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sphynix06

Bad PTSD/MST C&P...HELP!!!

Question

Hello all.

I had a c&p exam for my ptsd/mst claim on 1/19/17 at the VA Outpatient center in Fort Worth and just got the results back today. I was quite shocked by the notes. I feel that the c&p psychologist did not review the merits of my case properly and just opined hat I was exaggerating my symptoms based on a 15 question "MENT" test which consisted of me differentiating between happy, angry and sad faces. She also asked me to remember 5 items after 5 minutes (which she gave me the answer after I couldn't remember 2 of them). She asked me nothing about my symptoms or about the events of the trauma. She picked what parts of my VA medical records she included in the report (i.e., sleep disturbance). I feel like I have been shafted. She is basically refuting the diagnosis given by my TWO VA psychiatrists, VA psychologist and my VA social worker.

I waited over 25 years to file my sexual assault claim due to me being extremely embarrassed and unable to bring myself to talk about the events that occurred while I served as a submariner in the Navy. The assault happened in 1988; back before don't ask, don't tell. Needless to say I was traumatized and afraid of being kicked out. Nonetheless, I was medically discharged a year later due to asthma brought on by anxiety and panic attacks while onboard my duty station.

So, now I am at the point where I am finally seeking help and I spend 20 minutes with a c&p psychologist who seems to be indifferent about my condition. I almost feel like I should have just retreat back to my home in silence instead of being treated like a liar!!!

What can I do about this?

Here is my c&p exam:

 LOCAL TITLE: COMP & PEN MENTAL HEALTH/PSYCHOLOGY EXAM           STANDARD TITLE: PSYCHOLOGY C & P EXAMINATION CONSULT            DATE OF NOTE: JAN 19, 2017@09:30     ENTRY DATE: JAN 19, 2017@11:27:37            AUTHOR: 

EXP COSIGNER:                                URGENCY:                            STATUS: COMPLETED                    
 Initial Post Traumatic Stress Disorder (PTSD)                        Disability Benefits Questionnaire                         * Internal VA or DoD Use Only *
  Name of patient/Veteran:                                      

SECTION I:  

1. Diagnostic Summary  

Does the Veteran have a diagnosis of PTSD that conforms to DSM-5 criteria based on today's evaluation?   

[ ] Yes   [X] No       

2. Current Diagnoses     

a. Mental Disorder Diagnosis #1: No Diagnosis          

Comments, if any: Psychological Testing
 A test of response bias specifically related to PTSD symptoms was administered to the veteran during this examination to assess the              credibility of his self-report. The name of this measure is withheld in this report in order to protect the integrity of the test. This test was specifically standardized on a sample of veterans applying for financial remuneration for a claim of disability resulting from PTSD. The veteran's score on this test was significantly above the established cutoff, indicating that his performance was not consistent with persons diagnosed with PTSD but was consistent with the test performances of disability claimants simulating symptoms of PTSD. As such, there is reason to suspect symptom exaggeration and a response style indicative of attempts to portray himself as worse off than he actually may be with regard to              PTSD symptoms. Based on the Veteran's scores, additional testing was performed to further evaluate the possibility of overreporting or exaggeration of mental health symptoms.
             

A second test of response bias was given that was specifically designed to assess the credibility of reported psychopathology symptoms of response bias related to mental illness. Each item on this test was designed to evaluate constructs and behaviors useful in identifying overreporting. This test was developed and validated using both simulation and known-groups designs to identify individuals attempting to overreport symptoms of mental illness. In addition, the validity of this exam has been generalized across various racial/ethnic groups, genders and settings. The Veteran's total score on this measure was above the cutoff, indicating that his responses were not consistent with persons diagnosed with any mental illness. In addition, the Veteran's scores on this interview indicate that his behavior was inconsistent with his reported symptoms and he endorsed very extreme and uncommon symptoms, symptom combinations that are both unlikely and inconsistent with              common mood and psychotic disorders, and  he had a tendency to endorse severe and unusual psychotic symptoms. He also endorsed an unusual course of illness that is inconsistent with the course of  most psychiatric disorders recognized in clinical practice.
             

