This appears to be a favorable exam but I am confused. I was previously denied for PTSD so I submitted new evidence and also claimed Depressive disorder. I just went to my exam last week and this was the results. The doctor checked the box that would warrant a 30% rating but I definitely feel this is a low ball. My life has not been the same and just keeps declining. He noted in here my suicide attempt and the ideation that still occurs so would that help in the ratings game? I honestly just think that working isnt going to happen much longer. I think IU is in my future but if you could help me understand what the rater may choose I would appreciate it.
LOCAL TITLE: C&P MENTAL DISORDER
STANDARD TITLE: MENTAL HEALTH C & P EXAMINATION CONSULT
DATE OF NOTE: SEP 20, 2017@10:00 ENTRY DATE: SEP 20, 2017@16:45:06
AUTHOR: RAY,CHRISTOPHER L EXP COSIGNER:
URGENCY: STATUS: COMPLETED
*** C&P MENTAL DISORDER Has ADDENDA ***
Initial Post Traumatic Stress Disorder (PTSD)
Disability Benefits Questionnaire
* Internal VA or DoD Use Only *
SECTION I:
----------
1. Diagnostic Summary
---------------------
Does the Veteran have a diagnosis of PTSD that conforms to DSM-5 criteria
based on today's evaluation?
[X] Yes [ ] No
ICD code: F43.10
2. Current Diagnoses
--------------------
a. Mental Disorder Diagnosis #1: Posttraumatic Stress Disorder
ICD code: F43.10
Mental Disorder Diagnosis #2: Other Specified Depressive Disorder
b. Medical diagnoses relevant to the understanding or management of the
Mental Health Disorder (to include TBI): Knee pain, sleep apnea,
diabetes.
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?
[ ] Yes [X] No [ ] Not applicable (N/A)
If no, provide reason that it is not possible to differentiate what
portion of each symptom is attributable to each diagnosis and discuss
whether there is any clinical association between these diagnoses:
Some symptoms, such as his insomnia, irritability, trouble
concentrating,and social withdrawal characterize both PTSD and
Other Specified Depressive Disorder. His concentration deficits
also characterize ADHD. It is difficult to differentiate what
portion of each symptom is attributable to each diagnosis without
resorting to speculation.
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 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 reason that it is not possible to differentiate what
portion of the indicated level of occupational and social impairment
is attributable to each diagnosis:
It is difficult to determine to what extent his three conditions
are impacting his social and occupational functioning. This is
because of shared symptoms.
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:
The veteran was referred for a compensation and pension examination. The
veteran was informed of the nature and purpose of the examination and
confidentiality limits. He was also informed of the risks and benefits of
the current examination. He was provided with a chance to ask questions
about the evaluation procedures. He voiced an adequate understanding of
the evaluation procedures. He was informed that this examiner is not his
treating clinician or the legal determiner of compensation or pension.
Instead, he was informed that this examiner is an independent provider of
clinical information and expertise to assist those who review and make
legal compensation and pension claim decisions and would not be
participating in his healthcare. The veteran indicated understanding of
these terms and explicitly and freely consented to the evaluation. He was
also notified that judgments of symptoms and opinions in this evaluation
report are offered to a reasonable degree of professional certainty and
are only based upon the information available at the time of the evaluation.
He was notified that a copy of the C&P mental disorder evaluation report
would be provided to the Veterans Benefits Administration (VBA) and that a copy
can be requested through VBA or through the Release of Information
Department at the Columbus VA. The psychological evaluation consisted of a
review of the veteran's CPRS records, a review of his VBMS/Virtual VA
records, JLV records, a clinical interview, and the veteran's assessment results.
On 6/1/17 the veteran had an initial evaluation of residuals of TBI with
Dr. Lin. Although the veteran had difficulty with concentration, memory,
and comprehension, these issues were not due to a TBI but attributable to
other causes. Multiple records showed no evidence of TBI.
The veteran's CPRS records indicate that he has received mental
health treatment at the Columbus VA since 12/6/10. The veteran's most recent meeting with Dr. Haraburda, a VA psychologist, was on 10/28/16. The veteran was upset about a C&P exam when he was not diagnosed with PTSD due to overreporting. The veteran said he was interested in couples counseling.
The veteran was diagnosed PTSD and Alcohol Abuse. The veteran's most recent psychiatric appointment was with Dr. Churchill, a VA psychiatrist, on 8/17/17. The veteran was diagnosed with ADHD, Combined Type, PTSD, Chronic and Major Depressive Disorder, Recurrent. The veteran indicated that his mood was low and his anxiety was always high. He was psychiatrically hospitalized at the VA in 2012 for 3 days and received substance abuse treatment as well as vocational rehabilitation. Theveteran indicated having problems with depression after returning from Iraq inlate 2010. He said he had been on multiple medications and once made a suicide attempt in January 2012.
