PTSD claim denied, I have hurt myself by withholding info due to being ashamed of issues.

[Diablopup]

I've been having issues for years but didn't even realize for a long time they were related to my time in service (88-92).  I just pushed the feelings down deep inside and avoided thinking about it.  When I finally went to a civilian Dr for my depression back in 2003/2004 I was put on every drug available but nothing worked for long.  When I lost my job and went back to school to get an associates degree I had to find a way to continue treatment so i started going to the VA.  Problem is while I would sometimes be honest with my Dr about how I was feeling, other times I would deny currently suffering.  I didn't want to appear weak, especially if it was a woman treating me.  I know that my fault, partly because of how I was raised and partly due to my time in the Marines.  Depending on who saw me, their DX differed.  My primary care Dr and a social worker suspected PTSD, but the Psychiatrists DX was MDD and SAD.  Finally after I graduated college and started a new job I lost the ability to cope and had trouble concentrating and handling the stress.  I was let go and spiraled out of control.  For the past 3 years now I havn't worked and I only leave my house every couple weeks to buy groceries late at night or to visit my Dr at the VA (if I don't end up canceling or missing my appt due to feeling sick at the thought of leaving the house).  I finally decided to apply for compensation as my family who has been supporting me has reached their financial limit.  I hoped for the best as I now know I really have a horrible problem and need help to survive and not end up under a bridge somewhere.  I will post the C & P examiners exam results now and hope someone can find something to help me with my next step.  Also he references several other mental health evaluations.  I will post those as replys to myself as this is going to be a LONG post.  I will only be editing out my and the examiners name, everything else I will leave in.  I know now I can't get help if I leave out information.  Thank you for any advice in advance.  

Semper Fi

Initial Post Traumatic Stress Disorder (PTSD)

Disability Benefits Questionnaire

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: Major Depressive Disorder
          ICD code: F33.1
          Comments, if any:
             Less likely than not due to, caused by, or incurred during military
            service.
             Military records indicate no treatment for this condition and
             discharge physical exam indicated no mental health problems.  The
             veteran did not have any mental health treatment until many years
             after military service.
             

      Mental Disorder Diagnosis #2: Social Anxiety Disorder
          ICD code: F40.10
          Comments, if any:
             Less likely than not due to, caused by, or incurred during military service.
             Military records indicate no treatment for this condition and
             discharge physical exam indicated no mental health problems.  The
             veteran did not have any mental health treatment until many years
             after military service.
             

      Mental Disorder Diagnosis #3: Attention Deficit/Hyperactivity Disorder
         (ADHD)
          ICD code: F90.0
          Comments, if any:
             Less likely than not due to, caused by, or incurred during military service.
             Military records indicate no treatment for this condition and
             discharge physical exam indicated no mental health problems.  The
             veteran did not have any mental health treatment until many years
             after military service.
             Furthermore, ADHD, by its very definition and nature, begins in
             childhood, and his not caused by any external events.
             

   b. Medical diagnoses relevant to the understanding or management of the
      Mental Health Disorder (to include TBI): GERD, history of headaches,
      history of neck pain

   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:
             Due to symptom overlap and multidirectional interactions among the
             disorders.
             
             
   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 deficiencies in most areas,
          such as work, school, family relations, judgment, thinking and/or mood

   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: Due to symptom overlap and multidirectional interactions among the 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
   [X] Other (please identify other evidence reviewed):

         The vet brought a copy of his recent Statement in support of claim
         which was on his smart phone screen.  This examiner reviewed that.  It
         had not been submitted yet to the Regional office.  The veteran also
         brought in a wooden plaque with a Marine Corps Meritorious Mast award
         on it dated 12/14/1989 indicating that he was involved in capturing an
         intruder on their base in the Philippines as part of their patrol.         


   2. History
   ----------
   a. Relevant Social/Marital/Family history (pre-military, military, and
      post-military):
         This veteran has had a number of past mental health evaluations here 
at the VA.  Please see the 12/16/2011 psychology evaluation, the 4/272012
         psychiatry intake, and the 10/17/2016 psychology mental health
         treatment plan for details of his history.

         The veteran is 47 and is divorced since 2001 (past records noted above
         suggest this seems to have had little to do with his mental health
         issues). His last relationship ended in 2012 he reported today that she apparently had another man already lined up, as she was dating him just a couple days after they broke up.  He reported no current/recent relationship. He reported he really has not been getting out much at
         all - says he does not like himself and reported he worries others will judge and talk about him. He says he is watchful and on guard for
         others' negative evaluations.  He resides alone, with his small dog.  Mother and brother are 2 hours away in XXXXXXX.  He has little contact,
         avoiding her alot and her possible questions about his job hunt. He used to play some online gaming and still does, but only occasionally.
         No groups, clubs, organizations or church. No close individual friends.  He reported no other recreation/leisure. He says he sleeps on the 
couch since his relationship breakup about 5 years ago, as the bed reminds him of her. He says his sleep schedule is widely varied and he will do alot of daytime sleeping, watches some TV.  He only rarely goes to the store and does so late at night so as to avoid other people and their
         perceived judgement.  He reports he has had little motivation to attend to household tasks and becomes easily overwhelmed and thus avoids or
         procrastinates.  As a result, he reports there are many empty grocery bags laying around, and he simply piles the mail on the kitchen table.
         Part of that may also be  due to avoiding what might be in the mail.  He reports he keeps phone ringer off so as to avoid contact from the
         bill collectors.  He says he owes $50,000 in school loans and years ago put $20,000 of his girlfriend's school loans on his credit card and
         cannot pay fully. It seems his attempt at coping is through avoidance, which then adds to the problems he has.

