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any opinions on this... have a claim for increase and TDIU
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tylerb333
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: Posttraumatic Stress Disorder
ICD Code: F43.10
Mental Disorder Diagnosis #2: Opioid Use Disorder, Severe, In early
remission, on maintenance therapy
ICD Code: F11.20
b. Medical diagnoses relevant to the understanding or management of the
Mental Health Disorder (to include TBI):
No response provided.
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: The veteran's symptoms are primarily related to his PTSD
since he has not used substances in more than six months.
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: The veteran's
impairment is related to his PTSD.
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
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).
[X] 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).
[X] Intense or prolonged psychological distress at exposure
to
internal or external cues that symbolize or resemble an
aspect of the traumatic event(s).
[X] Marked physiological reactions to internal or external
cues that symbolize or resemble an aspect of 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).
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] Persistent negative emotional state (e.g., fear, horror,
anger, guilt, or shame).
[X] Persistent inability to experience positive emotions
(e.g., inability to experience happiness, satisfaction,
or
loving feelings.)
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] Exaggerated startle response.
[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] Suspiciousness
[X] Chronic sleep impairment
[X] Disturbances of motivation and mood
[X] Difficulty in establishing and maintaining effective work and social
relationships
5. Behavioral observations
--------------------------
The veteran arrived 10 minutes late for his appointment and was pleasant
upon meeting. The veteran was oriented to person, place, situation, and
time. His grooming and hygiene were adequate. He made appropriate eye
contact and presented with a depressed mood with a congruent affect. His
speech was within normal limits for tone, volume, and rate. His thoughts
were logical, linear, and goal-directed. He did not evidence any
psychotic
symptoms, including responding to auditory or visual hallucinations and
delusional beliefs.
On a brief mental status exam he was able to freely recall two of three
words presented after a brief delay. He was able to recall six digits
forward and three digits backward. He was able to complete a serial seven
subtraction task with no errors to seven places. He was able to spell the
word WORLD forwards and backwards. He was able to complete a two-digit
addition and subtraction tasks. He was able to compare an apple and
banana
and was able to reason abstractly when comparing a poem and a statue. His
response to the proverb "don't cry over spilled milk" was good. He was
not
able to provide a response to the proverb "people in glass houses should
not throw stones."
6. Other symptoms
-----------------
Does the Veteran have any other symptoms attributable to PTSD (and other
mental disorders) that are not listed above?
[ ] Yes [X] No
7. Competency
-------------
Is the Veteran capable of managing his or her financial affairs?
[X] Yes [ ] No
8. Remarks, (including any testing results) if any:
---------------------------------------------------
The veteran was administered a psychological measurement that is useful
for interpreting the veracity of other data provided by an examinee
during
a psychological or neuropsychological examination. This assessment can
assist in evaluating and making a clinical opinion regarding the veracity
of an examinee's purported symptoms. Research has determined that this
tool is a useful instrument to administer in order to screen for possible
feigning of PTSD symptoms. The following results should be interpreted in
light of the fact that the measurement that was chosen is a screening
tool
and not designed as a definitive measure of whether or not an individual
is feigning mental illness. The Veteran's total score was not elevated
beyond the cut-off score. Therefore, his PTSD symptoms are considered to
be credible.
The veteran was administered the Minnesota Multiphasic Personality
Instrument-2-Restructred Form (MMPI-2-RF), which is a self-report
psychological assessment used to identify a variety of psychological
syndromes. The veteran was provided a quiet, private room to complete the
testing. It appears the veteran understood the items and responded to the
items in a consistent manner. The veteran over-reported psychological
dysfunction, which is evidenced by a considerably larger than average
number of infrequent responses. The veteran also possibly overreported
symptoms associated with non-credible memory complaints. Although there
is
evidence of over reporting of symptoms, the profile is considered valid
and will be interpreted.
Overall, the veteran endorsed considerable emotional distress that is
likely perceived as a crisis. The veteran reported feeling sad and
dissatisfied with his currently circumstances. He reported a lack of
positive emotional experiences, a lack of energy, and a lack of interest
in activities. He also reported experiencing various negative emotional
experiences including anxiety, anger, and fear. The veteran also reported
a significant history of antisocial behavior. This behavior includes
involvement with the criminal justice system, difficulty with authority
figures, conflictual interpersonal relationships, impulsivity, juvenile
delinquency, and substance abuse. The veteran also endorsed various
unusual thought and perceptual processes.
The veteran endorsed a diffuse pattern of cognitive difficulties
including
memory complaints. He also reported past suicidal ideation and feelings
of
helplessness. The veteran endorsed feelings of anxiety, being anger
prone,
and experiencing multiple fears that restrict his activity inside and
outside of the home. He also reported being unassertive and shy. The
veteran endorsed not enjoying social events and avoiding social
situations. He also reported disliking being around people. On a scale of
personality pathology, the veteran endorsed being self-critical and
guilt-prone. He also endorsed being pessimistic and feeling depressed.
The veteran is currently diagnosed with Posttraumatic Stress Disorder and
Opioid Use Disorder, Severe, In early remission, on maintenance therapy.
The veteran currently lives alone and is not involved in a romantic
relationship. He maintains phone contact with his daughter. He has a
close
relationship with his mother, sister, and two friends. He is currently
working for his mother's company. He reported experiencing symptoms of
PTSD. He is attempting to cope with his emotions without the use of
drugs.
The veteran has been employed numerous times and has been fired for
tardiness or alcohol and drug use. He is currently working 5-6 hours per
week for his mother's company. According to the previous C&P exam, he is
not able to work many hours due to not being permitted to work inside of
a
bank due to his felony record. The veteran reported that he was "working"
during his 10 years in prison selling drugs. He denied having any
difficulties while in prison. The veteran is capable of following
instructions and performing simple tasks. He is able to concentrate on a
simple task and respond appropriately to coworkers and supervisors.
/es/ ALLISON C HOULE, PHD
C&P Psychologist
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