Hi all! This is so confusing to me. It seems like the box she checked is in direct conflict with the symptoms she chose. I feel like that lowballed me, am I looking at this right? Took almost 2.5 hrs and this is what I got:
I removed doctors names and personal information but again, I don't understand what this means. Can someone please take a look and tell me? I am sorry it is long, I am just really confused by the language of it. In a PCL-5, what is a 72 out of 38? This is all jibberish to me. Can someone please help?
Initial Post Traumatic Stress Disorder (PTSD) Disability Benefits Questionnaire *
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 [ ] No2. Current Diagnoses --------------------
a. Mental Disorder Diagnosis #1: Post Traumatic Stress 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 [X] No [ ] Not shown in records reviewed4. 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 occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation
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
1. Evidence Review ------------------ Evidence reviewed (check all that apply): [X] VA e-folder (VBMS or Virtual VA) [X] CPRS [X] Other (please identify other evidence reviewed): The veteran brought civilian records of diagnoses and procedures to session.
2. History ---------- a. Relevant Social/Marital/Family history (pre-military, military, and post-military):The veteran was referred for a DBQ Initial PTSD evaluation for Post Traumatic Stress Disorder. Information in this assessment is based on the veteran's self-report unless otherwise indicated. The veteran is a 32 year old divorced female. She said that her mother had her when she was 14 years old. She described her childhood as abusive and very difficult. Her mother was "a junkie." Her mother was very abusive emotionally and physically, and two of her stepfathers were also abusive. She said that she tended to take the punishment for her two younger brothers. Her mother was stabbed to death by her brothers' father when the veteran was 9 years old, and she and her brothers witnessed the stabbing. Her own father was declared unfit, so she went into foster care. She has 14 siblings total, but was only raised with the two younger brothers. She is still in contact with some of her siblings. Her brother lives with her. One sister committed suicide recently due to the deaths of her husband and children in a car accident. The veteran has been married 3 times. She stated that she married the first time in order to get her brother out of foster care. He came to live with her and her husband. They had no children. She married a second time and they had 2 sons, now ages 11 and 9. She had one daughter with her third husband, age 4. She stated, "Sometimes I marry people because I'm bored and I don't have friends." She is currently involved in a relationship with her fianc?, FUTURESPOUSE. She stated that this is a good relationship and that he is loving and supportive. He lives in the household with her, her brother, and her 3 children. When asked about friends, she stated that she doesn't have any friends. She considers FUTURE SPOUSE and her little brother to be her friends. She does not associate with anyone else. She stated that she does not like to go out and does not like to interact with people. When asked about an average day, she stated that she works and cares for her children and FUTURESPOUSE. She enjoys reading.
b. Relevant Occupational and Educational history (pre-military, military, and post-military):The veteran has a bachelor's degree in Business, and an associate's degree in Criminal Justice. She would like to continue her education to get a master's degree in Emergency and Disaster Management. Although she claims to have ADHD, she denied having any symptoms of it during childhood and denied having any academic difficulties. Her high school transcripts indicate that she had a B average. She stated that her grades have been good throughout her academic career and that she was always on the dean's list in college. She currently works in administration and operations. She stated that it is a small company and she does everything - HR, IT, and finance for it. She has held this position for 10 months. She stated that she anticipates that she will be fired soon due to missing a lot of work. Because it is a small company, it does not honor FMLA policies. She said that she misses work because she does not sleep well. When she has a rough night, she knows that she will be irritable so she does not go in the next day. Prior to her current position, she worked at Comcast. She had maintained that position for one year. She said that she had difficulties with attendance at that job too. She served in the U.S. Army. She was released for medical reasons due to a fractured ankle. She cited an incident of MST during her service that occurred in March 2004. She stated that she had gone to a party, had been drinking, and was sleeping it off. She awoke to find one man having sex with her, another putting his pants on, and a third masturbating beside her. She stated that she became pregnant from this encounter and had an abortion. There is do cumentation of mental health treatment in her STR from 7/8/04 to 10/15/04, with diagnoses of Adjustment Disorder, Alcohol Abuse, Cyclothymia, and Depression.
