Response to Cliche Magnet

[Mark D Worthen PsyD]

This is a reply to @Cliche Magnet's post -  PTSD's long term effects. Did you win a decision? For some reason I was not able to reply the usual way (I could not type into the box). 

Incurrence and Continuity
When did you discharge from military service, and when did you first seek mental health treatment? 

If you began to manifest symptoms of a psych disorder during service, and you sought treatment soon after discharge, and you have suffered from that same (or similar) disorder since that time, i.e., you have shown continuity of symptoms, then it is possible that VBA could find that the disorder was incurred during your military service and you are entitled to VA disability benefits. [See: 38 C.F.R. §3.303(a) and (b)].

This principle would apply whether or not your diagnosis is PTSD. In other words, if you manifested some posttraumatic stress symptoms, but not enough to satisfy the DSM-5 diagnostic criteria for the disorder, but all your psych symptoms considered collectively, for example, posttraumatic stress symptoms + depression sx + anxiety sx, do meet diagnostic criteria for another mental disorder, then that mental disorder could be service-connected, 

Service connection for a psych disorder under these incurrence and continuity principles poses some challenges, but I evaluated several veterans over the years who received disability compensation for such conditions. Usually the biggest challenge is that the veteran did not seek treatment until many years after discharge. In those cases, one of the fundamental questions the C&P examiner and the VBA adjudicator have to consider is, "If he had a mental disorder that caused functional disability for all those years, why didn't he seek help?" 

Of course, there are some very legitimate answers to that question, e.g., socialization causing men to avoid seeking help due to the narrow, rigid masculine role identity our society has historically imposed on boys and men; plus an ethos in the military to eschew mental health treatment because others will likely perceive it as a sign of weakness and incompetence.

As an aside, I should mention that if a veteran suffers from psychoses during or shortly after military service, and he or she still has disabling symptoms from the same or similar psychotic disorder, then service connection is covered under a different regulation concerning chronic conditions. [See: C.F.R. 38 §3.307 and §3.309(a)].

PTSD
If you have PTSD due to watching your friend burn to death, and your friend's tragic demise is documented, and your presence on the scene can also be demonstrated via documentation and/or lay testimony, then yes, the PTSD can be service connected. And in that case, a letter from your commander and others would be helpful. 

You could certainly seek an IME (I use the term, IPE, since I am a psychologist ;-), and that is something I do in my private practice, but frankly it costs $1000 or more and you can get a C&P exam for free. If the C&P exam ends up being inadequate and VBA denies service connection, then an IME/IPE would make more sense. Of course, that's just my opinion. You should also see what other knowledgeable people think.

Dual Role Conflict
In general, treating psychologists should not write 'nexus letters' or complete DBQs because doing so constitutes a dual role conflict.

A C&P exam is a forensic mental health evaluation, where the 'client' is VBA, the 'referral questions' are directly related to legal issues, and the goal is to conduct an independent, objective, unbiased evaluation. In terms of the C&P psychologist, he or she is an expert witness, providing expert witness testimony in a federal legal proceeding.

Psychotherapy is a treatment/helping relationship, where you are the client, the referral questions relate to helping you, and the objective is to help you achieve your recovery goals. In terms of the treating psychologist, he or she is providing a healthcare service.

As you can see, the professional relationship between the psychologist and the veteran in these two scenarios are very different. In situations like the one you mentioned, i.e., asking a treating psychologist to write a nexus letter, it's helpful to know that such treating psychologists must be very careful about being in two very different roles at the same time with the same person. Usually it is not a good idea. (See: American Psychological Association's (APA) Ethical Principles of Psychologists and Code of Conduct, Ethical Standards 3.06 and 3.07.

All the Best,

Mark

[Berta]

Dr. Mark, that is excellent info.

I am glad you raised the Chronic Presumptives as well , as to psychosis.

It is unfortunate that after the 2010 PTSD regulations came out , the VA will only accept an initial PTSD diagnosis from a VA MH provider,if the claim is initially filed after the regulation date in 2010.(July 13th 2010 ?? I think)

 After a VA PTSD diagnosis is made however, any psychologist/psychiatrist could proved an IMO/ IME to determine if a higher rating should be awarded,if the veteran claims their rating is too low.

I have seen vets here who have locked themselves into claiming PTSD but do not have proof of a stressor, as VA defines a stressor ( there is an article here on that I did years ago available under a search.)

But if they claim other theories of entitlement as well ,such as depression, acquired adjustment disorder, etc etc , they might be better able to establish an inservice nexus and VA diagnosis  that could lead to compensation.

 

 

 

 

[Cliche Magnet]

Thanks guys... The real problem for me here is that an IMO costs nearly all of my disability check which is used for rent and food.  The rest is ironically easier to deal with, just gotta follow the tracks and contact old witnesses, NCOs, and Commanders.  

 

 

[Berta]

I thought maybe I should find some recent BVA decisions on acquired adjustment disorder claims that were successful:

http://www.index.va.gov/search/va/view.jsp?FV=http://www.va.gov/vetapp16/Files2/1614766.txt

http://www.index.va.gov/search/va/view.jsp?FV=http://www.va.gov/vetapp16/Files1/1602947.txt

 

 

 

 

 

Edited June 16, 2016 by Berta

[Mark D Worthen PsyD]

5 hours ago, Berta said:

Dr. Mark, that is excellent info.

I am glad you raised the Chronic Presumptives as well , as to psychosis.

