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Coltrane49

C&P Results any feedback would be greatly appreciated

Question

SECTION I:

---------- 1. Diagnostic Summary

---------------------
Does the Veteran have a diagnosis of PTSD that conforms to DSM-5 criteria based on today's evaluation?
[ ] Yes [X] No

If no diagnosis of PTSD, check all that apply:

[X] Veteran's symptoms do not meet the diagnostic criteria for PTSD under

DSM-5 criteria
[X] Veteran has another Mental Disorder diagnosis. Continue to complete

this Questionnaire and/or the Eating Disorder Questionnaire:

2. Current Diagnoses
--------------------
a. Mental Disorder Diagnosis #1: Major Depressive Disorder, with anxious

distress
Comments, if any:

Major Depressive Disorder is considered as progression of the previously diagnosed condition of Specified depressive disorder.

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?

[ ] Yes [X] No

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 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?
[ ] 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 [ ] 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:

[ ] 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
[ ] 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
[ ] Other:

b. Was pertinent information from collateral sources reviewed? [ ] Yes [ ] No

C&P examination dated 07/29/14 - Veteran was diagnosed with "Specified depressive disorder which is at least as likely as not a condition that was diagnosed in military service as depression and anxiety" and "Alcohol use disorder is at least as likely as not secondary to specified depressive disorder."

a. Stressor #1: sexual assualt (see above)

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: Non-combat event

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.

Marker identified by regional office

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] Intense or prolonged psychological distress at exposure 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: No response provided.

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

of
the traumatic event(s) that lead to the individual to blame himself/herself or others.

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)

the following:
[X] Persistent, distorted cognitions about the cause or consequences

of
No response provided.

Criterion F:
No response provided.

Criterion G:
No response provided.

Criterion H:
No response provided.

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 that occur weekly or less often

[X] Chronic sleep impairment


[X] Disturbances of motivation and mood

6. Behavioral Observations --------------------------
No response provided

7. 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:
Major Depressive Disorder:
- Depressed mood
- Markedly diminished interest or pleasure in almost all activities
- Increase in appetite

- Hypersomnia (veteran reported sleeping 12 hours a day)

- Fatigue


- Feelings of worthlessness


- Inappropriate guilt (veteran blames himself for assault, ruminates about his actions)

- Recurrent thoughts of death (veteran stated that he thinks about "glamourous?romantic ways to die")


- Anxious distress: Feeling keyed, difficulty concentrating because
of worry, fear that something awful may happen

TESTING:


BDI-2 Score: 42 indicates severe depression.


BAI Score: 35 indicates moderate anxiety.


The veteran completed the Beck Anxiety Inventory (BAI) and the Beck
Depression Inventory-II (BDI-II). These are standardized self-report measures that are widely used to assess current levels of depressive and anxiety symptoms. As self-report measures, the items are transparent in their intent, which makes intentional over- and under-reporting of symptoms possible.

Veteran was asked how his experience of sexual assault has affected him. He replied that he has no confidence in himself and his sexual desire is "almost gone." He noted that he is now "terrified of ntimacy." He said he was very social in the past and now stays at home.

Veteran was given an opportunity to provide any additional information regarding his mental health and overall functioning that was not covered in the structured clinical interview. He indicated that he did not have anything else to add. "I don't
think so."

8. Competency
-------------
Is the Veteran capable of managing his or her financial affairs?

[X] Yes [ ] No

9. Remarks, (including any testing results) if any --------------------------------------------------

Veteran recently sought mental health services, antidepressant medication, to treat his reported symptoms. It is plausible that with ongoing treatment (and the possible addition of evidence-based psychotherapies for depression), he may experience a significant reduction in symptoms.

Veteran completed a comprehensive mental disorder C&P 07/29/2014 which was reviewed prior to this evaluation. Please refer to that examination for additional psychosocial history and past psychological complaints.

MEDICAL OPINION REQUEST

OPINION: Direct service connection
Does the Veteran have a diagnosis of (a) PTSD-MST that is at least as likely as not (50 percent or greater probability) incurred in or caused by
(the) Military Sexual Trauma during service?

EXAMINER RESPONSE:
Veteran does not have a separate diagnosis of PTSD. Symptoms associated with reported MST (see PTSD symptom section above) are already better accounted for by the diagnosis of Major Depressive Disorder with anxious distress.

In that, I am neither acting as a fact witness (not present at the time of the claimed assault) nor a detective, I can offer no meaningful opinion on whether a sexual assault occurred. Such is more appropriately the province of the trier of fact or criminal justice personnel. Instead, as a psychologist with respect to mental health, practicing within scope dictates that the only opinion I can provide there that there is a diagnosis of Major Depressive Disorder.

The diagnosis obtained was based on the criteria contained in DSM-V.

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 wouldn't worry to much about the ptsd diagnosis and would be happy with the mdd opinion the examiner opined.  You can only be rated for one mental disorder and if it's mdd instead of ptsd you will still get treatment for your problems.  I was diagnosed as mdd even though i am a combat veteran and would have thought i had ptsd.  I do have several stressors but the c&p doc said it was easier to get it rated as mdd because i had depression noted in my service medical records.  Either way i was rated at 50% for mdd.  It looks like you have the same  DSM-V diagnosis that i did. I guess if you aren't getting the right treatment then you could try to get it switched to ptsd.  JMHO!!  

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