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mstsurvivor

PTSD MST C&P RESULT

Question

hi everyone, if anyone has any insight on the results of my C&P exam it would be greatly appreciated. i was sexually assaulted while AD AF, my claim was quick start filed 5 months ago, i had the exams over a month ago and things seemed to be going well, it went to pending decision approval two weeks ago and then all of a sudden dropped back to gathering of evidence and a pending appointment request. my AMVETS lady never answers me and when she does she says she will get back to me... and never does. my PTSD is at an all time high not knowing what all of this means. i also have a few other claims in for chronic pain and chronic gastritis (gastritis c&p stated that it was more likely psych related) 
                               

 

   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: PTSD
           ICD code: 309.81

    b. Medical diagnoses relevant to the understanding or management of the
       Mental Health Disorder (to include TBI): Chronic Pain

    3. Differentiation of symptoms
    ------------------------------
    a. Does the Veteran have more than one mental disorder diagnosed?
       [ ] Yes   [X] No
       
    c. Does the Veteran have a diagnosed traumatic brain injury (TBI)?
       [ ] Yes   [X] No   [ ] 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   [ ] No   [X] No other mental disorder has been diagnosed
       
    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
        [ ] Military enlistment examination
        [ ] Military separation examination
        [ ] Military post-deployment questionnaire
        [X] 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:
              VBMS, CPRS
              
    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 was raised in ________by her biological parents.
          She described her
          childhood as "really good, compared to people I served with and 
hearing
          where they came from I was definitely blessed."  
          She described her relationship with her parents as "normal" and
          indicated that they did not get along while she was an adolescent, but
          are now "best friends."  She denied any experiences of abuse growing up.

          The veteran is currently living in ________ with her
          husband who is currently active duty in the military.  She has no
          children and no other marriages.  The veteran reports that they were married just 2
          weeks prior to her sexual assault which occurred while they were
          stationed at separate bases.  She indicated that although she is 
living
          with him now, they are estranged because of her ongoing symptoms since
          the assault.  She plans to move in with her parents as soon as they
          have room for her to do so.
She
          indicated that her husband says she's not the same person he married
          and that he doesn't know her anymore even though they've been together
          for 6 years.  They have not been physically intimate since her 
assault.
          The veteran indicated that they plan to proceed with a divorce once
          she has addressed her medical and military issues.

          The veteran indicated that at present she is engaged in very few
          activities and spends the majority of her time at home.  She indicated
          that she tries to take care of chores around the house or go grocery
          shopping, but she finds even those tasks to be challenging and her
          husband often has to remind her to do them.  She indicated that she 
has
          few friends and that "I don't like people, I don't like
          talking to people, social settings."  Prior to her sexual assault she
          describes herself as being a "social butterfly."  Now, she spends a 
lot
          of time watching shows on Netflix.  She typically would enjoy going to
          the gym, but has been unable to because of a back injury.
          
    b. Relevant Occupational and Educational history (pre-military, military, 
and
       post-military):
          The veteran's highest level of education is a high school diploma.  
She
          The veteran is currently unemployed both due to
          physical limitations (she has difficulty standing for long periods of
          time due to a back injury) as well as mental health issues (she is
          afraid of people).  She has no income and her husband is currently
          supporting her financially.

          She was
          never deployed to an area where she received hazardous duty pay.  Her
        Veteran received an honorable
          discharge due to "Hardship; Service Member Initiated Due to
          Dependency."  The veteran reports that prior to her sexual assault she
          loved the work she did in the military and got along with her
          coworkers; she was "really happy and really proud."  After the assault
          she reports that she was "emotionally checked out" at work and was
          reprimanded for insubordination by a superior officer.
          
    c. Relevant Mental Health history, to include prescribed medications and
       family mental health (pre-military, military, and post-military):
          The veteran reported receiving sporadic mental health treatment 
through
          the Air Force following her sexual assault.  Her medical records
          in VBMS reflect this.  She was prescribed medication to assist with
          sleep and mood including melatonin, biotin, prozac, flexaril, and
          trazodone.  She indicated that prior to this she was also seen for
          evaluation and treatment for ADD and was prescribed ritalin.  The
          veteran indicated that since discharging she has run out of her
          medications and has not been on anything for several weeks.