c. Relevant Mental Health history, to include prescribed medications and family mental health (pre-military, military, and post-military):The veteran was psychiatrically hospitalized at the Meadows in 1997 and 1998, then again in 2008. She has had two suicide attempts. There is documentation of mental health treatment in her STR from 7/8/04 to 10/15/04, with diagnoses of Adjustment Disorder, Alcohol Abuse, Cyclothymia, and Depression. She received mental health treatment on an outpatient basis in the community until recently.CPRS records indicate that she attended intake appointments at the VA in June 2016 with a psychiatrist,, and a social worker, but did not make any follow up appointments due to a stated need to refrain from missing work. Her CPRS chart indicates diagnostic impressions of anxiety and chronic depression. She stated that she had been prescribed Adderall and Xanax in the community but Dr would not refill these and she has not taken any psychotropic medication since April 2016. He had offered psychological testing to confirm ADHD but she declined his offer. She said that she had taken several SSRIs in the past but they did not help. She endorsed current symptoms indicative of Post Traumatic Stress Disorder.
d. Relevant Legal and Behavioral history (pre-military, military, and post-military):The veteran denied any past or current problems in this area.
e. Relevant Substance abuse history (pre-military, military, and post-military):The veteran stated that she had problems with alcohol beginning in the military. She drank more after the rape in 2004. There is documentation in her record that she was drinking a pint of whiskey every two days. She said that she currently drinks once per month, and stated that she drinks 1 or 2 drinks. She was noted to have 2 cups each containing 31 ounce Starbucks coffees with her to this interview. She stated that she needs a lot of caffeine during the day because she cannot sleep at night. She usually drinks 4-6 of these 31 ounce drinks per day, indicating that she is getting 1120 to 1680mg of caffeine per day. She does not consider this to be a problem. Family history is significant in that her mother "was a junkie."
f. Other, if any: No response provided.
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 in March 2004Does 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
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.
There is documentation of mental health treatment in her STR from 7/8/04 to 10/15/04, with diagnoses of Adjustment Disorder, Alcohol Abuse, Cyclothymia, and Depression.There is documentation of an elective abortion dated 6/14/04, with the comments, "Conception the result of documented sexual assault. Both post operative instructions and sexual assault support group documentation provided."
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 Criterion 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 Criterion 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 violence, 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] 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 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] 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 -----------Veteran's diagnoses: [X] Depressed mood [X] Anxiety [X] Suspiciousness [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] Inability to establish and maintain effective relationships [X] Suicidal ideation
6. Behavioral Observations -------------------------- The veteran was alert and responsive, and oriented to time, person, and place. She was cooperative throughout interview. Eye contact was adequate. Affect was constricted, mood anxious. She was jittery and had difficulty sitting still. Speech was fluent, spontaneous, and goal-directed. Rate, rhythm, and volume were within normal limits. Thought processes were coherent. She denied perceptual disturbances. Memory was adequate for both recent and remote events. Fund of information was adequate. Attention and concentration were adequate. Thinking was abstract. She denied having any current suicidal or homicidal thoughts or plans. Judgment and insight were adequate.
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 [ ] No9. Remarks, (including any testing results) if any-------------------------------------------------- This was not an ACE examination. The veteran was evaluated in person. All available electronic records, including VBMS file were reviewed.The PCL-5 was administered to the veteran during this evaluation.She obtained a score of 72, significantly above the cut off score of 38, suggestive of a PTSD diagnosis.Based on Veteran's self-report, review of all available electronic records, clinical interview, and the scores on the above assessment, she meets DSM-5 criteria for Post Traumatic Stress Disorder. It is believed that her mood and attentional symptoms are manifestations of PTSD and do not represent separate, discrete disorders.Her symptoms are significantly interfering with her daily activities and her social and occupational functioning.It is at least as likely as not (50 percent or greater probability) that this disorder was caused or exacerbated by the military sexual trauma events she experienced during her military service.