         MILITARY:
         The veteran enlisted into the Marine Corps and served August 1988 to
         August 1992.  He rose to an E4 rank and had an honorable discharge.  
He served time both in the Philippines and in the Persian Gulf during the
         Desert storm/desert shield..  His MOS was mortars.
         His statement in support of claim seen on his cell phone screen today
         listed two events, one of which he reported occurred in the 
Philippines in May 1990.  He says he and his girlfriend at the time work in the
         marketplace and then went to a bar down the street.  Not too long
         afterwards, he and others in the bar found out that two airman had 
been shot in the market area where he had been not long before.  This
         examiner notes that while this could be an upsetting or shocking bit 
of information to find out, the veteran did not experience any actual
         trauma.  He did not witness the shooting and was not even aware of it
         until being told shortly after it occurred. The second incident he
         reported was from February 1991 in Kuwait and reported that they took
         small arms fire at one point and also took enemy mortar fire and they
         were in a mortar battle.  He felt the enemy mortars were getting
         closer, as close as 50 yards away, until the enemy position was
         neutralized.  This event would meet DSM?five trauma criteria for PTSD.
         Other VA notes also refer to the veteran being next to a man who 
almost committed suicide, but a sergeant apparently prevented it.  This would
         also not meet trauma criteria as nothing actually happened.  There was
         no trauma witnessed, and the veteran himself was not in significant
         threat. The veteran today said he really wanted to have a career in 
the USMC, but also noted that the reason he actually got out was due to a
         Reduction In Force at that time.  
         
         
   b. Relevant Occupational and Educational history (pre-military, military, 
and
      post-military):
         This veteran has had a number of past mental health evaluations here 
at
         the VA.  Please see the 12/16/2011 psychology evaluation, the 4/272012
         psychiatry intake, and the 10/17/2016 psychology mental health
         treatment plan for details of his history.

Vet reported today that he has had mental health treatment in the
         private sector starting about 2003/2004 regarding ADHD and was placed
         on Adderal as well as a number of antidepressants.

         He started here at the VAMC in 2011, dealing with issues of ADHD,
         Depression and Anxiety (particularly Social Anxiety). He has seen
         psychiatry, psychology and social work at various times since then, up
         until the preseent. 

         He also had Neuropsychological testing on 10/14/2011 regarding an ADHD
         eval.

         Psychiatry records indicate medication has not been all that effective
         regarding his depression and social anxiety. 
         He currently is treated with Adderal for ADHD and recently was
         (re)started on escitalopram.

         He has also been in and out of psychotherapy for the above conditions. 


         This examiner notes that the previous evaluations noted above assessed
         for PTSD but indicated he did not meet criteria.

         Those evaluations also indicated that the veteran's depression
         condition really worsened in recent years following the breakup of his
         long-term relationship about five or six years ago, though a little 
bit before that there was some increased depression.  Furthermore, those
         evaluations also indicate the veteran has felt that he always has
         tended to be rather anxious and depressed with low self-esteem.  The
         records indicate a history of a very strict and harsh, verbally
         abusive, father as well as a history of being bullied in school, 
though did not get any mental health services.  Curiously, VA social work
         notes from more recent times such as 5/18/2017, seem to describe the
         social anxiety as being caused by or started in the military, related
         to harsh treatment by a corporal.  This is not likely accurate given
         the previous treatment notes described in the first paragraph above
         that indicate a long history of this type of feeling even in his 
youth, as well as more recent onset/worsening of symptoms just a few years 
ago following the relationship breakup.
         
         
   d. Relevant Legal and Behavioral history (pre-military, military, and
      post-military):
         This veteran has had a number of past mental health evaluations here 
at the VA.  Please see the 12/16/2011 psychology evaluation, the 4/272012
         psychiatry intake, and the 10/17/2016 psychology mental health
         treatment plan for details of his history.

         None
         
         
   e. Relevant Substance abuse history (pre-military, military, and
      post-military):
         This veteran has had a number of past mental health evaluations here 
at the VA.  Please see the 12/16/2011 psychology evaluation, the 4/272012
         psychiatry intake, and the 10/17/2016 psychology mental health
         treatment plan for details of his history.

         None.
         
         
   f. Other, if any:
         n/a
         
         
   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: Small arms fire and mortar battle in Gulf War
   
         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)
                  [X] Witnessing, in person, the traumatic event(s) as they
                      occurred to others

      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] No criterion in this section met.

      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] No criterion in this section met.

      Criterion F:
      
                  [X] No criterion in this section met.

      Criterion G:
      
                  [X] No criterion in this section met.

      Criterion H:
      
                  [X] No criterion in this section met.

      Criterion I: Which stressor(s) contributed to the Veteran's PTSD
                   diagnosis?:
                   No response provided.
                   
