0% rating for adjustment disorder?

[justaspouse]

My wife is rated at 30% for asthma. She filed for depression and we looked at the copy of the C&P. 

The examiner left out many important testimony and seemed to paint a false narrative. Furthermore, I travelled to the C&P exam with her to provide secondary testimony and to my surprise they denied me access to the exam. 

We are rather stressed out from the outcome since my wife had to quit her job 8 months ago because of her asthma attacks (she was a manager at her employment for over 10 years) so things are a bit stressful. Anyway I will display the meat of the C&P hoping to get some good advice. 

Thanks everyone for your time. 

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
    
       ICD code:  
    If no diagnosis of PTSD, check all that apply:
    
       [x ] Veteran's symptoms do not meet the diagnostic criteria for PTSD 
under
           DSM-5 criteria
       [ ] Veteran does not have a mental disorder that conforms with DSM-5
           criteria
       [x ] Veteran has another Mental Disorder diagnosis.  Continue to complete
           this Questionnaire and/or the Eating Disorder Questionnaire:

    2. Current Diagnoses
    --------------------
    a. Mental Disorder Diagnosis #1: Adjustment disorder with depressed mood
           ICD code: 
Comments, if any: It is at least as likely as not that the veteran's
adjustment disorder is related to her service connected asthma. The veteran does
not meet criteria for PTSD as she did not report experiencing a Criterion A
stressor. The veteran does not meet full criteria for a major depressive
disorder. She did not report symptoms sufficient to satisfy criteria for a major
depressive disorder. Her depressive symptoms are rather mild and a few symptoms
(i.e., fatigue, poor sleep) are likely better accounted for as secondary to her
physical health concerns. The veteran does not meet criteria for an anxiety
disorder as she denied clinically defined anxiety criteria. She reported some
anxious feelings when having trouble breathing or hyperventilating.
Hyperventilation can mimic the effects of anxiety though this is not true 
anxiety
in a clinical sense. The veteran has no history of mental health treatment to
verify her claims. Her self-report was found to be credible for the current
examination. 

              
       Mental Disorder Diagnosis #2:  
       ICD code:  
       Comments, if any:
          

       Mental Disorder Diagnosis #3:  
       ICD code:  
       Comments, if any:
          

       If additional diagnoses, list using above format:
          
         
    b. Medical diagnoses relevant to the understanding or management of the
       Mental Health Disorder (to include TBI):  
       
       ICD code:  
       Comments, if any:
          
         
    2. Differentiation of symptoms
    ------------------------------
    a. Does the Veteran have more than one mental disorder diagnosed?
       [ ] Yes  [x ] No
       
    b. Is it possible to differentiate what symptom(s) is/are attributable to
       each diagnosis?
       [ ] Yes  [ ] No  [x ] 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:


             
           If yes, list which symptoms are attributable to each diagnosis and
           discuss whether there is any clinical association between these
           diagnoses:
             

             
    c. Does the Veteran have a diagnosed traumatic brain injury (TBI)?
       [ ] Yes  [ ] No  [x ] Not shown in records reviewed
       
           Comments, if any:
              
             
    d. Is it possible to differentiate what symptom(s) is/are attributable to
       each diagnosis?
       [ ] Yes  [ ] No  [x ] 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:
             


           If yes, list which symptoms are attributable to each diagnosis:
                          

             
    3. 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)
       
       [ ] No mental order diagnosis
       [x ] A mental condition has been formally diagnosed, but symptoms are not 

           severe enough either to interfere with occupational and social 
           functioning or to require continuous medication
       [ ] Occupational and social impairment due to mild or transient symptoms 
           which decrease work efficiency and ability to perform 
           occupational tasks only during periods of significant stress, 
           or; symptoms controlled by medication
       [ ] 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
       [ ] Occupational and social impairment with reduced reliability and 
           productivity
       [ ] Occupational and social impairment with deficiencies in most areas, 
           such as work, school, family relations, judgment, thinking 
           and/or mood
       [ ] Total occupational and social impairment

       

    b. For the indicated level of occupat
ional 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
       
           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: 

              	
           If yes, list which portion of the indicated level of occupational and 

           social impairment is attributable to each diagnosis:
               
              
    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
       
           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:

             
           If yes, list which portion of the indicated level of occupational and 

           social impairment is attributable to each diagnosis:

             
                                   SECTION II:
                                   -----------
                               Clinical Findings:
                               ------------------
    1. Evidence Review
    ------------------
    Evidence reviewed (check all that apply):

    [ ] Not requested
    [ ] No records were reviewed
    [ ] VA claims file (hard copy paper C-file)
    [X ] VA e-folder (VBMS or Virtual VA)
    [X ] CPRS
    [ ] Other (please identify other evidence reviewed):
         

    Evidence Comments:
      
No history of mental health treatment. 