Question
Jessamine
Hi all! This is so confusing to me. It seems like the box she checked is in direct conflict with the symptoms she chose. I feel like that lowballed me, am I looking at this right? Took almost 2.5 hrs and this is what I got:
I removed doctors names and personal information but again, I don't understand what this means. Can someone please take a look and tell me? I am sorry it is long, I am just really confused by the language of it. In a PCL-5, what is a 72 out of 38? This is all jibberish to me. Can someone please help?
Initial Post Traumatic Stress Disorder (PTSD) Disability Benefits Questionnaire *
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 2. Current Diagnoses --------------------
a. Mental Disorder Diagnosis #1: Post Traumatic Stress 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 [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 occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation
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 ------------------ Evidence reviewed (check all that apply): [X] VA e-folder (VBMS or Virtual VA) [X] CPRS [X] Other (please identify other evidence reviewed): The veteran brought civilian records of diagnoses and procedures to session.
2. History ----------
a. Relevant Social/Marital/Family history (pre-military, military, and post-military): The veteran was referred for a DBQ Initial PTSD evaluation for Post Traumatic Stress Disorder. Information in this assessment is based on the veteran's self-report unless otherwise indicated. The veteran is a 32 year old divorced female. She said that her mother had her when she was 14 years old. She described her childhood as abusive and very difficult. Her mother was "a junkie." Her mother was very abusive emotionally and physically, and two of her stepfathers were also abusive. She said that she tended to take the punishment for her two younger brothers. Her mother was stabbed to death by her brothers' father when the veteran was 9 years old, and she and her brothers witnessed the stabbing. Her own father was declared unfit, so she went into foster care. She has 14 siblings total, but was only raised with the two younger brothers. She is still in contact with some of her siblings. Her brother lives with her. One sister committed suicide recently due to the deaths of her husband and children in a car accident. The veteran has been married 3 times. She stated that she married the first time in order to get her brother out of foster care. He came to live with her and her husband. They had no children. She married a second time and they had 2 sons, now ages 11 and 9. She had one daughter with her third husband, age 4. She stated, "Sometimes I marry people because I'm bored and I don't have friends." She is currently involved in a relationship with her fianc?, FUTURESPOUSE. She stated that this is a good relationship and that he is loving and supportive. He lives in the household with her, her brother, and her 3 children. When asked about friends, she stated that she doesn't have any friends. She considers FUTURE SPOUSE and her little brother to be her friends. She does not associate with anyone else. She stated that she does not like to go out and does not like to interact with people. When asked about an average day, she stated that she works and cares for her children and FUTURESPOUSE. She enjoys reading.
b. Relevant Occupational and Educational history (pre-military, military, and post-military): The veteran has a bachelor's degree in Business, and an associate's degree in Criminal Justice. She would like to continue her education to get a master's degree in Emergency and Disaster Management. Although she claims to have ADHD, she denied having any symptoms of it during childhood and denied having any academic difficulties. Her high school transcripts indicate that she had a B average. She stated that her grades have been good throughout her academic career and that she was always on the dean's list in college. She currently works in administration and operations. She stated that it is a small company and she does everything - HR, IT, and finance for it. She has held this position for 10 months. She stated that she anticipates that she will be fired soon due to missing a lot of work. Because it is a small company, it does not honor FMLA policies. She said that she misses work because she does not sleep well. When she has a rough night, she knows that she will be irritable so she does not go in the next day. Prior to her current position, she worked at Comcast. She had maintained that position for one year. She said that she had difficulties with attendance at that job too. She served in the U.S. Army. She was released for medical reasons due to a fractured ankle. She cited an incident of MST during her service that occurred in March 2004. She stated that she had gone to a party, had been drinking, and was sleeping it off. She awoke to find one man having sex with her, another putting his pants on, and a third masturbating beside her. She stated that she became pregnant from this encounter and had an abortion. There is do cumentation of mental health treatment in her STR from 7/8/04 to 10/15/04, with diagnoses of Adjustment Disorder, Alcohol Abuse, Cyclothymia, and Depression.
