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PTSD Increase C&P Results


elijahdoe

Question

I am currently rated at 50% for PTSD and just had my C&P exam for an increase.  Below is my current C&P results. Any input would be appreciated on to what my outcome may be.  Thank you

 

 

                                   SECTION I:
                                   ----------
    1. Diagnostic Summary
    ---------------------
    Does the Veteran now have or has he/she ever been diagnosed with PTSD?
    [X] Yes[ ] No

    2. Current Diagnoses
    --------------------
    a. Mental Disorder Diagnosis #1: PTSD, moderate to severe, chronic
         Comments, if any: The trauamtic event was learning that a close friend
         of his killed two older female civilians.  PTSD also causes secondary
         panic attacks 2-3 times per week.

    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[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
        [ ] Veterans Health Administration medical records (VA treatment  records)
        [X] Civilian medical records
        [ ] Interviews with collateral witnesses (family and others who have
            known the Veteran before and after military service)
        [ ] No records were reviewed
        [ ] Other:
              
    b. Was pertinent information from collateral sources reviewed?
    [X] Yes[ ] No
    
      If yes, describe:
        On 11/25/2014, Dr. XXX conducted a C&P Initial Evaluation for
        PTSD and diagnosed the veteran with PTSD with panic attacks.
        
    2. Recent History (since prior exam)
    ------------------------------------
    a. Relevant Social/Marital/Family history:
          Mr. XX  is currently married to his wife of 10 years.  He describes
          the quality of his current marriage as, "loving - but my wife puts up
          with me."  He reports his irritability and anger can stress his wife.
          He adopted his wife's 14 year old daughter. He reports he has no
          friends of his own, but he reports he is friendly with many of his
          wife's friends.  He tends to avoid crowds and group social activities.
          He is quite close with his parents. His main hobby is drumming and
          working on computers. Overall his social support is limited. He reports
          that the primary effect of his psychiatric symptoms on his social
          relationships are tension and distance caused by irritability, rage
          (including yelling, swearing, and very occasional violence towards
          inanimate objects  - like punching a hole in the door), withdrawal, 
          and emotional numbing.
          
    b. Relevant Occupational and Educational history:
          Mr. XXX  highest level of education is some college.  He served in
          the Airforce.   He is currently employed as a cyber security analyst 
          at XXX a telecommunications company called XXX.   He has worked at XXX
          since 2011. In 2012, he was written up for "going off on a customer."
          He reports he works from home or calls in sick 4-5 days a month due to
          feeling stressed.  He reports during times of stress he impulsively
          loses his temper when talking with customers or makes careless
          mistakes. He is a lead, and he has five other analysists who report to
          him.
          
    c. Relevant Mental Health history, to include prescribed medications and
       family mental health:
          Mr. XXX denied history of psychiatric hospitalization, receiving
          out-patient therapy, receiving any type of psychopharmacological
          treatment, or prior suicide attempts.  He has been referred to a
          psychiatrist by his PCP but he is not currently engaged in therapy. He
          receives medication management from his private PCP, and he is
          currently maintained on a regimen of  Zoloft, hydroxyzine, prazosin 
and diazepam.
          
    d. Relevant Legal and Behavioral history:
          No arrests.  Received an article 15 in the military after he learned of the murders.
          
    e. Relevant Substance abuse history:
       No response provided.
       
    f. Other, if any:
       No response provided.
       
    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] Witnessing, in person, the traumatic event(s) as they
                       occurred to others
                   [X] Learning that the traumatic event(s) occurred to a close
                       family member or close friend; cases of actual or
                       threatened death must have been violent or accidental; or,
                       experiencing repeated or extreme exposure to aversive
                       details of the traumatic events(s) (e.g., first responders
                       collecting human remains; police officers repeatedly
                       exposed to details of child abuse); this does not apply to
                       exposure through electronic media, television, movies, or
                       pictures, unless this exposure is work related.

       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).

       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] 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] 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] 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] 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

    5. Behavioral Observations:
    ---------------------------
       Mr. XXX  was casually dressed, and was cooperative throughout the
       examination.  His speech was fluent.  His psychomotor behavior was
       appropriate.  His affect was constricted and his mood was anxious.  His
       insight was intact.  Thought process was linear, goal directed, and 
future oriented.   No reported hallucinations or delusions. No reported 
homicidal or suicidal ideation.
       
    6. Other symptoms
    -----------------
    Does the Veteran have any other symptoms attributable to PTSD (and other
    mental disorders) that are not listed above?
    [ ] Yes[X] No
    
    7. Competency
    -------------
    Is the Veteran capable of managing his or her financial affairs?
    [X] Yes[ ] No
    
    8. Remarks, (including any testing results) if any:
    ---------------------------------------------------
       Veteran's PTSD and panic attacks currently cause moderate
       socio-occupational impairment.
       

Edited by elijahdoe
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Looks like you will continue at the 50% rate bud based on the Social and Occupational Impairment Statement. Good luck and keep us posted

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After looking at my C&P results, the examiner left out a lot of my symptoms.

 

I also typed up a letter for the VA explaining all the problems that I am having including the information from my primary doctor.

 

I hope that take those other items into consideration because it annoys me when the C&P examiner does not include all of the problems that I am having.

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