   5. Symptoms
   -----------
   For VA rating purposes, check all symptoms that actively apply to the
   Veteran's diagnoses:
   
      [X] Depressed mood
      [X] Anxiety
      [X] Disturbances of motivation and mood
      [X] Difficulty in establishing and maintaining effective work and social
          relationships
      [X] Difficulty in adapting to stressful circumstances, including work or 
a
          worklike setting

   6. Behavioral Observations
   --------------------------
   The veteran's affect was broad, though mood appeared dysphoric and anxious.
   He was quite talkative and animated at times.  He was polite and 
cooperative.
   Eye contact and behavior were normal.

   7. Other symptoms
   -----------------
   Does the Veteran have any other symptoms attributable to PTSD (and other
   mental disorders) that are not listed above?
      [X] Yes   [ ] No
      
          If yes, describe:
             The veteran has a history of attention deficit/hyperactivity
             disorder (ADHD), inattentive type.  Please see the DSM?five as well
             as the neuropsychological testing from 10/14/2011 for details of
             such symptoms.
             
   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 exam request form states/asks:

      "Exams on this request: 
      DBQ INITIAL PTSD

      ** Status of request: 
      Pending, reported to MAS
      
--------------------------------------------------------------------------
      ------



      DBQ PSYCH PTSD Initial
      _________________________________________________________________________

      The following contentions need to be examined:

      PTSD
      Active duty service dates:
      Branch: Marine Corps
      EOD: 08/02/1988
      RAD: 08/01/1992

      DBQ PSYCH PTSD Initial:
      Please review the Veteran's electronic folder in VBMS and state that it 
      was reviewed in your report.

      MEDICAL OPINION REQUEST
      TYPE OF MEDICAL OPINION REQUESTED: Direct service connection
      OPINION: Direct service connection

      Does the Veteran have a diagnosis of (a) PTSD that is at least as likely 
      as not (50 percent or greater probability) incurred in or caused by (the) 

      Combat Action Ribbon during service?

      Rationale must be provided in the appropriate section. Your review is not 

      limited to the evidence identified on this request form, or tabbed in the 

      claims folder. If an examination or additional testing is required, 
      obtain them prior to rendering your opinion.

      POTENTIALLY RELEVANT EVIDENCE:


      NOTE:  Your (examiner) review of the record is NOT restricted to the 
      evidence listed below.  This list is provided in an effort to assist the 
      examiner in locating potentially relevant evidence.

      Tab A (DD Form 214 in VBMS): TAB A- CAR COMBAT ACTION RIBBON IN DESERT 
      STORM AND DESERT SHIELD  dated 06/27/2017

      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."


      ------?????????

      As noted above, this veteran does not appear to meet criteria for PTSD,
      lacking sufficient number, frequency, and severity of symptoms to warrant
      such a diagnosis.  The veteran does have depression and anxiety (mainly
      social anxiety) and ADHD conditions described above, though it is this
      examiner's opinion that they are less likely due to, caused by, or
      incurred during military service for the reasons noted above.

      Today, the veteran denied any delusions or hallucinations.  There are no
      panic attacks and no OCD.  He denied any suicidal or homicidal ideation.
      He says that he knows if he were ever to kill himself, it would hurt his
      mother significantly and he would did not want to do that.  He does 
report frequently being in a low, sad and depressed mood.  He reported crying
      spells, decreased hope, low self-esteem, feeling easily overwhelmed,
      feeling "stuck" and self critical.  He described feeling depressed over
      various regrets he has in his life.  He also reported a lot of anxiety.
      Some of this is regarding his current life situation including financial
      difficulties, though a lot also appears to be related to socially related
      anxiety feelings.  He feels others judge and evaluate him in a negative
      manner.  He feels he just does not measure up and worries when others are
      looking at him, that they are thinking negative thoughts or critical
      thoughts about him.  This also creates not only emotional anxiety, but
      also physical symptoms such as nausea.  Regarding PTSD issues, the 
veteran says he has sometimes dreamt that he is in the US Marine Corps but is out
      of shape.  He reported no recent issues with any actual trauma related
      nightmares.  He also says he has negatively dreamed recently about his
      most recent ex-girlfriend (from five years ago).  The veteran did not
      describe upsetting intrusive trauma memories nor severe distress at any
      particular cues.  The veteran does not appear to actually meet criteria
      for HYPERvigilance.  He seemed to deny his issues with anxiety around
      people have to do with actual fear for his physical safety.  This
      avoidance of people and public has to do more with worrying about their
      judging him.  He reports when driving he is aware of other cars and where
      people are around him, though this does not appear to be related to 
trauma or represent any PTSD.  The veteran seems to describe having no real set
      sleep schedule and he will go to sleep at widely varying times.  He says
      he has some difficulty falling asleep but once he is asleep, he will 
sleep for as long as 12-16 hours.  This may be related to his nonservice related
     anxiety/depression condition and his negative coping strategy of
      avoidance.
 

NOTE: VA may request additional medical information, including additional examinations if necessary to complete VA's review of the Veteran's application.

XXXXXXXXX XXXXXX,

PhD Clinical Psychologist

[Diablopup]

Of the evaluations he listed I was only able to bring up two online.  But I will post just one of them, unless someone thinks it necessary to post both.  One more thing, there are are few things stated here that are incorrect.  The Intern who interviewed me must have not been paying complete attention as there are several statements I am reported as saying but I did not.  I have an appt with my Psychiatrist on Wednesday and will bring this up to her and see what can be done about having it corrected.   Some of the assumptions that the C & P examiner make really leave me feeling misunderstood and helpless.   There are several things that cause me mental anguish, but he just seems to discard them as being of any import or having no detrimental effect on me.  Thank you again to anyone who will be trying to assist me in getting the facts straight, I really can't thank you enough.  

