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C and p questions ptsd mst


Eliza

Question

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: F43.10; F60.3
 
 2. Current Diagnoses
 --------------------
 a. Mental Disorder Diagnosis #1: PTSD
 ICD code: F43.10
 Comments, if any:he veteran presents for an initial PTSD C&P assessment based 
on
 MST. She has a h/o premilitary trauma, and post military trauma.
 SMRs show a diagnosis of PTSD following her military psych
 admission. Her PTSD therefore predates her postmilitary trauma.
 Despite documented awareness of her pre-military trauma, numerous
 records and providers have documented her PTSD as being d/t her
 MST. Although she continues to have some occasional reexperiencing
 symptoms related to her premilitary trauma, the major and 
intensity
 of her reexperiencing symptoms is related to her MST, rather then
 her other traumas (nonmilitary). MST remains the focus of her
 treatment. There is no evidence that her post-military trauma
 caused any permanent worsening of her PTSD beyond its normal
 course. 
 Her PTSD is therefore felt to be primarily d/t her MST. There are
 markers of a potential MST in her SMR and Personnell records.
 Evidence indicates that she reported a MST the next day, had a 
rape
 kit performed at a private hospital 1 day later (results were no
 DNA evidence but some evidence of physical trauma), and that an 
OSI
 investigation occured. Her sudden desire to get out of the service
 (after wanting to make it a career) and ER psych visits within 2
 weeks of her MST and psych hospitalization show a change in
 behavior and psychiatric symptoms following her MST which is
 consistent with MST and which previously was not present. Her
 enlistment exam is negative for MH symptoms and treatment. A
 routine psych screening performed on 7-14-08 showed no evidence of
 psychiatric symptomatology prior to her MST. Additionally, she has
 had difficulty with intimacy and occupational functioning
 uncharacteristic of her pri-military functioning. There therefore
 is sufficient evidence that the MST, as likely as not, occured and
 resulted in a change in behavior and symptoms. 
 Records indicate that command had difficulty believing her account
 of MST given the veteran's "changing events/timeline/and 
details"
 of the initial report and also making additional claim that she 
was
 assaulted and held at knifepoint in a vehicle outside her barracks
 by one of her assailants that was proven to be false. Minor 
changes
 in her account are however not atypical of rape victims, as
 indicated by the psych consultant who saw her on 12/15/08 in the
 ER. Her false report can be adequately explained by her 
frustration
 with not being believed by her command, her desire to hold her
 assailant accountable and with her desire to "get out of the
 service" after the MST. Since being d/c'd from theaccount of the MST has been fairly consistent in minor details and
 completely consistent in the major details.
 Mental Disorder Diagnosis #2: Borderline Personality Disorder
 ICD code: F60.3
 Comments, if any:
 There is clear evidence of a personality disorder as evidenced by
 an active diagnosis of Borderline PD in both her outpt and inpt
 psych records. Her personality disorder is not felt to be caused 
by
 the service or permanently aggravated by the service. Personality
 disorders tend to be conditions which develop in adolescence or
 early adulthood and tend to develop in response to severe or
 prolonged trauma, as is the case with this veteran. She has a
 pre-military history of extensive emotional and physical abuse by
 various people and a h/o a sexual assault. She has a h/o self
 cutting since age 16yo. Personality Disorders are often associated
 with mood disorders and/or substance abuse which tend to stem from
 long term behavior problems and psychosocial functioning
 difficulties which stem from the personality disorder. It is more
 likely than not that the presence of her preexisting personality
 disorder is the primary cause of her relationship problems, self-
 destructive behavior and difficulty adapting to the service and
 pattern of misconduct which is documented in the SMRs and military
 Personnell records and was the eventual cause of her 
Administrative
 separation after only 8-9 months. Although she did not endorse
 mental health symptoms at the time of her enlistment exam, this
 does not mean that she was not symptomatic in regard to her
 personality disorder and (from premilitary trauma), especially in
 light of her self admission (per her own statements in the 
records)
 of a pattern of lying and h/o self mutilation. Although it is as
 likely as not that her Personality Disorder and PTSD mutually
 affect each other, there is no clear evidence that her personality
 disorder was permanently worsened by her PTSD/MST beyond it's
 normal course. 
 
