I had a c&p last April and went from 50 to 70%. Had a c&p exam last week (TDIU) and I do not think it is an accurate representation of my disability. The lady diagnosed me with antisocial personality disorder (never had that before) and said my PTSD is basically non existent as long as I'm sober. ??? This is a terrible report (in my opinion) but any other thoughts on it?
SECTION I:
----------
1. Diagnostic Summary
---------------------
Does the Veteran now have or has he/she ever been diagnosed with PTSD?
[X] Yes[ ] No
ICD Code: F43.20
2. Current Diagnoses
--------------------
a. Mental Disorder Diagnosis #1: ALCOHOL USE DISORDER
ICD Code: F12.20
Comments, if any: THIS IS VET'S MAIN AND MOST DISABLING CONDITION.
Mental Disorder Diagnosis #2: ANTISOCIAL PERSONALITY DISORDER
ICD Code: F60.2
Comments, if any: VET HAS 8 FELONIES INCLUDING 4 COUNTS OF AGGRAVATED
BATTERY OF POLICE OFFICERS IN 2007 AND 2010, DOMESTIC BATTERY IN 2007,
CRIMINAL DAMAGE TO GOVT PROPERTY IN 2010, CRIMINAL DAMAGE TO STATE
PROPERTY IN 2006, AND AGGRAVATED DUI (3RD) IN 2006. HE HAS BEEN
INCARCERATED IN STATE PRISONS TWICE AND IS FACING JAIL TIME AT HIS NEXT
COURT DATE.
Mental Disorder Diagnosis #3: PTSD
ICD Code: F43.20
Comments, if any: PCL-5 TOTAL SCORE TODAY WAS 65 SUGGESTING MODERATE
PTSD SYMPTOMS. HE HAS NOT BEEN COMPLIANT WITH MEDICATION OR MH
TREATMENT
AND HAD IMPROVED PTSD SYMPTOMS IN THE PAST WHEN MEDICATED AND ATTENDING
TREATMENT MORE REGULARLY.
b. Medical diagnoses relevant to the understanding or management of the
Mental Health Disorder (to include TBI):
No response provided.
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?
[X] Yes[ ] No[ ] Not applicable (N/A)
If yes, list which symptoms are attributable to each diagnosis and
discuss whether there is any clinical association between these
diagnoses:
ALCOHOL USE DISORDER - CONTINUED EXCESSIVE USE OF ALCOHOL DESPITE
SOCIAL AND LEGAL CONSEQUENCES, DEPRESSED AND ANXIOUS AFFECT,
DECREASED
MEMORY, POOR JUDGMENT, DECREASED MOTIVATION, INTERPERSONAL
DIFFICULTY,
DIFFICULTIES IN A WORK SETTING, IMPULSE CONTROL DIFFICULTIES,
DECREASED CONCENTRATION, PERSISTENT NEGATIVE COGNITIONS,
IRRITABILITY,
ANGER OUTBURSTS, INSOMNIA, DECREASED INTEREST.
ANTISOCIAL PERSONALITY DISORDER - CONTINUED CRIMINAL ACTS WITH 8
FELONIES AND REPEATED INCARCERATION, CONNING OTHERS FOR PERSONAL
PROFIT, IMPULSIVITY, IRRITABILITY, AGGRESSIVENESS, RECKLESS DISREGARD
FOR SAFETY OF SELF OR OTHERS, CONSISTENT IRRESPONSIBILITY WITH
REPEATED FAILURE TO HONOR FINANCIAL OBLIGATIONS, LACK OF REMORSE,
INTERPERSONAL DIFFICULTY IN THE WORKPLACE, POOR JUDGMENT.
PTSD - FLASHBACKS, NIGHTMARES, AVOIDANCE, EMOTIONAL NUMBING,
HYPERVIGILANCE, SUSPICIOUSNESS.
c. Does the Veteran have a diagnosed traumatic brain injury (TBI)?
[ ] Yes[X] No[ ] Not shown in records reviewed
Comments, if any: TBI EXAM DATED 5/18/15 DID NOT DIAGNOSE TBI BUT
PTSD
AND ALCOHOL DEPENDENCE
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 reduced reliability and
productivity
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?
[X] Yes[ ] No[ ] No other mental disorder has been diagnosed
If yes, list which portion of the indicated level of occupational and
social impairment is attributable to each diagnosis:
ALCOHOL USE DEPENDENCE, SEVERE - SOCIAL AND OCCUPATIONAL IMPAIRMENT
IN
MOST AREAS INCLUDING SCHOOL, FAMILY RELATIONSHIPS, INTERPERSONAL
RELATIONS, WORK, MOOD, JUDGMENT AND IMPULSE CONTROL.
ANTISOCIAL PERSONALITY DISORDER - SOCIAL AND OCCUPATIONAL IMPAIRMENT
IN MOST AREAS INCLUDING SCHOOL, FAMILY RELATIONSHIPS, INTERPERSONAL
RELATIONS, WORK, MOOD, JUDGMENT AND IMPULSE CONTROL.
PTSD - REDUCED RELIABILITY AND PRODUCTIVITY.
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 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
[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:
CP PTSD REVIEW EXAM DATED 4/30/15 WAS ALSO REVIEWED.
b. Was pertinent information from collateral sources reviewed?
[X] Yes[ ] No
If yes, describe:
VET'S FIANCEE AMBER ACTIVELY PARTICIPATED IN TODAY'S EXAM. BOTH WERE
TEARFUL DURING THE EXAM.
2. Recent History (since prior exam)
------------------------------------
a. Relevant Social/Marital/Family history:
MR Xxxx IS A 3X YEAR OLD SINGLE, UNEMPLOYED, CAUCASIAN
MALE VETERAN OF THE MARINE CORPS WHO SERVED IN IRAQ AND IS 70% SC FOR
PTSD.
SINCE HIS LAST C&P PTSD EXAM ON 4/30/15, HE CONTINUES TO BE SINGLE BUT
LIVES WITH HIS FIANCEE AND THEIR 2 YEAR OLD DAUGHTER IN A HOME THAT
THEY RECENTLY PURCHASED. HE DESCRIBED THEIR RELATIONSHIP AS
CATASTROPHIC SINCE "I CAN'T EVER DO ANYTHING RIGHT". HE SAID THEY
ARGUE
CONSTANTLY BUT PUT ON A HAPPY FACE WHEN AROUND HER FAMILY. HE SAID SHE
IS WORN OUT FROM DEALING WITH HER PTSD. HIS 2/3/16 SW NOTE INDICATED
THAT HE CHEATED RECENTLY ON HIS FIANCEE AND THAT STRAINED THEIR
R
ELATIONSHIP. HE HAD ALTERCATIONS WITH HER FAMILY MEMBERS. IN 10/15,
VET WAS ARRESTED AFTER ASSAULTING AMBER'S STEP-FATHER, PUNCHING HIM
NUMEROUS TIMES IN THE FACE AND CAUSING A BLACK EYE. CHARGES WERE
DROPPED. HE MAINTAINS CONTACT WITH HIS SISTER WHO IS IN THE ARMY AND
IN
KANSAS. HIS FATHER LIVES AN HOUR AWAY BUT HAS LITTLE TO DO WITH THEM,
TAKES THEM TO DINNER AND LEAVES. VET FEELS VERY DISTANT FROM HIS DAD.