 

Semper Fi

 

Was this appointment related to (a) the Veteran's service-connected disability, (b) military sexual trauma, or (c) experiences during Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (i.e., combat vet status)?: NO

Safety Assessment: See Psychology Note dated 6/23/2016 for information regarding safety assessment from current intake appointment. Reason patient entered care (patient's own words): Veteran reported that he has experienced depressive symptoms for two years, which worsened when he lost his job in December 2014. He reports that he rarely leaves his home, has gained weight, and prefers not to see or be seen by others. He stated "something has to change" because he has been dependent financially on his mother while unemployed and would like to work again to support himself.

Mental Status Exam/Behavioral Observations: Veteran was mostly cooperative, at times appeared guarded. Pt.'s grooming and hygiene were good. Pt.'s appearance was appropriate. Pt.'s mood was good. Pt. spoke matter-of-factly about his current symptoms; at times his affect appeared incongruent with content. Pt.'s psychomotor activity level was within normal limits. Pt.'s speech was clear and fluent. Pt.'s thought processes appeared linear and logical, though at times tangential. Pt.'s thought content appeared appropriate. Pt.'s intellectual functioning appeared to be within the average range.   Pt.'s immediate and remote memory appeared grossly intact. Pt. was judged to be an fair historian. Pt.'s reality testing appeared within normal limits. Pt. does NOT report experiencing hallucinations. Pt. does NOT appear to be experiencing delusions. Pt.'s insight appeared fair. Pt.'s judgment appeared good. History of current problem: Veteran reported that he has experienced depressive symptoms for two years, which worsened when he lost his job in December 2014. He reports that he was depressed for at least six months prior to this as well. Recently he reports leaving his house very little and experiencing depressive anxiety in response to thoughts about applying for jobs (i.e., avolition); however, he would like to work again so he may be financially independent (currently reliant on his mother).

Psychiatric/Treatment History: Veteran denied past psychiatric hospitalizations. He noted that he has tried "lots" of medications to treat his depression with varying results. Veteran also reports completing a one-week alcohol treatment program in 1992 while in the Marine Corp. He denied receiving psychotherapy for depression or anxiety, "I've never done anything"; Veteran relayed that he wasn't sure why individual treatment did not continue in 2011 (see below for additional information). He also reported a history of having an Adderall prescription for ADHD through a non-VA provider. Pt. stated that this prescription was cancelled in about December 2014 following a UA with lower than expected levels of the medication, resulting in suspicion the Pt. may be selling the medication. Per chart, Veteran was seen briefly byXXXXXXX, Ph.D. in PCMHI (see Psychology Notes dated 5/24/11 and 8/26/11) with concerns related to attention difficulties, anxiety, and depression. As a result, Pt. completed a neuropsychological evaluation in October 2011 (see Neuropsychological Consult note dated 10/25/2011), which resulted in a diagnoses of attentiondeficit/hyperactivity disorder, predominantly inattentive type. At the time it was noted by XXXXXXXXX, Psy.D. that Pt's concentration and attention difficulties were likely exacerbated by anxiety and depression. Veteran was referred to MHC for medication management; consult was discontinued following two no-show appointments. The Veteran also completed a MHC intake evaluation with XXXXXXXX (Psychology Intern) in fall 2011 (see intake report and treatment plan in Psychology Consult note dated 12/6/2011). During this evaluation the Pt. was diagnosed with social anxiety disorder and depression nos; PTSD was ruled out. At the time Veteran elected to pursue individual psychotherapy for social anxiety, specifically attention retraining (CBAR); however, the Pt's work schedule at the time prevented him from completing individual treatment (according to chart). He was subsequently referred to MHC for medication management (see MHC Outpt Intake consult dated 4/13/2012) of his symptoms which he continued until early 2014, with recent reengagement in medication management (see MHC Intake/consult dated 6/10/16 following presentation to PCMHI (see Social Work Note dated 5/20/16). In April 2013, Veteran was referred to MHC Outpt Social work by his psychiatrist Dr. XXXXX, for "CBT or appropriate weekly therapy" to address depression and social anxiety. Veteran was subsequently offered group therapy options for depression and social anxiety in MHC, but declined with preference for individual therapy. Pt. was seen once by XXXXXXXXX, LCSW for brief assessment during which Veteran's symptoms were conceptualized as related to PTSD and a plan to complete EMDR was started. Veteran attended one session of EMDR (see MHC Individual Therapy note dated 7/7/2013); Veteran noshowed following appointment and chart indicates at least one attempt to reach him. Mental Illness and Substance Use Disorders in Family of Origin: Veteran reported that a distant relative had committed suicide, though he was not close with this person. He denied history of suicide, suicide attempts, or mental illness in his immediate family.

