ptsd Help me, please!!!

[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,

                     

 1. Diagnosis
    ------------
    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

 

       Mental Disorder Diagnosis #2: Unspecified Bipolar Disorder
       and Related
       Disorder
       ICD code: 296.80
       Comments, if any:
         Bipolar I-II have been diagnosed previously

 

       Mental Disorder Diagnosis #3: Alcohol Use Disorder
       ICD code: 303.90

 

       If additional diagnoses, list using above format:
         #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
      

 

    2. 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:

 

             Substance use and anxiety and depression are co-morbid
             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

 

    b. For the indicated level of occupational and social
    impairment, is it
       possible to differentiate what portion of the occupational
       and social
       impairment indicated above is caused by each mental disorder?
       [ ] Yes[X] No[ ] No other mental disorder has been diagnosed
      
           If no, provide reason that it is not possible to
           differentiate what
           portion of the indicated level of occupational and social
           impairment
           is attributable to each diagnosis:

 

             Substance use and anxiety and depression are co-morbid
             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.

 

    This is a C&P examination report dealing specifically with a
    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.

 

    Latest Civilian Jobs:No changes since his last C&P evaluation on
    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 Hospitalizations: Veteran reports  no inpatient
    mental health
    treatment.
    Alcohol/Drug Use History:  Drug Treatment Programs:currently in
    drug
    treatment at VA. 30 day program-then to TRP

 

    Current Use: Last Use-ETOH, Cocaine-January 20, 2016

 

    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.

 

    Medication Currently Taking: Aripiprazole, Buproprion

 

 

 

    Mental Status: Veteran speech was clear, audible, logical, and
    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.  

 

    There was not any evidence of hallucinations, delusions, loose
    associations,
    or flight of ideas. Veteran denied any current thoughts of
    harming himself,
    others, or property. Veteran was provided the Veterans Crisis
    Hotline number.

 

    Veteran was oriented to time, place, person, and purpose. The
    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's memory functions were not rendered impaired, as
    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.

 

 

 

    Assessments: Veteran's overall MMSE score is29\30, which is
    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.

 

    Veteran reports, "Not to well. I am not sleeping. I am having
    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;

 

 

 

    Loneliness-y; low self-worth-y; fatigue-y; lack of motivation-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 

 

 

 

    guilt/shame-y, not being able to provide for family; withdrawal
    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.

 

    Veteran continues to be on high risk for suicide, in the
    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.

 

 

Edited March 1, 2016 by Closure
no response

[flores97]

Closure, congratulations, I wish you the best and I hope that this gives you peace of mind. Take a vacation if your able, relax, and take care. 

[Palma114]

Congrats

[Corpsman8404]

Congrats Closure, and thank you for your service and sacrifice!