On 9/1/17 the veteran met with Dr. Nigl, a VA neuropsychologist. Dr. Nigl had previously assessed the veteran in 2011 at which time no significant
primary cerebral dysfunction was detected although some ADHD symptoms were endorsed consistent with the veteran's developmental history. Dr. Nigl indicated that even though there was no evidence of primary brain dysfunction, ADHD was not ruled out. Dr. Nigl told the veteran that one or
2 concussions in years past would not be anticipated to lead to permanent brain damage. The veteran was glad to learn that his current concerns were not TBI-related. The veteran stated that his cognitive concerns included forgetting details of conversations, misplacing things, zoning out and needing to write much more down. The veteran was informed that chronic ADHD symptoms are likely being exacerbated by increased depression, PTSD, pain, and sleep that was not optimally controlled by OSA. The veteran's cognitive concerns were more likely than not due to problems with attention and/or encoding. The veteran was diagnosed with PTSD, Depression and ADHD.
A statement written by the veteran's wife was reviewed. She indicated that their relationship had been "rocky." Wife noted that the veteran tends to be very jumpy and has trouble going places because he does not want to be around groups of people. She noted that he has not been the same since he went to Iraq. She referenced how he attempted suicide in January 2012 and was psychiatrically hospitalized at the Chillicothe VA.
2. History
----------
a. Relevant Social/Marital/Family history (pre-military, military, and
post-military): The veteran stated that he was born and raised in Columbus, Ohio. He
indicated he grew up with his parents, who divorced "when I was 10 or
11. I lived with mom and we moved to Newark. My dad stayed on the East side of Columbus." The veteran added, "Both of my parents remarried. My mom and stepdad moved to South Carolina and I stayed 6 months but didn't like it and came back to Ohio to live with my father and stepfmother." The veteran said he has one stepbrother. The veteran did not report being abused or neglected.
When asked about his relationship history, the veteran reported,"I married the same woman twice. I got hurt in Iraq and things went downhill. I drank a lot." The veteran stated that he and his wife were married the first time for 2 years, and they have been married the second time for 4 years. According to the veteran, "Ourrelationship is not the greatest. We dated after the divorce and found out we're having our first son. She's left a few times and we argue quite a bit. We have ups and downs." The veteran said he has two children ages 1 and 4. Regarding his social support system, the veteran stated, "My wife is a nurse and says she is supportive of my mental health issues, but she has said I don't have as bad of a case of PTSD as I make it out to be."
The veteran added, "I don't really talk to my mom or dad about things." The veteran noted that he keeps up "with some people I went to basic training with on Facebook." When asked about his interests or hobbies, the veteran reported."I used to love to do a lot but don't really do much anymore. I kind of go to school, work, and then go home."
b. Relevant Occupational and Educational history (pre-military, military,
and
post-military):
The veteran stated that he graduated from high school. He said that he had a 3.4 GPA. The veteran reported that he did not have any learning disabilities and was never enrolled in special education classes. He said he took Adderall "for about a year. My mom thought I had ADHD (Attention-Deficit/Hyperactivity Disorder) but I stopped taking the medicine on my own and didn't notice a difference." The veteran reported that he attends Park University. He noted, "I seem to have a hard time now understanding and remembering material." He noted, "I failed quite a few classes. I have pretty good grades in some classes. I'm in Voc Rehab right now." Before the military, the veteran stated, "I worked at Golden Corral in Whitehall." The veteran reported that he served in the U.S. Army from January 2008 until January 2014. He stated that his highest rank was E-5. The veteran indicated that his MOS was military police. The veteran reported that he was deployed to Iraq from August 2009-August 2010. He noted that he received the Combat Action Badge among other medals. The veteran's DD-214 contained in his VBMS records indicates that he was awarded the Army Commendation Medal, National Defense Service Medal, Global War on Terrorism Service Medal, Iraq Campaign Medal with Campaign Star, Army Service Ribbon, Overseas Service Ribbon, Armed Forces Reserve Medal with M Device. Notably, there was no mention of the Combat Action Badge. The veteran reported that he had an honorable discharge, which is consistent with his DD-214.
