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PTSD claim

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sauerkraut1977

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Need some hell understanding this egal for increase and na Diagnose Ptsd. Thank you!

 

LOCAL TITLE: COMP & PEN MENTAL HEALTH/PSYCHOLOGY EXAM 
STANDARD TITLE: PSYCHOLOGY C & P EXAMINATION CONSULT 
DATE OF NOTE: MAY 03, 2017@09:30 ENTRY DATE: MAY 05, 2017@17:31:30 
 AUTHOR: DAYTON,GREGORY D EXP COSIGNER: 
 URGENCY: STATUS: COMPLETED 
 Mental Disorders
 (other than PTSD and Eating Disorders)
 Disability Benefits Questionnaire
 Name of patient/Veteran: Preble, Jason Dewayne
 
 Is this DBQ being completed in conjunction with a VA 21-2507, 
 C&P Examination
 Request?
 [X] Yes [ ] No
 
 SECTION I:
 ----------
 1. Diagnosis
 ------------
 a. Does the Veteran now have or has he/she ever been diagnosed 
 with a mental
 disorder(s)?
 [X] Yes [ ] No
 
 If the Veteran currently has one or more mental disorders 
 that conform to
 DSM-5 criteria, provide all diagnoses:
 
 Mental Disorder Diagnosis #1: Other Unspecified Anxiety 
 Disorder
 Mental Disorder Diagnosis #2: Alcohol Use Disorder

Mental Disorder Diagnosis #3: Adjustment Disorder with Mixed 
 Disturbance
 of Emotions and Conduct
 b. Medical diagnoses relevant to the understanding or management 
 of the
 Mental Health Disorder (to include TBI): None
 
 2. 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?
 [X] Yes [ ] No [ ] Not applicable (N/A)
 
 If yes, list which symptoms are attributable to each 
 diagnosis and
 discuss whether there is any clinical association between 
 these
 diagnoses:
 Other unspecified anxiety disorder: anxiety.
 Alcohol use disorder: impaired judgment, depressed mood, 
 difficulty
 establishing and maintaining effective work and social
 relationships, suspiciousness, chronic sleep impairment. 
 Adjusmtent disorder with mixed disturbance of emotions 
 and conduct:
 depressed mood, difficulty establishing and maintaining 
 effective
 work and social relationships, suspiciousness, chronic 
 sleep
 impairment. 
 
 
 c. Does the Veteran have a diagnosed traumatic brain injury 
 (TBI)?
 [ ] Yes [X] No [ ] Not shown in records reviewed
 
 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)

[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?
 [X] Yes [ ] No [ ] No other mental disorder has been 
 diagnosed
 
 If yes, list which portion of the indicated level of 
 occupational and
 social impairment is attributable to each diagnosis:
 This writer is of the opinion that, in total, his 
 service-connected
 Other Unspecified Anxiety Disorder accounts for no more 
 than 20% of
 his current occupational and social impairment. Non-
 service
 connected Alcohol Use Disorder and Adjustment Disorder 
 with Mixed
 Disturbance of Emotions and Conduct, account for the 
 remaining 80%
 (40% each).
 
 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):
 Virtual VA and VBMS.
 2. History
 ----------
 a. Relevant Social/Marital/Family history (pre-military

military, and
 post-military):
 
 See the 11/2/15 Contract MH C&P report for background 
 information. He is
 currently living in Patriot House, the "homeless program." 
 He has never
 married and is not dating.
 
 b. Relevant Occupational and Educational history (pre-military, 
 military, and
 post-military):
 
 See the 11/2/15 Contract MH C&P report for background 
 information. The
 veteran has not been employed since working as a forklift 
 operator for
 Coca Cola between January and May 2016. He told this writer 
 he was fired
 for difficulty getting along with others; but has 
 previously testified
 he was terminated when his legal history was uncovered.
 
 c. Relevant Mental Health history, to include prescribed 
 medications and
 family mental health (pre-military, military, and post-
 military):
 