Trauma History (military and non-military, MST): Veteran denied experiencing physical or sexual abuse as a child. Veteran also denied witnessing domestic violence as a child. Veteran denied MST. He denied physical and sexual abuse as an adult. However, he did report experiencing one physical assault while in the military; Pt. reports he was attacked and beat up by a group of people following a night of drinking, while stationed in the Philippines. Veteran reported a history of traumatic experiences related to his military service. Pt. reports witnessing a soldier attempt to commit suicide as he sat next to the Pt.; the man was stopped by those around him. Veteran also reports experiencing nearby mortar fire while in Kuwait in 1992. Veteran stated that these events do not bother him today; he denied a history of intrusive thoughts, avoidance, and hyperarousal related to them. Veteran stated that "other things bother me more" related to his military service; particularly, the Pt. reports persistent harsh bullying from a superior officer. Veteran expressed that he believes the person "poisoned them [peers, other officers] against me"; Veteran believes this negatively impacted his military career stating "before that everything was great". Pt. shared that he had originally planned to be career military. Legal Problems: Veteran denied a history of legal problems. He has been divorced one time, and described the process as amicable. .

Substance Use/Addictive Behaviors History: Veteran reported history of substance use. By his report, he used alcohol for the first time in the Marine Corps. He reports using alcohol heavily while in the service, with frequent weekend binge drinking. He reports various disciplinary actions as a direct or indirect result of his alcohol use (though he denied Article 15s); including missing roll call and resulting difficulty with a superior officer and being ordered to attend a week long rehab program (1992). During college, he reports drinking a 12-pack of beer each night during the weekend. Veteran also reports marijuana use beginning during his marriage from 1995-1997.  Veteran denied current illicit drug use or prescription abuse. He denied current alcohol and marijuana use. He reports he stopped drinking alcohol and using substances about three years ago; he stated that he was depressed after a significant relationship ended and felt "too depressed to go out" and use alcohol or marijuana.

Medical History: See medical record for details. Veteran reported experiencing chronic pain, including back pain and recurrent headaches. History of Head Injury: Denied, including during substance use. Childhood/Developmental History: Veteran grew up in XXXXXXXXX with both biological parents. He stated that his childhood was good overall; he added that his father could be "harsh" at times requiring Pt. and his younger brother to call him "Sir" at all times.

Cultural/Religious/Spirituality Issues: Veteran stated he grew up in a conservative Christian family, though he does not identify with this now. Denied current related concerns. Academic/Education History: Veteran reports that he has completed a B.A. in Business and Geography. He has also completed Physical Therapy Assistant school and worked in this capacity most recently (ending in 2014). Sexual Orientation and Development: Veteran identified as being heterosexual. He denied concerns related to sexuality.

Military History: Veteran joined the Marines following high school and served for 4 years, 1988-92. He reports deployment to the Persian Gulf and worked as a mortar man at E4. He reports receiving an honorable discharge. He denied Article 15s and reported a number of "unofficial" disciplinary actions in addition to mandated alcohol treatment as a result of his alcohol use during military service.

Employment History: Veteran has had 4 jobs since leaving the military. Most recently, he worked as a physical therapy assistant; however, he was fired from this job in December 2014 for failure to complete a SOAP note for a patient contact, per Pt's report. Prior to this, he worked for XXXXXXXXfor 10 years. Current significant family and/or peer group relationships: Veteran speaks with his mother about once per month; he reports that his once-close relationship with his brother has deteriorated during Pt's current bout of depression (~2years). He denied having any friends currently or confidants. Veteran was married from 1995-1997; his marriage ended somewhat amicably, though Veteran reports it "still weighs heavy" on him that his ex-wife was likely unfaithful during their marriage. Veteran also reports a significant relationship of several years that ended in 2011, resulting in significant depressive symptoms. Veteran reports that he also believes his ex-girlfriend may have cheated on him. Veteran endorsed reluctance to pursue future relationships, though he does report a number of casual sexual experiences.

Housing/Living Environment: Veteran reported living alone in a home that is "paid for". He reports a history of homelessness, but denied current housing instability. Leisure: Veteran reported the following interests/hobbies: playing video games, though not enjoyed recently while depressed. He also enjoys reading. Diagnostic Information: Information below reflects that gathered by XXXXXXXXX, Psychology Intern, during MHC Psychology intake on 6/29/16 and 7/7/16.

POST-TRAUMATIC STRESS DISORDER: Veteran reported multiple trauma experiences (described above in Traumatic Experiences). Pt. reports witnessing a soldier attempt to commit suicide as he sat next to the Pt.; the man was stopped by those around him. Veteran also reports experiencing nearby mortar fire while in Kuwait in 1992. Veteran stated that these events do not bother him today; he denied a history of intrusive thoughts, avoidance, and hyperarousal related to them. Veteran was assessed for and does not meet criteria for PTSD at this time. MAJOR DEPRESSIVE EPISODE: 5 or more, (one must be either mood or decreased activity) [x] Depressed mood [x] Diminished interest in activities: not enjoying playing video games [ ] Weight loss or gain: **Pt. reports weight gain during past two years; he attributed this to both antidepressants and lack of physical activity rather than increased appetite. [x ] Sleep disturbance: Veteran reports inconsistent sleep, with late bedtimes, early waking, and long lengths of daytime sleeping. [ ] Agitation/retardation  [x] Fatigue [x] Worthlessness/guilt: Pt. reports feeling inadequate as a Marine, stating he "hasn't lived up" to expectations. [x ] Decreased concentration, indecision [ ] Recurrent thoughts of death/ SI [x ] Cause clinically significant distress: Pt. reports increased social isolation during past two years, especially after job loss in December 2014; depressive symptoms have also negatively impact Pt's occupational functioning, as he has withdrawn from nearly all social interactions and therefore has not pursued employment. Not due to other medical condition or substance use. Current episode? _x__yes ___no Has the individual experienced previous MDE's? _x__yes: several times during adult life, especially following breakup in 2011. PERSISTENT DEPRESSIVE DISORDER (Dysthymia) (A) [x ] Depressed mood for most of the day, more days than not, for 2+ years (B) Need 2+: [x ] sleep disturbance [x ] poor appetite or overeating [ x ] low energy/fatigue [x ] low self-esteem [x ] poor concentration or diff making decisions [x ] hopelessness (C) [x ] During the 2 years, never w/out symptoms for 2+ months at a time (D) [x ] Criteria for MDD may be continuously present (in which case, just 1 diagnosis is coded: Dysthymia w the appropriate specifier below (e.g., "PDD w intermittent MDEs, w current episode") (E) [x ] Pt has NEVER HAD A MANIC OR HYPOMANIC EPISODE or Cyclothymia (F) [x] Not better explained by schizoaffective dx, schizophrenia, delusional disorder, or other psychotic dx (G) [x ] Not due to SUDs or medical condition (e.g., hypothyroidism) (H) [x ] Clinical distress or impairment in social, occupational, or other important areas