Since the veteran left the military, he stated, "I was a police officer from December 2013 until February 2017. Now I work as a criminal investigator. I left the police officer job since I had anxiety and I didn't trust myself carrying a side arm.I have a letter from my old patrol supervisor. She noticed that I had a lot of anxiety and panic attacks." The veteran indicated that his job performance at his current job "is ok but my big problem is my memory. There are things I've left out and forgot in my cases. I have good days and bad days."
c. Relevant Mental Health history, to include prescribed medications and
family mental health (pre-military, military, and post-military):
The veteran denied receiving mental health treatment before the military. The veteran reported that while in the military "after my deployment to Iraq I started coming to the VA. I saw Dr. H, and had a break while I was going to the Chillicothe VA. I did the domiciliary and vocational rehab then came back up here. I reconnected with Dr. H up here." The veteran added that he receives psychiatric care with Dr. C. According to the veteran, he is prescribed venlafaxine and nortriptyline hcl. The veteran indicated that his medications are partially helpful in alleviating his mental health symptoms.
d. Relevant Legal and Behavioral history (pre-military, military, and
post-military):
The veteran denied any legal problems before the military. The veteran did not report receiving any Article 15s, non-judicial punishments, infractions or arrests while in the military. The veteran denied receiving any criminal charges since leaving the military.
e. Relevant Substance abuse history (pre-military, military, and
post-military):
Before the military the veteran stated that he tried "pot (marijuana) a few times but that was it." While in the military the veteran did not report consuming illegal drugs. He acknowledged that while in the military he drank alcohol "especially after Iraq. That's when I abused pain meds (Vicodin and Percocet)." After the military the veteran said his use of alcohol has "waxed and waned. I don't know that I've been addicted." The veteran stated, "I have not had a beer in a few weeks." In the past the veteran noted that he has had cravings for alcohol but not recently. The veteran denied any recent negative impact on jobs or relationships. The veteran reported that he has not used opioids since January 2012.
f. Other, if any:
The veteran reported that he is service connected "for both knees. It shoots into my hips. I also have sleep apnea, diabetes, and high blood pressure." His CPRS records show the following active problems:
Code Description
719.46 Knee: arthralgia (ICD-9-CM 719.46)
305.1 Nicotine Dependence (ICD-9-CM 305.1)
836.0 Meniscus Tear, Med (Current) (ICD-9-CM 836.0)
V71.09 No Diagnosis or Condition on Axis I (ICD-9-CM V71.09)
R52. Pain (SCT 22253000)
110.9 Tinea (ICD-9-CM 110.9)
692.6 Contact dermatitis and other eczema due to plants (except
food) (ICD-9-CM 692.6)
309.24 WITH ANXIETY (ICD-9-CM 309.24)
Z63.0 Partner relationship problem (SCT 1041000119100)
R03.0 Essential hypertension (SCT 59621000)
F33.8 Chronic depression (SCT 192080009)
F10.10 Alcohol abuse (SCT 15167005)
305.50 Opioid abuse (ICD-9-CM 305.50)
F43.12 Chronic post-traumatic stress disorder following military
combat (SCT 699241002)
His CPRS records show the following active medications:
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: Removed for privacy
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
b. Stressor #2: Removed for privacy
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
c. Stressor #3: Removed for privacy
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
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)
[X] Learning that the traumatic event(s) occurred to a close
family member or close friend; cases of actual or
threatened death must have been violent or accidental;
or,
experiencing repeated or extreme exposure to aversive
details of the traumatic events(s) (e.g., first
responders
collecting human remains; police officers repeatedly
exposed to details of child abuse); this does not apply
to
exposure through electronic media, television, movies, or
pictures, unless this exposure is work related.
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] Intense or prolonged psychological distress at exposure
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).
[X] Avoidance of or efforts to avoid external reminders
situations) that arouse 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 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)
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] Problems with concentration.
Criterion F:
[X] Duration of the disturbance (Criteria B, C, D, and E) is
more than 1 month.
Criterion G:
[X] The disturbance causes 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.
Criterion I: Which stressor(s) contributed to the Veteran's PTSD
diagnosis?:
[X] Stressor #1
[X] Stressor #2
[X] Stressor #3
5. 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] Mild memory loss, such as forgetting names, directions or recent
events
6. Behavioral Observations
--------------------------
The veteran was alert and oriented to person, place, the date, time, and situation. The veteran's clothing was appropriate to the situation and weather. He maintained appropriate eye contact. The veteran exhibited acceptable hygiene. His speech was within normal limits with regard to rate, rhythm and volume. He walked with a normal gait. The veteran was cooperative and actively participated in the evaluation procedures. His affect was appropriate to discussion and well-modulated. The veteran described his mood as "down." The veteran endorsed symptoms of depression including sadness, low energy, sleep disturbance, concentration deficits, loss of pleasure, agitation, indecisiveness, and hopelessness. The veteran reported suicidal thinking (without current intent or plan). He noted one past attempt "when I drank a lot and took a lot of Ativan. That was in January 2012." He denied thoughts of harming others. The veteran did not report nor were there clear indications of obsessions, compulsions, or manic symptoms. Regarding the veteran's mental content, his thought processes were linear. The veteran's associations were goal-directed. There were no indications of delusions or hallucinations. Regarding ADLs, he reported that he keeps up with his personal hygiene. The veteran stated that he is able to cook, clean, and complete other basic household chores. The veteran reported that he has a
bank account and driver's license. The veteran's judgment in hypothetical situations is intact. The veteran exhibits adequate abstract reasoning and comprehension. The veteran was able to remember events from the past indicating no significant long term memory issues. On a forward digit span task the veteran correctly repeated back 6 digits. The veteran accurately recalled 3 of 3 words after 5 minutes on a brief word learning task. He accurately recalled the months in reverse order. He correctly spelled the word WORLD forwards and backwards. The veteran responded accurately to four basic calculation tasks. Overall there is no obvious evidence of possible short-term memory and/or concentration deficits. The veteran's intellectual functioning appears to be in the average range based upon his educational attainment and vocabulary.