 See the 11/2/15 Contract MH C&P report for background 
 information.
 During this review period, the veteran was seen at the 
 Houston VA until
 October 2016, before coming to Dallas. Notes indicate 
 "drinking to self
 medicate his anxiety"; "being fearful that he will have to 
 go back to
 prison"; "expresses frustration at the many challenges he 
 has faced
 since release from prison"; and "tendency to return to 
 drinking when
 stressed." He was prescribed sertraline in Houston. He 
 admitted to
 providers in Houston his stepmother "made him" go to a 
 mental health
 professional several times during childhood; and that he 
 was prescribed
 ritalin as a child. "He reported a two week period during 
 his deployment
 to Kuwait when his until was constantly relocating and he 
 feared being
 attacked." He said he'd twice attempted suicide: when he 
 was told by the

Army they were going to court martial him; and when he was 
 sentenced to
 prison in 2007. 
 When he was first seen in Dallas, he was homeless and 
 unemployed, had
 run out of his mediation from Houston VA providers, and was 
 experiencing
 anxiety and panic as well as some nightmares. He was also 
 drinking hard
 liquor 3-4 times a week. He reported being diagnosed with 
 PTSD in
 Houston, but apparently related to his history of sexual 
 abuse for years
 as a child. He also reported MST, and that his little 
 s
ister's death of
 SIDS when he was 5 "significantly affected his mother 
 (committed), which
 in turn affected him." He was started on sertraline, 
 doxipin, and
 disulfiram, and referred for therapy. As of April 2017, the 
 veteran was
 enrolled in the Dallas VA Community Based Employment 
 Program. 
 Today, the veteran described functioning better- and 
 enjoying a better
 quality of life- prior to his 2007 arrest. He'd completed 
 an associates
 degree and was working toward a pilots license. He was 
 working and was
 not homeless. "It all went to shit because of me drinking 
 and chasing
 xxxxx all the time", he told this writer. 
 See "Remarks", end of this report.
 
 d. Relevant Legal and Behavioral history (pre-military, 
 military, and
 post-military):
 
 See the 11/2/15 Contract MH C&P report for background 
 information.
 During this review period, the veteran has twice been in 
 trouble with
 the authorities, and was jailed for 22 days in Dallas, 
 apparently for
 failing to report to his agreed upon housing. In Houston, 
 prior to
 moving to this area, he was arrested for "soliciting" and 
 this was later

changed to "transporting for immoral purposes." The veteran 
 is still on
 probation following his 2007-2015 incarceration for sexual 
 abuse of a
 child.
 
 e. Relevant Substance abuse history (pre-military, military, and
 post-military):
 
 See the 11/2/15 Contract MH C&P report for background 
 information. The
 veteran said "I don't get DRUNK drink anymore"; but 
 admitted he is still
 drinking regularly and sometimes heavily, which is a 
 violation of his
 parole. He last drank "last night"; and said, "I got a 
 gallon of vodka
 in my car!"
 
 f. Other, if any:
 No response provided.
 
 3. 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] Impaired judgment
 [X] Difficulty in establishing and maintaining effective work 
 and social
 relationships
 4. Behavioral observations
 --------------------------
 Appropriately dressed and groomed. Psychomotor behavior anxious. 
 Mood and
 affect irritable. Speech was rapid and pressured, and he 
 peppered his speech
 with vulgarities thoughout the examination, describing other 
 people's
 behavior or situations in which he'd felt mistreated. No gross 
 deficits in
 short- or long-term memory evidenced. Thought processes coherent 
 and
 goal-directed. No delusions, hallucinations, obsessions.
 
