cp any errors, presumption of soundness ignored?

[deerdown]

LOCAL TITLE: REMOTE VISN 11 C&P EXAMS                          
STANDARD TITLE: C & P EXAMINATIO
     URGENCY:                            STATUS: COMPLETED                    
                  Initial Post Traumatic Stress Disorder (PTSD)
                        Disability Benefits Questionnaire
                         * Internal VA or DoD Use Only *
   the end of this exam saidepression diagnosis less likely than not service connected and followed normal course
   
                                   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
   
    If no diagnosis of PTSD, check all that apply:
   
       [X] Veteran's symptoms do not meet the diagnostic criteria for PTSD under
           DSM-5 criteria
       [X] Veteran has another Mental Disorder diagnosis.  Continue to complete            this Questionnaire and/or the Eating Disorder Questionnaire:
 
    2. Current Diagnoses
    --------------------
a. Mental Disorder Diagnosis #1: Unspecified Depressive Disorder
           ICD code: 311.00            Comments, if any:               none
             
b. Medical diagnoses relevant to the understanding or management of the
       Mental Health Disorder (to include TBI): none
         ICD code: xxxxx
         Comments, if any: none
        
    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   [ ] 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 due to mild or transient symptoms            which decrease work efficiency and ability to perform occupational            tasks only during periods of significant stress, or; symptoms            controlled by medication
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
      
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
    Evidence Comments:       none
     
    2. History
    ----------
    a. Relevant Social/Marital/Family history (pre-military, military, and        post-military):
          45 year old married for 2 years Caucasian male; resides with wife and           wife's son
          1997-2000 1st marriage; 2003-2008 2nd marriage; children: ages 17, 20,
          10
          Grew up in Indianna, raised by both parents until age 15, then was           raised by a foster family. Sibling: 1 younger brother. The Veteran           stated that growing up he was fine. Denied any abuse or neglect.           Socially did good, had a girlfriend, enjoyed sports and camping.
          Social life: no contact with friends, rare contact with brother, father
          deceased in 00's, rare contact with mother, no contact with children
          Daily functioning: no regular schedule, get up around 6am, part-time           work, watch TV
          Per review of VBMS and VA medical records, the Veteran has extensive           history of childhood physical and sexual abuse.
         
         
b. Relevant Occupational and Educational history (pre-military, military,
and        post-military):
          Education
          1989 HS graduation
          Military
          1990-1992
          assault amphibien vehicle repairer
          E-2
          Marine Corps
          General Under Honorable Conditions (Discharge           involuntarily-homosexuality-Admission)
          Occupation
          90's-00's short-term jobs in auto shops
          2006-2009 tire shop
          2009-2015 short-term jobs
          2015-present auto shop maintenance(10 hrs/week)
          Income: hourly pay, VA benefits
         