It is unfortunate that after the 2010 PTSD regulations came out , the VA will only accept an initial PTSD diagnosis from a VA MH provider,if the claim is initially filed after the regulation date in 2010.(July 13th 2010 ?? I think)

 After a VA PTSD diagnosis is made however, any psychologist/psychiatrist could proved an IMO/ IME to determine if a higher rating should be awarded,if the veteran claims their rating is too low.

I have seen vets here who have locked themselves into claiming PTSD but do not have proof of a stressor, as VA defines a stressor ( there is an article here on that I did years ago available under a search.)

But if they claim other theories of entitlement as well ,such as depression, acquired adjustment disorder, etc etc , they might be better able to establish an inservice nexus and VA diagnosis  that could lead to compensation.

Thank you @Berta! 

Yes, the VA policy regarding Initial PTSD C&P exams is not well-justified. For example, why can non-VA psychologists or psychiatrists conduct an Initial Mental Disorder C&P exam, but not an Initial PTSD exam? 

I agree that an IMO/IME can definitely help with regard to claims for an increased disability rating, and Individual Unemployability, if applicable. 

And I wholeheartedly agree about everyone being over-focused on PTSD. Of course, it's completely understandable with all the VA's emphasis on the disorder, and our society's and media's extensive coverage of PTSD.

That's mostly a good thing, btw, i.e., increasing awareness. But it has led some vets to (understandably) think they have PTSD, when they actually have another mental disorder, usually depression and/or anxiety disorders, or they have subsyndromal posttraumatic stress + depression and/or anxiety. 

When I had vets present to me for an Initial PTSD exam, and they did not have PTSD, but I thought they did have a service-related mental disorder, I would write up the report as such, and provide two 'medical opinions' with detailed rationales: 

1) The veteran does not have PTSD.

2a) But the veteran does have [other mental disorder] which was incurred during his or her military service.

2b) But the veteran does have [other mental disorder] which is proximately due to, or the result of, his or her currently service-connected [medical condition]. 

When I wrote reports like that I was technically not following the rules because C&P examiners are not supposed to "provide opinions that VBA did not ask for" (there are some exceptions). The rationale for the rule is that the veteran should file a new claim for the other mental disorder, and by doing so his or her claim could be fully developed by VBA.

That rationale does make sense in some cases, and there were times I did not give the second opinion for various reasons, but I would say something in the report about the possibility of a service-related mental disorder, and, of course, I would tell the vet to file the new claim!

Otherwise, when I did provide two opinions with rationales, which is what I did most of the time, I never had one returned to me by VBA, and the vets always received service connection for the mental disorder. Fortunately the VBA Regional Office that adjudicated most of the cases I worked on (Winston-Salem, NC) was a good one with many Raters who would go the extra mile to make it work within the regs. 

I did get dinged a couple of times by VHA (as opposed to VBA) for "giving unsolicited opinions." I just ignored those little memos. 

All the Best,

Mark

P.S. I put 'medical opinion' in single quotes because, except for VA-related cases, I would not use the term 'medical' in that context since I am a psychologist, not a physician. But that is what the VA calls C&P examiner's opinions, whether the examiner is a physician, psychologist, audiologist, or nurse practitioner. 

Edited June 16, 2016 by Mark D Worthen PsyD
forgot to say what happened when i gave 2 opinions; typo

[Berta]

Mark, when the proposed 2010 PTSD regs came out in the Federal Register , anyone could offer comments to them.

I sure did as well as many Vet reps, vet lawyers and veterans themselves. All comments to proposed new regulations are public and are carefully read by the VA.

But only about 600 of us commented and I cannot recall a single comment that was for the proposed VA MH DX requirement.That is 600 of us nationwide.

That is 600 in include civilians like me, vet reps, vet lawyers and there was as I recall a comment from John999, and I think from Carlie Cash, both   members here, but I didnt recognize anyone else's name who is a hadit member.

Of course many here use 'handles' instead of their real names and might have commented ,but I was shocked when I knew this regulation would eventually make it more difficult for vets filing for PTSD after July 2010, 

yet so few , even from the major vet orgs, took the time to even respond to the link I put here for it in the federal register.

If there had been 6 thousand comments against the new regulation,maybe  it could have made a difference.

The good part is that most vets with pending PTSD claims, prior to July 2010 were 'grandfathered ' into the older regulations.( I hope)

And I sure agree that some vets think they have PTSD but have a different MH issue.

( and I even have a friend who seems to 'want' to have PTSD.)

 

 

 

 

 

 

 

 

 

 

[Andyman73]

Mark,

I, for one, am thanking God that you are a member here.  I messaged you earlier with a brief rundown on my issue(one of many).

Thank you for giving such thought out opinions and answers that even the lowliest laymen among us(like me) can understand them.

I am one of those men you mentioned earlier, who went far too long, without treatment, for fear of public humiliation. Or, like in my case more specifically, I thought help wasn't there for me, but for those that were in combat or combat arms MOSs. Or experienced non-combat traumatic events, and/or MST. Since I have none of those in my history, I just hid myself away in the darkest corner closet of my mind, never seeking the light of day(help).  Even now, having been in treatment at my VAMC, for a year, have barely opened that closet door. My VA MH doc likes to talk about what's bothering me at the moment, which is all well and good, too.  But that's like washing your car, when it needs a frame off resto-mod to make it right.

Anyway...