HIS MOTHER DIED NEARLY 8 YEARS AGO WHILE HE WAS INCARCERATED AND VET
CONTINUES TO GRIEVE FOR HER. HE HAS SOCIAL MEDIA CONTACT WITH MILITARY
FRIENDS. HE HAS ONE FRIEND THAT HE MET WHEN HE WORKED AT GOOD WILL.
VET
CALLS HIM TO TAKE HIM TO VA APPOINTMENTS. VET CURRENTLY LIVES IN
XXXX, IL IN A HOME THAT HE AND HIS FIANCEE RECENTLY PURCHASED. HE
MET ONE NEIGHBOR BUT GENERALLY HE KEEPS TO HIMSELF. HE SAID HE HAS AN
AWESOME RELATIONSHIP WITH HIS 2 YEAR OLD DAUGHTER HALEY, BUT HE HAS
HAD
EXTREME VIOLENT BEHAVIOR IN FRONT OF HER. HE HAS YELLED AT HER AND
FEARS THAT HE WILL LOSE HER IF THINGS DON'T WORK OUT WITH AMBER. IT
HURTS HIM TO SEND HER TO DAYCARE RECENTLY BECAUSE HE WOULD PREFER TO
TAKE CARE OF HER. A DCFS CHILD ENDANGERMENT CASE WAS FOUNDED IN 2/16
AFTER VET WAS VIOLENTLY ASSAULTING HIS FIANCEE'S STEPFATHER IN FRONT
OF
THE CHILD. WHILE VET STATED THAT HE HAS NO/FEW FRIENDS, HIS 6/6/16
PSYCHIATRIST NOTE INDICATED THAT HE GOES OUT TO BARS DRINKING WITH
FRIENDS.
b. Relevant Occupational and Educational history:
VETHAS BEEN ATTENDING COLLEGE CLASSES SINCE 2006 COMMUNITY COLLEGES
AND
FAILED 3 CLASSES LAST SEMESTER BUT PASSED HIS MATH CLASS. HE HAS BEEN
TRYING TO GET HIS ASSOCIATE'S DEGREE FOR THE PAST 10 YEARS AND HOPES
TO
GET A DEGREE IN SOCIAL WORK EVENTUALLY. HIS GPA IS LESS THAN 1.0. HE
TOOK 3 ONLINE CLASSES WHICH HE FAILED BUT PASSED THE MATH CLASS IN THE
CLASSROOM CLASS. HE DIDN'T ASSOCIATE WITH TEACHERS OR OTHER STUDENTS.
VET LAST WORKED FULL TIME AT GOOD WILL INDUSTRIES FROM 2/13 TO 4/15,
WAS PROMOTED TO KEYHOLDER, THEN WAS TERMINATED IN 4/15. REASONS FOR
THE
TERMINATION WERE UNCLEAR BUT DOCUMENTS FROM WORK INDICATED THAT HE HAD
LOUD VERBAL ALTERCATION WITH A COWORKER IN 1/14, WAS ABSENT 8 TIMES IN
12 MONTHS AND WORKED 3 PARTIAL SHIFTS BY 12/14, AND POINTED HIS FINGER
AT COWORKERS CAUSING TENSION AT WORK ON 12/18/14. THERE WAS NO OTHER
DOCUMENTATION OF WORK PROBLEMS SUBMITTED TO INDICATE WHY HE WAS
TERMINATED IN 4/16.
HE HAS HAD NO OTHER PAID WORK SINCE 4/15. MH NOTES INDICATED THAT HE
WAS NOT LOOKING FOR EMPLOYMENT BUT WAS GOING TO COLLEGE FULL TIME AND
WATCHING HIS YOUNG DAUGHTER WHILE HIS WIFE WORKED. THERE WAS NO
EVIDENCE THAT HE HAD APPLIED FOR WORK BUT HIS 8 FELONIES, LOSS OF
DRIVER'S LICENSE (SINCE 2006), 3RD DUI(IN 2010), AND CONTINUED
CRIMINAL
BEHAVIOR ARE LIKELY TO INTERFERE WITH OBTAINING WORK.
VET'S MH NOTES REPEATEDLY NOTE THAT HE IS ONLY VIOLENT AND AGGRESSIVE
WHEN DRINKING. THERE WAS NO EVIDENCE IN TODAY'S EXAM OR IN REVIEW OF
VET'S MH RECORDS SINCE 2006 THAT HIS PTSD WAS EVER SEVERE ENOUGH, BY
ITSELF, TO PREVENT HIM FROM OBTAINING OR MAINTAINING SUBSTANTIALLY
GAINFUL EMPLOYMENT.
c. Relevant Mental Health history, to include prescribed medications and
family mental health:
SINCE 4/15, HE HAS BEEN FOLLOWED BY SHAWN SLAGLE, SW AND DR LIM,
PSYCHIATRIST AT THE LASALLE CBOC. HE HAS NOT BEEN COMPLIANT WITH
TREATMENT AND WAS TOLD BY HIS SW ON 2/3/16 THAT NOT GETTING TREATMENT
FOR HIS PTSD IS THE PROBLEM, NOT HIS PTSD. HE DID NOT SEE HIS
PSYCHIATRIST FROM 10/26/15 UNTIL 6/6/16 AND LAST FILLED ALL HIS MH
MEDICATIONS IN 2/16. HE ONLY CONTACTED HIS PSYCHIATRIST IN 11/15 AND
12/15 WHEN HE NEEDED FORMS DOCUMENTING HIS TREATMENT FOR COURT DATES.
HE RETURNED TO MH ON 6/6/16 DUE TO HAVING A COURT DATE ON 6/30/16 THAT
WILL DECIDE WHETHER HE GOES TO JAIL OR RESIDENTIAL TREATMENT.
HE DID NOT SEE HIS SW FOR INDIVIDUAL THERAPY BETWEEN 6/15 AND 2/16,
MISSING SEVERAL APPOINTMENTS.
HE APPLIED FOR ADMISSION TO LOVELL'S SDTU PROGRAM (RESIDENTIAL TRAUMA
TREATMENT) BUT WAS TOLD THAT HE HAD TO COMPLETE SUBSTANCE ABUSE
TREATMENT FIRST SINCE HIS SUBSTANCE USE WAS STILL HIGH. HE HAS BEEN
ENCOURAGED TO ENTER THE SDTU AT LOVELL VAMC BY HIS SW SINCE 8/27/12
BUT
HAS REFUSED AND NOT FOLLOWED THROUGH. A PHONE INTERVIEW WITH THE SDTU
WAS HELD ON 5/3/16 AND VET WAS REFERRED TO THE MHRRTP TO TREAT HIS
ADDICTIONS BEFORE ADDRESSING TRAUMA WORK. HIS ADMISSION TO THE SDTU IS
DELAYED UNTIL HE COMPLETES ADDICTIONS TREATMENT. HE HAS AN INTERVIEW
WITH THE MHRRTP PROGRAM ON 6/20/16.
CURRENTLY, HE WILL BE TAKING DULOXETINE AND TRAZODONE FOR HIS PTSD AND
NALTREXONE FOR ALCOHOL CRAVINGS. THEY WERE ORDERED ON 6/7/16 BUT VET
HAS NOT RECEIVED THEM YET. HE STOPPED TAKING MH MEDS AFTER 2/16 AND
DIDN'T REORDER MEDICATIONS AFTER THEY RAN OUT.