         
c. Relevant Mental Health history, to include prescribed medications and       family mental health (pre-military, military, and post-military):           The Veteran denied any history of mental health treatment prior to           service.
          Per review of VBMS and VA medical records, the Veteran has history of           depression with suicidal attempts, psychiatric admissions, and history           of physical and sexual abuse
          STR:
          04/26/1990 Enlistment Exam: silent for mental health
          12/30/1991 clinical note "referred for suicide ideation. Pt.
recently           depressed over 2 last weeks (over poss. sexual preferences). no           financial difficulties. recently totalled a motorcycle. No definite           date/plan for suicide. Pt. has past hx depression with inpatient Rx x3           in past prior to USMC (denied this on enlistment history and physical).           hx of one suicidal gesture in the past; does not know real parents           (adopted); parents (step) divorced Thought process intact. No loose           associations; no hx delusions; no hallucinations; Impressions:           depression with suicidal ideation; Fraudulent enlistment"
          1/2/1992 clinical addendum "pt attempted to cut wrist on 31 Dec
1991
          while in barracks. Pt was being checked every 30 minutes by duty. Pt           was then placed in company office for 24 hour supervision. SNCO decided
          not to refer pt to ER this time. Today I interviewed pt who states that
          he cannot go living like this (with 24 hr supervision nad difficulties           from pending disciplinary actions)
          01/10/1992 psychiatry consult "...referred after he made a suicidal           gesture while drinking.. out of anger. Currently he is pending process           for homosexuality. Of note, he had some homosexual activity with an           adoptive brother but none since. He may have some unusual sexual           fantasies but is no more than sexually confused. He drinks abusively           drunk 2/month. He was drunk when he made a suicidal gesture and when           another male made sexual advance on him. DX; Alcohol Abuse, past           history of psychiatric treatment; Sexual Identity Issues; Impulsive,           immature traits"
          02/26/1992 separation medical examination: veteran endorsed depression
          VISTA:
          Orlando OPC
          2007 records are silent for mental health; depression screen negative
          Lake Baldwin CBOC
          2009 records are silent for mental health
          CPRS: Detroit VAMC
          08/20/1999 mental health note "seek
ing assistance in the MHS was
          because he was court ordered to attend a substance abuse program s/p           assault charges. He also stated that he has had mental health treatment
          first at the age of 7..."I had ptsd after my father tried to blow my
          head off with a shot gun...says he was placed on Mellaril for an           unremembered time." Vet currently states he has a diagnosis of gender
          dysphoria and is seeking           sexual reassignment"
          12/07/2001 psychiatric admission "This is a 29-year-old divorced white
          female who came to Admitting with a history of feeling depressed,           suicidal and homicidal for the last couple of weeks. He had a sleeping           problem. The patient stated that he was also hearing voices, that is,           of another person whom he referred as 'him'. The patient admitted that
          this is not me, but 'him' for suicidal and homicidal thoughts. The
          patient also admitted that because of 'him', he used to cross dress,
          though he did not like it personally. The patient's father and ex-wife           mentioned that the patient had a disturbed childhood. He was sexually           and physically abused. The patient lived with adopted parents, where he
          was sexually and physically abused by one of the adopted guys. Then at           the age of 13, the patient's adopted parents divorced. The patient and
          the patient's brother started living with the adopted father. Then one
          day, the patient's father caught the patient and his brother because of
          the sexual thing they were doing to each other, the patient's father           took them to court and he was put in a teen ranch as punishment. Then,           he was picked up by another family in Ohio, from where he graduated.           The patient was abused by his adopted mother. One time, she grounded           him in the room for one month, without allowing him to go outside and           he ate in this room for one month. This incident, however, made the           patient very disturbed. The patient's brother also mentioned that the
          patient liked to become a female. He first noticed this, when the           patient was seven years old, at the time of Christmas, when he asked to           dress up like a female and then everybody laughed at him. The patient           also has a history of stealing his mother's underwear for dressing up.
          The patient's ex-wife and brother also mentioned that the patient used
          to do male prostitution, he did that for three to four years for money.
          The patient tried to suffocate his wife and had been in jail for           another 10 months" Dx: Psychosis, NOS
          psychiatric medications since 07/2017
          Zoloft 50mg
          Hydroxyzine 25mg x3           Prazosin 1mg
          VBMS:
          08/2017-present weekly individual counseling at Great Lakes Psychology
          Group
          8/01/2017 initial assessment, DX: PTSD
          05/12-13/2013 psychiatric admission at Henry Ford Macomb hospital; DX:           Depressive Disorder, NOS, Gender Identity Disorder, Alcohol Abuse           admission note for suicidal attempt "he was involved with a man the
          night of his suicide attempt and felt so ashamed and conflicted that he
          acted out. States he was not thinking about suicide any time prior to           the incident. His biggest issue is the urge to cross dress and his           sporadic relationships with men. Admits to struggling with some           depression.
          The veteran reported average of 4 hours of broken sleep, nightmares           about assault, wakes up anxious, problems initiating sleep due to fear           about having dreams, mood - anxious and easily irritable, recurrent           passive suicidal thoughts with no intent, problems concentrating, feels           emotionally overwhelmed, history of cross dressing until 2013, history           of being promiscuous engaging with men, last episode in 2013, confusion           around sexual orientation. 
          Alert and oriented times three; attention well sustained. Good eye to           eye contact; fair grooming and hygiene; speech with normal rate,           rhythm, and fluency, goal directed. No thought disorganization noted.           No suicidal/homicidal ideation reported. Anxious mood, tearful at times           congruent to thinking; Affect appropriate and full in range.
         
