PTSD C&P Exam Complete with MH Dr. Comments

[Grumpbox]

Any feedback would be greatly appreciated here. 

Below the reader will find my most recent (5 years since retirement) C&P Exam comments from the Doctor.  

Currently, I am 100% SC'd since retirement.  

If anyone would make a stab at these comments and provide me with some insight on how things look for future ratings???

 

Again, THANK ANYONE for taking the time to provide his/her opinion!!!

GB

 

LOCAL TITLE: C&P EXAMINATION
STANDARD TITLE: C & P EXAMINATION NOTE
DATE OF NOTE: OCT 20, 2017@10:00 ENTRY DATE: OCT 20, 2017@10:57:04
AUTHOR: SULLIVAN,DANIEL J EXP COSIGNER:
URGENCY: STATUS: COMPLETED

Review Post Traumatic Stress Disorder (PTSD)
Disability Benefits Questionnaire
Name of patient/Veteran: *****
Is this DBQ being completed in conjunction with a VA 21-2507, C&P
Examination
Request?

[X] Yes [ ] No
SECTION I:
----------
1. Diagnostic Summary
---------------------
Does the Veteran now have or has he/she ever been diagnosed with PTSD?
[X] Yes [ ] No

2. Current Diagnoses
--------------------
a. Mental Disorder Diagnosis #1: Posttraumatic Stress Disorder
b. Medical diagnoses relevant to the understanding or management of the
Mental Health Disorder (to include TBI):
No response provided.

3. Differentiation of symptoms
------------------------------
a. Does the Veteran have more than one mental disorder diagnosed?
[ ] Yes [X] No
c. Does the Veteran have a diagnosed traumatic brain injury (TBI)?
[ ] Yes [ ] 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 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 [ ] No [X] No other mental disorder has been diagnosed
c. If a diagnosis of TBI exists, is it possible to differentiate what
portion of the occupational and social impairment indicated above is caused by
the TBI?
[ ] Yes [ ] No [X] No diagnosis of TBI

SECTION II:
-----------
Clinical Findings:
------------------
1. Evidence Review
------------------
Evidence reviewed (check all that apply):
[X] VA e-folder (VBMS or Virtual VA)
[X] CPRS

2. Recent History (since prior exam)
------------------------------------
a. Relevant Social/Marital/Family history:
Veteran stated that he is married to his 3rd wife of 1 month. He
stated that his wife is older than him, he cares for her and she takes care
of veteran and his daughter. Veteran stated that they had dated 1.5 to 2
years.
Veteran reported having one child, who is 15 years of age.
Veteran stated that he gained primary physical custody in **/****
because his child and her mother were not getting along. Veteran
described his relationship with his child as "real rough."
He explained that the child is very loving and affectionate and child wants to
hug veteran a lot. He said that he is not comfortable with physical or
emotional affection.
Veteran indicated that he has no good friends. He said that he is
friends with a friend from high school, a cousin and someone he served
with. Veteran stated that he speaks with these people via phone
occasionally.
b. Relevant Occupational and Educational history:
Veteran stated that the only time that he has worked since his last
PTSD C&P exam in 07/2012 was he worked from 08/2016 through 11/2016
in personal security in Baghdad. He said that the situation was anxiety
provoking and he had problems with concentration and stress that led
to him quitting the job.
Veteran reported that he took classes through *** and ******
University online in 2015 to study *****. He said that he took 2-3
classes but dropped out because it was too stressful and was not
interesting for veteran.
c. Relevant Mental Health history, to include prescribed medications and
family mental health:
Veteran was treated PTSD through the VA with Duloxetine in 2013. He
had an initial assessment at the Murfreesboro VAMC on 06/13/2014. He was
diagnosed with PTSD and MDD with a GAF of 60 and was prescribed
Cymbalta and Trazadone. He was last seen by mental health through the
VA on 04/27/2015. There is documentation of veteran not showing for 2
appts after that.
Veteran stated that he went to see a mental health provider on 4-6
occasions at ******* in ***** around 2014. He said that he was
treated with medication and psychotherapy. He said that he stopped
going because he did not feel that it was helpful.

