PTSD C&P - Denial coming How should I proceed?

IMEF-Gunny · July 20, 2017

So, I was diagnosed with PTSD at my VAMC, attend therapy there, take Zoloft, Prazosin & Bupropion. I filed a claim, they verified stressors, sent all my records, buddy statements. I just attended my C&P, doc says no PTSD, granted I stressed how I'm currently affected and should have went into greater detail on stressors....but I was so fuc*ing anxious/nervous. Doc basically said Major Depressive Disorder, present pre-USMC as indicated in my STR's and alluded to alcohol issues...less likely than not therefor due to military service. His basis was that I had problems in 1991, was essentially problem free for decades and then they started 3-5 years ago....so, not related to service. Problem is NO WHERE is that supported. My buddy statements from spouse, family, employers ALL show issues with depression, anxiety, anger, write ups, etc from 1992 - today....so, there is no basis for his statement that I went decades symptom free. Question is, PTSD denial is imminent of course, but can I ask/attempt to get SC for Major Depressive disorder instead? Here is my C&P......and following, my letter to VA in regard to my disagreement with the C&P examiners assumption.............my anxiety right now is redlined......any help/advice is greatly appreciated and Neeeed!

LOCAL TITLE: C&P Examination

STANDARD TITLE: C & P EXAMINATION NOTE

DATE OF NOTE: JUL 14, 2017@08:00 ENTRY DATE: JUL 17, 2017@08:51:04

AUTHOR: LONG,WILLIAM R EXP COSIGNER:

URGENCY: STATUS: COMPLETED

Medical Opinion

Disability Benefits Questionnaire

Name of patient/Veteran: Michael

ACE and Evidence Review

-----------------------

Indicate method used to obtain medical information to complete this

document:

[X] In-person examination

Evidence Review

---------------

Evidence reviewed (check all that apply):

[X] CPRS

[X] Other (please identify other evidence reviewed):

JLV (Joint Legacy Viewer)

CONFIDENTIAL Page 4 of 27

MEDICAL OPINION SUMMARY

-----------------------

RESTATEMENT OF REQUESTED OPINION:

a. Opinion from general remarks: DBQ PSYCH PTSD Initial

____________________________________________________________________________

The following contentions need to be examined:

PTSD (post traumatic stress disorder) (related to: PTSD - Non-Combat)

Active duty service dates:

Branch: Marine Corps

RAD: 04/29/1991

DBQ PSYCH PTSD Initial:

Please review the Veteran's electronic folder in VBMS and state that it

was

reviewed in your report.

The Veteran is claiming service connection for PTSD (post traumatic stress

disorder) (related to: PTSD - Non-Combat) due to the claimed stressor of

fear/hostile environment. Please examine the Veteran for a chronic

disability related to his or her claimed condition and indicate the current

level of severity.

If more than one mental disorder is diagnosed please comment on their

relationship to one another and, if possible, please state which symptoms

are attributed to each disorder.

If your examination determines that the Veteran does not have diagnosis of

PTSD and you diagnose another mental disorder, please provide an opinion as

to whether it is at least as likely as not that the Veteran's diagnosed

mental disorder is a result of an in-service stressor related event.

b. Indicate type of exam for which opinion has been requested: DBQ PTSD

Initial

CONFIDENTIAL Page 5 of 27

TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR DIRECT SERVICE

CONNECTION ]

b. The condition claimed was less likely than not (less than 50%

probability) incurred in or caused by the claimed in-service injury, event

or

illness.

c. Rationale: The primary rationale for this opinion is the presence of

symptoms similar to his current symptoms prior to joining the military (see

Mental Health history, Substance Abuse history). As stated in a December 1,

1989 Mental Health note "referral for eval of EPTE SA in 1987 of putting

his

head through a glass window while drunk. States he was in a state of

depression at the time." and goes on "Significant hx of feeling

dression with

suicidal ideation both sober and intoxicated. Has stopped himself from

killing himself with gun but can not verbalize why he stopped."

Similarly, veteran's history is inconsistent with his service being the

major

precipitant of his current distress. While veteran identifies distress upon

his return and a June 1, 2017 buddy statement by his mother, indicates

distress after deployment (see partial statement below), his history

indicates he experiences marked distress before the deployment and was

relatively symptom free until 3 to 5 years ago. Such a history is

inconsistent with that expected of the deployment being the primary truama.

June 1, 2017 buddy statement by his mother, states, "After returning

from the

war in Desert Storm he seemed reserved, no longer having a close

relationship

with friends or family. He seemed more intense with any perceived conflict.

