ptsd C&P Exam/ PTSD-MST

[Firewalker]

. 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: Rape in 1989 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: not related to military conflict 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 are no markers of the assault 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] Recurrent, involuntary, and intrusive distressing memories 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] Feelings of detachment or estrangement from 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) 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] 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 ----------- 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] Disturbances of motivation and mood [X] Impaired impulse control, such as unprovoked irritability with periods of violence [X] Persistent delusions or hallucinations 6. Behavioral Observations -------------------------- The veteran was seen for 60 minutes. Her VBMS file and CPRS notes were reviewed prior to the interview. It was explained to the veteran that these exams are not full psychological evaluations, but rather evaluations for rating purposes that include questions and language dictated by the VARO. The limits of confidentiality were explained to her and she agreed to participate in the C&P evaluation. She was alert, fully oriented and cooperative. She was well groomed. Her reported mood was good, her affect was flat. Speech and thought content were within normal limits. Thought processes were logical and goal-directed. No evidence or report of delusions or hallucinations. Memory and attention appeared grossly intact. Insight and judgment were intact. The veteran denied current suicidal or homicidal ideation. 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: manic and psychotic symptoms are managed at this time with risperidone (IM) 8. Competency ------------- Is the Veteran capable of managing his or her financial affairs? [X] Yes [ ] No 9. Remarks, (including any testing results) if any -------------------------------------------------- The veteran's bipolar disorder, when she is noncompliant with medications or using alcohol, has contributed to severe functional limitations, loss of custody of her children, loss of her home and inability to work. She is likely able to function in a work environment that is low in stress as long as she maintains medication compliance. There is no significant evidence of a military sexual trauma. Nevertheless, her PTSD symptoms are based upon trauma experienced both prior to and during the military. She has been in treatment for PTSD since 2013. Her bipolar disorder and alcohol use disorder, both of which have contributed to severe impairment in functioning, are not causally related to the PTSD. Her PTSD symptoms, when other disorders are managed, cause less impairment and have responded well to treatment. NOTE: VA may request additional medical information, including additional examinations if necessary to complete VA's review of the Veteran's application

Edited November 1, 2016 by Firewalker

[EDWIN]

Sorry. The 10% is for tinnitus only. I filed a new claim for major depression and the only evidence I have while I was in service is the one for 1986. (it was for MILD DEPRESSION)

[Firewalker]

I don't know what to think now with my appeal....The DRO ordered a new DBQ but just reviewing hospital records from April hospitalization....no exam with me present. That was completed a week or so ago. Today on ebennies i noticed in my appeal that they added mental disorder as part of the appeal with today's file date. Is this a good thing? What does this mean?