          The veteran described symptoms including intrusive thoughts,
          flashbacks, nightmares, emotional and physical distress at trauma 
cues,
          avoidance of trauma related memories/feelings/conversations and
          situations, gaps in her memory of the event, emotional numbness,
          disconnection from others, negative change in beliefs about
          herself/others/world, persistent negative emotional state, anhedonia,
          irritability, difficulty sleeping, poor concentration, hypervigilance.
          She also reported having panic attacks daily (with increased heart
          rate, throat swelling, difficulty breathing, face flushed, feeling out
          of control, shakiness, uncontrollable tears) and feeling depressed.  

          The veteran described feeling like she's on a "roller coaster."  She
          indicated that she has nightmares of her assault nightly and finds
          herself triggered by other people who she now fears may be similarly
          harmful to her.  Additional triggers include hearing the 
"Law-and-Order
          SVU" theme song and hearing about Bill Cosby in the news.  She has not
          been back to base despite being able to get free healthcare there
          (because her husband is active duty), in order to avoid being 
triggered
          to remember what happened.  She has a sense of "impending doom" and
          always feels that she needs to keep her guard up because something
          might happen.  The perpetrator's family is involved in illegal 
activity
          and she worries that they might come after her, or that he will once 
he
          is released from prison.  She has been sleeping in a separate bedroom
          from her husband and keeps the door to her room locked at night.  On
          one occasion he heard her screaming and crying in the middle of the
          night and entered her room, and she punched him before she was fully
          aware of what was happening.  She has difficulty sleeping at night
          because at the time of her assault she was sleeping next to someone 
she
          trusted, so now even sleep does not feel safe.  She reported that when
          she was still working at ________, she would often miss work because 
her
          sleep medication would "knock me out for half the day."  She indicated
          that she has been unable to relate to/open up to anyone and feels that
          she can't connect with others, even friends from childhood.  She is
          embarrased about what happened and doesn't want others to know.  She
          indicated that whereas she used to enjoy fashion and getting
          dressed-up, she now makes an effort to look unattractive; she does not
          shave her legs or wear make-up anymore.  She goes days without
          showering and only does so when her husband directs her to.  She
          reports that she often will not leave her house for days at a time.
          She spends a great deal of time watching Netflix and cooking in order
          to avoid memories of the event.  She indicated that she has to force
          herself to eat, but that she often throws up what she's eaten.  She 
has
          chronic gastritis and she indicated that the stress of the assault
          caused it to "flare-up."  The veteran indicated that immediately after
          the assault she considered suicide, but got support from a friend and
          did not take any action.  Since then she has had suicidal ideation, 
but
          no plan or intent.  She reports that she last had thoughts of suicide
          at the end of January 2016.  She continues to feel hopeless and has
          thoughts such as "I don't know what the point of all of this is," but
          has had no recent active suicidal ideation.  She denied current or 
past
          self-injurious behavior.
          
    d. Relevant Legal and Behavioral history (pre-military, military, and
       post-military):
          The veteran denied any current or past legal problems with the
          exception of the case related to her military sexual assault.
          
    e. Relevant Substance abuse history (pre-military, military, and
       post-military):
          The veteran reported that she typically drinks one bottle of wine per
          month.  She reported that for a week after the sexual assault she was
          binge drinking, roughly one bottle of wine daily every day of that
          week.  She indicated that she stopped because she was having 
difficulty
          functioning at work and did not want to be sent for substance abuse
          treatment.  She denied any history of drug use or experimentation.  

          
    f. Other, if any:
          The veteran reported that 2 weeks following her marriage she was sexually assaulted by a friend. 

 A court martial was pursued against her assailant, and the veteran, along with other victims testified against
          the perpetrator.  The perpetrator was sentenced to time in prison,
          loss of rank, and dishonorable discharge.  Please see documentation in
          VBMS for additional details.

          The veteran reported that the period between the report of her 
assault,
          and the completion of the court martial has been very difficult.  She
          indicated that she feels her case was mishandled by the military for
          several reasons.  First, she reports that she was encouraged to drop
          the charges initially which was "the biggest slap in the face."  She
          also reports that at one point her supervisor addressed her in front 
of
          her peers about the incident.  She indicated that once others became
          aware of what had happened she was ostracized.  Male friends gave her
          the "cold-shoulder" because they worried she would "call rape" on 
them.
          She indicated that she was further harassed by another supervisor who
          interrogated her about what happened and then slapped her on her 
behind
          and called her "fake tits."  The veteran reports that she continued to
          have negative experiences even after she was transferred to a 
different
          unit.  She was told that she was insubordinate by a supervisor and
          people continued to ostracize her.
          