It seems like he builds walls to keep some people at bay, keeping his

feelings inside, and exhibiting a saddened mood for the most part, but

explosive when he becomes agitated. He was not the same young man that left

for Desert Srorm. He lost a tremendous amount of weight after returning

home

and seemed to rely on alcohol more when he would have especially dark moods.

Mike seemed distraught and saddened."

*************************************************************************

****************************************************************************

Initial Post Traumatic Stress Disorder (PTSD)

Disability Benefits Questionnaire

* Internal VA or DoD Use Only *

CONFIDENTIAL Page 6 of 27

Name of patient/Veteran: Michael

SECTION I:

----------

1. Diagnostic Summary

---------------------

Does the Veteran have a diagnosis of PTSD that conforms to DSM-5 criteria

based on today's evaluation?

[ ] Yes [X] No

2. Current Diagnoses

--------------------

a. Mental Disorder Diagnosis #1: Major Depressive Disorder

Comments, if any:

Veteran's symptoms are:

over-reactive, blaming irritability (see Behavioral Observations,

Irritability)

diminished pleasure (see Family history)

psychomotor agitation (see Occupational history, see Behavioral

Observations,

aggressive behavior)

concentration difficulties (see Remarks section, concentration

difficulty, PTSD

symptom checklist

recurrent thoughts of death (repeatedly holding a gun with

consideration of suicide)

While veteran is very intensely involved in his sense of being

wronged (see discussion of intrusive thoughts, PTSD symptom

checklist, Remarks section), his overall emotional distress is

relatively low (see MMPI-2-RF). Assessment of social/occupational

functional diffiuculties are based on his marital difficulties

(see

Family history) and interpersonal anger (see Occupational

history).

Veteran experiences himself as having PTSD; however, he does not

report intrusive or avoidance symptoms of PTSD (see Remarks

section).

Buddy statements as available are consistent with major depression

and do not indicate significant intrusive symptoms of PTSD. As

stated in a June 28, 2017 buddy statement by Tim Pulliam,

supervisor, "During his time at JCI (Johnson Controls), Mr.

McGuire's interaction with co-workers and management was

often

strained due to personality conflicts, angry outbursts and a

general anti-social nature on his part." And as stated in a

May 1,

2017 buddy statement by Christina McGuire, wife "Mike has

struggled

CONFIDENTIAL Page 7 of 27

with anxiety, anger/mood issues and depression off and on

throughout most of the time that we have been together. The last

3-5 years has been much more pronounced." The statement goes

on,

"In the past, when Mike would struggle with

depression/anxiety,

especially when he focused too much on military talks, discussions

with vet buddies, he would sometimes self-medicate with alcohol.

Those incidents, although they didn't occur often, would usually

result in erratic, angry behavior and sometimes emotional

breakdowns or incidents of rage. Mike has broken household items

and even his hand during such a case because of this, whiche

caused

him to be off work for months and have surgery and

rehabilitation."

In light of his previous alcohol history and possible denial (see

Substance Abuse history), the possibility of an additional Alcohol

Use disorder should be considered if more history of abuse becomes

salient.

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?

[ ] Yes [X] No

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 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?

[ ] Yes [ ] No [X] No other mental disorder has been diagnosed

CONFIDENTIAL Page 8 of 27

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] CPRS

[X] Other (please identify other evidence reviewed):

JLV (Joint Legacy Viewer)

2. History

----------

a. Relevant Social/Marital/Family history (pre-military, military, and

post-military):

Veteran was raised, "70% of time" by his maternal

grandparents. His

parents, "got married very young, I was a surprise so to

speak." They

divorced when he was age 8. He was very close to his grandparents,

particularly his grandmother, "grandmother never drank, never

cursed,

never drove a car, do anything for you, definition of unconditional

love, I was her favorite." When he was 10, his mother remarried

and

continues to be with his stepfather to this date. He has a full

sister, 5 years younger than him and a half brother by his father and

a

half sister by his mother.

Veteran describes a distant relationship with all of his family.

Regarding his mother he reports, "we get along, we love each

other,"

but "I don't see her much." He last saw her, "3 or

4 months ago, ran

into each other in a store." He last saw his biological father

"6

months ago, again just publicly, I think he and I get along okay."

He

has not seen any of his siblings in more than a year.