    2. History
    ----------
    a. Relevant Social/Marital/Family history (pre-military, military, and
post-military): The veteran was born and raised in Wisconsin by both
parents; 1 older sister. Veteran reported having a good childhood. "I had good
parents, a good life." She denied a history of abuse/neglect. She denied a 
family
history of substance abuse or mental illness. She reported that she maintains a
good relationship with her family. 

The veteran has been married for 16 years; 2 children. She reported that they
have a good relationship. No abuse. She reported that she does not have any
friends that she spends time with. "I'm always sick" which she explained as 
being
problems with breathing, hyperventilating, and migraine headaches 1-2x a month.
She reported that she has been having more frequent problems with asthma and
breathing in the last 8 years. "They want to go out but I don't want to." No
social groups. She said that she spends most of her time sleeping.       
          
         
    b. Relevant Occupational and Educational history (pre-military, military, 
and
post-military): Veteran graduated high school in 1996. She described
herself as an A/B student. No learning or behavioral problems. After high 
school,
she graduated from UMD in 2000 with a degree in criminal justice.

Air Force 09/2000-11/2005; Hon DC, O3. Logistics Readiness. She was deployed to
Oman (2002). 

The veteran was working at Super Value as a warehouse supervisor where she 
worked
for 10 years. She quit her position because "I couldn't do it physically
anymore." She was getting bronchitis frequently when she was in the refrigerated
area. She said that she moved around a lot. Eventually she said that has not
looked for employment saying that she would need a position that pays well and
allows for "a lot of sick and vacation time."
          
         
    c. Relevant Mental Health history, to include prescribed medications and
family mental health (pre-military, military, and post-military): No
history of mental health treatment.        
          
         
    d. Relevant Legal and Behavioral history (pre-military, military, and
       post-military): No legal history 
          
         
    e. Relevant Substance abuse history (pre-military, military, and
       post-military): Veteran reported that she does not drink alcohol.

No drug use.

Veteran does not drink coffee, rare soda, no energy drinks.

No tobacco        
          
         
    f. Other, if any:


    
    3. Stressors
    ---------------------------
      
The stressful event can be due to combat, personal trauma, other life 
threatening
situations (non-combat related stressors).

NOTE: For VA purposes, "fear of hostile military or terrorist activity" means
that a Veteran experienced, witnessed, or was confronted with an event or
circumstance that involved actual or threatened death or serious injury. Or a
threat to the physical integrity of the Veteran or others, such as from an 
actual
or potential improvised explosive device; vehicle-imbedded explosive device;
incoming artillery rocket, or mortar fire; grenade; small arms fire, including
suspected sniper fire; or attack upon friendly military aircraft.

Describe one or more specific stressor event(s) the Veteran considers traumatic
(may be pre-military, military, or post-military):
    
    a. Stressor #1: 
    
          Does this stressor meet Criterion A (i.e., is it adequate to support
          the diagnosis of PTSD)?
          [ ] Yes  [ ] No
          
          Is the stressor related to the Veteran's fear of hostile military or
          terrorist activity?
          [ ] Yes  [ ] No
          
              If no, explain:
                
                
          Is the stressor related to personal assault, e.g. military sexual
          trauma?
          [ ] Yes  [ ] No
          
              If yes, please describe the markers that may substantiate the
              stressor.
                

    
    b. Stressor #2: 
    
          Does this stressor meet Criterion A (i.e., is it adequate to support
          the diagnosis of PTSD)?
          [ ] Yes  [ ] No
          
          Is the stressor related to the Veteran's fear of hostile military or
          terrorist activity?
          [ ] Yes  [ ] No
          
              If no, explain:
                
                
          Is the stressor related to personal assault, e.g. military sexual
          trauma?
          [ ] Yes  [ ] No
          
              If yes, please describe the markers that may substantiate the
              stressor.


    
    c. Stressor #3: 
    
          Does this stressor meet Criterion A (i.e., is it adequate to support
          the diagnosis of PTSD)?
          [ ] Yes  [ ] No
          
          Is the stressor related to the Veteran's fear of hostile military or
          terrorist activity?
          [ ] Yes  [ ] No
          
              If no, explain:
                
                
          Is the stressor related to personal assault, e.g. military sexual
          trauma?
          [ ] Yes  [ ] No
          
              If yes, please describe the markers that may substantiate the
              stressor.



    d. Additional stressors: If additional stressors, describe (list using the
       above sequential format):

         
    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
stress/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 (DMS-5). 