HE WENT TO ILLINOIS VALLEY COMMUNITY HOSPITAL ER WHEN INTOXICATED ON
10/25/15 AND WANTED TO TRANSFER TO 2S AT HINES BUT VET INSISTED ON A
PRIVATE BED. WHEN HE WAS TOLD THEY COULDN'T GUARANTEE A PRIVATE BED,
VET REFUSED TO GO. HE WAS DISCHARGED FROM THE COMMUNITY HOSPITAL AFTER
A FEW HOURS OF OBSERVATION.
VET CLEARLY DID BETTER WITH PTSD SYMPTOMS WHEN HE WAS NOT DRINKING,
ACCORDING TO MULTIPLE MH NOTES. HE HAD GOOD RESPONSE TO MH MEDICATIONS
BUT STOPPED TAKING THEM OR DIDN'T TAKE THEM AS PRESCRIBED.
HE OFTEN SEEKS OUT MH TREATMENT WHEN HE IS IN LEGAL TROUBLE IN ORDER
TO
NOT FACE CONSEQUENCES FOR HIS ACTIONS. HE HAS USED HIS PTSD AND
ALCOHOL
USE DISORDER DIAGNOSES TO AVOID JAIL TIME.
HE HAD NO SUICIDE ATTEMPTS OR PSYCHIATRIC HOSPITALIZATIONS IN THE PAST
YEAR. IN FACT, HE HAD NO PSYCHIATRIC HOSPITALIZATIONS SINCE 3/13.
IT IS IMPORTANT TO NOTE THAT VET HAS A GREAT DEAL OF MENTAL ILLNESS IN
HIS FAMILY THAT WAS NOT NOTED ON PRIOR C&P PTSD EXAMS. HIS SISTER WAS
HOSPITALIZED FOR DEPRESSION IN HIGH SCHOOL AND TAKES ANTIDEPRESSANTS,
A
COUSIN COMMITTED SUICIDE A FEW YEARS AGO OF A GSW TO THE HEAD (PER HIS
8/12 MH INTAKE NOTE), HIS PATERNAL AUNT AND UNCLE HAVE PSYCHIATRIC
PROBLEMS, AND VET WAS A VICTIM OF PHYSICAL ABUSE ACCORDING TO HIS
7/6/06 SARP ASSESSMENT.
d. Relevant Legal and Behavioral history:
SINCE 4/15, VET WAS ARRESTED ON 11/28/15 AND CHARGED WITH BATTERY FOR
HITTING AMBER'S STEPFATHER BUT THEY DROPPED THE CHARGES. HE WAS
ARRESTED FOR DRIVING ON A REVOKED LICENSE IN 3/16. VET HAD 3 DUIS AND
HAS NOT HAD A DRIVER'S LICENSE SINCE 2006. HE HAS A COURT DATE PENDING
ON 6/30 REGARDING HIS LATEST OFFENSE. HE MAY GO TO JAIL OR MAY BE
ALLOWED TO ENTER RESIDENTIAL TREATMENT. HE HAS HAD CHRONIC DIFFICULTY
WITH BEING IN DEBT DUE TO HIS SUBSTANCE ABUSE, IMPULSE CONTROL, CREDIT
CARDS AND LEGAL EXPENSES.
e. Relevant Substance abuse history:
SINCE 4/15, VET HAS DRANK EXCESSIVELY. HE WOULD LIKE TO DRINK EVERY
NIGHT AND TRIES TO MANIPULATE AMBER TO BE ABLE TO DRINK. HE WILL DRINK
A 6 PACK OR BOTTLE OF WINE PER SITTING. THEIR HOUSE IS 1 BLOCK AWAY
FROM A BAR AND 2 BLOCKS FROM A CONVENIENT STORE. WHEN AMBER COMES
HOME
FROM WORK, THERE WILL BE ALCOHOL IN THE REFRIGERATOR OR EMPTY BOTTLES
IN THE TRASH. HE STORMS OUT WHEN ARGUING WITH HER AND GOES TO THE BAR
WHERE HE CONSUMES 6+ DRINKS. ALCOHOL WAS INVOLVED BEFORE VET BECAME
VIOLENT WITH HER FATHER IN 11/15. HE PUSHED AMBER IN 10/15 WHEN SHE
CALLED THE POLICE DURING HIS INTOXICATED RAGE.
CURRENTLY, HE DRANK HEAVILY ON MEMORIAL DAY, BINGE DRINKS, THEN TRIES
NOT TO DRINK. HE LAST DRANK LAST WEEK WHEN HE HAD 2 GLASSES OF WINE.
VET SMOKES MARIJUANA OCCASIONALLY, 1-2 TIMES PER MONTH. ON 6/6/16, DR
LIM REPORTED THAT HE USES IT 2-3 TIMES PER MONTH. HE HAS NOT ACTIVELY
SOUGHT IT OUT RECENTLY AND LAST USED IT 2 WEEKS AGO. IT UPSETS AMBER
SO
HE TRIES NOT TO.
IT IS IMPORTANT TO NOTE THAT VET'S 8/21/12 MH INTAKE NOTE AT HINES
INDICATED THAT VET DRANK ALCOHOL SINCE 17 IN HIGH SCHOOL AND USED
MARIJUANA SINCE AGE 16. HE BECOMES AGGRESSIVE AND VIOLENT WHEN HE IS
INTOXICATED AND IT LEADS TO LEGAL PROBLEMS. HIS 7/1/06 ALCOHOL
TREATMENT NOTE INDICATED THAT ALCOHOLISM WAS PREVALENT ON BOTH SIDES
OF
THE FAMILY, ACCORDING TO VET'S PARENTS. HIS FATHER AND MATERNAL UNCLE
WERE ALCOHOLIC AND HIS MATERNAL UNCLE ABUSED DRUGS. VET ALSO USED
COCAINE 10 TIMES, MOST RECENTLY IN 2010, AND USED MUSHROOMS, LSD AND
ECSTASY SEVERAL TIMES IN 2006, ACCORDING TO HIS 8/12 MH INTAKE NOTE.
ON
8/2/06, A BIOPSYCHOSOCIAL ASSESSMENT INDICATED THAT VET'S ALCOHOL AND
DRUG USE INTERFERED WITH HIS SCHOOL PERFORMANCE.
VET HAD A HISTORY OF ABUSING PRESCRIPTION NARCOTICS BUT SAID HE HAS
NOT
IN THE PAST YEAR.
f. Other, if any:
VET HAS ANNIVERSARY REACTIONS RELATED TO HIS FRIEND DYING IN IRAQ IN
APRIL 2004, HIS MOTHER'S DEATH IN 5/08. HIS FIANCEE SAID SOMETHING
ALWAYS HAPPENS IN THE SPRING WITH VET'S BEHAVIOR.
3. PTSD Diagnostic Criteria
---------------------------
Please check criteria used for establishing the current PTSD diagnosis. The
diagnostic criteria for PTSD, are from the Diagnostic and Statistical Manual
of Mental Disorders, 5th edition (DSM-5). The stressful event can be due to
combat, personal trauma, other life threatening situations (non-combat
related stressors.) 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 #6 - "Other
symptoms".
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)
[X] Witnessing, in person, the traumatic event(s) as they
occurred to others
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, distorted cognitions about the cause or
consequences of the traumatic event(s) that lead to the
individual to blame himself/herself or others.
[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] Reckless or self-destructive behavior.
[X] Hypervigilance.
[X] Exaggerated startle response.
[X] Problems with concentration.
[X] Sleep disturbance (e.g., difficulty falling or staying
asleep or restless sleep).
Criterion F:
[X] The duration of the symptoms described above in Criteria
B, C, and D are more than 1 month.
Criterion G:
[X] The PTSD symptoms described above cause 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.