 5. Other symptom

Does the Veteran have any other symptoms attributable to mental 
 disorders
 that are not listed above?
 [ ] Yes [X] No
 
 6. Competency
 -------------
 Is the Veteran capable of managing his or her financial affairs?
 [X] Yes [ ] No
 
 7. Remarks (including any testing results), if any:
 ---------------------------------------------------
 DSM-5 diagnoses: Other Unspecified Anxiety Disorder, at least as 
 likely as
 not incurred in or caused by service; Alcohol Use Disorder, not 
 incurred in
 or caused by service; and Adjustment Disorder with Mixed 
 Disturbance of
 Emotions and Conduct, not incurred in or caused by service. 
 The previous examiner diagnosed unspecified anxiety disorder, 
 and this is
 continued by this writer. However, the previous examiner noted 
 his
 polysubstance abuse disorder was in full remission; this is not 
 the case
 today. The veteran's alcohol use disorder is not in remission, 
 but is active
 (see body of report, "Relevant Substance Abuse History"). 
 This writer's diagnosis of Adjusment Disorder with Mixed 
 Disturbance of
 Emotions and Conduct accounts for the mood and conduct symptoms 
 exhibited by
 this veteran that are NOT related to service. This diagnosis- 
 together with
 his Alcohol Use Disorder- accounts for the majority of his 
 occupational and
 social impairment. 
 The veteran has already been diagnosed with a service-connected 
 anxiety
 condition, and this writer is willing to conceed that a small 
 portion of his
 current impairment is related to mood symptoms precipitated by 
 stressful
 events in service many years ago (see below). However, even that 
 situation-
 which led to his General discharge- occured within the context 
 of his abusing
 multiple substances, which he's previously admitted impaired his

judgment in
 service. This writer is of the opinion that, in total, his 
 service-connected
 Other Unspecified Anxiety Disorder accounts for no more than 20% 
 of his
 current occupational and social impairment. Non-service 
 connected Alcohol Use
 Disorder and Adjustment Disorder with Mixed Disturbance of 
 Emotions and
 Conduct, account for the remaining 80% (40% each). 
 The veteran has told others- and implied today- that military 
 service, and
 specifically deployment to Kuwait, is responsibe for all his 
 mental health
 issues. "What happened over there is the reason I'm like 
this", 
 he told his
 social worker last July. This writer does not agree with that 
 assessment of
 the etiology and course of his mental illness. It doesn't take 
 into account
 five years of sexual molestation as a child by his stepbrother; 
 his mother's
 mental disintegration (including hospitalization) after the 
 death of the
 veteran's little sister when he was 5; his history of 
 psychiatric treatment
 in childhood; alcohol, benzodiazapine, and opioid abuse in 
 service, which
 started before he went to Kuwait and then continued after 
 service (he still
 drinks excessively); conviction of sexual assault of a child 
 years after
 service, leading to attempted suicide and a 7-year prison term, 
 during which
 he was witness to traumatic events; and since release from 
 prison, difficulty
 finding work or housing due to his legal history, resulting in 
 homelessness
 and unemployment. He neglected to tell the previous MH C&P 
 examiner about the
 years of sexual abuse as a child, or about having been treated 
 by mental
 health professionals in childhood. And he didn't even mention 
 Kuwait as a
 potential stressor during that previous examination. 
 None of these stressful events and circumstances have to do with 
 service,
 started during service, or are related to service (except the 
 substance