DSM-5 ASSESSMENT OF PTSD:
I REMOVED THIS PORTION FOR PRIVACY BUT NOTE THAT THE DOCTOR INDICATED THAT I MET ALL CRITERIA NEEDED
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
The MMPI-2-RF was administered to measure symptom patterns associated with particular classes of psychopathology. The test includes validity scales to identify unusual test-taking attitudes, including the detection of possible feigning or denial of symptoms. Possible underreporting is indicated in that the veteran presented himself in a positive light by denying some minor faults and shortcomings that most people acknowledge. Inconsistent responding was ruled out. Any absence of elevations on the substantive scales were interpreted with caution as they may underestimate the problems assessed by those scales. The veteran's test scores indicate preoccupation with suicide and death. His test scores suggest that he may have recently attempted suicide. These test results also indicate the presence of helplessness and hopelessness. According to the veteran's test results, he reported feeling anxious. This testing profile suggests the presence of intrusive ideation, anxiety and anxiety-related problems, sleep difficulties, including nightmares and posttraumatic distress. According to the veteran's test results, he reported not enjoying social events and avoiding social situations, including parties and other events where crowds are likely to gather. His test results suggest that the veteran is introverted, has difficulty forming close relationships, and is emotionally restricted.
Opinion & Rationale:
It is my opinion, with reasonable professional certainty, that it as likely as not (a 50% probability) that his Posttraumatic Stress Disorder resulted from his Iraq trauma stressors. My opinion is based upon my clinical experience and expertise, a review of the veteran's CPRS records, a review of his VBMS/Virtual VA records, the results of a clinical interview, and the veteran's assessment results. The veteran showed no signs of significant exaggeration or feigning of mental disorder symptoms on objective testing. Remote records reviewed by Chillicothe VA staff, however, suggest that the veteran's commanding officer had confronted the veteran because his reported military experiences either did not occur or did not occur to the veteran. Also, during the clinical interview the veteran said he had a Combat Action Badge, which was not located on his DD-214. On the other hand, his VBMS records contain a statement written by battle buddy, who provided information consistent with the veteran's statements about his trauma stressors. Overall, it is beyond the scope of the current evaluation procedures to determine if the veteran's statements concerning his trauma stressors are accurate. Assuming that the veteran's statements about his trauma stressors are true, there appears to be a direct link between his PTSD symptoms and his trauma stressors experienced in Iraq. The veteran's CPRS records suggest that a number of treatment providers have diagnosed him with PTSD.
It is my opinion that it is less likely as not (less than a 50% probability) that the veteran's Other Specified Depressive Disorder is proximately due to his physical pain associated with his knees. Although his physical pain likely contributes to some degree to his feelings of depression, there are multiple factors that explain his chronic feelings of sadness. Some of these include his relationship problems with his wife and military trauma stressors. In the past his excessive use of alcohol and drugs have also exacerbated his depressive symptoms. Of note is that the diagnosis of Other Specified Depressive Disorder was chosen because the veteran was vague about the frequency of his depressive symptoms. Concentration deficits were endorsed because even though his mental status did not specifically show concentration issues, information from Dr. N suggests that the veteran's concentration deficits likely are associated with the veteran's mental health concerns, pain, and sleep problems due to obstructive sleep apnea.
NOTE: VA may request additional medical information, including additional
examinations if necessary to complete VA's review of the Veteran's
Question
armyvet89
This appears to be a favorable exam but I am confused. I was previously denied for PTSD so I submitted new evidence and also claimed Depressive disorder. I just went to my exam last week and this was the results. The doctor checked the box that would warrant a 30% rating but I definitely feel this is a low ball. My life has not been the same and just keeps declining. He noted in here my suicide attempt and the ideation that still occurs so would that help in the ratings game? I honestly just think that working isnt going to happen much longer. I think IU is in my future but if you could help me understand what the rater may choose I would appreciate it.