 Mental Disorder Diagnosis #3: Major Depression, moderate recurrent
 ICD code: F32.1
 Comments, if any:
 Her depression is felt to be d/t a combination of her PTSD and
 Personality Disorder. Both conditions are frequently associated
 with depression. Since there is an overlap in symptoms and she has
 significant psychosocial functioning difficulties related to each
 condition, it would be speculative to try to determine which
 condition is the cause of her depression (without resorting to 
mere
 speculation).
 b. Medical diagnoses relevant to the understanding or management oftheeMental Health Disorder (to include TBI): noncontributory
 ICD code: see medical notes
 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:
 There is such an overlap in symptoms that it would be speculative
 to try to differentiate which symptoms and which psychosocial
 functioning difficulties are due to any one condition with the
 following exception:
 Due to PTSD exclusively: Hypervigilance, mistrust, re-experiencing
 symptoms, increased startle reaction, avoidance of crowds
 Due to Borderline PD exclusively: deceitfulness/lying; pattern of
 unstable interpersonal relationships self image and affects;
 impulsivity; abandonment issues; pattern of parasuicidal
 behavior/self harm; unstable self image; chronic feelings of
 emptiness; victim mentality; transient stress related paranoia
 
 
 
 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 with deficiencies in most areas,
 such as work, school, family relations, judgment, thinking and/or 
mood
 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:
 There is such an overlap in symptoms that it would be speculative
 to try to differentiate which psychosocial functioningdifficulties
 specifically are due to any one condition. Each condition appears
 to cause moderate to serious psychosocial functioning difficulty
 (based on the severity of each condition).
 
 
 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:
 
 [X] Military service treatment records
 [X] Military service personnel records
 [X] 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)
 [X] 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:
 statement of claim
 
 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):
 PREMILITARY HISTORY: 
 The veteran was born and raised in Ohio. She lived with her mother
 after her parents divorced when she was very young. She has one 
brother
 and 7 1/2 brothers. They moved almost every year; she indicates that 
it
 was difficult to always have to make new friends. She indicates that
 her father was barely involved in her life. She was repeatedly
 emotionally abused by her mother and her mother's boyfriends. Her
 brother's friend once tried unsuccessfully to rape her. Her mother 
is
 described as an alchoholic. Eventually her father took her brother to
 live with him (when she was 13yo); she went to live with her
 grandmother when she was 13yo. When her grandmother died, she returned
 to her mother's home; she indicates that it was more stable after 
she
 married when the veteran was 11yo. She had stayed with her 
grandmother
 off and on in the summers previously. She graduated high school with
 average grades with certification as a nursing assistant. She was
 active in the drama club, track and cross country. She worked at a
 local restaurant for 1.5 years before graduating and joining the
 service. She wanted to make it a career. 
 Abuse or neglect: as per above
 Discipline problems: none reported
 Juvenile offenses: none
 ETOH problems in adolescence: none
 MILITARY HISTORY:
 Branch: Air Force 
 Duration: 9 months (7/08-4/09)
 Location/MOS/: noncombat; MOS: services helper
 Discharge: General under Honorable-E1 (pattern of misconduct)
 Active combat exposure: no
 Military Sexual Trauma: Yes 
 Disciplinary Actions: 2 article XV for altering public records and
 making a false statement or attack
 General comments:
 POSTMILITARY HISTORY: The veteran is single and has never married. She
 moved in with her HS sweetheart after leaving the service. He was
 emotionally abusive and physically abusive on one occasion. The
 relationship resulted in 2 children (5yo and 1yo) but lasted only 6
 years. For the last 8 months she has been in a new relationship with
 her best friend's son (her age). She lives with her friend Emily,Emily's 2 children and her 2 children. She endorses almost 
impulsively
 marrying someone that she hardly knew after her MST. She indicates 
that
 both of her relationships were negative affected by her difficulty 
with
 intimacy which started after her MST. Her relationship currently is
 also negatively affected by irritability, emotional detachment and
 social withdrawal. She keeps to herself and does not interact with
 neighbors or coworkers. She has 2-3 friends. She endorses mistrust of
 most people. She has little contact with family. 
 Neglect of ADLs: none
 Neglect of hygiene/appearance: none
 Involvement in organizations: none
 Activities/hobbies: horseback riding; service dog; kids; reading 
 