c. Relevant Mental Health history, to include prescribed medications and family mental health (pre-military, military, and post-military): The veteran was psychiatrically hospitalized at the Meadows in 1997 and 1998, then again in 2008. She has had two suicide attempts. There is documentation of mental health treatment in her STR from 7/8/04 to 10/15/04, with diagnoses of Adjustment Disorder, Alcohol Abuse, Cyclothymia, and Depression. She received mental health treatment on an outpatient basis in the community until recently. CPRS records indicate that she attended intake appointments at the VA in June 2016 with a psychiatrist,, and a social worker, but did not make any follow up appointments due to a stated need to refrain from missing work. Her CPRS chart indicates diagnostic impressions of anxiety and chronic depression. She stated that she had been prescribed Adderall and Xanax in the community but Dr would not refill these and she has not taken any psychotropic medication since April 2016. He had offered psychological testing to confirm ADHD but she declined his offer. She said that she had taken several SSRIs in the past but they did not help. She endorsed current symptoms indicative of Post Traumatic Stress Disorder.
d. Relevant Legal and Behavioral history (pre-military, military, and post-military): The veteran denied any past or current problems in this area.
e. Relevant Substance abuse history (pre-military, military, and post-military): The veteran stated that she had problems with alcohol beginning in the military. She drank more after the rape in 2004. There is documentation in her record that she was drinking a pint of whiskey every two days. She said that she currently drinks once per month, and stated that she drinks 1 or 2 drinks. She was noted to have 2 cups each containing 31 ounce Starbucks coffees with her to this interview. She stated that she needs a lot of caffeine during the day because she cannot sleep at night. She usually drinks 4-6 of these 31 ounce drinks per day, indicating that she is getting 1120 to 1680mg of caffeine per day. She does not consider this to be a problem. Family history is significant in that her mother "was a junkie."
f. Other, if any: No response provided.
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 in March 2004 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
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.
There is documentation of mental health treatment in her STR from 7/8/04 to 10/15/04, with diagnoses of Adjustment Disorder, Alcohol Abuse, Cyclothymia, and Depression. There is documentation of an elective abortion dated 6/14/04, with the comments, "Conception the result of documented sexual assault. Both post operative instructions and sexual assault support group documentation provided."
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 Criterion 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 Criterion 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 violence, 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] 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 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] 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 ----------- Veteran's diagnoses:
[X] Depressed mood
[X] Anxiety
[X] Suspiciousness
[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] Inability to establish and maintain effective relationships
[X] Suicidal ideation
6. Behavioral Observations -------------------------- The veteran was alert and responsive, and oriented to time, person, and place. She was cooperative throughout interview. Eye contact was adequate. Affect was constricted, mood anxious. She was jittery and had difficulty sitting still. Speech was fluent, spontaneous, and goal-directed. Rate, rhythm, and volume were within normal limits. Thought processes were coherent. She denied perceptual disturbances. Memory was adequate for both recent and remote events. Fund of information was adequate. Attention and concentration were adequate. Thinking was abstract. She denied having any current suicidal or homicidal thoughts or plans. Judgment and insight were adequate.
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 -------------------------------------------------- This was not an ACE examination. The veteran was evaluated in person. All available electronic records, including VBMS file were reviewed. The PCL-5 was administered to the veteran during this evaluation. She obtained a score of 72, significantly above the cut off score of 38, suggestive of a PTSD diagnosis.Based on Veteran's self-report, review of all available electronic records, clinical interview, and the scores on the above assessment, she meets DSM-5 criteria for Post Traumatic Stress Disorder. It is believed that her mood and attentional symptoms are manifestations of PTSD and do not represent separate, discrete disorders. Her symptoms are significantly interfering with her daily activities and her social and occupational functioning. It is at least as likely as not (50 percent or greater probability) that this disorder was caused or exacerbated by the military sexual trauma events she experienced during her military service.
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Jessamine
Hi all! This is so confusing to me. It seems like the box she checked is in direct conflict with the symptoms she chose. I feel like that lowballed me, am I looking at this right? Took almost 2.5 hrs
ArNG11
Judging from what you shared I agree with Andy. 70% seems to be the most accurate rating for your symptoms. The biggest hurdle is service connection, once you have that taken care of you can appeal
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