    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: Sexual Assault
    
          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?
          [ ] Yes  [X] No
          
              If no, explain:
                Related to military sexual trauma that occurred stateside
                
                
          Is the stressor related to personal assault, e.g. military sexual
          trauma?
          [X] Yes  [ ] No
          
              If yes, please describe the markers that may substantiate the
              stressor.
                Sexual assault case was brought to trial in the military and the
                veteran's assailant was sentenced to time in prison, 
dishonorable
                discharge, and loss of rank.  Veteran's symptoms began to emerge
                shortly after the assault and medical records show that she was
                seen for mental health treatment at that time and received
                medication.
                
    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] Recurrent distressing dreams in which the content and/or affect of
              the dream are related to the traumatic event(s).
          [X] 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).
          [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).
          [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] 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).
          [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] Irritable behavior and angry outbursts (with little or no
              provocation) typically expressed as verbal or physical aggression
              toward people or objects.
          [X] Hypervigilance.
          [X] Problems with concentration.
          [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.
              
       Criterion I: Which stressor(s) contributed to the Veteran's PTSD
                    diagnosis?:
          [X] Stressor #1

    5. Symptoms
    -----------
    For VA rating purposes, check all symptoms that actively apply to the
    Veteran's diagnoses:
    
       [X] Depressed mood
       [X] Anxiety
       [X] Panic attacks more than once a week
       [X] Chronic sleep impairment
       [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] Suicidal ideation
       [X] Neglect of personal appearance and hygiene
       [X] Intermittent inability to perform activities of daily living,
           including maintenance of minimal personal hygiene

    6. Behavioral Observations
    --------------------------
    The veteran presented for the evaluation on time, appropriately dressed and
    groomed, and appearing her stated a

ge.  She wore an oversized sweatshirt.
    The veteran was alert throughout the evaluation, and was oriented to person,
    place, and time. Speech was normal in rhythm, rate, tone, and volume.
    Content was coherent and goal directed.  Affect was full range and
    appropriate, and her mood appeared to be anxious and depressed.  There was 
no
    evidence of hallucinations or delusions.  Cognitive functioning was grossly
    intact.  Insight and judgment were fair.  The veteran denied current 
suicidal
    and homicidal ideation, plan, and intent.

    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
    --------------------------------------------------
       The veteran currently meets DSM-V criteria for a diagnosis of PTSD
       stemming from her military sexual trauma.  Her symptoms fall within the
       severe range and have had a significant impact on her functioning in all
       domains since the incident.  Please see above for a full accounting of 
the
       veteran's symptoms and their impact, as well as a detailed account of the
       assault and its aftermath.  With appropriate treatment, veteran's 
symptoms
       may improve over time.
       
    NOTE: VA may request additional medical information, including additional
    examinations if necessary to complete VA's review of the Veteran's
    application.

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I fully believe that they will grant your claim but don't know how they will rate it.

And I certainly wish you never had this experience. The evidence is there that all of this happened.

We have other MST survivors here.

 "Her symptoms fall within the
       severe range and have had a significant impact on her functioning in all
       domains since the incident.  "

To me this should warrant a high rating, but if they low ball your rating (that has happened to many here) you can definitely appeal it.

The PTSD rating criteria ( DC code 9411) is here in our VA Schedule of Ratings forum....about half way down the long document.

 

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1 minute ago, Berta said:

I fully believe that they will grant your claim but don't know how they will rate it.

And I certainly wish you never had this experience. The evidence is there that all of this happened.

We have other MST survivors here.

 "Her symptoms fall within the
       severe range and have had a significant impact on her functioning in all
       domains since the incident.  "

To me this should warrant a high rating, but if they low ball your rating (that has happened to many here) you can definitely appeal it.

The PTSD rating criteria ( DC code 9411) is here in our VA Schedule of Ratings forum....about half way down the long document.

 

thank you so much, i will look into it. I'm just concerned because the doc wrote so much in the note but then didn't check off all the applicable boxes in the "for VA rating purposes" section. 

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God bless u in your journey and stay strong the report reads to me 50/70% good luck

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just spoke to by vso, i was rated at 70% for ptsd and combined with whatever claims they approved 80%. thanks for the two of you that replied! gave me some peace of mind yesterday i truly appreciate it. 

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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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