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Thanks in advance for any help.  I had my C&P and this was my report.  What should I expect, if anything, from the VA?  


1. Diagnostic Summary --------------------- Does the Veteran have a diagnosis of PTSD that conforms to DSM-5 criteria based on today's evaluation? [X] Yes [ ] No 2. Current Diagnoses -------------------- a. Mental Disorder Diagnosis #1: PTSD Comments, if any: VETERAN'S PTSD SYMPTOMS ARE MOST LIKELY CAUSED BY OR RELATED TO HIS FEAR OF HOSTILE MILITARY OR TERRORIST ACTIVITY DURING ACTIVE DUTY SERVICE IN THE PERSIAN GULF Mental Disorder Diagnosis #2: ALCOHOL USE DISORDER, IN EARLY REMISSION b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): NONE REPORTED BY VETERAN 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? [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: PTSD: RECURRING AND DISTRESSING MEMORIES/DREAMS RELATED TO TRAUMA, AVOIDANCE OF TRAUMA-RELATED STIMULI, HYPERVIGILANCE, EXAGGERATED STARTLE RESPONSE ALCOHOL USE DISORDER: PROBLEMATIC ALCOHOL USE THAT LEADS TO SIGNIFICANT IMPAIRMENT OR DISTRESS (E.G., UNSUCCESSFUL EFFORTS TO CONTROL USE, FAILING TO FULFILL MAJOR OBLIGATIONS/ROLES, TOLERANCE/WITHDRAWAL). MALADAPTIVE USE OF ALCOHOL CAN INDUCE/WORSEN PROBLEMS WITH ANXIETY, MOOD, AND SLEEP 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 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 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: AT PRESENT, VETERAN'S IMPAIRMENT IS SUSPECTED TO BE SOLELY DUE TO PTSD. VETERAN REPORTS BEING SOBER SINCE 1/17 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): CHILDHOOD RAISED BY: MOTHER AND STEPFATHER. VETERAN NEVER MET HIS BIOLOGICAL FATHER WHERE RAISED: CALIFORNIA SIBLINGS: YOUNGER STEPBROTHER WHO WAS MUCH YOUNGER. VETERAN HAD ALREADY STARTED SERVING IN THE MILITARY WHEN HE WAS BORN  QUALITY OF FAMILY RELATIONSHIPS: VETERAN STATED THAT HIS STEPFATHER WAS "A REAL NEGATIVE GUY". HIS RELATIONSHIP WITH MOTHER WAS "NOT BAD AT ALL"; MOTHER HAD ISSUES WITH ALCOHOL BUT HE DOES NOT RECALL THIS HAVING AN ADVERSE AFFECT ON FAMILY RELATIONSHIPS HISTORY OF ABUSE: VETERAN STATED THAT HIS STEPFATHER WAS EMOTIONALLY ABUSIVE AND "PLAYED MIND GAMES". HE ADDED THAT HIS GOING INTO THE MILITARY WAS LARGELY MOTIVATED BY DESIRE TO GET AWAY FROM HIS STEPFATHER **************** ADULTHOOD: CURRENT LIVING SITUATION: VETERAN LIVES IN  WITH HIS WIFE OF 21 YEARS AND 2 CHILDREN. THEY MOVED TO THEIR CURRENT LOCATION FROM FORT PAYNE, ALABAMA ABOUT 2-3 YEARS AGO MARRIAGES: X 1 CHILDREN: 16 YO SON AND 8 YO DAUGHTER QUALITY OF FAMILY RELATIONSHIPS: VETERAN STATED THAT HIS RELATIONSHIPS WITH HIS WIFE AND CHILDREN ARE "PRETTY GOOD". HE CONSIDERS THEM TO BE THE "BEST PART OF MY LIFE". VETERAN MOVED FROM FORT PAYNE BECAUSE HE GOT TIRED OF OTHER FAMILY ASKING HIM "WHAT'S WRONG?" AND FEELING PRESSURE TO BE THE MAN THAT THEY KNEW BEFORE HIS MILITARY SERVICE QUALITY OF SOCIAL RELATIONSHIPS: VETERAN DENIED HAVING CLOSE FRIENDS HOBBIES/ACTIVITIES: VETERAN DENIED HAVING SIGNIFICANT HOBBIES OR LEISURE PURSUITS. AT HOME, HE MAY SPEND TIME ON THE COMPUTER OR WATCH TV b. Relevant Occupational and Educational history (pre-military, military, and