He reports that his father abused alcohol when he was younger and that

CONFIDENTIAL Page 9 of 27

he had an uncle, "got a DUI at one time." He concludes,

"my paternal

grandmother drank quite a bit."

FAMILY PSYCHIATRIC HISTORY: The Veteran reported no known family

history of serious mental illness or suicide attempts.

Veteran denied history of sexual abuse, physical abuse, or domestic

violence.

Veteran did not describe any psychiatric difficulties with activities

of daily living.

Veteran denies belonging to a church or any organized social group.

Veteran was first married from 1992 to 1995. He sees the marriage as

a

mistake, "I got married for wrong reasons," and that the

marriage

dissolved due to his, "anger issues." He has 2 children from

the first

marriage, a son, 23, "got Asperger's, he has a lot of

problems besides

just the Asperger's, lives in a group home." He last saw the

this son

at Christmas of 2016. He has a daughter, 21, "okay

relationship," he

saw her "a couple months ago, they went with us hiking."

Veteran met his current wife in 1996 and they married in 1999. He

does

not know if the marriage will last, "divorce has come up, last

time

about 2 weeks ago." During stressful times they both talk about

divorce, "seemed pretty mutual." He was unable to identify

the source

of the distress beyond vague statements, "life, finances, kids,

work."

Last night they had an argument. He and his wife stayed in a hotel to

avoid an early morning drive to this appointment, "she got upset

with

me because I didn't want to do anything, didn't want to take

a horse

and carriage ride." He notes, "I know she wanted to have

sex," which

he felt was very insensitive to his anxiety and distress, "that

upset

me, seemed ridiculous that she would be upset, we didn't do

something

fun." She expressed anger, "you act like you're

old."

CONFIDENTIAL Page 10 of 27

The couple has 5 children, 4 sons, 18, 15, 5, and 1, and a daughter,

10. He reports all the children "are okay, all smart, athletic

kids."

Veteran sees himself as a home body who prefers to avoid crowds. He

does run family errands without incident, for example, he went to the

grocery store yesterday by himself, "one of my kids was sickly,

got

prescriptions, went okay I guess." Similarly, he went out to

dinner

last night, "it went all right;" however, this was first time

eating

out, "in a long time."

Initially, veteran denies having any friends; however, when pressed

for

details he describes several on-going relationships. He has a

neighbor, "navy veteran, occasionally go over and talk." His

"best

friend" in high school, "is married to my sister." He

has a friend

that he served with who comes by his house regularly, the last time,

"3, 4 weeks ago." Veteran reports that he enjoys preparing

meals for

his family on the grill but denies any other pleasurable activities in

his life.

b. Relevant Occupational and Educational history (pre-military, military,

and

post-military):

Veteran is a high school graduate. History of learning disability,

special education, or being held back a grade was denied. Veteran

reports only one suspension from school at age 14, "drank too

much

alcohol in the morning before school," he was suspended and placed

in a

mandatory alcohol treatment program. He describes high school as

otherwise, "pretty good, played football, had girlfriends most of

the

time, went through school with 2 of my best friends." He

obtained,

"B's and C's mostly." He obtained an

Associate's in Robtotics in 1998.

Currently, veteran has worked the last 10 years in a "waste water

treatment plant." He reports the job is going "mostly okay,

technically I'm proficient." He has been counseled about his

behavior

on the job. The behavioral difficulties were described in an April

CONFIDENTIAL Page 11 of 27

19,

2017 buddy statement by Steven Atteberry, Foreman, as "complaint

was

that he displayed 'Angry, intimidating and condescending'

behaviors

that disrupted the workplace." The complaint lead to, "a

written

warning and a 1 year probation in September, 2015." He works 10

hour

daytime shifts Monday through Thursday. He reports missing 5 days

over

the last year for, "personal ailments."

Veteran reports being fired only one time in 1999, "on the first

day of

the job," when they discovered he was red/green color blind,

"they

skipped a certain portion of the interview, told me I had to

leave."

He left a job in the early 2000's without notice, "it was a

clean room,

stuck in a clean room for 12 hours [in a clean suit for 12 hours], I

hated it."

His longest period of unemployment was for a year and half after his

divorce. He had no explanation for the period of unemployment beyond,

"I lost job that I had, basically a welder, for Johnson

controls." He

had this job for 3 and half years, it was his first job after leaving

the military.