It is possible that the veteran suffers from a mental illness. However, I am ethically unable to provide a diagnosis at this time given the veteran's response pattern of overreporting on three objective, reliable and valid psychological tests. Providing a diagnosis would require this examiner to resort to mere speculation  and would violate the American Psychological Association's (APA) Ethical Principles of Psychologists and Code of Conduct.             


 b. Medical diagnoses relevant to the understanding or management of the  Mental Health Disorder (to include TBI):

Deferred to a physician
 

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] No mental disorder diagnosis
 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

2. History   

a. Relevant Social/Marital/Family history (pre-military, military, and post-military):         

Family - Veteran was raised in a "normal" environment by his mother. "I wasn't that close to my father." Veteran has two brothers and two sisters. Veteran's mother was a kindergarten teacher and his father was a "mobile home constructor". Veteran denied any childhood medical/mental health problems. Veteran denied a family history of mental illness.
         

Marital - Veteran has never been married. His last relationship ended around October of 2016 due to his "agitation." "She wanted to talk about stuff and I didn't want to discuss issues with her." Veteran has three sons (ages 16, 20 and 22). "My oldest two sons I don't really talk to since    they're gone-one is overseas and the other I think moved up North. I call them every now and then and try to reach them but I hardly get in          contact with them. I have a close relationship with my youngest son. He keeps me going."
 

Social - "I had a lot of friends growing up but over the years they sort of fell to the wayside. I had friends going into the military and in boot camp but after sub school I stayed to myself. I had some associates but I didn't want to make any friends after sub school. Currently I have a few associates but I wouldn't call them friends." Prior to the military, the veteran enjoyed running track, playing football, singing in the choir and being in the art club ("I was the cartoonist for the school paper."), science and chess club. "During the military I didn't have any activities other than working on my rating. After I got out I got into oil painting, swimming, cycling and home renovation. I can no longer cycle or swim because of my back and respiratory issues. I haven't attended church in three years and my mother is now a pastor."             

b. Relevant Occupational and Educational history (pre-military, military, and post-military):

Educational - Veteran earned a Bachelor's Degree in Electrical Engineering in 1995  and a Master's Degree in Biomed Engineering in 2009. Veteran informed that he was a good student and denied a history of suspensions, expulsions or learning problems.
         

Occupational - Veteran's job history prior to the military includes custodian and lawn care (self-employed). Veteran serve in the Navy from July 13, 1987- May 16,1989. Veteran was a college student from 1990-1997 and 2004-2009. Since being discharged from the military the veteran has worked as an RF engineer/consultant (1997-2004: "I got into an argument with my supervisor because he always wanted to include me on projects he was working on and I thought that was inappropriate. I thought he had an interest in me even though he didn't say it outright. He wanted to go out and do stuff outside of work hours."); and bioengineer/prosthetic designer for the Department of Commerce (2010-March of 2016: "I got in  several arguments because of space and eventually withdrew and stopped producing. I had to share a small space with a coworker and he was constantly rolling back in his chair asking me questions and tapping me on the shoulder so it finally came to a head.").
         

Occupational problems reported include poor social interaction ("Shouting at people and avoiding contact with guys in the office. I worked better with females."), difficulty concentrating ("Because I was focused on not being in a vulnerable position. I missed deadlines or didn't finish tasks because I couldn't focus. I asked to have my own office but you can't have one as a junior engineer."), difficulty following instructions ("If men tried to get close to me because it reminded me of sub school and the threat of not being advanced or promoted."), forgetfulness, and increased absenteeism ("In 2015 I couldn't deal with the office so I started working from home but my supervisor didn't want me to sever myself from the office totally. I had anxiety about going back and sharing an office with another male. I felt better working by myself because I was more productive.").

In regards to reprimands, the veteran informed that he was written up for poor work performance, absenteeism, being AWOL and conflicts with his officemate. "The conflicts with my officemate led to me being fired."   Veteran informed that he has applied for one job since being fired.          When asked if he was a productive and reliable employee he stated, "As long as I was alone and no one was being touchy with me."
Veteran denied the following occupational problems: assignment of different duties and tardiness
         

An October 5, 2016 MH OUTPT NOTE states, "He is unemployed and uses income from renting rooms to pay living expenses."
         

An October 5, 2016 MH Attending note states, "Lost his last job as a biomedical engineer in March 2016 after "tussling" with an older man in his office who would repeatedly come up behind him and touch/pat his shoulders which reminded him of his Navy experience...Owns home and rents out rooms for income."             

c. Relevant Mental Health history, to include prescribed medications and family mental health (pre-military, military, and post-military):          Mental Health Veteran began mental health treatment at the North Texas VA in August of 2016 and is compliant with his medication regimen of risperidone, prazosin and sertraline despite feeling "groggy and spaced-out." Veteran denied a history of psychiatric hospitalizations.
         