post-military): PREMILITARY HIGHEST GRADE COMPLETED: 12 GRADES: B'S AND C'S ACTIVITIES: FOOTBALL AND BASEBALL  ACADEMIC PROBLEMS: NONE DISCIPLINE/BEHAVIORAL PROBLEMS: NONE WORK EXPERIENCE: RESTAURANT WORK THROUGHOUT HIGH SCHOOL MILITARY BRANCH/DATES OF SERVICE: ARMY 4/95 - 4/98 MOS: FIRE SUPPORT SPECIALIST AWARDS/MEDALS: NATIONAL DEFENSE SERVICE DISCIPLINARY/ADJUSTMENT PROBLEMS: NONE DEPLOYMENTS: SOUTHWEST ASIA 9/96 - 1/97 DISCHARGE/RETIREMENT: HONORABLE, RANK OF E4 POSTMILITARY TYPES OF WORK: VETERAN HAS WORKED AT VARIOUS CONSTRUCTION JOBS; HE MAINLY DOES BATHROOM REMODELS. WHEN HE LIVED IN FORT PAYNE, HE ALSO MANAGED A CONVENIENCE STORE OWNED BY HIS MOTHER AND STEPFATHER. VETERAN RELATED THAT SINCE HE QUIT DRINKING 1/17 HE HAS BEEN HAVING MORE PANIC ATTACKS, SOME OF THEM IN CUSTOMERS' HOMES. HE HAS STARTED TAKING EASIER JOBS THAT ONLY LAST A SHORT TIME BECAUSE "I DON'T WANT TO BE IN PEOPLES' HOUSES FOR LONG" DISCIPLINE/BEHAVIOR ISSUES : NONE EDUCATIONAL ATTAINMENTS: VETERAN ATTENDED COMMUNITY COLLEGE FOR ABOUT 1 SEMESTER IN 1999 c. Relevant Mental Health history, to include prescribed medications and family mental health (pre-military, military, and post-military): PREMILITARY: NONE MILITARY: NONE POSTMILITARY: VETERAN REPORTED THAT HE HAD NIGHTMARES AND PANIC ATTACKS SINCE MILITARY DISCHARGE BUT THAT HE SPENT YEARS SELF-MEDICATING WITH DRUGS AND ALCOHOL. HE HAS BEEN SEEING A VA CLINICAL SOCIAL WORKER FOR COUNSELING SINCE 3/31/17. DIAGNOSIS IS PTSD SUICIDE ATTEMPTS/HOSPITALIZATIONS: NONE  d. Relevant Legal and Behavioral history (pre-military, military, and post-military): VETERAN DENIED HISTORY OF LEGAL/BEHAVIORAL PROBLEMS e. Relevant Substance abuse history (pre-military, military, and post-military): VETERAN REPORTED THAT HE EXPERIMENTED WITH ALCOHOL PRIOR TO MILITARY SERVICE BUT THAT HIS USE WAS NOT CONSISTENT OR PROBLEMATIC. HE ADDED THAT HE DID NOT DRINK MUCH IN THE MILITARY. AFTER MILITARY DISCHARGE, VETERAN STATED THAT HIS USE OF MJ, WHICH HAD PREVIOUSLY BEEN ONLY RECREATIONAL, BECAME A HABIT. HE STOPPED SMOKING 2 YEARS AGO BECAUSE MJ SEEMED TO BE CONTRIBUTING TO HIS PANIC ATTACKS. AT THIS POINT, HOWEVER, HE STARTED DRINKING ALCOHOL MORE FREQUENTLY AND HEAVILY. VETERAN RELATED THAT HE STOPPED DRINKING AFTER A PERIOD OF SELF-REFLECTION ON NEW YEARS' EVE 2016; HE REALIZED THAT HE DID NOT WANT TO BE LIKE HIS MOTHER AND THAT HE WANTED TO "GET BETTER" 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: IN KUWAIT, VETERAN AND HIS TEAM WERE INSERTED INTO AREAS TO FIND TARGETS AND THEN THEY CALLED IN AIR FORCE ARTILLERY STRIKES. THEY OBSERVED BOMBS FALLING FROM THE SKY AND FELT THE IMPACT WHEN THEY HIT THEIR TARGETS. THEY THEN WALKED TO THE LOCATIONS THAT HAD BEEN BOMBED TO CONFIRM CASUALTIES/DO DAMAGE ASSESSMENTS. VETERAN NOTED THAT SOMETIMES NEARBY SHANTIES AND TENTS WERE IN THE LINE OF FIRE AND THAT ON SEVERAL OCCASIONS HE OBSERVED PEOPLE RUNNING FROM STRUCTURES WHILE ON FIRE OR DECEASED INDIVIDUALS ON THE GROUND. HE SMELLED BURNING FLESH. ON OCCASION, HE AND OTHER SOLDIERS HAD TO FIRE UPON SURVIVORS OF THE AIR STRIKES BECAUSE THEY DID NOT KNOW WHETHER OR NOT THEY WERE HOSTILES 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? [X] Yes [ ] No Is the stressor related to personal assault, e.g. military sexual trauma? [ ] Yes [X] No 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 stressor/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 (DSM-5). Criterion A: Exposure to actual or threatened a) death, b) serious injury, c) sexual violence, in one or more of the following ways: [X] Witnessing, in person, the traumatic event(s) as they occurred to others [X] 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. 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). 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] Hypervigilance. [X] Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep). Criterion F: [X] Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month. Criterion G: [X] The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Criterion H:  CONFIDENTIAL Page 17 of 42 [X] The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition. Criterion I: Which stressor(s) contributed to the Veteran's PTSD diagnosis?: [X] Stressor #1 5. Symptoms ----------- For VA rating purposes, check all symptoms that actively apply to the Veteran's diagnoses: [X] Depressed mood [X] Anxiety [X] Suspiciousness [X] Panic attacks more than once a week [X] Chronic sleep impairment [X] Mild memory loss, such as forgetting names, directions or recent events 6. Behavioral Observations -------------------------- GENERAL APPEARANCE: CASUALLY DRESSED WITH ADEQUATE GROOMING AND HYGIENE PSYCHOMOTOR ACTIVITY: UNREMARKABLE SPEECH: CLEAR AND COHERENT THOUGHT PROCESS/CONTENT: UNREMARKABLE. NO SIGNS OF DISTORTED THOUGHTS OR PERCEPTIONS ATTITUDE TOWARD EXAMINER: POLITE AND COOPERATIVE AFFECT: SLIGHTLY CONSTRICTED 7. 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: MOOD/INTERPERSONAL: VETERAN REPORTED BEING EASILY IRRITATED BY EVEN MINOR STRESSORS. IT TAKES HIM 15-20 MINUTES TO CALM DOWN. VETERAN EXPRESSED THAT HE HAS A HARD TIME RECONCILING HIS KILLING OTHERS WHILE ON DEPLOYMENT WITH HIS CHRISTIAN VALUES; HE DOES NOT FEEL GOOD ABOUT HIS ACTIONS OVERSEAS AND OTHERS THANKING HIM FOR HIS SERVICE IS "A REMINDER" ANXIETY/BEHAVIORAL: VETERAN REPORTED HAVING UNCUED PANIC ATTACKS (CHEST PAIN, SOB, ARM NUMBNESS) EVERY DAY. HE DOES NOT LIKE BEING IN CROWDS BECAUSE HE DOES NOT KNOW THE PEOPLE AROUND HIM OR WHAT THEIR MOTIVES ARE. HE LAMENTED THAT HE DOES NOT FEEL COMFORTABLE ENOUGH TO GO PLACES INCLUDING HIS SON'S FOOTBALL GAMES. VETERAN NOTED THAT HE OFTEN THINKS ABOUT HIS UPSETTING DEPLOYMENT EXPERIENCES BUT THAT HE DOES NOT TALK ABOUT THEM WITH ANYONE; ON HIS COMPUTER HE FREQUENTS CHAT ROOMS POPULATED BY FELLOW VETERANS WITH WHOM HE SERVED BUT HE AVOIDS GETTING INVOLVED IN CONVERSATIONS ABOUT WHAT THEY DID OVERSEAS. HE ALSO DOES NOT TALK TO HIS WIFE ABOUT HIS EXPERIENCES ("I DON'T WANT HER TO THINK OF ME LIKE THAT") SLEEP DISTURBANCE: VETERAN ENDORSED HAVING 3-4 NIGHTMARES ABOUT HIS DEPLOYMENT EXPERIENCES A WEEK. OVERALL, HE AVERAGES 2-3 HOURS OF SLEEP A NIGHT. HE OFTEN WAKES UP IN SWEATS AND THEN HAS A HARD TIME FALLING BACK ASLEEP MEMORY AND ATTENTION/CONCENTRATION: DID NOT REPORT ANY SIGNIFICANT PROBLEMS ENERGY/MOTIVATION: VARIABLE APPETITE: STABLE; USUALLY