I recently did a new C&P for PTSD when I filed for I.U. He neglected to mark a lot of my symptoms. I am currently rated at 50% PTSD, was wondering if you think this keeps me a the same or warrants an increase. He did forget to mark my suicidal ideations and a few other symptoms though so I am worried I won't be rated correctly.
Is this DBQ being completed in conjunction with a VA 21-2507, C&P
Examination
Request?
[X] Yes [ ] No
SECTION I:
----------
1. Diagnostic Summary
---------------------
Does the Veteran now have or has he/she ever been diagnosed with PTSD?
[X] Yes [ ] No
ICD Code: F43.10
2. Current Diagnoses
--------------------
a. Mental Disorder Diagnosis #1: PTSD
ICD Code: F43.10
Mental Disorder Diagnosis #2: Panic Disorder
ICD Code: F41.0
Mental Disorder Diagnosis #3: Major Depressive Disorder, Recurrent
ICD Code: F33.1
Mental Disorder Diagnosis #4: No Axis II 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?
[X] Yes [ ] No
b. Is it possible to differentiate what symptom(s) is/are attributable to
each diagnosis?
[ ] Yes [X] No [ ] Not applicable (N/A)
If no, provide reason that it is not possible to differentiate what
portion of each symptom is attributable to each diagnosis and discuss
whether there is any clinical association between these diagnoses:
The
PTSD is currently the more severe and responsible for the veteran's
current level of impairment; the clinical depression and the Panic
Disorder are certainly significant, however. The depression and
Panic
Disorder are seen as more likely than not caused by the chronic PTSD
symptoms. It is difficult to ferret out the contribution of the
three
disorders due to the overlap of symptoms and variability of degree;
at
times any of the three disorders may be the more severe, but the PTSD
is responsible for the current level of impairment.
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 [X] No [ ] No other mental disorder has been diagnosed
If no, provide reason that it is not possible to differentiate what
portion of the indicated level of occupational and social impairment
is attributable to each diagnosis: The PTSD is currently the more
severe and responsible for the veteran's current level of impairment;
the clinical depression and the Panic Disorder are certainly
significant, however. The depression and Panic Disorder are seen as
more likely than not caused by the chronic PTSD symptoms. It is
difficult to ferret out the contribution of the three disorders due
to
the overlap of symptoms and variability of degree; at times any of
the
three disorders may be the more severe, but the PTSD is responsible
for the current level of impairment.
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
2. Recent History (since prior exam)
------------------------------------
a. Relevant Social/Marital/Family history:
Veteran received his previous PTSD C&P on Mar 2016. At that time he
was living in an aparments. He still lives in
but has moved to a different aprtment. He lives with a
roommate. He is not in a relationship. The veteran is not employed.
His typical day consists of going to school, "I have classes five days
a week but "I only go two days a week because of panic attacks. When
I'm home I sometimes lay in bed and cry or think about everything."
He
noted he does not sleep much at all. He
said he only gets out for school; is roommate will cook and get most
of
the
groceries.
b. Relevant Occupational and Educational history:
The veteran has not worked since he was discharged from the Air Force
in
2016. He has applied for jobs and tried to do a work study
but quit
because of panic attacks; at times he will scream and hit his back
pack.
He started there in August and is
taking 12
units. He is schedule to attend classes five days a week but rarely
makes all
five days. "I'm close to failing a couple of classes for attendance.
c. Relevant Mental Health history, to include prescribed medications and
family mental health:
The veteran is current being followed by a staff psychologist every
two
weeks;
he has being seeing her since August. He is also followed by a staff
psychiatrist who prescribes: prazosin and Celexa. He has taken other
medications. He said they help only a little bit.
d. Relevant Legal and Behavioral history:
Denied by the veteran. He did say he got into an altercation about
two
weeks
ago at the gym when he through a dumbbell at the floor; he was kicked
out.
e. Relevant Substance abuse history:
The veteran has not drank alcohol for over one years; he denied ever
abusing it.
He does not use illegal substances.
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 symptom
s below that are clearly not
attributable to the Criterion 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 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] 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:
[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, distorted cognitions about the cause or
consequences of the traumatic event(s) that lead the
individual to blame himself/herself or others.
[X] Markedly diminished interest or participation in
significant activities.
[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] 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] Depressed mood
[X] Anxiety
[X] Panic attacks more than once a week
[X] Mild memory loss, such as forgetting names, directions or recent
events
[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] Neglect of personal appearance and hygiene
5. Behavioral observations
--------------------------
No unusual behaviors observed.
6. 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:
The veteran reports having suicidal thoughts 3-4 times a week but
doesn't dwell on them. He said he would never attempt suicided
because of his kids.