4. Symptoms
-----------
For VA rating purposes, check all symptoms that actively apply to the
Veteran's diagnoses:
[X] Depressed mood
[X] Anxiety
[X] Suspiciousness
[X] Chronic sleep impairment
[X] Mild memory loss, such as forgetting names, directions or recent
events
[X] Impaired judgment
[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] Impaired impulse control, such as unprovoked irritability with
periods
of violence
5. Behavioral Observations:
---------------------------
VET ARRIVED EARLY FOR TODAY'S EXAM AND WAS ACCOMPANIED BY HIS FIANCEE
AMBER. HE DISPLAYED DEPRESSED AFFECT DURING THE EXAM AND BECAME TEARFUL
AT
SEVERAL TIMES. SPEECH, BEHAVIOR, AFFECT, THOUGHT AND EYE CONTACT WERE
OTHERWISE WITHIN NORMAL LIMITS. APPEARANCE, GROOMING AND HYGIENE WERE
ACCEPTABLE.
6. Other symptoms
-----------------
Does the Veteran have any other symptoms attributable to PTSD (and other
mental disorders) that are not listed above?
[X] Yes[ ] No
If yes, describe:
HE REPORTED PANIC ATTACKS WHERE HE FEELS ANGRY AND CAN'T CONTROL
THINGS. THESE ARE ANGER ATTACKS, NOT ACTUAL PANIC ATTACKS. HIS
FIANCEE NOTED THAT HE EATS EXCESSIVELY, EATING 28 WHITE CASTLE
HAMBURGERS AND AN ENTIRE CAKE IN 2 DAYS. HIS WEIGHT FLUCTUATES AND
HE EATS DURING THE NIGHT. H AVOIDS WATCHING THE NEWS,
CONVERSATIONS
ABOUT THE MILITARY, AND TELLING OTHERS THAT HE WAS A MARINE. HE
HAS
LOST INTEREST IN GOING OUT, DOING RECREATIONAL THINGS THAT DON'T
INVOLVE DRINKING, AND GOING TO STATE PARKS. HE SLEEPS 4-5 HOURS
WITH MEDICATION.
7. Competency
-------------
Is the Veteran capable of managing his or her financial affairs?
[X] Yes[ ] No
8. Remarks, (including any testing results) if any:
---------------------------------------------------
MR Xxxx CONTINUES TO MEET CRITERIA FOR PTSD BUT HIS PTSD IS OF
MODERATE SEVERITY, WHICH INDICATES A DECREASE IN SEVERITY SINCE HIS LAST
C&P PTSD REVIEW EXAM IN 4/15. HIS PTSD CURRENTLY CAUSES REDUCED
RELIABILITY AND PRODUCTIVITY IN A WORKPLACE SETTING. THERE WAS NO
EVIDENCE
IN TODAY'S EXAM OR IN REVIEW OF VET'S VA TREATMENT RECORDS SINCE 2006,
THAT HIS PTSD WAS EVER SEVERE ENOUGH TO RENDER HIM UNABLE TO OBTAIN OR
MAINTAIN SUBSTANTIALLY GAINFUL EMPLOYMENT. HE WAS ABLE TO KEEP THE SAME
FULL TIME JOB FROM 2/13 TO 4/15 AND WAS PROMOTED TO KEYHOLDER AT GOOD
WILL. THERE WAS NO EVIDENCE TO DOCUMENT THE REASON THAT HE LOST HIS JOB
IN
4/15. HIS MH NOTES INDICATE THAT HE WAS NOT APPLYING FOR OTHER WORK BUT
PLANNED TO GO TO COLLEGE FULL TIME AND WATCH HIS DAUGHTER WHILE HIS WIFE
WORKED.
HIS MOST DISABLING CONDITIONS ARE HIS ALCOHOL USE DISORDER AND ANTISOCIAL
PERSONALITY DISORDER, WHICH CAUSE SOCIAL AND OCCUPATIONAL IMPAIRMENT IN
MOST AREAS OF HIS LIFE INCLUDING WORK, SCHOOL, FAMILY RELATIONS,
INTERPERSONAL RELATIONSHIPS, JUDGMENT, IMPULSE CONTROL, THOUGHT AND MOOD.
THERE IS NO EVIDENCE TO SUGGEST THAT VET'S PERSONALITY DISORDER OR
ALCOHOL
USE DISORDER ARE RELATED TO THE MILITARY. VET WAS USING ALCOHOL AND
CANNABIS SINCE AGE 17 AND 16 RESPECTIVELY, AND HAS A STRONG BIOLOGICAL
PREDISPOSITION FOR A SUBSTANCE USE AND A MH DISORDER. HE HAS MULTIPLE
FAMILY MEMBERS (INCLUDING HIS FATHER AND SISTER) WITH EITHER SUBSTANCE
USE
DISORDERS OR MH DISORDERS AND HAD A COUSIN COMMITTED SUICIDE BY GUNSHOT
WOUND TO THE HEAD. THERE IS NO EVIDENCE TO SUGGEST THAT EITHER OF VET'S
CONDITION WORSENED BEYOND THEIR EXPECTED PROGRESSION AS A RESULT OF
MILITARY EXPERIENCES.
ALTHOUGH VET HAS BEEN INVOLVED IN SUBSTANCE ABUSE AND MH TREATMENT AT THE
VA SINCE 2006, MUCH OF HIS TREATMENT WAS PRECIPITATED BY LEGAL PROBLEMS
INCLUDING HIS 3 DUIS AND MOST RECENTLY HIS ARREST FOR DRIVING ON A
REVOKED
LICENSE. HE ORIGINALLY CAME FOR ALCOHOL TREATMENT AT DANVILLE VA ON
6/30/06 AFTER GETTING 2 DUIS IN A 5 MONTH PERIOD. AT THE TIME, HE HAD A
LARGE SOCIAL NETWORK OF FRIENDS WHO ABUSED ALCOHOL AND DRUGS, AND WAS
EXPERIMENTING WITH COCAINE, ACID, ECSTASY AND MUSHROOMS, BESIDES DRINKING
12-15 BEERS PER NIGHT AND USING 2 GMS OF CANNABIS PER DAY. HIS 11/2/05 MH
NOTE INDICATED THAT HE WAS DOING MUCH BETTER ON CELEXA FOR ANXIETY BUT HE
STOPPED TAKING IT. HIS 10/26/15 PSYCHIATRIST NOTE INDICATED THAT HE ONLY
GOT AGITATED WHEN INTOXICATED. DESPITE URGING FROM HIS SW TO GET RESIDENTIAL SDTU TREATMENT SINCE 8/12,VET HAS BEEN UNWILLING TO FOLLOW UP UNTIL NOW WHEN HE FACES JAIL TIME OR RESIDENTIAL TREATMENT. HIS MH NOTES INDICATE THAT HE DOES BETTER WHEN HE IS SOBER AND WHEN HE IS COMPLIANT WITH MH MEDICATION AND TREATMENT. IT IS LIKELY THAT VET WOULD BE ABLE TO MAINTAIN SUBSTANTIALLY GAINFUL FULL TIME EMPLOYMENT AND HEALTHIER RELATIONSHIPS IF HE REMAINED SOBER AND
COOPERATED WITH TREATMENT ON A CONSISTENT BASIS.
TODAY'S DIAGNOSES OF ALCOHOL USE DISORDER, ANTISOCIAL PERSONALITY DISORDER AND PTSD ARE BASED UPON DSM-5 CRITERIA AND ICD-10 CODING.