EATS 2 MEALS A DAY 8. Competency ------------- Is the Veteran capable of managing his or her financial affairs? [X] Yes [ ] No 9. Remarks, (including any testing results) if any -------------------------------------------------- DETAILS FROM MENTAL STATUS EXAM ORIENTATION: FULLY ORIENTED MEMORY: IMMEDIATE WORD RECALL: 3/3 WORD RECALL SHORT TIME DELAY: 1/3; RECALLED 2ND AND 3RD WORDS WITH FORCED CHOICE AFTER FAILING TO BENEFIT FROM SEMANTIC CUEING WORD RECALL LONG TIME DELAY: 3/3 ATTENTION: WNL ABSTRACT REASONING: FAIR TO GOOD JUDGMENT: AVERAGE INTELLIGENCE: AVERAGE INSIGHT: FAIR IMPULSE CONTROL: FAIR CURRENT SUICIDAL/HOMICIDAL IDEATION: DENIED ***********************  UNEMPLOYABILITY: VETERAN HAS WORKED FOR A NUMBER OF YEARS IN CONSTRUCTION/REMODELING. HE IS REPORTING INCREASED FREQUENCY OF PANIC ATTACKS SINCE HE STOPPED DRINKING 1/17, WHICH IN TURN HAS LED TO INCREASING DISCOMFORT IN CUSTOMERS' HOMES VETERAN'S PANIC SYMPTOMS, PRESUMABLY RELATED TO HIS PTSD, TEMPORARILY CAUSE EMOTIONAL DISTRESS AND REDUCED ABILITY TO COMPLETE PROJECTS. HOWEVER, HE HAS BEEN COMPENSATING BY BEING MORE SELECTIVE ABOUT THE WORK PROJECTS TO WHICH HE AGREES (HE OFTEN TAKES ON JOBS THAT DO NOT REQUIRE A LOT OF TIME TO COMPLETE). HE CAN PROBABLY CONTINUE TO FUNCTION ADEQUATELY AS LONG AS HE HAS THIS FLEXIBILITY. MORE GENERALLY, VETERAN WOULD LIKELY BE ABLE TO FUNCTION AT MOST JOBS AS LONG AS HE WAS ABLE TO WORK ALONE/IN ISOLATION; MUCH OF HIS DISTRESS IS RELATED TO BEING IN CROWDED ENVIRONMENTS AND/OR HAVING OTHERS' PRESENT WHEN HE HAS ANXIETY ATTACKS

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  • HadIt.com Elder

I would think a 70% Chronic PTSD Rating is in store.



I am not an Attorney or VSO, any advice I provide is not to be construed as legal advice, therefore not to be held out for liable BUCK!!!

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I would not guess that high because this veteran can work in environments that isolate him...But still-

whatever the rating is (and this is definitely a favorable C & P exam) the medical evidence in addition to the C & P might well warrant a good rating.Please don't overlook the value of going to a vet center.

Congratulations on your recovery . My husband stopping drinking in 1983 because he realized it made his PTSD worse.Vietnam vet..I can relate to every stressor you had. I worked in a Vet center combat PTSD group. A safe environment. They kept non vets out. ( except me. I am a civilian.)And we talked about all the things they could never tell their kids or spouses or even the VA.


GRADUATE ! Nov 2nd 2007 American Military University !

When thousands of Americans faced annihilation in the 1800s Chief

Osceola's response to his people, the Seminoles, was

simply "They(the US Army)have guns, but so do we."

Sameo to us -They (VA) have 38 CFR ,38 USC, and M21-1- but so do we.

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Lock in the 70% since it wasn't a total occupational impairment but with the Va anything can happen until it's an appeal then they go by the law and rules not just what the rater thinks is good....

Edited by jfrei
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