       Criterion A: Exposure to actual or threatened a) death, b) serious 
injury,
                    c) sexual violation, in one or more of the following ways:
          [ ] Directly experiencing the traumatic event(s)
          [ ] Witnessing, in person, the traumatic event(s) as they occurred to
              others
          [ ] 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.
          [x ] No criterion in this section met.

       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:
          [ ] Recurrent, involuntary, and intrusive distressing memories of the
              traumatic event(s).
          [ ] Recurrent distressing dreams in which the content and/or affect of
              the dream are related to the traumatic event(s).
          [ ] 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).
          [ ] Intense or prolonged psychological distress at exposure to 
internal
              or external cues that symbolize or resemble an aspect of the
              traumatic event(s).
          [ ] Marked physiological reactions to internal or external cues that
              symbolize or resemble an aspect of the traumatic event(s).
          [x ] No criterion in this section met.

       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:
          [ ] Avoidance of or efforts to avoid distressing memories, thoughts, 
or
              feelings about or closely associated with the traumatic event(s).
          [ ] 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).
          [x ] No criterion in this section met.

       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:
          [ ] Inability to remember an important aspect of the traumatic 
event(s)
              (typically due to dissociative amnesia and not to other factors
              such as head injury, alcohol, or drugs).
          [ ] 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").
          [ ] Persistent, distorted cognitions about the cause or consequences 
of
              the traumatic event(s) that lead to the individual to blame
              himself/herself or others.
          [ ] Persistent negative emotional state (e.g., fear, horror, anger,
              guilt, or shame).
          [ ] Markedly diminished interest or participation in significant
              activities.
          [ ] Feelings of detachment or estrangement from others.
          [ ] Persistent inability to experience positive emotions (e.g.,
              inability to experience happiness, satisfaction, or loving
              feelings.)
          [x ] No criterion in this section met.

       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:
          [ ] Irritable behavior and angry outbursts (with little or no
              provocation) typically expressed as verbal or physical aggression
              toward people or objects.
          [ ] Reckless or self-destructive behavior.
          [ ] Hypervigilance.
          [ ] Exaggerated startle response.
          [ ] Problems with concentration.
          [ ] Sleep disturbance (e.g., difficulty falling or staying asleep or
              restless sleep).
          [x ] No criterion in this section met.

       Criterion F:
          [ ] Duration of the disturbance (Criteria B, C, D, and E) is more than
              1 month.
          [x ] Veteran does not meet full criteria for PTSD
          
       Criterion G:
          [ ] The disturbance causes clinically significant distress or
              impairment in social, occupational, or other important areas of
              functioning.
          [x ] Veteran does not meet full criteria for PTSD

       Criterion H:
          [ ] The disturbance is not attributable to the physiological effects 
of
              a substance (e.g., medication, alcohol) or another medical
              condition.
          [x ] Veteran does not meet full criteria for PTSD


       Criterion I: Which stressor(s) contributed to the Veteran's PTSD
                    diagnosis?:
                    
                   [ ] Stressor #1
                   [ ] Stressor #2
                   [ ] Stressor #3
                   [ ] Other, please indicate stressor number (i.e., Stressor 
#4,
                       #5, etc.) as indicated above:
                   [x ] No criterion in this section met.