Branch: Marines

Dates of Service: November, 1990 to April, 1991

Discharge Type: HONORABLE

Rank on Discharge: E3

Veteran was deployed to Bahrain and Saudi Arabia during his active

service as above.

c. Relevant Mental Health history, to include prescribed medications and

family mental health (pre-military, military, and post-military):

MENTAL HEALTH TREATMENT AFTER MILITARY: Veteran denies formal mental

health treatment before approaching the St Louis VA in January of this

year. Prior to that he did approach a primary care provider "in

1994

maybe, I was having a lot of troubles at work." The "company

doctor

prescribed me Buspar, couldn't take it, threw my equilibrium off,

never

went back."

CONFIDENTIAL Page 12 of 27

He has been seen regularly through the VA since January with a

diagnosis of PTSD.

A March 3, 2017 Behavioral Medicine note reports remarkable progress,

"reports that he is doing much better. 'I wanted to call you

the other

day and thank you, I really didn't think I could feel normal

again.'"

The note went on, "Vet is happy that he has been able to enjoy

life, he

stated his wife has really noticed a difference. Vet stated he

hadn't

cried in three weeks. Vet has had no suicidal ideations. Vet states

he feels his memory may be a little better." The note finishes,

"Vet

stated he and his wife have been going out one night per week and he

has been enjoying that." Veteran confirms this initial success

which

he attributes to Zoloft. He feels that his symptoms are still

improved

but that the initial period of "almost euphoria" have left.

Veteran has been diagnosed with PTSD by his providers; however, the

basis of this diagnosis is unclear. Veteran's January 6, 2017

Initial

Psychiatry Consult does not report apparent intrusive symptoms of

PTSD.

As described there, "HISTORY OF PRESENT ILLNESS: Vet reports he

cries

whenever he comes to the VA, Vet states he also cries sometimes at

home

for no reason. Vet reports problems sleeping, states he is up five

times per night. Vet does check locks every night, he contributes it

to

having small children, not to being hypervigilant. Vet reports road

rage. Vet states he doesn't feel depressed, Vet denies suicidal

or

homicidal ideations. Vet does not wish to take any medications. Vet

states he will think about buying Melatonin over the counter to try

for

sleep. Vet is agreeable to discussing with his wife and made f/u

appointment with this writer for one month. Vet provided with

information for the Vet Center. Vet reports poor short term memory,

Vet

states that he makes lists on his phone, Vet is worried that he will

not be able to 'remember anything when I am 50.'" He

was initially

referred to behavioral health by his primary care providers with a

diagnosis of Major Depression and concerns about his crying and sleep

difficulties (see August 5, 2016 Clinic note). Treatment notes do

discuss "nightmares" but not in a way that meets criteria as

an

CONFIDENTIAL Page 13 of 27

intrusive symptom. For example, the March 3, 2017 Behavioral Medicine

note states, "Vet reports that he believes he has nightmares,

although

he doesn't remember them. Vet states he sleeps well some nights

and

others not as good. Vet and wife have not slept in the same bed for

over 6 years."

Current medications include:

Jun 14, 2017 SERTRALINE HCL 100MG TAB ACTIVE Mar 04, 2018 STL

MENTAL HEALTH TREATMENT DURING MILITARY: Veteran denies mental health

treatment in the military. He was evaluated by Mental Health,

"when I

got to boot camp," because he reported prior treatment for

alcohol

abuse. A December 1, 1989 Mental Health note apparently documents

this

visit, "18 y/o ... referral for eval of EPTE SA in 1987 of putting

his

head through a glass window while drunk. States he was in a state of

depression at the time. Secondary to 'his situations.'"

The note

continues, "has gone through ETOH tx including AA." Based on

the

change in writing style, a second author adds to the same note,

"Significant hx of feeling dression with suicidal ideation both

sober

and intoxicated. Has stopped himself from killing himself with gun

but

can not verbalize why he stopped. Treatment received for alcohol was

mandatory outpt group education following drunk and disorderly at

school." The note concludes, "Impression: I. Alcohol Abuse

by

history."

MENTAL HEALTH TREATMENT PRIOR TO THE MILITARY: See above

PSYCHIATRIC HOSPITALIZATIONS: None

SUBSTANCE ABUSE RELATED HOSPITALIZATIONS: Veteran reports a third

significant incident related to alcohol in addition to those described

in the December 1, 1989 Mental Health note. He reports the incident

was shortly after his school suspension. He and his friends came

across, "big box of bottles, vodka, rum, poured a big glass of

it." He

drank it all, "more or less showing off, [he became unconscious

and]

ended up hospital, .27 BAL." He was kept overnight and released.