Veteran denied taking any medications or other mental health treatment
at the time of this exam. He said that he was told by the Murfreesboro
and Nashville VAs that they were not able to see veteran because of
lack of available resources.
d. Relevant Legal and Behavioral history:
Veteran denied since his last exam in 2012.
e. Relevant Substance abuse history:
Veteran reported drinking alcohol nightly, 2 beers per night. He
denied
illicit drug use.
f. Other, if any:
No response provided.
3. PTSD Diagnostic Criteria
---------------------------
Please check criteria used for establishing the current PTSD diagnosis. The
diagnostic criteria for PTSD, are from the Diagnostic and Statistical Manual
of Mental Disorders, 5th edition (DSM-5). The stressful event can be due to
combat, personal trauma, other life threatening situations (non-combat
related stressors). 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 #6 - "Other
symptoms".

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
[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).
[X] Marked physiological reactions 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 and exaggerated negative beliefs or
expectations about oneself, others, or the world (e.g.,
"I am bad,: "No one can be trusted,: "The world is
completely dangerous,: "My whole nervous system is permanently
ruined").
[X] Persistent, distorted cognitions about the cause or
consequences of the traumatic event(s) that lead the
individual to blame himself/herself or others.
[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.
[X] Persistent inability to experience positive emotions
(e.g., inability to experience happiness, satisfaction,
or loving feelings.)

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] Exaggerated startle response.
[X] Problems with concentration.
[X] Sleep disturbance (e.g., difficulty falling or staying
asleep or restless sleep).

Criterion F:
[X] The duration of the symptoms described above in Criteria
B, C, and D are more than 1 month.

Criterion G:
[X] The PTSD symptoms described above cause 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.

4. Symptoms
-----------
For VA rating purposes, check all symptoms that actively apply to the
Veteran's diagnoses:
[X] Depressed mood
[X] Anxiety
[X] Suspiciousness
[X] Panic attacks more than once a week
[X] Chronic sleep impairment
[X] Mild memory loss, such as forgetting names, directions or recent
events
[X] Impairment of short- and long-term memory, for example, retention of
only highly learned material, while forgetting to complete tasks
[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

5. Behavioral observations
--------------------------
Veteran was on time for his exam. He was somewhat agitated and anxious
throughout the exam. He was cooperative and responsive to questions
asked.
Veteran was oriented x4 with logical and linear thought processes. He was
oriented x4 with logical and linear thought processes. He had a limited
affective range but his affect was not flat.
6. Other symptoms
-----------------
Does the Veteran have any other symptoms attributable to PTSD (and other
mental disorders) that are not listed above?
[ ] Yes [X] No
7. Competency
-------------
Is the Veteran capable of managing his or her financial affairs?
[X] Yes [ ] No
8. Remarks, (including any testing results) if any:
---------------------------------------------------
Veteran was able to understand and successfully carry out complex
commands. There was no evidence of significantly Impaired judgment. He
denied Suicidal ideation and impaired impulse control in the past year.
Veteran stated that he keeps up with his personal hygiene and appearance
and is able to complete all of his activities of daily living.

[Grumpbox]

@Gastone   You are center mass now!!!  

Yes, the PTSD review/request is the result of a 5 year check up!!!  I was medically retired, 22 Nov 2011 at 50% for PTSD, along with my other ratings.  However, about one year later...at an annual check up with the VA - one that was due to a C&P request for my first annual, they bumped me to 100% for PTSD.  That C&P was around August or so 2012.  Thus why this recent C&P occurred, 20 Oct 2017.

A couple of things concern me however.  I weaned myself of meds around 2015, stopped attending mental health apts, because I felt things weren't improving.  It was a bad time in my life, whereby I had zero luck with employment, couldn't maintain relationships, and tried college, but had no luck.  It was about a year later when I feel the 'delayed' part of my PTSD really grew to what it is today.  After things continued in decline, I thought I should go back to the VA for help.  Only problem was that I tried calling both major locations for the VA here in TN, only to be told that they had no openings for appointments at MH.  I was really shocked, pissed, and had a change in heart about what the VA could do to help me.  In short, I took matters in to my own hands and have somehow weathered the storm since...

