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sauerkraut1977
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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sauerkraut1977
Sure wish I kept my mouth shut. The VA wants to blame everything on stuff that happened before the military instead of focusing on the combat and how it changed my life forever. Hope the system gets i
AirForceVet81
I sure hope everything works out for u sir
sauerkraut1977
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
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