SUMMARY: Veteran endorses depressive symptoms occurring more days than not during a two week period, including the day of assessment. Veteran reports periods of time throughout his adult life where he experienced depressed symptoms for two weeks or more. Whiles these major depressive episodes have been intermittent during his life, the Veteran has also met criteria for persistent depressive disorder during the past two years, without relief greater than two months. The Veteran shared that these symptoms began prior to losing his job in December 2014-he stated that at least six months prior to that he had already started experiencing depressed symptoms (fatigue, depressed mood, reduced enjoyment of pleasurable activities, sleep disturbances). The current major depressive episode includes increases in depressed mood, social isolation, fatigue and early waking, inappropriate guilt, anhedonia, and behavioral avoidance. Veteran meets criteria currently for Persistent Depressive Disorder with intermittent major depressive episodes, with current episode moderate. MANIA/HYPOMANIA: Veteran was assessed for and denied history of manic and hypomanic episodes. PSYCHOSIS: Veteran was assessed for and denied history of psychotic symptoms, including experiencing auditory or visual hallucinations. SUBSTANCE USE DISORDER: Pt. reports history of heavy drinking during his time in the service and for several years afterward. He denied current use of alcohol and substances, reporting that he ceased use of both alcohol and marijuana three years ago due to depression ("I stopped going out"). Pt. does not currently meet criteria for a substance use disorder. OBSESSIVE-COMPULSIVE DISORDER: Veteran was assessed for and does not meet criteria for OCD at this time. GENERALIZED ANXIETY DISORDER: Veteran has been diagnosed with GAD per chart. However, during this current assessment he could not identify excessive worries about a number of activities or events. He did state that he worries that other people are "noticing me, what I look like" (see Social Anxiety Disorder below for additional information). Veteran described himself as "even keel" and did not endorse excessive worry about a range of topics; he does not meet criteria for GAD at this time. SOCIAL ANXIETY DISORDER: A: [ x ] Marked fear or anxiety of 1+ social situations in which the person is exposed to possible scrutiny by others (e.g., meeting new people, having a conversation, being observed while eating/drinking, performing in front of others such as a speech) B: [x ] Individual fears that s/he will act in a way or show anxiety symptoms that will be negatively evaluated C: [ ] Social situations almost always provoke anxiety D: [ ] Social situations are avoided or endured w/ intense fear or anxiety E: [ ] Fear & anxiety are out of proportion to the event F: [x ] The fear/anxiety is persistent (e.g., 6+ months) G: [x ] The fear & anxiety interferes significantly w social or occupational (academic) functioning H: [x ] Not due to direct physiological effects of a substance or medical condition I: [ ] Not due to the symptoms of another mental disorder J: [ ] If a medical condition (e.g., Parkinson's) is present, fear is clearly excessive or unrelated