An October 12, 2016 SLEEP TELEPHONE NOTE states, "I called the patient and explained their sleep test results in detail. I explained him that  the study did not show significant sleep apnea despite his sleeping on his back. He is unable to sleep on his side due to his shoulder          problems...Encouraged the patient to lose weight."
         

A November 2, 2016 MH PTSD INDIVIDUAL NOTE states, "Veteran believes that gay men are going to hurt him. He also informed worker that  he has experienced a lot of fear and worry this Halloween with people who are transgender, to the point that he is not sleeping for fear they          will break into his home. Veteran is worried that he may have to "barricade" his home with bars on  the windows."
         

A November 3, 2016 MH Attending Note states, "Updates that since last  appt, his GF ended their relationship, "she said I was over agitated."    Last week, he describes an incident at a restaurant when a transgendered person was standing by him, he turned and saw the person,
 got so upset that he ran out of the restaurant and vomited.  Since last week has felt progressively worse.  "It's harder to tell which people          to stay aware from.. it's a whole new ballgame with transgendered [people]...I don't know who my enemy is."  He states he needs to set a          perimeter on his house, put bars on his windows/doors, and update his security alarm.  Reports poor sleep, gets out of bed 3-4x/night to          check doors/windows and frequency of NMs has increased. Appetite is low. Feels that he cannot focus, "I'm constantly thinking how to avoid     these people."  Reports hearing male voices talking outside of his windows so he fears they will break in (reason for "setting perimeter"). When he is in public he has thoughts of "I need to get them before they get me" when he passes male strangers.  Has not had any violence but does say he has had verbal arguments (told someone in the Wal-Mart line to back up and they argued with him, for example)...+ MST in Navy- unwanted taunts, suggestive remarks and genital contact and kissing from supervisor."                    

A December 5, 2016 MH ATTENDING NOTE states, "Updates writer that he has spent ~$3000 since last visit adding bars to the outside of his first floor home window and installing a security system with cameras. Reports he still plans to add more cameras to monitor his roof because "maybe someday deterred by the barricade downstairs might want to get in up there."  Reports vague AH of hearing footsteps on his second floor when he is down on the first floor.  Denies hearing voices from  upstairs or outside his window like he endorsed last visit.  Reports nighttime is the hardest for him because "that's when they are outside...the enemy, the transsexuals."  Denies actually seeing anyone outside of his house at night.  Reports he is comfortable with certain people coming up to his house, like the mailman, but states he is not comfortable when strangers come up.  States he is not aggressive but tells them to go away.  Does not take his gun with him to the front door.  States he now feels better with his house more protected.  Is able to watch movies and enjoy them during the day.  His security system is on his phone app and he checks it every 3 hours.  At night he "secures the perimeter" every 2 hours, has an alarm set."             

d. Relevant Legal and Behavioral history (pre-military, military, and post-military):         

Behavioral - "In 2005 I grabbed a guy that was dressed like a female. We were meeting for a date but his profile said he was a female. Two months ago a person behind me in line was transgender. I pushed him to the side and ran outside."
         

Legal - Veteran denied a history of legal problems.             

e. Relevant Substance abuse history (pre-military, military, and  post-military):         

Substance Abuse - Veteran denied a history of substance abuse.             

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: MST February-April of 1988:

CPRS states, "A male teacher began touching him during class and stepped over lines trying to get too close that made him feel very uncomfortable. Veteran says there was never genital contact because there was touching and kissing on the part of the instructor." Veteran's stressor statement states, "One trainer would come up behind me and massage my shoulders. He also grabbed my waist and pressed himself against me. I could feel his erect penis against my buttocks. He also made sexual innuendos and jokes. He also asked me if my nipples were hard because I was glad to see him. He then said, 'I bet you have a nice sized tool'. He then touched my left nipple and kissed my neck. When I confronted him he stated that if I didn't cooperate, I may not pass through with my classmates. He then grabbed my crotch and said, 'Pass or no pass. You make the determination.' My relationship with my long time high school sweetheart ended that summer (June of 1988) because I withdrew fro the relationship and was too ashamed to confide in her." Please note that this last statement is in contrast to the statement provided by his former girlfriend who stated that the veteran "mentioned that a sexual assault happened to him during training that changed him and that he needed time to work through it."                   

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. Veteran's treatment records, buddy statement and stressor                statement were reviewed. However, there are no markers in the veteran's STRs or personnel records which the VBA has confirmed.                   

4. PTSD Diagnostic Criteria 

No response provided.
   

5. Symptoms    

No response provided.       