CONFIDENTIAL Page 14 of 27

d. Relevant Legal and Behavioral history (pre-military, military, and

post-military):

HISTORY OF TROUBLE AS YOUTH: Veteran denies contact with the police

other than, "incident there at school, when I got suspended."

MILITARY DISCIPLINARY PROBLEMS (ARTICLE 15/NJP/CAPTAIN?S MAST/COURT

MARTIALS): None

LIST ALL NON-MILITARY LEGAL OFFENSES AND LEGAL CONSEQUENCES: Veteran

reports being arrested, "right after my divorce, for invasion of

privacy, I went to my ex-wife's apartment," when there was

a,

"restraining order against me." He denies other arrests.

e. Relevant Substance abuse history (pre-military, military, and

post-military):

CAFFEINE: cup of coffee in the morning

ALCOHOL: Veteran report limited current consumption of alcohol,

consuming only a single serving on 2 separate occasions during the

last

week and not consuming over 5 servings at one time in over a year.

He reports his heaviest period of use was 1992 to 1996. He reports

drinking, "too much, maybe 3 days a week," 5 or 6 servings on

a typical

day. His January 6, 2017 Psychiatry Consults suggests greater use

during that period, "Vet stated that he drank anything he could,

whiskey, beer."

The May 1, 2017 buddy statement by Christina McGuire, his wife

suggests

that veteran's current difficulties with alcohol may be greater

than

that reported above. As stated there, ""In the past, when

Mike would

struggle with depression/anxiety, especially when he focused too much

on military talks, discussions with vet buddies, he would sometimes

self-medicate with alcohol. Those incidents, although they

didn't

occur often, would usually result in erratic, angry behavior and

sometimes emotional breakdowns or incidents of rage. Mike has broken

household items and even his hand during such a case because of this,

whiche caused him to be off work for months and have surgery and

rehabilitation [2013]." The statement continues, "Mike has

made a

tremendous effort to avoid alcohol when he wrestles with anxiety and

depression."

ILLICIT DRUG USE: Veteran reports only experimental use of marijuana

as a child.

CONFIDENTIAL Page 15 of 27

f. Other, if any:

The following is cut and pasted from JLV (Joint Legacy Viewer):

PROBLEM LIST

Mar 03, 2017 POST-TRAUMATIC STRESS DISORDER, CHRONIC F43.12 ACTIVE

STL

Dec 05, 2016 NICOTINE DEPENDENCE, CIGARETTES, WITH UNSPECIFIED

NICOTINE-INDUCED

Dec 05, 2016 PATIENT'S OTHER NONCOMPLIANCE WITH MEDICATION

REGIMEN Z91.14 ACTIVE

Sep 08, 2016 ESSENTIAL (PRIMARY) HYPERTENSION I10. ACTIVE STL

Sep 08, 2016 HYPERLIPIDEMIA, UNSPECIFIED E78.5 ACTIVE STL

Sep 08, 2016 TESTICULAR HYPOFUNCTION E29.1 ACTIVE STL

Sep 08, 2016 NICOTINE DEPENDENCE, CIGARETTES,

UNCOMPLICATED F17.210 ACTIVE STL

Sep 08, 2016 ABDOMINAL DISTENSION (GASEOUS) R14.0 ACTIVE STL

Sep 08, 2016 SLEEP DISORDER, UNSPECIFIED G47.9 ACTIVE STL

MEDICATION LIST

Jun 14, 2017 ATORVASTATIN CALCIUM 80MG TAB ACTIVE Sep 01, 2017

STL

Jun 14, 2017 SERTRALINE HCL 100MG TAB ACTIVE Mar 04, 2018 STL

Feb 02, 2017 HCTZ 12.5/LISINOPRIL 20MG TAB ACTIVE Feb 03, 2018

STL

Aug 31, 2016 NICOTINE 21MG/24HR PATCH EXPIRED Sep 30, 2016

STL

Aug 31, 2016 HCTZ 12.5/LISINOPRIL 20MG TAB DISCONTINUED Nov 04,

2016

STL

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: multiple SCUD attacks including debris coming to his

position

in an ammo dump

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

CONFIDENTIAL Page 16 of 27

Is the stressor related to personal assault, e.g. military sexual

trauma?

[ ] Yes [X] No

b. Stressor #2: just avoiding friendly fire

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

c. Stressor #3: Saudi nationals pointing weapons in his direction

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] 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

CONFIDENTIAL Page 17 of 27

traumatic event(s) occurred: