C&P Mental Examination Results Opinions?

[CaliBay]

Hello everyone,

It has been a while but I finally received my C&P examination for mental health.  Currently am 50% for Major Depression, seeking 70%.  I went to my examination in stained sweats, faded shirt, flip flops, unshaven, and hair frizzy and not brushed.  For some reason, I believe my C&P examiner was wishing I did not come so she could go to lunch early based on her reaction to my arrival and her BSing with the receptionist prior.  Anyway, I feel angry after reading her assessment and would like to know what you all think.  I think she checked the box for 30% which is a decrease but all the symptoms are 70% looking.  It feels really bad she is trying to make me out to be a liar when she doesn't know how I really feel.  I have been suicidal, I have made attempts, I have researched the best methods, made plans, etc.  The closest I have come is purchasing roper, tying it in a noose, and testing out a bar at work to see if it could support me in hanging myself.  But I have really been feeling like crap and feel I have to fight really hard to not let my thoughts become the truth.   All things she did not ask.  What do you think will happen based on the below exam results?  I thank you for your time and responses.

 

CaliBay

 

Mental Disorders (other than PTSD and Eating Disorders)

Disability Benefits Questionnaire

 

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?

 [X] Yes [ ] No

ICD code: F33.2

If the Veteran currently has one or more mental disorders that conform to

DSM-5 criteria, provide all diagnoses:

Mental Disorder Diagnosis #1: Major Depressive Disorder, severe, recurrent

ICD code: F33.2

Mental Disorder Diagnosis #2: Generalized Anxiety Disorder, with panic attacks

ICD code: F41.1

b. Medical diagnoses relevant to the understanding or management of the

Mental Health Disorder (to include TBI): severe sleep apnea

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

Depression - depressed mood, not feeling pain, poor motivation, nightmares, few friends, feel worthless and helpless.

Anxiety: doesn't like to leave his house, uncomfortable in crowds, some paranoia shakes

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

If no, provide a reason that it is not possible to differentiate what portion of the indicated level of occupational and social impairment is attributable to each diagnosis:

symptoms of GAD and MDD overlap and it is nearly impossible to differentiate between disorders.

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):

The veteran has been married for 25 years, and they have 4 children ages 17, 12, and 7. His father lives at their home, but he is self-sufficient and assists caring for the children. His spouse works at Kohls.

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

He works for the Federal Government as Transportation Specialist at the GS-11 pay grade.  He stated that his supervisor has made a verbal accommodation for his mental disabilities to let him come and go as he pleases including arriving late and leaving early for work for appointments.  He states he does not know exactly what he does at work but feels like a government worker that is unqualified for his position and got lucky to obtain his current job.  He states he answers email correspondence all day and surfs the Internet.  He stated that his duties are not really defined and much of his job requires little effort mentally or physically.  He creates spreadsheets in Excel and analyzes financial data for travel.  He works from 8:00 am to 5:00 pm.  He stated that he has used his all of his vacation and sick time because of his disability.  He was out of work on FMLA for three months to receive mental health care and has returned in May 2017 with difficulty adjusting.

c. Relevant Mental Health history, to include prescribed medications and family mental health (pre-military, military, and post-military):

He stated that he was feeling better during for two months in a 12-month period.  Since he returned to work, his depression has increased and has frequent panic on a daily basis. He stated that he feels paranoid that someone is out to get him. He feels like he is worthless at work even though his managers have never told him his performance is poor.

He does not recall periods of remission and stated that he only remembers all the bad things that have happened to him.  He uses a CPAP machine but states he rips it off his face every night due to nightmares.  He has always had nightmares of when his daughter passed away and escorting human remains off of military cargo planes.  He estimates waking up every hour to check on his children to see if they are still alive.  He self-admitted to a Mental Health Hospital for 3 months. He was suicidal and very depressed.  He has not seen a Therapist but he has spoken to his Psychiatrist.

Nightmares: never decreased, nightly or every other night. His nightmares are of the same theme.

No exercise

Medical records review:

DBQ from private provider

Statement from veteran

Treatment records from Private Hospital

Treatment records from Mental Hospital

These records are consistent with a diagnosis of Major Depressive Disorder, and Generalized Anxiety Disorder. Many medications have been

tried. He is at low risk of suicide at this point.

Current Medication:

Wellbutrin

Abilify

Prozac

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

None

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

He drinks occasionally and states he is a “light weight” in consuming alcoholic beverages.  Sometimes he inhales CO2 from whip cream to get a temporary high.

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] Chronic sleep impairment

[X] Flattened affect

[X] Disturbances of motivation and mood

[X] Suicidal ideation

4. Behavioral observations

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

No response provided.

5. Other symptoms

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

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:

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

This 45-year-old veteran still struggles with depression and anxiety. I cannot diagnose him with PTSD because it appears to be secondary to MDD.  He has not seeked therapy other than admitting himself to a Mental Health Facility.  The veteran has been advised to get help for his symptoms and he has not complied.  There doesn't appear to be any changes in his mental health status. The fact that this veteran continues to work without incident suggests that he may be functioning better than what he is showing.  I recommend that this veteran receives intensive therapy and be re-evaluated after a year of consistent treatment.

[jfrei]

One lumped in rating for 70 my guess because they couldn't differentiate the level of impairment just symtoms

[Berta]

I think the C & P exam will warrant a proposed reduction.