LOCAL TITLE: C&P MENTAL DISORDER
STANDARD TITLE: MENTAL HEALTH C & P EXAMINATION CONSULT
DATE OF NOTE: SEP 20, 2017@10:00 ENTRY DATE: SEP 20, 2017@16:45:06
AUTHOR: RAY,CHRISTOPHER L EXP COSIGNER:
URGENCY: STATUS: COMPLETED
*** C&P MENTAL DISORDER Has ADDENDA ***
Initial Post Traumatic Stress Disorder (PTSD)
Disability Benefits Questionnaire
* Internal VA or DoD Use Only *
SECTION I:
----------
1. Diagnostic Summary
---------------------
Does the Veteran have a diagnosis of PTSD that conforms to DSM-5 criteria
based on today's evaluation?
[X] Yes [ ] No
ICD code: F43.10
2. Current Diagnoses
--------------------
a. Mental Disorder Diagnosis #1: Posttraumatic Stress Disorder
ICD code: F43.10
Mental Disorder Diagnosis #2: Other Specified Depressive Disorder
ICD code: F32.89
Mental Disorder Diagnosis #3: Unspecified Attention-Deficit/Hyperactivity
Disorder
ICD code: F90.9
b. Medical diagnoses relevant to the understanding or management of the
Mental Health Disorder (to include TBI): Knee pain, sleep apnea,
diabetes.
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?
[ ] Yes [X] No [ ] Not applicable (N/A)
If no, provide reason that it is not possible to differentiate what
portion of each symptom is attributable to each diagnosis and discuss
whether there is any clinical association between these diagnoses:
Some symptoms, such as his insomnia, irritability, trouble
concentrating,and social withdrawal characterize both PTSD and
Other Specified Depressive Disorder. His concentration deficits
also characterize ADHD. It is difficult to differentiate what
portion of each symptom is attributable to each diagnosis without
resorting to speculation.
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 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 reason that it is not possible to differentiate what
portion of the indicated level of occupational and social impairment
is attributable to each diagnosis:
It is difficult to determine to what extent his three conditions
are impacting his social and occupational functioning. This is
because of shared symptoms.
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:
The veteran was referred for a compensation and pension examination. The
veteran was informed of the nature and purpose of the examination and
confidentiality limits. He was also informed of the risks and benefits of
the current examination. He was provided with a chance to ask questions
about the evaluation procedures. He voiced an adequate understanding of
the evaluation procedures. He was informed that this examiner is not his
treating clinician or the legal determiner of compensation or pension.
Instead, he was informed that this examiner is an independent provider of
clinical information and expertise to assist those who review and make
legal compensation and pension claim decisions and would not be
participating in his healthcare. The veteran indicated understanding of
these terms and explicitly and freely consented to the evaluation. He was
also notified that judgments of symptoms and opinions in this evaluation
report are offered to a reasonable degree of professional certainty and
are only based upon the information available at the time of the evaluation.
He was notified that a copy of the C&P mental disorder evaluation report
would be provided to the Veterans Benefits Administration (VBA) and that a copy
can be requested through VBA or through the Release of Information
Department at the Columbus VA. The psychological evaluation consisted of a
review of the veteran's CPRS records, a review of his VBMS/Virtual VA
records, JLV records, a clinical interview, and the veteran's assessment results.
On 6/1/17 the veteran had an initial evaluation of residuals of TBI with
Dr. Lin. Although the veteran had difficulty with concentration, memory,
and comprehension, these issues were not due to a TBI but attributable to
other causes. Multiple records showed no evidence of TBI.
The veteran's CPRS records indicate that he has received mental
health treatment at the Columbus VA since 12/6/10. The veteran's most recent meeting with Dr. Haraburda, a VA psychologist, was on 10/28/16. The veteran was upset about a C&P exam when he was not diagnosed with PTSD due to overreporting. The veteran said he was interested in couples counseling.
The veteran was diagnosed PTSD and Alcohol Abuse. The veteran's most recent psychiatric appointment was with Dr. Churchill, a VA psychiatrist, on 8/17/17. The veteran was diagnosed with ADHD, Combined Type, PTSD, Chronic and Major Depressive Disorder, Recurrent. The veteran indicated that his mood was low and his anxiety was always high. He was psychiatrically hospitalized at the VA in 2012 for 3 days and received substance abuse treatment as well as vocational rehabilitation. Theveteran indicated having problems with depression after returning from Iraq inlate 2010. He said he had been on multiple medications and once made a suicide attempt in January 2012.
On 9/1/17 the veteran met with Dr. Nigl, a VA neuropsychologist. Dr. Nigl had previously assessed the veteran in 2011 at which time no significant
primary cerebral dysfunction was detected although some ADHD symptoms were endorsed consistent with the veteran's developmental history. Dr. Nigl indicated that even though there was no evidence of primary brain dysfunction, ADHD was not ruled out. Dr. Nigl told the veteran that one or
2 concussions in years past would not be anticipated to lead to permanent brain damage. The veteran was glad to learn that his current concerns were not TBI-related. The veteran stated that his cognitive concerns included forgetting details of conversations, misplacing things, zoning out and needing to write much more down. The veteran was informed that chronic ADHD symptoms are likely being exacerbated by increased depression, PTSD, pain, and sleep that was not optimally controlled by OSA. The veteran's cognitive concerns were more likely than not due to problems with attention and/or encoding. The veteran was diagnosed with PTSD, Depression and ADHD.
A statement written by the veteran's wife was reviewed. She indicated that their relationship had been "rocky." Wife noted that the veteran tends to be very jumpy and has trouble going places because he does not want to be around groups of people. She noted that he has not been the same since he went to Iraq. She referenced how he attempted suicide in January 2012 and was psychiatrically hospitalized at the Chillicothe VA.
2. History
----------
a. Relevant Social/Marital/Family history (pre-military, military, and
post-military): The veteran stated that he was born and raised in Columbus, Ohio. He
indicated he grew up with his parents, who divorced "when I was 10 or
11. I lived with mom and we moved to Newark. My dad stayed on the East side of Columbus." The veteran added, "Both of my parents remarried. My mom and stepdad moved to South Carolina and I stayed 6 months but didn't like it and came back to Ohio to live with my father and stepfmother." The veteran said he has one stepbrother. The veteran did not report being abused or neglected.
When asked about his relationship history, the veteran reported,"I married the same woman twice. I got hurt in Iraq and things went downhill. I drank a lot." The veteran stated that he and his wife were married the first time for 2 years, and they have been married the second time for 4 years. According to the veteran, "Ourrelationship is not the greatest. We dated after the divorce and found out we're having our first son. She's left a few times and we argue quite a bit. We have ups and downs." The veteran said he has two children ages 1 and 4. Regarding his social support system, the veteran stated, "My wife is a nurse and says she is supportive of my mental health issues, but she has said I don't have as bad of a case of PTSD as I make it out to be."
The veteran added, "I don't really talk to my mom or dad about things." The veteran noted that he keeps up "with some people I went to basic training with on Facebook." When asked about his interests or hobbies, the veteran reported."I used to love to do a lot but don't really do much anymore. I kind of go to school, work, and then go home."
b. Relevant Occupational and Educational history (pre-military, military,
and
post-military):
The veteran stated that he graduated from high school. He said that he had a 3.4 GPA. The veteran reported that he did not have any learning disabilities and was never enrolled in special education classes. He said he took Adderall "for about a year. My mom thought I had ADHD (Attention-Deficit/Hyperactivity Disorder) but I stopped taking the medicine on my own and didn't notice a difference." The veteran reported that he attends Park University. He noted, "I seem to have a hard time now understanding and remembering material." He noted, "I failed quite a few classes. I have pretty good grades in some classes. I'm in Voc Rehab right now." Before the military, the veteran stated, "I worked at Golden Corral in Whitehall." The veteran reported that he served in the U.S. Army from January 2008 until January 2014. He stated that his highest rank was E-5. The veteran indicated that his MOS was military police. The veteran reported that he was deployed to Iraq from August 2009-August 2010. He noted that he received the Combat Action Badge among other medals. The veteran's DD-214 contained in his VBMS records indicates that he was awarded the Army Commendation Medal, National Defense Service Medal, Global War on Terrorism Service Medal, Iraq Campaign Medal with Campaign Star, Army Service Ribbon, Overseas Service Ribbon, Armed Forces Reserve Medal with M Device. Notably, there was no mention of the Combat Action Badge. The veteran reported that he had an honorable discharge, which is consistent with his DD-214.