SUMMARY: Veteran was assessed for social anxiety disorder. While he endorses strong concerns that other people may "notice" or "criticize" him, it is difficult to differentiate Pt's report of these symptoms from concern related to recent weight gain; from long-standing concern that others find him inadequate; from long-standing belief that he "needs to be perfect"; and from depressive rumination related to current low social functioning and negative beliefs about himself. Additionally, Pt. reports very few social interactions as he has found it difficult since losing his job in December 2014 to "go out" and maintain friendships while depressed. He stated that he does not always avoid social situations, but recently has preferred to because he worries about others noticing his recent weight gain; he denied always feeling anxious in social situations and denied experiencing intense fear or anxiety in social situations. At this time, Pt. does not meet criteria for Social Anxiety Disorder; however, further assessment of role of long-standing interpersonal style and preferences in social situations will help to further clarify. PANIC ATTACKS: Veteran was assessed for and does not meet criteria for panic disorder at this time. He denied experiencing sudden onset of intense fear and discomfort at any time in the past. AGORAPHOBIA: Marked fear or anxiety about 2+: [ ] Public transportation [ ] Open spaces [x ] Enclosed places [ ] Standing in line/crowds [ ] Outside of the home alone [x ] fear/avoidance is because of thoughts of no escape or no help available [x ] situations almost always elicit fear/anxiety [] situations are actively avoided, or need a companion or endured with intense fear/anxiety [] fear/anxiety is out of proportion to the danger [x ] Persists for 6 months or more [ ] Causes clinically significant distress or impairment [ ] If a medical condition (e.g., Parkinson's) is present, fear/anxiety/avoidance is clearly excessive [x ] Not due to the symptoms of another mental disorder SUMMARY: Veteran endorses experiencing fear and anxiety when in small spaces, such as "caves or crawl spaces". He denied avoiding these feared situations.  Veteran shared that he "dreads" leaving his house, but attributed this to the anticipated effort it takes given his depressive symptoms; he stated that being outside his home does not cause fear. Veteran does not meet criteria for Agoraphobia at this time. BORDERLINE PERSONALITY DISORDER: [x]Pervasive pattern of instability in relationships, self-image, and affect [] Marked impulsivity beginning by early adulthood Five or more of the following: [ ] Frantic efforts to avoid real or imagined abandonment [ ] Unstable & intense relationships, fluctuating between idealization and devaluation [x ] Marked and persistent unstable self-image or sense of self [ ] At least 2 self-damaging impulsive behaviors (spending, sex, substance, reckless driving, binge eating) ***reports long history of one-night stands*** [ ] Recurrent suicidal behavior, gestures, or threats or self-mutilating behavior: **Denied** [ ] Affective instability due to reactivity to mood (intense episodic dysphoria, irritability, anxiety) **denied, "even keel"*** [ ] Chronic feelings of emptiness **denied, "No, I'm filled with too many emotions"** [ ] Inappropriate, intense anger or difficulty controlling anger **denied** [ ] Transient, stress-related paranoid ideation or severe dissociative symptoms **denied**

SUMMARY: Veteran endorsed a long-standing and strong sense of not knowing "who the real" him is. He denied instability in his relationships as well as fear of abandonment; he shared that at the end of his marriage and two serious relationships, he felt quite upset but also was able to accept them ending. However, Pt. stated "I don't like to be alone" and also explained that after having sex with a woman he often feels as if he has "no emotions for them at all". Veteran shared that he has a long history of engaging in one-night-stands, beginning during his military service after high school and continuing today. However, this is somewhat inconsistent with Pt's reported lack of social interactions and therefore it is unclear how often or recently these have occurred. Veteran does not meet criteria for Borderline Personality Disorder at this time; however, some inconsistent responses combined with additional responses to further personality disorder assessment (see below) warrant reassessment of this in the future reasonable. PERSONALITY DISORDERS: ADDITIONAL CONSIDERATIONS Criteria for Avoidant Personality Disorder and Paranoid Personality Disorder were reviewed with Pt. using the SCID-II, given some of his responses during this intake, in hopes of clarifying differential diagnosis related to social anxiety. However, Pt.'s inconsistent, and at times unusual, responses make clearly ruling out a personality disorder difficult at this time. Indeed a potential pattern consistent with Obsessive-Compulsive Personality Disorder emerged and would need further assessment (e.g., "I have to be perfect"; Pt. reports spending hours writing SOAP notes in former job). Additional assessment focused on R/O a personality disorder, especially BPD, avoidant, paranoid, and obsessive-compulsive personality disorders, would be helpful. Veteran endorsed the following regarding his long-standing patterns of behavior: Related to a persistent pattern of social inhibition, feeling inadequate, hypersensitivity to negative evaluation (Avoidant Personality Disorder) patient endorsed: 1. Avoiding occupational activities that require significant interpersonal interactions. a. However, Pt. pursued a career in physical therapy and reports enjoying the work with patients the most. He also reports trying to attend all workrelated social functions in order to meet people and maintain friendships. 2. Being unwilling to be involved with others unless certain of being liked. a. Pt. stated he "doesn't hang back, nor avoid", but will go to great lengths to "gauge" the other person's interest; he described spending significant amount of time coming up with and reviewing text messages to others before sending (this is possibly more related to a sense of perfectionism rather than hypersensitivity to negative evaluation). 3. Avoiding new activities due to fear of embarrassment. a. Veteran states he dislikes walking across a room for this reason. Related to pervasive distrust and suspiciousness of others (Paranoid Personality Disorder), Pt. endorsed the following: 1. Suspecting without cause that others are exploiting him. a. Pt. reports frequently loaning money to others and not being paid back, thus not trusting others to pay him back in the future (though this fear appears reasonable); he added that he "can't say no". 2. Reluctance to confide in others. a. Pt. stated, "I don't know what to confide, it's hard when I don't know who the real me is". 3. Feeling guilty and remorseful. a. Pt. stated "I regret so much" and "I spend the majority of my time regretting the past". However, Pt. could not provide concrete examples of the things he regrets.

DSM-5 DIAGNOSES: 300.4 Persistent Depressive Disorder with intermittent major depressive episodes, with current episode, moderate. R/O Social Anxiety Disorder R/O Personality Disorder IMPRESSIONS: Patient is a 45 year old, male, Marine Corps Veteran who presented to PCMHI requesting return to services in MHC due to depression symptoms. He was then referred for psychology intake by MHC psychiatrist, Dr. Gill. Patient reports long-standing depressive symptoms and meets criteria for PDD with intermittent major depressive episodes. He reports some social anxiety, though this appears limited to perceptions that others will notice the weight gain that has occurred in the past two years. Veteran also reports a strong sense of not "knowing who [he] is" along with long-standing patterns of sensitivity to scrutiny, concerns related to not trusting others yet being overly generous to the same individuals, and a belief that he "must be perfect". Veteran's report of having few social interactions is incongruent with his report of frequent one-night stands - at times it is unclear if Veteran responded to questions with recent information, even when prompted to do so. Further assessment is needed to clarify the role of these concerns and patterns in Veteran's reported anxiety symptoms.