         
d. Relevant Legal and Behavioral history (pre-military, military, and       post-military):
          NJP: 920103 - disobeyed a direct order to remain in Company Office;
          911231 drinking beer in his room and using provoking speech           02/1992 administrative separation "...PFC Barnaba...declaring himself
          to be bisexual"
          1998, 1999 robbery at a store using a gun, dropped down to larceny in a
          building
          1997 arrested for forgery and counterfeiting, dropped to uttering and           publishing           1998 assault
          1992 armed robbery, dropped to larceny in a building
2013 Domestic Violence
         
         
e. Relevant Substance abuse history (pre-military, military, and       post-military):
          Alcohol:
2013 stopped drinking liquor
          2013-present weekly 8 beers in one sitting
          Cannabis:
          06/2017-present 2/week edible
          treatment
          90's-present off and on AA meetings
         
         
f. Other, if any:
          none
                   
    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: "Summer of 1991 sergeant offered me a ride and took me to a
          secluded area where he raped me."
         
          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?
          [ ] Yes  [X] No
         
          Is the stressor related to personal assault, e.g. military sexual           trauma?           [X] Yes  [ ] No
         
              If yes, please describe the markers that may substantiate the               stressor.
                Per review of records and in-person examination, the Veteran                 provides inconsistent information about life events and                 experiences.
               
               
    b. Stressor #2: none
   
4. PTSD Diagnostic Criteria
    ---------------------------

       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 1 symptoms
                    associated with the traumatic event(s), beginning after the
                    traumatic event(s) occurred:
                   
                   [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] No criterion in this section met.
       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] No criterion in this section met.
       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] 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] No criterion in this section met.
       Criterion H:
      
                   [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] No criterion in this section met.
5. Symptoms
    -----------
    No response provided.
   
6. Behavioral Observations
    --------------------------
    alert, oriented times three, fair eye contact, fair hygiene
7. Other symptoms
    -----------------
    Does the Veteran have any other symptoms attributable to PTSD (and other     mental disorders) that are not listed above?
       [ ] Yes   [X] No
      
8. Competency
    -------------
    Is the Veteran capable of managing his or her financial affairs?
       [X] Yes   [ ] No
      
    9. Remarks, (including any testing results) if any
    --------------------------------------------------
       No symptoms were marked in Section 3 for rating purposes.
             
 

[deerdown]

also there are some obvous ommisiions of symptoms that I told her.i tried to file mental health b4  it was denied for preexisting condition...I did not appeal dident have the heart to fight....this is a mst claim. the doctors after my service have been using the statement I made after suicide attempt..to say I had a bad childhood which I did not... I was trying to get out in the fastest way I could find and hoped that if I told them I lied in entrance exam that I would get out faster...was being harassed by company first sgt

[jfrei]

The term less likely than not means not service connected and is the reason for the denial I am sorry have to keep sharing this incident. As far as evidence goes was the incident in 91 was it reported to command or any other paper trail. The fact that after the incident happened you began acting wreckless to me shows a pattern of n issue and the 91 seems to me as the root of when it began. You may need to provide a IMO showing the entire picture to the VA. Sadly I knew someone with the same story except he then reported to the command and had a witness. That was another SNCO and was busted down to CPL and forced him to live in the barrack while he was processed out of the military. Had this been connected it may have been rated at 10% due to mild occupational impairment just my guess had it been connected.

Edited August 25, 2017 by jfrei