Since the veteran left the military, he stated, "I was a police officer from December 2013 until February 2017. Now I work as a criminal investigator. I left the police officer job since I had anxiety and I didn't trust myself carrying a side arm.I have a letter from my old patrol supervisor. She noticed that I had a lot of anxiety and panic attacks." The veteran indicated that his job performance at his current job "is ok but my big problem is my memory. There are things I've left out and forgot in my cases. I have good days and bad days."
c. Relevant Mental Health history, to include prescribed medications and
family mental health (pre-military, military, and post-military):
The veteran denied receiving mental health treatment before the military. The veteran reported that while in the military "after my deployment to Iraq I started coming to the VA. I saw Dr. H, and had a break while I was going to the Chillicothe VA. I did the domiciliary and vocational rehab then came back up here. I reconnected with Dr. H up here." The veteran added that he receives psychiatric care with Dr. C. According to the veteran, he is prescribed venlafaxine and nortriptyline hcl. The veteran indicated that his medications are partially helpful in alleviating his mental health symptoms.
d. Relevant Legal and Behavioral history (pre-military, military, and
post-military):
The veteran denied any legal problems before the military. The veteran did not report receiving any Article 15s, non-judicial punishments, infractions or arrests while in the military. The veteran denied receiving any criminal charges since leaving the military.
e. Relevant Substance abuse history (pre-military, military, and
post-military):
Before the military the veteran stated that he tried "pot (marijuana) a few times but that was it." While in the military the veteran did not report consuming illegal drugs. He acknowledged that while in the military he drank alcohol "especially after Iraq. That's when I abused pain meds (Vicodin and Percocet)." After the military the veteran said his use of alcohol has "waxed and waned. I don't know that I've been addicted." The veteran stated, "I have not had a beer in a few weeks." In the past the veteran noted that he has had cravings for alcohol but not recently. The veteran denied any recent negative impact on jobs or relationships. The veteran reported that he has not used opioids since January 2012.
f. Other, if any:
The veteran reported that he is service connected "for both knees. It shoots into my hips. I also have sleep apnea, diabetes, and high blood pressure." His CPRS records show the following active problems:
Code Description
719.46 Knee: arthralgia (ICD-9-CM 719.46)
305.1 Nicotine Dependence (ICD-9-CM 305.1)
836.0 Meniscus Tear, Med (Current) (ICD-9-CM 836.0)
V71.09 No Diagnosis or Condition on Axis I (ICD-9-CM V71.09)
R52. Pain (SCT 22253000)
110.9 Tinea (ICD-9-CM 110.9)
692.6 Contact dermatitis and other eczema due to plants (except
food) (ICD-9-CM 692.6)
309.24 WITH ANXIETY (ICD-9-CM 309.24)
Z63.0 Partner relationship problem (SCT 1041000119100)
R03.0 Essential hypertension (SCT 59621000)
F33.8 Chronic depression (SCT 192080009)
F10.10 Alcohol abuse (SCT 15167005)
305.50 Opioid abuse (ICD-9-CM 305.50)
F43.12 Chronic post-traumatic stress disorder following military
combat (SCT 699241002)
His CPRS records show the following active medications:
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: Removed for privacy
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
b. Stressor #2: Removed for privacy
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
c. Stressor #3: Removed for privacy
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
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)
[X] Learning that the traumatic event(s) occurred to a close
family member or close friend; cases of actual or
threatened death must have been violent or accidental;
or,
experiencing repeated or extreme exposure to aversive
details of the traumatic events(s) (e.g., first
responders
collecting human remains; police officers repeatedly
exposed to details of child abuse); this does not apply
to
exposure through electronic media, television, movies, or
pictures, unless this exposure is work related.
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] Intense or prolonged psychological distress at exposure
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).
[X] Avoidance of or efforts to avoid external reminders
(people, places, conversations, activities, objects,
situations) that arouse 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 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)
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] Problems with concentration.
Criterion F:
[X] Duration of the disturbance (Criteria B, C, D, and E) is
more than 1 month.
Criterion G:
[X] The disturbance causes 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.
Criterion I: Which stressor(s) contributed to the Veteran's PTSD
diagnosis?:
[X] Stressor #1
[X] Stressor #2
[X] Stressor #3
5. 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] Mild memory loss, such as forgetting names, directions or recent
events
6. Behavioral Observations
--------------------------
The veteran was alert and oriented to person, place, the date, time, and situation. The veteran's clothing was appropriate to the situation and weather. He maintained appropriate eye contact. The veteran exhibited acceptable hygiene. His speech was within normal limits with regard to rate, rhythm and volume. He walked with a normal gait. The veteran was cooperative and actively participated in the evaluation procedures. His affect was appropriate to discussion and well-modulated. The veteran described his mood as "down." The veteran endorsed symptoms of depression including sadness, low energy, sleep disturbance, concentration deficits, loss of pleasure, agitation, indecisiveness, and hopelessness. The veteran reported suicidal thinking (without current intent or plan). He noted one past attempt "when I drank a lot and took a lot of Ativan. That was in January 2012." He denied thoughts of harming others. The veteran did not report nor were there clear indications of obsessions, compulsions, or manic symptoms. Regarding the veteran's mental content, his thought processes were linear. The veteran's associations were goal-directed. There were no indications of delusions or hallucinations. Regarding ADLs, he reported that he keeps up with his personal hygiene. The veteran stated that he is able to cook, clean, and complete other basic household chores. The veteran reported that he has a
bank account and driver's license. The veteran's judgment in hypothetical situations is intact. The veteran exhibits adequate abstract reasoning and comprehension. The veteran was able to remember events from the past indicating no significant long term memory issues. On a forward digit span task the veteran correctly repeated back 6 digits. The veteran accurately recalled 3 of 3 words after 5 minutes on a brief word learning task. He accurately recalled the months in reverse order. He correctly spelled the word WORLD forwards and backwards. The veteran responded accurately to four basic calculation tasks. Overall there is no obvious evidence of possible short-term memory and/or concentration deficits. The veteran's intellectual functioning appears to be in the average range based upon his educational attainment and vocabulary.