7. Competency
-------------
Is the Veteran capable of managing his or her financial affairs?
[X] Yes [ ] No
8. Remarks, (including any testing results) if any:
---------------------------------------------------
No remarks provided.
Question
TresSam
I recently did a new C&P for PTSD when I filed for I.U. He neglected to mark a lot of my symptoms. I am currently rated at 50% PTSD, was wondering if you think this keeps me a the same or warrants an increase. He did forget to mark my suicidal ideations and a few other symptoms though so I am worried I won't be rated correctly.
Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination Request? [X] Yes [ ] No SECTION I: ---------- 1. Diagnostic Summary --------------------- Does the Veteran now have or has he/she ever been diagnosed with PTSD? [X] Yes [ ] No ICD Code: F43.10 2. Current Diagnoses -------------------- a. Mental Disorder Diagnosis #1: PTSD ICD Code: F43.10 Mental Disorder Diagnosis #2: Panic Disorder ICD Code: F41.0 Mental Disorder Diagnosis #3: Major Depressive Disorder, Recurrent ICD Code: F33.1 Mental Disorder Diagnosis #4: No Axis II 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? [X] Yes [ ] No b. Is it possible to differentiate what symptom(s) is/are attributable to each diagnosis? [ ] Yes [X] No [ ] Not applicable (N/A) If no, provide reason that it is not possible to differentiate what portion of each symptom is attributable to each diagnosis and discuss whether there is any clinical association between these diagnoses: The PTSD is currently the more severe and responsible for the veteran's current level of impairment; the clinical depression and the Panic Disorder are certainly significant, however. The depression and Panic Disorder are seen as more likely than not caused by the chronic PTSD symptoms. It is difficult to ferret out the contribution of the three disorders due to the overlap of symptoms and variability of degree; at times any of the three disorders may be the more severe, but the PTSD is responsible for the current level of impairment. 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 [X] No [ ] No other mental disorder has been diagnosed If no, provide reason that it is not possible to differentiate what portion of the indicated level of occupational and social impairment is attributable to each diagnosis: The PTSD is currently the more severe and responsible for the veteran's current level of impairment; the clinical depression and the Panic Disorder are certainly significant, however. The depression and Panic Disorder are seen as more likely than not caused by the chronic PTSD symptoms. It is difficult to ferret out the contribution of the three disorders due to the overlap of symptoms and variability of degree; at times any of the three disorders may be the more severe, but the PTSD is responsible for the current level of impairment. 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 2. Recent History (since prior exam) ------------------------------------ a. Relevant Social/Marital/Family history: Veteran received his previous PTSD C&P on Mar 2016. At that time he was living in an aparments. He still lives in but has moved to a different aprtment. He lives with a roommate. He is not in a relationship. The veteran is not employed. His typical day consists of going to school, "I have classes five days a week but "I only go two days a week because of panic attacks. When I'm home I sometimes lay in bed and cry or think about everything." He noted he does not sleep much at all. He said he only gets out for school; is roommate will cook and get most of the groceries. b. Relevant Occupational and Educational history: The veteran has not worked since he was discharged from the Air Force in 2016. He has applied for jobs and tried to do a work study but quit because of panic attacks; at times he will scream and hit his back pack. He started there in August and is taking 12 units. He is schedule to attend classes five days a week but rarely makes all five days. "I'm close to failing a couple of classes for attendance. c. Relevant Mental Health history, to include prescribed medications and family mental health: The veteran is current being followed by a staff psychologist every two weeks; he has being seeing her since August. He is also followed by a staff psychiatrist who prescribes: prazosin and Celexa. He has taken other medications. He said they help only a little bit. d. Relevant Legal and Behavioral history: Denied by the veteran. He did say he got into an altercation about two weeks ago at the gym when he through a dumbbell at the floor; he was kicked out. e. Relevant Substance abuse history: The veteran has not drank alcohol for over one years; he denied ever abusing it. He does not use illegal substances. 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 symptom s below that are clearly not attributable to the Criterion 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 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] 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: [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, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others. [X] Markedly diminished interest or participation in significant activities. [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] 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] Depressed mood [X] Anxiety [X] Panic attacks more than once a week [X] Mild memory loss, such as forgetting names, directions or recent events [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] Neglect of personal appearance and hygiene 5. Behavioral observations -------------------------- No unusual behaviors observed. 6. 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: The veteran reports having suicidal thoughts 3-4 times a week but doesn't dwell on them. He said he would never attempt suicided because of his kids. 7. Competency ------------- Is the Veteran capable of managing his or her financial affairs? [X] Yes [ ] No 8. Remarks, (including any testing results) if any: --------------------------------------------------- No remarks provided.Link to comment
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