ptsd cp results

kfit83 · May 24, 2017

curious to what yall think. ptsd is affecting everything i do, and attitudes and doc mentions obsessive compulsive personality disorder. any ideas where this rating might fall or how that sharing traits of the ocpd may affect it?

Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination

Request?
[X] Yes [ ] No

SECTION I:

---------- 1. Diagnostic Summary

---------------------
Does the Veteran now have or has he/she ever been diagnosed with PTSD? [X] Yes [ ] No

2. Current Diagnoses
--------------------
a. Mental Disorder Diagnosis #1: PTSD

Comments, if any: Veteran continues to report symptoms of PTSD including

Emotional dysregulation in the form of recurrent anger, depression and anxiety in that order of frequency and severity; aggressiveness and anger outbursts; sleep disturbance, with nightmares and related fatigue; troubling recall of combat events; difficulty with concentration, attention, hypervigilant thoughts and behaviors; marital and family distress; interpersonal conflicts and avoidance of stimuli associated with his combat experiences.

Mental Disorder Diagnosis #2: Obsessive Compulsive Personality Disorder Comments, if any: Veteran experiences Obsessive Compulsive Personality Disorder symptoms including becoming preoccupied with details, lists, order, organization and scheduling to the extent that the major point of the activity is lost, he tends to be scrupulous and inflexible about matters of morality, ethics or values, he is reluctant to delegate tasks or work to others unless they submit to his exact way of doing things and he tends to be rigid and stubborn.

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: Veteran continues to report symptoms of PTSD including Emotional dysregulation in the form of recurrent anger, depression and
anxiety in that order of frequency and severity; aggressiveness and anger outbursts; sleep disturbance, with nightmares and related fatigue; troubling recall of combat events; difficulty with concentration, attention, hypervigilant thoughts and behaviors; marital and family distress; interpersonal conflicts and avoidance of stimuli associated with his combat experiences. His primary diagnosis is PTSD with reduced reliability and productivity due to PTSD signs and symptoms.

Veteran experiences Obsessive Compulsive Personality Disorder symptoms including becoming preoccupied with details, lists, order, organization and scheduling to the extent that the major point of the activity is lost, he tends to be scrupulous and inflexible about matters of morality, ethics or values, he is reluctant to delegate tasks or work to others unless they submit to his exact way of doing things and he tends to be rigid and stubborn. His OCPD traits appear to negatively impact his interpersonal and occupational functioning to an equal if not greater degree than his PTSD symptoms.

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] 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: Veteran continues to report symptoms of PTSD including Emotional dysregulation in the form of recurrent anger, depression and anxiety in that order of frequency and severity; aggressiveness and anger outbursts; sleep disturbance, with nightmares and related fatigue; troubling recall of combat events; difficulty with concentration, attention, hypervigilant thoughts and behaviors; marital and family distress; interpersonal conflicts and avoidance of stimuli associated with his combat experiences. His primary diagnosis is PTSD with reduced reliability and productivity due to PTSD signs and symptoms.

Veteran experiences Obsessive Compulsive Personality Disorder symptoms including becoming preoccupied with details, lists, order, organization and scheduling to the extent that the major point of the activity is lost, he tends to be scrupulous and inflexible about matters of morality, ethics or values, he is reluctant to delegate tasks or work to others unless they submit to his exact way of doing things and he tends to be rigid and stubborn. His OCPD traits appear to negatively impact his interpersonal and occupational functioning to an equal if not greater degree than his PTSD symptoms.

2. Recent History (since prior exam) ------------------------------------
a. Relevant Social/Marital/Family history:

Please refer to previous C&P PTSD exams dated 4/21/206 and 2/1/2017 for additional background and history. Veteran continues in his second marriage of two years. Veteran has an eleven year old son from first marriage and Veteran has full custody of him. Veteran has two step children ages ten and eight. Veteran added "we have them every other week". Veteran reported he has bi-monthly phone contact with his mother who lives in San Antonio, Texas. Veteran reported his brother has been living with them temporarily. Veteran added "We don't have a good relationship. He comes and goes and I can be standing there near him for 20 minutes and we don't talk". Veteran denied any additional social interactions other than with spouse and children. Veteran reported hobby/interest of "I will go to a gym a few days a week or work out at home. I watch whatever in on television".

b. Relevant Occupational and Educational history:
Veteran worked as a Police Officer for the city of Dallas, Texas for 7 years. Veteran reported he was last employed as a Police Officer in February 2016. Veteran reported he has tried to work several jobs sinceFebruary 2017 and added "I have a neighbor who has a moving company andI lasted a few days working for him. I worked for a few different cleaning crews and I lasted a half day at one and a few days at another one. I just have trouble getting up and going to the jobs".

c. Relevant Mental Health history, to include prescribed medications and family mental health:

Veteran's current psychotropic medications are fluoxetine and prazosin.

d. Relevant Legal and Behavioral history: None

e. Relevant Substance abuse history: None

3. PTSD Diagnostic Criteria ---------------------------

Please check criteria used for establishing the current PTSD diagnosis. The diagnostic criteria for PTSD, are from the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5). The stressful event can be due to combat, personal trauma, other life threatening situations (non-combat related stressors). 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 #6 - "Other symptoms".

Criterion A: Exposure to actual or threatened a) death, b) serious injury,

c) sexual violence, in one or more of the following ways: [X] Directly experiencing the traumatic event(s)

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 the of "I 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 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) the following:

[X] Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g.,

am bad,: "No one can be trusted,: "The world is completely

dangerous,: "My whole nervous system is permanently ruined").

of

[X] Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame).

[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)

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] Problems with concentration.
[X] Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).

Criterion F:
[X] The duration of the symptoms described above in Criteria

B, C, and D are more than 1 month.

Criterion G:
[X] The PTSD symptoms described above cause clinically

significant distress or impairment in social, occupational, or other important areas of functioning.

Criterion H:
[X] The disturbance is not attributable to the physiological

effects of a substance (e.g., medication, alcohol) or another medical condition.

4. Symptoms
-----------
For VA rating purposes, check all symptoms that actively apply to the Veteran's diagnoses:

[X] Depressed mood
[X] Anxiety
[X] Chronic sleep impairment
[X] Flattened affect
[X] Disturbances of motivation and mood
[X] Difficulty in establishing and maintaining effective work and social

relationships