/es/ KATHLEEN PARKER, PSY.D.
Signed: 06/10/2016 17:12
-------------------------------------------------------------------------
----------- END OF MY HEALTHEVET PERSONAL INFORMATION REPORT ----------
Edited by Tbird Removed personal identification information.
Question
Jroocan
I had a c&p last April and went from 50 to 70%. Had a c&p exam last week (TDIU) and I do not think it is an accurate representation of my disability. The lady diagnosed me with antisocial personality disorder (never had that before) and said my PTSD is basically non existent as long as I'm sober. ??? This is a terrible report (in my opinion) but any other thoughts on it?
SECTION I: ---------- 1. Diagnostic Summary --------------------- Does the Veteran now have or has he/she ever been diagnosed with PTSD? [X] Yes[ ] No ICD Code: F43.20 2. Current Diagnoses -------------------- a. Mental Disorder Diagnosis #1: ALCOHOL USE DISORDER ICD Code: F12.20 Comments, if any: THIS IS VET'S MAIN AND MOST DISABLING CONDITION. Mental Disorder Diagnosis #2: ANTISOCIAL PERSONALITY DISORDER ICD Code: F60.2 Comments, if any: VET HAS 8 FELONIES INCLUDING 4 COUNTS OF AGGRAVATED BATTERY OF POLICE OFFICERS IN 2007 AND 2010, DOMESTIC BATTERY IN 2007, CRIMINAL DAMAGE TO GOVT PROPERTY IN 2010, CRIMINAL DAMAGE TO STATE PROPERTY IN 2006, AND AGGRAVATED DUI (3RD) IN 2006. HE HAS BEEN INCARCERATED IN STATE PRISONS TWICE AND IS FACING JAIL TIME AT HIS NEXT COURT DATE. Mental Disorder Diagnosis #3: PTSD ICD Code: F43.20 Comments, if any: PCL-5 TOTAL SCORE TODAY WAS 65 SUGGESTING MODERATE PTSD SYMPTOMS. HE HAS NOT BEEN COMPLIANT WITH MEDICATION OR MH TREATMENT AND HAD IMPROVED PTSD SYMPTOMS IN THE PAST WHEN MEDICATED AND ATTENDING TREATMENT MORE REGULARLY. b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): No response provided. 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? [X] Yes[ ] No[ ] Not applicable (N/A) If yes, list which symptoms are attributable to each diagnosis and discuss whether there is any clinical association between these diagnoses: ALCOHOL USE DISORDER - CONTINUED EXCESSIVE USE OF ALCOHOL DESPITE SOCIAL AND LEGAL CONSEQUENCES, DEPRESSED AND ANXIOUS AFFECT, DECREASED MEMORY, POOR JUDGMENT, DECREASED MOTIVATION, INTERPERSONAL DIFFICULTY, DIFFICULTIES IN A WORK SETTING, IMPULSE CONTROL DIFFICULTIES, DECREASED CONCENTRATION, PERSISTENT NEGATIVE COGNITIONS, IRRITABILITY, ANGER OUTBURSTS, INSOMNIA, DECREASED INTEREST. ANTISOCIAL PERSONALITY DISORDER - CONTINUED CRIMINAL ACTS WITH 8 FELONIES AND REPEATED INCARCERATION, CONNING OTHERS FOR PERSONAL PROFIT, IMPULSIVITY, IRRITABILITY, AGGRESSIVENESS, RECKLESS DISREGARD FOR SAFETY OF SELF OR OTHERS, CONSISTENT IRRESPONSIBILITY WITH REPEATED FAILURE TO HONOR FINANCIAL OBLIGATIONS, LACK OF REMORSE, INTERPERSONAL DIFFICULTY IN THE WORKPLACE, POOR JUDGMENT. PTSD - FLASHBACKS, NIGHTMARES, AVOIDANCE, EMOTIONAL NUMBING, HYPERVIGILANCE, SUSPICIOUSNESS. c. Does the Veteran have a diagnosed traumatic brain injury (TBI)? [ ] Yes[X] No[ ] Not shown in records reviewed Comments, if any: TBI EXAM DATED 5/18/15 DID NOT DIAGNOSE TBI BUT PTSD AND ALCOHOL DEPENDENCE 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 reduced reliability and productivity 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? [X] Yes[ ] No[ ] No other mental disorder has been diagnosed If yes, list which portion of the indicated level of occupational and social impairment is attributable to each diagnosis: ALCOHOL USE DEPENDENCE, SEVERE - SOCIAL AND OCCUPATIONAL IMPAIRMENT IN MOST AREAS INCLUDING SCHOOL, FAMILY RELATIONSHIPS, INTERPERSONAL RELATIONS, WORK, MOOD, JUDGMENT AND IMPULSE CONTROL. ANTISOCIAL PERSONALITY DISORDER - SOCIAL AND OCCUPATIONAL IMPAIRMENT IN MOST AREAS INCLUDING SCHOOL, FAMILY RELATIONSHIPS, INTERPERSONAL RELATIONS, WORK, MOOD, JUDGMENT AND IMPULSE CONTROL. PTSD - REDUCED RELIABILITY AND PRODUCTIVITY. 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 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 [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: CP PTSD REVIEW EXAM DATED 4/30/15 WAS ALSO REVIEWED. b. Was pertinent information from collateral sources reviewed? [X] Yes[ ] No If yes, describe: VET'S FIANCEE AMBER ACTIVELY PARTICIPATED IN TODAY'S EXAM. BOTH WERE TEARFUL DURING THE EXAM. 2. Recent History (since prior exam) ------------------------------------ a. Relevant Social/Marital/Family history: MR Xxxx IS A 3X YEAR OLD SINGLE, UNEMPLOYED, CAUCASIAN MALE VETERAN OF THE MARINE CORPS WHO SERVED IN IRAQ AND IS 70% SC FOR PTSD. SINCE HIS LAST C&P PTSD EXAM ON 4/30/15, HE CONTINUES TO BE SINGLE BUT LIVES WITH HIS FIANCEE AND THEIR 2 YEAR OLD DAUGHTER IN A HOME THAT THEY RECENTLY PURCHASED. HE DESCRIBED THEIR RELATIONSHIP AS CATASTROPHIC SINCE "I CAN'T EVER DO ANYTHING RIGHT". HE SAID THEY ARGUE CONSTANTLY BUT PUT ON A HAPPY FACE WHEN AROUND HER FAMILY. HE SAID SHE IS WORN OUT FROM DEALING WITH HER PTSD. HIS 2/3/16 SW NOTE INDICATED THAT HE CHEATED RECENTLY ON HIS FIANCEE AND THAT STRAINED THEIR R ELATIONSHIP. HE HAD ALTERCATIONS WITH HER FAMILY MEMBERS. IN 10/15, VET WAS ARRESTED AFTER ASSAULTING AMBER'S