 
 b. Relevant Occupational and Educational history (pre-military, military, 
and
 post-military):
 Educational history: The veteran graduated high school with average
 grades. She had no difficulties with disciplinary problems. She
 attended some classes at Stark State while in HS. When she graduated
 from HS, she had her STNA certification. In 2011, she graduated from
 Brown Macky College with a LPN. GPA 3.0. She failed anatomy and
 physiology the first time. 
 Work history: She worked at a restaurant for 1.5 years in HS. Since
 separating from the service, she has had problems keeping a job. She
 was a full time student for 2 years. After graduating, she has 
averaged
 3-5 jobs per year, with most jobs (all LPN positions) lasting <3 
months
 until she was fired for calling off and going home early d/t
 anxiety/PTSD symptoms. She has been at her current position as a LPN
 charge nurse (supervising STNAs) for the last year. She is on 
probation
 and will be terminated if she calls off work one more time (she showed
 this writer 3 reprimand letters). She has exhausted and gone beyond
 their call off limitations, but supervisors have worked with her to
 some degree because she is on FMLA and disclosed her PTSD to them. She
 keeps to herself and does not interact with coworkers. She is well
 liked by residents. She works the night shift on a psych ward and 
feels
 that she can related to the residents; she feels that she has last
 longer at her current position becasue "things are quiet on the 
night
 shift". However she endorses panic attacks which causes her to go 
home
 early 3-4x/mo. She endorses difficulties with productivity,reliability
 or effectiveness/efficiency d/t anxiety/panic and poor concentration.
 She has been repeatedly reprimanded for charting errors. She denied
 difficulty with accepting supervision and/or criticism. She endorses
 difficulty with flexibility, concentration or impulsivity on the job.
 
 
 c. Relevant Mental Health history, to include prescribed medications and
 family mental health (pre-military, military, and post-military):
 FAMILY History (mental health, substance abuse, suicide attempts): 
 ETOH: mother
 autism: 1/2 brother
 suicide: 1/2 brother
 PTSD: brother
 
