changes since his last C&P evaluation on 3-16-15.
goal directed.
Eye contact was good. There were no bizarre or unusual gestures
or
mannerisms. Veteran related to the examiner as well as he could
given his
current emotional state. Veteran reported mood to be "anxious".
Affect was
observed to be EXTREMELY anxious with limited range of affect.
Affective
responses were mood content congruent.
associations,
or flight of ideas. Veteran denied any current thoughts of
harming himself,
others, or property. Veteran was provided the Veterans Crisis
Hotline number.
quality of
Veteran's thinking was adequate, as Veteran could answer/explain
3/3 of the
proverb questions, without difficulty. Veteran's abstract-
conceptual thinking
was adequate as Veteran could relate to 2/2 of the
abstractions.
Veteran was able to
recall 3/3 objects presented earlier upon immediate recall and
2/3 after a
one minute and 2/3 after a three minute delay. Veteran's mental
control is
viewed as adequate as Veteran was able to spell WORLD forward
and backwards,
recite the alphabet without error, count forward by three's, and
conducted
basic mental calculations without pencil and paper, with ease.
Veteran's
insight and judgment are considered adequate. Veteran's overall
intellectual
ability is clinically estimated to be at least average based on
his
vocabulary, fund of information, and language usage.
suggestive of
normal cognitive functioning. The MMSE is a screening instrument
designed as
a screening tool for cognitive impairment and it is not designed
for
diagnostic purposes.
alot of
anxiety. I hear voices. off and on since the past 5 years or
longer". I-"run
off the road". "I had one suicide attempt in Dec. 2015 took
pills"-20-refused
treatment when ambulance came. I get real depressed and that
makes me
irritable and I can't concentrate and focus. I have bad
relationships and I
get in fights with family and people in the community. I have
racing
thoughts. I am always thinking about dying, either me or my
family. I see a
dark spots and then it disappears when I look".
Veteran reports to C&P for the Mental Health DBQ. Veteran was
assessed for
the following clinical symptoms. Veteran reported how much the
following
symptoms were bothersome over the last two weeks, using the
rating scale 1
(little)-10 (great deal) or d (denies experiencing the symptom
over the past
two weeks). Please note that a self-report assessment is not
sufficient to
use alone for diagnostic purposes.
Impulsivity-y; poor memory-y; mood changes-y;
sadness/depression-y; loss of
interest/pleasure-y; hopelessness-y; thoughts of death-denies
current si, no
plans, no intentions; self-harm behaviors-see above; harming
others-ddenies;
crying spells-y;
appetite
changes-x2 meals daily; gambling problems-not currently; sexual
problems-ED;
relationship problems-separated from wife; auditory
hallucinations-see above,
command male voice; visual hallucinations-see shadows, tactile
hallucinations-d; gustatory hallucinations-d; olfactory
hallucinations-d;
racing thoughts-y; excessive energy-manic x2-3 monthly lasting 4
days
from
people-y; anxiety-y/worry-death/panic attacks-y, x1 weekly; fear
away from
home-y, scared something is going to happen; social discomfort-
y; obsessive
thoughts-ruminate about death all the time; compulsive
behaviors-d;
aggression-y/ fights-x30 including wife; frequent arguments-
wife;
irritability-y/anger-y; flashbacks-x2-3 weekly, kissed me on my
neck in the
service, fighting; sleep problems-y; nightmares-kissed in
service, denied
treatment for problems, anguish about service, x2 weekly;
recurring/disturbing memories-saa, x4-5 weekly; and work/school
problems-
last worked 2014, paranoid due to abseenteeism; hypervigilance-
y; exaggerated
startle reflex-loud and grinding; and avoidance-gay people-
reminded me of
being molested as a child and kissed me.
molested by cousin who was gay, kissed by shipmate, fear that he
is gay
because of molestation and being targeted by other gay men.
Veteran's Diagnosis is based on the DSM V.
Veteran Jones is a 44 year old African American
married/separated male that
served in Navy as a cook(MOS) and received several service
accommodations for
his service. Veteran reported that due to his experiences while
being
deployed he feared for his life and feared he was in great
danger due to
being in a hostile environment. This information was confirmed
by documents
in the records.
Remarks rationale: Based on the clinical interview, analyses of
symptoms
endorsed, reported events/stressors (MST/MTE), VBMS and CPRS
review, and
collateral information, the Veteran meets the criteria for a
diagnosis of
PTSD, Unspecified Bipolar, Alcohol Use, and Cocaine Use
Disorder, that is
debilitating for this VEteran. Veteran's triggers to his
untreated PTSD is
causing on-going symptoms and further exacerbating his Bipolar
Disorder in
which he is service connected.
substance use unit,
and take medications as prescribed.
IU
Veteran's PTSD, Bipolar, and substance use disorders cause
severe impairment
in social and occupational functioning that reduces his ability
to be around
others; increased noise level, uncertainty/unpredictability, and
other known
and unknown triggers to PTSD, bipolar, and anxiety further
exacerbate his
symptoms
and further results in isolation and decompensation and
debilitating anxiety.
Veterans symptoms will be present whether he is sitting or
standing.
Therefore the likelihood of him functioning in a work setting in
a productive
manner at this time is highly unlikely. In fact, working in and
environment
that is outside of isolation of one-on-one, predictable, and
controlled is
likely to increase his symptoms.
no response
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Buck52
Closure , you got this buddy, beings you have a 70% rating and they give you a 100% stand alone rating , that automatically qualifies you for HB Homebound,,,a SMC S Award *special Monthly compensati
Vync
Hi Closure, I compared your exam results to the MH rating criteria found at: http://www.ecfr.gov/cgi-bin/text-idx?rgn=div5;node=38:1.0.1.1.5#se38.1.4_1130 (shown further below). The easiest way
Closure
Thanks to all of you, my claim was granted 100% P&T.
9 answers to this question
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