6. Behavioral Observations   

MENTAL STATUS EXAM - Appearance, Behavior, and Speech Veteran's appearance and dress were appropriate for the exam. His speech was normal in rate and tone. Veteran's response to the evaluation was guarded but engaged. Rapport was easily established with the Veteran who put forth a conscientious effort to answer all questions to the best of his ability.
   

Thought Process - There was no evidence of loose associations, flight of ideas, circumstantial, or tangential thought process. Veteran completed similarities and interpreted  proverbs accurately.
   

Thought Content - Veteran denied having any obsessions or suicidal/homicidal ideations. However, delusions regarding the security of his home and transgenders were reported. "Transgenders are trying to get back at me because I grabbed the transgender that I was supposed to go on a date with. His profile said he was female. I have to hone in and decipher whether someone is male or female because my initial problems came with my sexual assault in training so I've distanced myself from males who are the enemy. The transgender caught me off guard and now they're trying to trick me. It's a whole new ball game."
   

Perceptual Abnormalities - "I keep hearing my instructors voice in my head. Especially if I get around someone who has to make choices that involve me. I keep hearing 'pass or no pass' which is what he said to me. I hear a human voice outside my windows. When I go look there's nothing there so I don't know if they've run away or what. That's why I put up security cameras."
   

Mood and Affect - Veteran's mood was "indifferent" and his affect was flat.
   

Sensorium and Cognition - Sensorium was clear. Veteran was oriented to time, place and person. Immediate memory was good as he was able to repeat five of seven numbers forward and six of seven numbers in backwards sequence. Recent memory was fair as he recalled two of three items after five minutes. Remote memory was  fair as he recalled the names of the last three presidents, the name of his high school, his youngest son's birthday, and his first job. Veteran was unable to recall the name of his elementary or junior high school nor his siblings or two oldest sons birthdays. In regards to concentration, Veteran spelled world forward and backwards and completed simple mathematics, serials    3's, and serial 7's. His intelligence appeared to be average.

Judgment and Insight - Veteran's insight is good as he understands the outcome of his behavior and the choices he makes. His judgment is impaired but he informed that he would return a library book to the library if found, pull over for the police, and return a wallet he found to the owner.

 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     

Financial: "My brother pays any bills that I can't pay online."      
   

NOTE: VA may request additional medical information, including additional examinations if necessary to complete VA's review of the Veteran's    application.
 

 

Edited by sphynix06
to remove my name

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sphynix06,

Welcome to hadit. I am so sorry for your pain.  I can only imagine what you went through.

I just had repressed memories explode in my head this past weekend. 

DADT was new or not even, so I was more afraid of getting kicked out than I was of anyone finding out what happened.  So I spent the last 22 years living a life based on a lie that I told myself so many times that it became my truth.

No one knows what happened. I've only just reached out for help, for MST, this week.  I have mentioned it here, on my own thread(what constitutes MST?) and I sent a secure message to my VA MH provider. I do have an appointment with them this Monday coming, but might not make it.  So I called the BH unit at my VAMC, this morning, and left a call back message/voicemail with the MST social worker.  No return call yet, but I will call again in a few minutes...

Andyman

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Well, yes this sounds like a bad  C and P exam. You should dispute it ASAP.  Your examiner stated "no diagnosis".  This is a deal breaker for your claim.  But, dont be alarmed..  VA often hires docs that give c an p exams favorable to them.  You just need something to refute it.  You may already have it..with your current VA docs.  

Chris Attig has written about something called, "develop to deny".  VA is not supposed to do this.  If they have competent docs with a diagnosis, and a nexus, then they should not need a c and p exam.  When they order one to try to deny you, that is "developing to deny".  You may need an attorney involved.  

You can challenge the competency of the examiner.  Does the examiner have experience and or training in treating MST?  It the examiner has no experience/training in treating PTSD/MST, then you can ask that this exam is thrown out.  

Order your cfile, and read it.  Did your docs diagnose and treat you for PTSD/MST?  You dont need a half dozen diagnosis, one should suffice.  

Did your docs state, to the effect, that your (PTSD/MST) was "at least as likely as not" due to

(event(s) that occured in service).  With PTSD, you need to document a "stressor".  (That means something happened triggering your PTSD..such as seing someone blown up, or something, like, for example, handling dead bodies)  If you are claiming MST, you should have documentation of an "in service event".  Hopefully you reported the event(s) and were treated in service.  

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Sorry you got a bad exam. seems later on in the exam they contradict the diagnoses. I would def contact the patient advocate at the facility you had your exam at and file a complaint.

If it is any help to ease your mind there is tons of legal VBA precedent that is in your favor based solely on the fact of multiple diagnoses and your story being consistent. if you go to the VBA website and search past cases and search MST you can find lots of cases that were found in favor of the veteran do to this.