abuse, which is not a service-connectible condition). Despite 
 telling this
 writer his substance abuse and treatment started after Kuwait, 
 he has
 previously clearly testified these occured while deployed to 
 Korea, before
 Kuwait. He has repeatedly told providers (and the previous C&P 
 examiner) the
 events that precipitated his General Discharge (destruction of 
 government
 property) were finding out his girlfriend cheated on him while 
 he was TDY;
 and the Army changing it's mind about allowing him to reclassify 
 as a
 recruiter. He admitted today that he "self-destructed" after 
 learning that
 his reclassification was withdrawn by the Army after their 
 review revealed
 his Article 15 in Korea. Neither of these events is a PTSD 
 Criterion A
 stressor. And neither of them have anything to do with Kuwait.
 The veteran's description of his experiences in Kuwait are not 
 supportive of
 a PTSD Criterion A stressor, either. What he described to others 
 as being
 "fired upon", he clarified today as: "They just came and got 
us 
 in the middle
 of the night, told us to pack our shit up." The only reason he 
 reported they
 were being fired upon was because they were forced to quickly 
 evacuate their
 position. Over the next two weeks, he said, they were told to 
 move several
 more times, which he said was very stressful, and made him 
 fearful of attack.
 Nevertheless, he was not actually exposed to any incoming fire 
 and did not
 experience any life-threatening events, based on his description 
 today. As
 already noted above, he did not mention his Kuwait deployment 
 during his 2015
 C&P examination for PTSD.
 In this writer's opinion, it is not clinically reasonable to 
 attribute a
 lifetime of emotional, behavioral, relationship, substance, 
 authority, legal,
 and financial problems to the events in Kuwait he described; a

girlfriend
 cheating on him; or disappontment over his failed bid for 
 reclassification.
 As described above, he has a long history of much more severe 
 stressors that
 not related to service, that are more likely responsible for his 
 mental and
 emotional problems today- and for most of his history. 
 Results of the MMPI-2-RF administered as part of today's C&P 
 exam, were
 invalid- the veteran responding in an inconsistent and 
 exaggerated fashion.
 This, too, is not supportive of his claim for increased service-
 connection. 
 
 
/es/ GREGORY D DAYTON, Ph.D.
Staff Psychologist
Signed: 05/05/2017 17:31

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Here is some more info now that Benefits decided to work.

  • Disabilities Claimed: PTSD (post traumatic stress disorder) (related to: PTSD - Combat) (New), Major depression (related to: PTSD - Combat) (New), Sleep disturbances (related to: PTSD - Combat) (New), Hypertension (related to: PTSD - Non-Combat) (New), Gastrointestinal problems (related to: PTSD - Non-Combat) (New), Hyperlipidemia (related to: PTSD - Non-Combat) (New), Adjustment reaction (New), Unemployability (New), Unspecified anxiety disorder with features of obsessive compulsive disorder and other trauma related disorder ( claimed as posttraumatic stress disorder (Increase)
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Sorry about your childhood but this is an all around denial to all claimed in my opinion

Edited by jfrei
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sauerkraut1977 - It appears to me that you have more "markers" for Non-service connected PTSD claim than a SERVICE connected. In saying that - you may receive a lower rating than you would expect.

Take the therapy as offered.  It will change your life in a good way. :)

Here is the link for the DSM-V criteria for PTSD diagnosis. Measure it - against only your IN SERVICE.... PTSD symptomatology. 

http://www.brainlinemilitary.org/content/2014/06/dsm-v-tr-criteria-for-ptsd.html

See if you can find any postings that are similar to yours for a measure. I ask for you to look for them yourself because as you read others posts, you will gain knowledge to help yourself with this claim.

Good Luck, 

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Thank you all for the feedback. I am SC 30% for Anxiety order and went ro the VA and they diagnosed me with cronic PTSD so thatvis why i filed a new claim and asked for an increase. Also because they rated the anxiety as PTSD i wanted my disability diagnosis changed to PTSD. I went to a benefits fair today and talked personally with someone from the regional office and she said all the shit he put in his notes with what he thinks the percenages should be not only was wrong but should have no affect on the rating. Section 3 for rating purposes he checked every box and and admitted the social imparment so in her option i should get a raise to 50 or 70. But as we all know with the VA also need to be prepared for another appeal if they tey to lower it. He conceded to the current diagnosis and i should hopefully stay at 30. We will see. Claim is in the preparstion for decision phase with June 30th date.

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sauerkraut1977 - Good Luck - your posting above is exactly why I got an IMO- It helps to validate the symptoms with an outside verifiable source. ( not just VA sources) 

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