STEP-FATHER, PUNCHING HIM NUMEROUS TIMES IN THE FACE AND CAUSING A BLACK EYE. CHARGES WERE DROPPED. HE MAINTAINS CONTACT WITH HIS SISTER WHO IS IN THE ARMY AND IN KANSAS. HIS FATHER LIVES AN HOUR AWAY BUT HAS LITTLE TO DO WITH THEM, TAKES THEM TO DINNER AND LEAVES. VET FEELS VERY DISTANT FROM HIS DAD. HIS MOTHER DIED NEARLY 8 YEARS AGO WHILE HE WAS INCARCERATED AND VET CONTINUES TO GRIEVE FOR HER. HE HAS SOCIAL MEDIA CONTACT WITH MILITARY FRIENDS. HE HAS ONE FRIEND THAT HE MET WHEN HE WORKED AT GOOD WILL. VET CALLS HIM TO TAKE HIM TO VA APPOINTMENTS. VET CURRENTLY LIVES IN XXXX, IL IN A HOME THAT HE AND HIS FIANCEE RECENTLY PURCHASED. HE MET ONE NEIGHBOR BUT GENERALLY HE KEEPS TO HIMSELF. HE SAID HE HAS AN AWESOME RELATIONSHIP WITH HIS 2 YEAR OLD DAUGHTER HALEY, BUT HE HAS HAD EXTREME VIOLENT BEHAVIOR IN FRONT OF HER. HE HAS YELLED AT HER AND FEARS THAT HE WILL LOSE HER IF THINGS DON'T WORK OUT WITH AMBER. IT HURTS HIM TO SEND HER TO DAYCARE RECENTLY BECAUSE HE WOULD PREFER TO TAKE CARE OF HER. A DCFS CHILD ENDANGERMENT CASE WAS FOUNDED IN 2/16 AFTER VET WAS VIOLENTLY ASSAULTING HIS FIANCEE'S STEPFATHER IN FRONT OF THE CHILD. WHILE VET STATED THAT HE HAS NO/FEW FRIENDS, HIS 6/6/16 PSYCHIATRIST NOTE INDICATED THAT HE GOES OUT TO BARS DRINKING WITH FRIENDS. b. Relevant Occupational and Educational history: VETHAS BEEN ATTENDING COLLEGE CLASSES SINCE 2006 COMMUNITY COLLEGES AND FAILED 3 CLASSES LAST SEMESTER BUT PASSED HIS MATH CLASS. HE HAS BEEN TRYING TO GET HIS ASSOCIATE'S DEGREE FOR THE PAST 10 YEARS AND HOPES TO GET A DEGREE IN SOCIAL WORK EVENTUALLY. HIS GPA IS LESS THAN 1.0. HE TOOK 3 ONLINE CLASSES WHICH HE FAILED BUT PASSED THE MATH CLASS IN THE CLASSROOM CLASS. HE DIDN'T ASSOCIATE WITH TEACHERS OR OTHER STUDENTS. VET LAST WORKED FULL TIME AT GOOD WILL INDUSTRIES FROM 2/13 TO 4/15, WAS PROMOTED TO KEYHOLDER, THEN WAS TERMINATED IN 4/15. REASONS FOR THE TERMINATION WERE UNCLEAR BUT DOCUMENTS FROM WORK INDICATED THAT HE HAD LOUD VERBAL ALTERCATION WITH A COWORKER IN 1/14, WAS ABSENT 8 TIMES IN 12 MONTHS AND WORKED 3 PARTIAL SHIFTS BY 12/14, AND POINTED HIS FINGER AT COWORKERS CAUSING TENSION AT WORK ON 12/18/14. THERE WAS NO OTHER DOCUMENTATION OF WORK PROBLEMS SUBMITTED TO INDICATE WHY HE WAS TERMINATED IN 4/16. HE HAS HAD NO OTHER PAID WORK SINCE 4/15. MH NOTES INDICATED THAT HE WAS NOT LOOKING FOR EMPLOYMENT BUT WAS GOING TO COLLEGE FULL TIME AND WATCHING HIS YOUNG DAUGHTER WHILE HIS WIFE WORKED. THERE WAS NO EVIDENCE THAT HE HAD APPLIED FOR WORK BUT HIS 8 FELONIES, LOSS OF DRIVER'S LICENSE (SINCE 2006), 3RD DUI(IN 2010), AND CONTINUED CRIMINAL BEHAVIOR ARE LIKELY TO INTERFERE WITH OBTAINING WORK. VET'S MH NOTES REPEATEDLY NOTE THAT HE IS ONLY VIOLENT AND AGGRESSIVE WHEN DRINKING. THERE WAS NO EVIDENCE IN TODAY'S EXAM OR IN REVIEW OF VET'S MH RECORDS SINCE 2006 THAT HIS PTSD WAS EVER SEVERE ENOUGH, BY ITSELF, TO PREVENT HIM FROM OBTAINING OR MAINTAINING SUBSTANTIALLY GAINFUL EMPLOYMENT. c. Relevant Mental Health history, to include prescribed medications and family mental health: SINCE 4/15, HE HAS BEEN FOLLOWED BY SHAWN SLAGLE, SW AND DR LIM, PSYCHIATRIST AT THE LASALLE CBOC. HE HAS NOT BEEN COMPLIANT WITH TREATMENT AND WAS TOLD BY HIS SW ON 2/3/16 THAT NOT GETTING TREATMENT FOR HIS PTSD IS THE PROBLEM, NOT HIS PTSD. HE DID NOT SEE HIS PSYCHIATRIST FROM 10/26/15 UNTIL 6/6/16 AND LAST FILLED ALL HIS MH MEDICATIONS IN 2/16. HE ONLY CONTACTED HIS PSYCHIATRIST IN 11/15 AND 12/15 WHEN HE NEEDED FORMS DOCUMENTING HIS TREATMENT FOR COURT DATES. HE RETURNED TO MH ON 6/6/16 DUE TO HAVING A COURT DATE ON 6/30/16 THAT WILL DECIDE WHETHER HE GOES TO JAIL OR RESIDENTIAL TREATMENT. HE DID NOT SEE HIS SW FOR INDIVIDUAL THERAPY BETWEEN 6/15 AND 2/16, MISSING SEVERAL APPOINTMENTS. HE APPLIED FOR ADMISSION TO LOVELL'S SDTU PROGRAM (RESIDENTIAL TRAUMA TREATMENT) BUT WAS TOLD THAT HE HAD TO COMPLETE SUBSTANCE ABUSE TREATMENT FIRST SINCE HIS SUBSTANCE USE WAS STILL HIGH. HE HAS BEEN ENCOURAGED TO ENTER THE SDTU AT LOVELL VAMC BY HIS SW SINCE 8/27/12 BUT HAS REFUSED AND NOT FOLLOWED THROUGH. A PHONE INTERVIEW WITH THE SDTU WAS HELD ON 5/3/16 AND VET WAS REFERRED TO THE MHRRTP TO TREAT HIS ADDICTIONS BEFORE ADDRESSING TRAUMA WORK. HIS ADMISSION TO THE SDTU IS DELAYED UNTIL HE COMPLETES ADDICTIONS TREATMENT. HE HAS AN INTERVIEW WITH THE MHRRTP PROGRAM ON 6/20/16. CURRENTLY, HE WILL BE TAKING DULOXETINE AND TRAZODONE FOR HIS PTSD AND NALTREXONE FOR ALCOHOL CRAVINGS. THEY WERE ORDERED ON 6/7/16 BUT VET HAS NOT RECEIVED THEM YET. HE STOPPED TAKING MH MEDS AFTER 2/16 AND DIDN'T REORDER MEDICATIONS AFTER THEY RAN OUT. HE WENT TO ILLINOIS VALLEY COMMUNITY HOSPITAL ER WHEN INTOXICATED ON 10/25/15 AND WANTED TO TRANSFER TO 2S AT HINES BUT VET INSISTED ON A PRIVATE BED. WHEN HE WAS TOLD THEY COULDN'T GUARANTEE A PRIVATE BED, VET REFUSED TO GO. HE WAS DISCHARGED FROM THE COMMUNITY HOSPITAL AFTER A FEW HOURS OF OBSERVATION. VET CLEARLY DID BETTER WITH PTSD SYMPTOMS WHEN HE WAS NOT DRINKING, ACCORDING TO MULTIPLE MH NOTES. HE HAD GOOD RESPONSE TO MH MEDICATIONS BUT STOPPED TAKING THEM OR DIDN'T TAKE THEM AS PRESCRIBED. HE OFTEN SEEKS OUT MH TREATMENT WHEN HE