DSM-5 ASSESSMENT OF PTSD:
I REMOVED THIS PORTION FOR PRIVACY BUT NOTE THAT THE DOCTOR INDICATED THAT I MET ALL CRITERIA NEEDED
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
--------------------------------------------------
Assessment Results:
The MMPI-2-RF was administered to measure symptom patterns associated with particular classes of psychopathology. The test includes validity scales to identify unusual test-taking attitudes, including the detection of possible feigning or denial of symptoms. Possible underreporting is indicated in that the veteran presented himself in a positive light by denying some minor faults and shortcomings that most people acknowledge. Inconsistent responding was ruled out. Any absence of elevations on the substantive scales were interpreted with caution as they may underestimate the problems assessed by those scales. The veteran's test scores indicate preoccupation with suicide and death. His test scores suggest that he may have recently attempted suicide. These test results also indicate the presence of helplessness and hopelessness. According to the veteran's test results, he reported feeling anxious. This testing profile suggests the presence of intrusive ideation, anxiety and anxiety-related problems, sleep difficulties, including nightmares and posttraumatic distress. According to the veteran's test results, he reported not enjoying social events and avoiding social situations, including parties and other events where crowds are likely to gather. His test results suggest that the veteran is introverted, has difficulty forming close relationships, and is emotionally restricted.
Opinion & Rationale:
It is my opinion, with reasonable professional certainty, that it as likely as not (a 50% probability) that his Posttraumatic Stress Disorder resulted from his Iraq trauma stressors. My opinion is based upon my clinical experience and expertise, a review of the veteran's CPRS records, a review of his VBMS/Virtual VA records, the results of a clinical interview, and the veteran's assessment results. The veteran showed no signs of significant exaggeration or feigning of mental disorder symptoms on objective testing. Remote records reviewed by Chillicothe VA staff, however, suggest that the veteran's commanding officer had confronted the veteran because his reported military experiences either did not occur or did not occur to the veteran. Also, during the clinical interview the veteran said he had a Combat Action Badge, which was not located on his DD-214. On the other hand, his VBMS records contain a statement written by battle buddy, who provided information consistent with the veteran's statements about his trauma stressors. Overall, it is beyond the scope of the current evaluation procedures to determine if the veteran's statements concerning his trauma stressors are accurate. Assuming that the veteran's statements about his trauma stressors are true, there appears to be a direct link between his PTSD symptoms and his trauma stressors experienced in Iraq. The veteran's CPRS records suggest that a number of treatment providers have diagnosed him with PTSD.
It is my opinion that it is less likely as not (less than a 50% probability) that the veteran's Other Specified Depressive Disorder is proximately due to his physical pain associated with his knees. Although his physical pain likely contributes to some degree to his feelings of depression, there are multiple factors that explain his chronic feelings of sadness. Some of these include his relationship problems with his wife and military trauma stressors. In the past his excessive use of alcohol and drugs have also exacerbated his depressive symptoms. Of note is that the diagnosis of Other Specified Depressive Disorder was chosen because the veteran was vague about the frequency of his depressive symptoms. Concentration deficits were endorsed because even though his mental status did not specifically show concentration issues, information from Dr. N suggests that the veteran's concentration deficits likely are associated with the veteran's mental health concerns, pain, and sleep problems due to obstructive sleep apnea.
NOTE: VA may request additional medical information, including additional
examinations if necessary to complete VA's review of the Veteran's
application.
/es/ CHRISTOPHER RAY PHD ABPP
Psychologist, C&P
Signed: 09/20/2017 16:45
09/20/2017 ADDENDUM STATUS: COMPLETED
The veteran's C&P exam was completed in CAPRI.
/es/ CHRISTOPHER RAY PHD ABPP
Psychologist, C&P
Signed: 09/20/2017 16:46
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