RECOMMENDATIONS 1. If Veteran would like to pursue treatment for his depression, the Overcoming Depression Group, beginning August 2016, in MHC may be a good opportunity as it provides both an evidence supported treatment as well as increased socialization, which the Pt. has identified as a goal. 2. If Veteran would prefer not to engage in group therapy, he may elect to complete CBT for Depression individually. ACT for Depression may also be considered. 3. A psychological assessment focused on clarifying social anxiety symptoms and long-standing patterns of interacting with the world and others would be helpful. This personality assessment may help Veteran identify helpful additional treatment following therapy for depression. PATIENT PARTICIPATION IN TREATMENT PLANNING: MET WITH PROVIDER. VETERAN AGREED TO PLAN (draft) DISCUSSED. TREATMENT PLAN PROBLEMS/NEEDS LISTED BY PRIORITY: Veteran reports symptoms of depression: increased social isolation, fatigue, avolition, anhedonia, negative cognitions about self and others,  sleep disturbances, persistent negative mood

TREATMENT PLAN: Problem: Veteran reports symptoms of depression: increased social isolation, fatigue, avolition, anhedonia, negative cognitions about self and others, sleep disturbances, persistent negative mood Goal: Veteran wants to increase pleasurable or mastery activities; Veteran stated, He'd like to "get out of the house more often, sleep better, start applying for jobs." Objective: Veteran will engage in additional pleasant and mastery activities as measured by self-report and by report on the Activity Monitoring Form. Intervention: Cognitive Behavioral Therapy for depression UPDATED/RESOLVED/INACTIVATED PROBLEMS & COMMENTS: ACTIVE PROBLEM: Veteran reports symptoms of depression: increased social isolation, fatigue, avolition, anhedonia, negative cognitions about self and others, sleep disturbances, persistent negative mood ACTIVE GOAL: Veteran wants to increase pleasurable or mastery activities; Veteran stated, He'd like to "get out of the house more often, sleep better, start applying for jobs."

Edited October 15, 2017 by Diablopup

[john999]

You don't want to use a cell phone as evidence in a VA claim.  Buddy statements that are signed/dated and notarized would be much better.  You are not dealing  with "Judge Judy".  The VA is saying they cannot rule out a  personality disorder.  If you get the PD diagnosis it is death to most mental health claims.  You must speak to these VA doctors with great care.   Avoid all statements about your pre-service life.  You were just fine before the military and now you are disabled. No discussions of childhood, high school, drug use,  law problems or marriage problems IMO.  You say you want to start applying for jobs?  This is just the worst thing you can say.  Do you know the difference between a personality disorder,  PTSD and Depression?  You need an IMO to clean these statements that quote you.  The main thing is "don't talk about anything that happened before the military".  You area being royally *&&^^% by what is coming out of your own mouth.  The less you say the better.  Let an IMO speak for you.

[Diablopup]

The cell phone was a last resort, I had been trying to upload that form to my claim but it wouldn't go through.  On the way into my C & P exam I emailed it to myself as a last resort to be able to show it to the examiner.  I didn't have any buddy statements as I hadn't spoken to anyone from my past for years and didn't want them to know how bad off i've been doing.  You are absolutely correct in your assessment of what I've been doing wrong and what I need to do.  I've just been feeling as though i'm drowning and try to find anything/reason to try and understand whats happening to me.  I need to just stop but in the past that's always felt like giving up.  I will be seeing my psych this week and I'm going to go over my medical record with her.  Its full of inaccuracies about what i was feeling to their opinions about my past and my father.  After that i'm done trying to explain or help with my recovery.  I'm just going to take the meds and shut up.  Thank you so much for taking the time to view my post and try and help me.  I'm really at the end of my rope here and don't want to continue this existence any longer.  If it wasn't for how it would effect my mother I wouldn't even be having this conversation with you right now.  I'm so tired.

Semper Fi

Edited October 16, 2017 by Diablopup

[john999]

Have you tried to get a VA lawyer to help you.   People here can give advice but it is usually general in nature.  Do you have a private shrink?  You cannot trust VA shrinks to help with your claim.  They are basically prohibited in giving you the sort of help you need for a claim.  I made all the same mistakes you made and then some over a 30 year period where I was spinning my wheels with the VA.  I did not even know what TDIU was until I was filing for it.   The fact I did not have good IMO/IME reports to submit with my claim over the years since 1972 to 2001 was the reason I never got a rating above 30%.  When I got good IMO's I quickly got 70% and then P&T.  After that I understood what was necessary  I got an extra 60%, 20%, four 10% ratings and SMC "S".    Medical evidence, the nexus and current disability are the whole deal.  Often a good IMO can provide all of this.  You have to do it step by step and if you are not able you need a professional to help you.  It is like a brick wall that you are building one brick at a time.   Don't give up and try to get a professional to help you.  If it gets too bad admit yourself to a VA hospital.   I did it twice and both times it ended up with me getting more disability.  Both times I was at the end of my rope or I would not have set foot in those places.