    5. Symptoms
    -----------
    For VA rating purposes, check all symptoms that apply to the Veterans
    diagnoses:
    
       [x ] Depressed mood
       [ ] Anxiety
       [ ] Suspiciousness
       [ ] Panic attacks that occur weekly or less often
       [ ] Panic attacks more than once a week
       [ ] Near-continuous panic or depression affecting the ability to function
           independently, appropriately and effectively
       [ ] Chronic sleep impairment
       [ ] Mild memory loss, such as forgetting names, directions or recent
           events
       [ ] Impairment of short- and long-term memory, for example, retention of
           only highly learned material, while forgetting to complete tasks
       [ ] Memory loss for names of close relatives, own occupation, or own name
       [ ] Flattened affect
       [ ] Circumstantial, circumlocutory or stereotyped speech
       [ ] Speech intermittently illogical, obscure, or irrelevant
       [ ] Difficulty in understanding complex commands
       [ ] Impaired judgment
       [ ] Impaired abstract thinking
       [ ] Gross impairment in thought processes or communication
       [ ] Disturbances of motivation and mood
       [ ] Difficulty in establishing and maintaining effective work and social
           relationships
       [ ] Difficulty in adapting to stressful circumstances, including work or 
a
           work like setting
       [ ] Inability to establish and maintain effective relationships
       [ ] Suicidal ideation


       [ ] Obsessional rituals which interfere with routine activities
       [ ] Impaired impulse control, such as unprovoked irritability with 
periods
           of violence
       [ ] Spatial disorientation
       [ ] Persistent delusions or hallucinations
       [ ] Grossly inappropriate behavior
       [ ] Persistent danger of hurting self or others
       [ ] Neglect of personal appearance and hygiene
       [ ] Intermittent inability to perform activities of daily living,
           including maintenance of minimal personal hygiene
       [ ] Disorientation to time or place


    6. Behavioral Observations
    --------------------------
     
Appeared alert and oriented. Grooming and dress were appropriate. Good eye
contact. No apparent pain or distress. Friendly, cooperative, and good effort
given. Good social skills. Adequate insight. Speech and thought content was
unremarkable. 

Described mood as "tired, depressed." Affect was tearful throughout the exam.
Energy described as "low, I just want to sleep." She described her sleep as "I
have trouble breathing and have to prop my head up on a couple of pillows." She
said that she does not get good sleep and wakes up tired most of the time. She
will "sleep as much as I can if I can" during the day as well. "I get cranky if 
I
can't  sleep." Reported having adequate self-esteem, "I just wish I was 
healthy."
Stated that she tends to stays positive about her future. Endorsed a few 
clinical
symptoms of depression including: low mood and isolation. Denied anxiety. She
said that she feels anxious if she starts hyperventilating. Denied manic
symptoms. Denied obsessive/compulsive symptoms. Did not describe panic attacks.
Described having adequate concentration and memory. "Sometimes it's not great.
Maybe because I'm not getting adequate." Denied SI/HI or psychosis.


    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
       
           If yes, describe:
              
              
    8. Competency
    -------------
    Is the Veteran capable of managing his or her financial affairs?
       [X ] Yes   [ ] No
       
           If no, explain:
              
              
    9. Remarks, if any
    ------------------



    Test Results
    ----------------

	MMPI2-RF: Validity: The veteran was attentive and consistent with her 
responses.
There was no indication of random, confused, or defensive responding. Profile is
valid and interpretable. 
		Clinical Correlates: Individuals with similar profiles are reporting
significant subjective distress. They are likely to describe themselves as
discouraged and demoralized. They are at increased risk for depression. They 
lack
positive emotional experiences, tend to withdraw from social settings, and are
likely passive in relationships. 

	

    Reliability and credibility of self-report
    ----------------------------------------------
	
No significant concerns noted


The purpose of the evaluation and limits of confidentiality were discussed and
the veteran gave informed consent. [Yes]


    Time spent in evaluation:
    -----------------------------

Clinical interview: 45
Record review: 45
Report preparation: 10

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

[Gastone]

Based on the PTSD C & P, looks like a Secondary MH SC at 0 or 10% possibly. PTSD C & P's are Forensic Exams and it's not unusual for the spouse to be excluded. Understandable, right?

The SC at 0% certainly isn't what she's hoping for but it's better than a Denial. Her foot's in the MH SC Ratings Door. While waiting for the Decision Letter, start planning Her NOD Filing.

File a VA FOIA request for a Disc Copy of her E-File in about 2 months say Aug or Sept. It will take up to 14 months to arrive but will be complete thru the date of the actual FOIA Filing.

I'd advise your wife to request a referral by her PCP to the VMC MH Dept for the treatment of her Depression symptoms. It's time to start laying a Paper Trail with VMC Clinician Treatment Notes.

Has she ever had an "Overnight Sleep Study" completed to determine the presence of Sleep Apnea (SA)? Review the SA List of usual suspects, symptoms & causes, looks like she may have a few. An SA DX'd to an SC issue is a 50% SC Secondary Award.

Semper Fi