My concern is that the VA will see my decline in seeking help and use this against me.  @john999 made so powerful points when he noticed the many contradictions in the MH Dr's DBQ notes.  For example, the doctor stated that my hygiene was kept 'neat'; however, I hadn't shaved in about three moths that day for the C&P.  To be honest, for that C&P I was a nervous wreck and felt pushed through the exam like cattle receiving their annual shots....

It was at this point (just after this most recent C&P) that my wife of two months started to notice some drastic changes in my behavior/sleep.  SO bad that she came to me and begged me to go and see someone at the local VA.  Well, I've done that and now seeing a MH Dr., who has issued me Prazosin for sleep to combat my nightmares and restlessness.  

Back to Ebenefits - I find myself debating the ebb and flow of my status/pending result from this most recent C&P dated, 20 Octo 2017.  There have been two times when a suspense date for final decision approached, whereby it would get bumped further in to the future.  Only this last time it occurred, the VA pushed it all the way to Jan/20 Feb 2018!  

My other concern is how the VA will view my lack of participation seeking help from 2015-Nov 2017?  I know it looks odd that I recently went to the local VA; especially, since it was AFTER this C&P in Oct 2017, but it was my wife that asked me to do this.  This is my third wife and shes been with me through thick and thin.  I was just hardheaded and didn't go seek help during 2015 up until now.  I don't wanna loose this wife, thus why I went for help.  

I wonder if the VA is viewing these last records from the local VA?  My hopes are they don't view me as someone trying to make up lost time, because this is not the case.  My marriage is more important.  The timing just looks bad....

[john999]

If I were you I would stay in treatment at the VA for your SC conditions.  You need to stay in treatment even if it is private care and keep records of your treatments.  This is what the VA will use to deny or accept a claim.  If you are not getting treatment or taking meds for mental health issues they seem to believe you are better and need to be reduced.  I get tons of meds and have been seeing VA shrinks for 20 years.  They don't do me much good but I will keep going until I get 20 years on my claim and it becomes really permanent.  I advise you to do the same.

[Grumpbox]

john999 - sage advice!  I will certainly follow this advice!  

[Gastone]

If you've held your PTSD Rating for 5+ yrs, this DBQ, in and of itself can't be used as the only MH Medical Opinion to reduce your current PTSD SC. However, if you've been completely off the VMC Treatment Grid for a couple of years, that could be problematic.

Without a VA or Private MH Treatment Paper Trail (including Rx), a Rater could be inclined to believe that your MH Disability picture has improved.

[Grumpbox]

@Gastone I concur - however, you and I both know that some of these grunts are hardheaded.  Just like myself!

I really got pissed when I couldn't get an apt at the VA back in 2015.  I tried calling Nashville, and Murffresboro, TN.  I got the same answer from both: "We are sorry, Sir, we just have no availability, currently."  And they wonder why 22 Vets commit suicide, daily!!

I really said,  "Screw it!"  If they won't help me, then I'll just manage myself.  But you are right, they could come back and hit me good.

I did see a civilian MH doctor briefly during this time and SW, but it was pretty short.  Yeah, they gave me meds, but no real lasting help.  That's when I went cold turkey on all help.  That was probably about 1.5 - 2 years ago.  But since then, my issues have tripled.  That's why I recently got asked by my 3rd wife of two months, to please go to the VA and speak with someone.  I did just that, on prazosin, about to start therapy, and the Dr. says I am full blown Chronic PTSD.  But that doesn't matter - I realize the VA can do whatever they want.  

Thanks Gastone!!

 

GB

[Gastone]

While you're still on good terms with your 3rd Wife, give consideration to having her complete a "Sworn Affidavit" as opposed to a regular VA 21-4138, attesting to your behavior that she has personally witnessed over the past (Date Specific) period.

Although considered a "Lay Person," she can testify as to what she has observed, possibly rebutting or reinforcing a couple of the recent DBQ area's of concern.

Is TN a "No Fault" Divorce State? No personal experience here, but X's for the most part, don't speak too highly of their spouses during and after the Divorce proceedings. Any accusations levied against you regarding anger, physical safety etc in any of the Divorce Filings could actually help you now.