 MENTAL HEALTH HISTORY: 
 Pre-military treatment: no treatment or symptoms except for one
 incident of self cutting at age 16yo
 Military treatment: SMR show that she presented for a routine psych
 assessment 7/14/08 and was found to have no psychiatric symptoms or
 diagnosis. After her MST, records show c/o many neurovegative symptoms
 of depression, anxiety and PTSD symptoms. She was seen in the ER on
 several occasions for psych complaints or vague GI symptoms. She was
 psychatrically hospitalized at Lackland AFB for several days d/t a
 suicidal gesture (cut on her leg) after her MST. She had some limited
 outpt treatment including therapy and ambien for sleep problems until
 she was separated. Records indicate that she was diagnosed with PTSD
 and Adjustment Disorder with depression. 
 POST-MILITARY TREATMENT: The veteran sought treatment at various
 civilian psych cewnters over the years, but had trouble trusting
 providers. Her PCP (Dr. Volpe DO) has been treating her for MD and
 PTSD since 2010 and continues to give her valium prn. Since 5/15, she
 has transfer her MH treatment to the VA. She was evaluated by the MST
 coordinator who confirmed a diagnosis of PTSD based on MST. She is now
 seen weekly for therapy and q3mo for medication management. She has
 found treatment to be helpful but remains quite symptomatic. She was
 psychiatrically admitted in 6/15, where she was diagnosed with PTSD 
and
 Borderline PD. She continues to have active diagnoses of PTSD,
 borderline PD and Major depression. She endorses chronic difficulty
 with depression, anxiety and panic attacks 3-4x/day. She endorses
 frequent irritability and anger outburst, but denies assault and
 violence. She endorses occasional passive thoughts of death, but 
denies
 active SI/HI, intent and plan. She also endorses serious difficulty
 with social withdrawal and emotional detachment. She has frequent
 difficulty with hopelessness, helplessness, concentration, energy, and
 impulsivity. She admits that she is impulsive with spending, reckless
 driving, risk taking behaviors, self cutting and ETOH. She endorses
 chronic nightmares and re-experiencing symptoms. She endorses
 hypervigilance and trouble relaxing/high anxiety. She has problemsintimacy, mistrust, fear of abandonment and chronic feelings of
 emptiness. She denies mania, OCD and psychotic symptoms. 
 Inpatient admissions: one in the military and one at the VA in 6/15
 Substance abuse treatment: none
 Suicide attempts: none, but intermittent suicidal gestures/thoughts
 and chronic passive thoughts of death
 Use of psychotropic meds: prozac, hydroxyzine and duloxetine (plus
 valium prn from her PCP)
 Side effects: GI upset
 RELEVANT RECORDS:
 #1. inpatient VA psych admission discharge summary 6/15:
 Was gang raped by six active duty military members she 
 knew after being drugged in October 2008. Filed a report, obtained a
 rape kit, 
 and was not believed by command. Was forced out of service under
 general 
 conditions after 9 months of service, despite her desire to make the 
AF
 a 
 career

 

 

 

There's even more to report. But I couldn't get all of it on here. Some of her wording I don't understand. I was fine before the mst happened and she makes it very clear but im concerned they'll blame it on my childhood. And according to the rating thing she rated a 70 percent. Is that right? I know the reviewer is the decide but I know c and p exam can weigh in pretty heavy. 

Edited by Eliza
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jmo

yes I would say your rating is 70%, being you have good hygiene and can take care of your finances  is why you were not rated 100%

I see nothing in your childhood  other than your parents being abusive  you were not clinically diagnose back in your childhood.

The MST is the cause of your PTSD that sealed your rating and diagnose, other symptoms may happen later on that would be secondary to PTSD and then you can file a another claim.

Although the rater could give you a 100% rating after reading this report....lot of it depends how the rater sees it.

jmo

My best to you and hope

&prayyou have a good & better  happier way of life

stay strong

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

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A rater has to input the exam findings which consist of several checked boxes. These occur in the latter pages of the exam DBQ.

the question of whether or not it will be service connected has been cleared up as Buck pointed out. 

How high the percentage will be is something that the VA's new VBMS-R system generates based on the input from the exam check boxes that I referred to.

There is wiggle room though. It's a mental rating and the rater has the option of going to the next higher or lower rating percentage if they can justify it in their narrative. It's called a "1 up 1 down" around the Regional Office where I worked. 

I've never seen the rater go "1 down", but I have seen plenty go "1 up".

Wish you luck.

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Thank you very much for responding. It helps me feel a little better because I couldn't understand the wording quite right. Hopefully it is 70 percent. I would take anything though. I have a tough time keeping jobs. 

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jmo

It could very well be a 100% rating  but don't get your hopes up.

 from what all I read in the C&P report  the examiner put down  as for as your hygiene goes '' None'' so to me that could go either way  again it depends on how the rater views this?

If your rated 100%PTSD you won't have to work anymore    actually you can't work with a 100%PTSD Rating.

let us know how it went for ya?

Thanks

jmo

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

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Someone whom I know is 100 percent and still worked. He doesn't anymore but he did while he was receiving the 100 percent. He said you can still work. I wouldn't want to work unless it was part time or something. My anxiety gets ridiculous. 

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