IS IN LEGAL TROUBLE IN ORDER TO NOT FACE CONSEQUENCES FOR HIS ACTIONS. HE HAS USED HIS PTSD AND ALCOHOL USE DISORDER DIAGNOSES TO AVOID JAIL TIME. HE HAD NO SUICIDE ATTEMPTS OR PSYCHIATRIC HOSPITALIZATIONS IN THE PAST YEAR. IN FACT, HE HAD NO PSYCHIATRIC HOSPITALIZATIONS SINCE 3/13. IT IS IMPORTANT TO NOTE THAT VET HAS A GREAT DEAL OF MENTAL ILLNESS IN HIS FAMILY THAT WAS NOT NOTED ON PRIOR C&P PTSD EXAMS. HIS SISTER WAS HOSPITALIZED FOR DEPRESSION IN HIGH SCHOOL AND TAKES ANTIDEPRESSANTS, A COUSIN COMMITTED SUICIDE A FEW YEARS AGO OF A GSW TO THE HEAD (PER HIS 8/12 MH INTAKE NOTE), HIS PATERNAL AUNT AND UNCLE HAVE PSYCHIATRIC PROBLEMS, AND VET WAS A VICTIM OF PHYSICAL ABUSE ACCORDING TO HIS 7/6/06 SARP ASSESSMENT. d. Relevant Legal and Behavioral history: SINCE 4/15, VET WAS ARRESTED ON 11/28/15 AND CHARGED WITH BATTERY FOR HITTING AMBER'S STEPFATHER BUT THEY DROPPED THE CHARGES. HE WAS ARRESTED FOR DRIVING ON A REVOKED LICENSE IN 3/16. VET HAD 3 DUIS AND HAS NOT HAD A DRIVER'S LICENSE SINCE 2006. HE HAS A COURT DATE PENDING ON 6/30 REGARDING HIS LATEST OFFENSE. HE MAY GO TO JAIL OR MAY BE ALLOWED TO ENTER RESIDENTIAL TREATMENT. HE HAS HAD CHRONIC DIFFICULTY WITH BEING IN DEBT DUE TO HIS SUBSTANCE ABUSE, IMPULSE CONTROL, CREDIT CARDS AND LEGAL EXPENSES. e. Relevant Substance abuse history: SINCE 4/15, VET HAS DRANK EXCESSIVELY. HE WOULD LIKE TO DRINK EVERY NIGHT AND TRIES TO MANIPULATE AMBER TO BE ABLE TO DRINK. HE WILL DRINK A 6 PACK OR BOTTLE OF WINE PER SITTING. THEIR HOUSE IS 1 BLOCK AWAY FROM A BAR AND 2 BLOCKS FROM A CONVENIENT STORE. WHEN AMBER COMES HOME FROM WORK, THERE WILL BE ALCOHOL IN THE REFRIGERATOR OR EMPTY BOTTLES IN THE TRASH. HE STORMS OUT WHEN ARGUING WITH HER AND GOES TO THE BAR WHERE HE CONSUMES 6+ DRINKS. ALCOHOL WAS INVOLVED BEFORE VET BECAME VIOLENT WITH HER FATHER IN 11/15. HE PUSHED AMBER IN 10/15 WHEN SHE CALLED THE POLICE DURING HIS INTOXICATED RAGE. CURRENTLY, HE DRANK HEAVILY ON MEMORIAL DAY, BINGE DRINKS, THEN TRIES NOT TO DRINK. HE LAST DRANK LAST WEEK WHEN HE HAD 2 GLASSES OF WINE. VET SMOKES MARIJUANA OCCASIONALLY, 1-2 TIMES PER MONTH. ON 6/6/16, DR LIM REPORTED THAT HE USES IT 2-3 TIMES PER MONTH. HE HAS NOT ACTIVELY SOUGHT IT OUT RECENTLY AND LAST USED IT 2 WEEKS AGO. IT UPSETS AMBER SO HE TRIES NOT TO. IT IS IMPORTANT TO NOTE THAT VET'S 8/21/12 MH INTAKE NOTE AT HINES INDICATED THAT VET DRANK ALCOHOL SINCE 17 IN HIGH SCHOOL AND USED MARIJUANA SINCE AGE 16. HE BECOMES AGGRESSIVE AND VIOLENT WHEN HE IS INTOXICATED AND IT LEADS TO LEGAL PROBLEMS. HIS 7/1/06 ALCOHOL TREATMENT NOTE INDICATED THAT ALCOHOLISM WAS PREVALENT ON BOTH SIDES OF THE FAMILY, ACCORDING TO VET'S PARENTS. HIS FATHER AND MATERNAL UNCLE WERE ALCOHOLIC AND HIS MATERNAL UNCLE ABUSED DRUGS. VET ALSO USED COCAINE 10 TIMES, MOST RECENTLY IN 2010, AND USED MUSHROOMS, LSD AND ECSTASY SEVERAL TIMES IN 2006, ACCORDING TO HIS 8/12 MH INTAKE NOTE. ON 8/2/06, A BIOPSYCHOSOCIAL ASSESSMENT INDICATED THAT VET'S ALCOHOL AND DRUG USE INTERFERED WITH HIS SCHOOL PERFORMANCE. VET HAD A HISTORY OF ABUSING PRESCRIPTION NARCOTICS BUT SAID HE HAS NOT IN THE PAST YEAR. f. Other, if any: VET HAS ANNIVERSARY REACTIONS RELATED TO HIS FRIEND DYING IN IRAQ IN APRIL 2004, HIS MOTHER'S DEATH IN 5/08. HIS FIANCEE SAID SOMETHING ALWAYS HAPPENS IN THE SPRING WITH VET'S BEHAVIOR. 3. PTSD Diagnostic Criteria --------------------------- Please check criteria used for establishing the current PTSD diagnosis. The diagnostic criteria for PTSD, are from the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5). The stressful event can be due to combat, personal trauma, other life threatening situations (non-combat related stressors.) 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 #6 - "Other symptoms". 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) [X] Witnessing, in person, the traumatic event(s) as they occurred to others 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, distorted cognitions about the cause or consequences of the traumatic event(s) that lead to the individual to blame himself/herself or others. [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] Reckless or self-destructive behavior. [X] Hypervigilance. [X] Exaggerated startle response. [X] Problems with concentration. [X] Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep). Criterion F: [X] The duration of the symptoms described above in Criteria B, C, and D are more than 1 month. Criterion G: [X] The PTSD symptoms described above cause 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. 4. Symptoms ----------- For VA rating purposes, check all symptoms that actively apply to the Veteran's diagnoses: [X] Depressed mood [X] Anxiety [X] Suspiciousness [X] Chronic sleep impairment [X] Mild memory loss, such as forgetting names, directions or recent events [X] Impaired judgment [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] Impaired impulse control, such as unprovoked irritability with periods of violence 5. Behavioral Observations: --------------------------- VET ARRIVED EARLY FOR TODAY'S EXAM AND WAS ACCOMPANIED BY HIS FIANCEE AMBER. HE DISPLAYED DEPRESSED AFFECT DURING THE EXAM AND BECAME TEARFUL AT SEVERAL TIMES. SPEECH, BEHAVIOR, AFFECT, THOUGHT AND EYE CONTACT WERE OTHERWISE WITHIN NORMAL LIMITS. APPEARANCE, GROOMING AND HYGIENE WERE ACCEPTABLE. 