 

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Sorry to hear that.

Edited by kent101

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Update:

I received my award/denial letter today which granted 30% for asthma and denied ptsd, sleep apnea, headaches, chronic fatigue and all my other conditions claimed as secondary to ptsd.

PTSD

In response to the ptsd denial, my VSO is putting together a response in the form of a CUE because the rater failed to consider my behavioral change while in service as evidence to support my mst. Surprisingly, the very reason my claim was denied was because there was nothing in my service records pointing to the mst; not because of the non-diagnosis and disparaging c&p exam. The rater examined the claim as if it was a standard ptsd instead of ptsd due to mst.

To help with my fight I am seeking the assistance of an outside vet friendly psychologist (Dr. Valette) to write an imo.($2k) So, that would make 3 mental health professional giving me a diagnosis that refutes the report of the c&p examiner. I am not sure if I should submit the imo along with the CUE or wait until the decision comes back. I am trying to avoid negating my $2k new material evidence in case the examiner denies it again. Thoughts??

Sleep Apnea

In response to the sleep apnea denial, I called the c&p examiner and asked for reconsideration because his report stated that asthma and sleep apnea are in no way related. I shared with him several articles which stated otherwise and also shared several BVA cases which granted sleep apnea as secondary to asthma. He told me that no one in the fort worth office has ever granted service connection for sleep apnea as secondary to asthma, but that I should refile and request service connection for asthma aggravating the sleep apnea. Huh??? isn't that still a connection in itself? Nonetheless, he stated that he would think about amending his notes to opine that my sleep apnea is at least as likely as not aggravated by my service connected asthma. If he does do this then I won't have to get an imo for the sleep apnea, but I am not to optimistic about his follow through.

 My headaches and chronic fatigue is claimed secondary to sleep apnea so I will have to refile those one I get connected for the sleep apnea.

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      2003 asthma denied because they said you didn't have 'chronic' asthma diagnosis


      2018 Asthma/COPD granted 30% effective Feb 2015 based on FEV-1 of 60% and inhalational anti-inflamatory medication.

      "...granted SC for your asthma with COPD w/dypsnea because your STRs show you were diagnosed with asthma during your military service in 1995.


      First, check the date of your 2018 award letter. If it is WITHIN one year, file a notice of disagreement about the effective date. 

      If it is AFTER one year, that means your claim has became final. If you would like to try to get an earlier effective date, then CUE or new and material evidence are possible avenues. 

       

      I assume your 2003 denial was due to not finding "chronic" or continued symptoms noted per 38 CFR 3.303(b). In 2013, the Federal Circuit court (Walker v. Shinseki) changed they way they use the term "chronic" and requires the VA to use 3.303(a) for anything not listed under 3.307 and 3.309. You probably had a nexus and benefit of the doubt on your side when you won SC.

      It might be possible for you to CUE the effective date back to 2003 or earlier. You'll need to familiarize yourself with the restrictions of CUE. It has to be based on the evidence in the record and laws in effect at the time the decision was made. Avoid trying to argue on how they weighed a decision, but instead focus on the evidence/laws to prove they were not followed or the evidence was never considered. It's an uphill fight. I would start by recommending you look carefully at your service treatment records and locate every instance where you reported breathing issues, asthma diagnosis, or respiratory treatment (albuterol, steroids, etc...). CUE is not easy and it helps to do your homework before you file.

      Another option would be to file for an increased rating, but to do that you would need to meet the criteria for 60%. If you don't meet criteria for a 60% rating, just ensure you still meet the criteria for 30% (using daily inhaled steroid inhalers is adequate) because they are likely to deny your request for increase. You could attempt to request an earlier effective date that way.

       

      Does this help?
    • Thanks for that. So do you have a specific answer or experience with it bouncing between the two?
    • Tinnitus comes in two forms: subjective and objective. In subjective tinnitus, only the sufferer will hear the ringing in their own ears. In objective tinnitus, the sound can be heard by a doctor who is examining the ear canals. Objective tinnitus is extremely rare, while subjective tinnitus is by far the most common form of the disorder.

      The sounds of tinnitus may vary with the person experiencing it. Some will hear a ringing, while others will hear a buzzing. At times people may hear a chirping or whistling sound. These sounds may be constant or intermittent. They may also vary in volume and are generally more obtrusive when the sufferer is in a quiet environment. Many tinnitus sufferers find their symptoms are at their worst when they’re trying to fall asleep.

      ...................Buck
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