6. Other symptoms ----------------- Does the Veteran have any other symptoms attributable to PTSD (and other mental disorders) that are not listed above? [X] Yes[ ] No If yes, describe: HE REPORTED PANIC ATTACKS WHERE HE FEELS ANGRY AND CAN'T CONTROL THINGS. THESE ARE ANGER ATTACKS, NOT ACTUAL PANIC ATTACKS. HIS FIANCEE NOTED THAT HE EATS EXCESSIVELY, EATING 28 WHITE CASTLE HAMBURGERS AND AN ENTIRE CAKE IN 2 DAYS. HIS WEIGHT FLUCTUATES AND HE EATS DURING THE NIGHT. H AVOIDS WATCHING THE NEWS, CONVERSATIONS ABOUT THE MILITARY, AND TELLING OTHERS THAT HE WAS A MARINE. HE HAS LOST INTEREST IN GOING OUT, DOING RECREATIONAL THINGS THAT DON'T INVOLVE DRINKING, AND GOING TO STATE PARKS. HE SLEEPS 4-5 HOURS WITH MEDICATION. 7. Competency ------------- Is the Veteran capable of managing his or her financial affairs? [X] Yes[ ] No 8. Remarks, (including any testing results) if any: --------------------------------------------------- MR Xxxx CONTINUES TO MEET CRITERIA FOR PTSD BUT HIS PTSD IS OF MODERATE SEVERITY, WHICH INDICATES A DECREASE IN SEVERITY SINCE HIS LAST C&P PTSD REVIEW EXAM IN 4/15. HIS PTSD CURRENTLY CAUSES REDUCED RELIABILITY AND PRODUCTIVITY IN A WORKPLACE SETTING. THERE WAS NO EVIDENCE IN TODAY'S EXAM OR IN REVIEW OF VET'S VA TREATMENT RECORDS SINCE 2006, THAT HIS PTSD WAS EVER SEVERE ENOUGH TO RENDER HIM UNABLE TO OBTAIN OR MAINTAIN SUBSTANTIALLY GAINFUL EMPLOYMENT. HE WAS ABLE TO KEEP THE SAME FULL TIME JOB FROM 2/13 TO 4/15 AND WAS PROMOTED TO KEYHOLDER AT GOOD WILL. THERE WAS NO EVIDENCE TO DOCUMENT THE REASON THAT HE LOST HIS JOB IN 4/15. HIS MH NOTES INDICATE THAT HE WAS NOT APPLYING FOR OTHER WORK BUT PLANNED TO GO TO COLLEGE FULL TIME AND WATCH HIS DAUGHTER WHILE HIS WIFE WORKED. HIS MOST DISABLING CONDITIONS ARE HIS ALCOHOL USE DISORDER AND ANTISOCIAL PERSONALITY DISORDER, WHICH CAUSE SOCIAL AND OCCUPATIONAL IMPAIRMENT IN MOST AREAS OF HIS LIFE INCLUDING WORK, SCHOOL, FAMILY RELATIONS, INTERPERSONAL RELATIONSHIPS, JUDGMENT, IMPULSE CONTROL, THOUGHT AND MOOD. THERE IS NO EVIDENCE TO SUGGEST THAT VET'S PERSONALITY DISORDER OR ALCOHOL USE DISORDER ARE RELATED TO THE MILITARY. VET WAS USING ALCOHOL AND CANNABIS SINCE AGE 17 AND 16 RESPECTIVELY, AND HAS A STRONG BIOLOGICAL PREDISPOSITION FOR A SUBSTANCE USE AND A MH DISORDER. HE HAS MULTIPLE FAMILY MEMBERS (INCLUDING HIS FATHER AND SISTER) WITH EITHER SUBSTANCE USE DISORDERS OR MH DISORDERS AND HAD A COUSIN COMMITTED SUICIDE BY GUNSHOT WOUND TO THE HEAD. THERE IS NO EVIDENCE TO SUGGEST THAT EITHER OF VET'S CONDITION WORSENED BEYOND THEIR EXPECTED PROGRESSION AS A RESULT OF MILITARY EXPERIENCES. ALTHOUGH VET HAS BEEN INVOLVED IN SUBSTANCE ABUSE AND MH TREATMENT AT THE VA SINCE 2006, MUCH OF HIS TREATMENT WAS PRECIPITATED BY LEGAL PROBLEMS INCLUDING HIS 3 DUIS AND MOST RECENTLY HIS ARREST FOR DRIVING ON A REVOKED LICENSE. HE ORIGINALLY CAME FOR ALCOHOL TREATMENT AT DANVILLE VA ON 6/30/06 AFTER GETTING 2 DUIS IN A 5 MONTH PERIOD. AT THE TIME, HE HAD A LARGE SOCIAL NETWORK OF FRIENDS WHO ABUSED ALCOHOL AND DRUGS, AND WAS EXPERIMENTING WITH COCAINE, ACID, ECSTASY AND MUSHROOMS, BESIDES DRINKING 12-15 BEERS PER NIGHT AND USING 2 GMS OF CANNABIS PER DAY. HIS 11/2/05 MH NOTE INDICATED THAT HE WAS DOING MUCH BETTER ON CELEXA FOR ANXIETY BUT HE STOPPED TAKING IT. HIS 10/26/15 PSYCHIATRIST NOTE INDICATED THAT HE ONLY GOT AGITATED WHEN INTOXICATED. DESPITE URGING FROM HIS SW TO GET RESIDENTIAL SDTU TREATMENT SINCE 8/12,VET HAS BEEN UNWILLING TO FOLLOW UP UNTIL NOW WHEN HE FACES JAIL TIME OR RESIDENTIAL TREATMENT. HIS MH NOTES INDICATE THAT HE DOES BETTER WHEN HE IS SOBER AND WHEN HE IS COMPLIANT WITH MH MEDICATION AND TREATMENT. IT IS LIKELY THAT VET WOULD BE ABLE TO MAINTAIN SUBSTANTIALLY GAINFUL FULL TIME EMPLOYMENT AND HEALTHIER RELATIONSHIPS IF HE REMAINED SOBER AND COOPERATED WITH TREATMENT ON A CONSISTENT BASIS. TODAY'S DIAGNOSES OF ALCOHOL USE DISORDER, ANTISOCIAL PERSONALITY DISORDER AND PTSD ARE BASED UPON DSM-5 CRITERIA AND ICD-10 CODING. /es/ KATHLEEN PARKER, PSY.D. Signed: 06/10/2016 17:12 ------------------------------------------------------------------------- ----------- END OF MY HEALTHEVET PERSONAL INFORMATION REPORT ----------Removed personal identification information.
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Berta
This exam result is drastically different from the other one you had last year. I feel they definitely might propose a reduction but since the PTSD DX is still established, you might be able to c
Gastone
This last C & P appears to be way more comprehensive and Forensic regarding your MH issues. If I were you, I think I would be very concerned regarding a possible Reduction. It would be a real
Buck52
Jroocan, if your sent a proposal to reduce...you keep your rating until after they prove your disability as indeed improved, they should send you a NOD Form with the proposal letter. as soon
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