Hello, I've utilized this site many times looking through other people's questions and gaining incite from those. This is the first time I've posted a question myself and I'm not really sure what I'm asking for to begin with. I guess I'm just hoping for a little input. A little background: I've had claims in for 5 years now. My initial C&P exam concluded that my mental issues were the result of alcohol abuse, not PTSD, hence the first of the two C&P exams I'll list here. I guess a good question would be does anyone think the initial C&P will carry more weight than these? I don't have a copy of it and didn't know that was the conclusion until I went to my current claims C&P. The Doc literally stated "WTF" when mentioning it. If anything has given me a little hope it's his attitude towards the initial exam. I guess there are some good people in the system. I have consistently held back when asked about suicidal thoughts and intentions. (Primarily because I've been institutionalized previously against my will and I consider firearms an intrinsic part of my identity, having those and my freedom taken away doesn't present a situation I'd like to repeat.) I understand that if I were more forthcoming I may receive a higher rating? I guess another question would be if there's a doc I trust enough to address those issues with, should I possibly go back for a higher rating? I think I'm on track for 30% and I'd be happy with that considering how hard of a time I've had simply getting appointments, let alone a claim that represented me fairly. At any rate, here are the DBQ's. I have redacted some information I felt wasn't pertinent.
______________________________
LOCAL TITLE: C&P PSYCH
STANDARD TITLE: PSYCHIATRY C & P EXAMINATION CONSULT
DATE OF NOTE: JUN 30, 2017@09:00 ENTRY DATE: JUL 28, 2017@11:04:15
Addendum / Clarification Disability Benefits Questionnaire Name of patient/Veteran: Carver, William Please utilize this form when responding to VBA requests for either addendums or clarifications of prior VHA examination reports. The stressor events in Iraq during the veteran's service included fear of terrorist activity. His mental disorder is not a result of his memory loss.
Review Post Traumatic Stress Disorder (PTSD) Disability Benefits Questionnaire
Name of patient/Veteran: Carver,*
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 ICD Code: F43.10
2. Current Diagnoses --------------------
a. Mental Disorder Diagnosis #1: PTSD ICD Code: F43.10 Mental Disorder Diagnosis #2: Major Depression ICD Code: F33.1
b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): Sleep Apnea
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?
[X] Yes [ ] No [ ] Not applicable (N/A)
If yes, list which symptoms are attributable to each diagnosis and discuss whether there is any clinical association between these diagnoses: Major Depression: Depressed Mood, including anhedonia, apathy, and previous suicidal ideation. Remainder are due to PTSD or both.
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 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?
[X] Yes [ ] No [ ] No other mental disorder has been diagnosed
If yes, list which portion of the indicated level of occupational and social impairment is attributable to each diagnosis:
In my opinion, the depression is secondary to his PTSD, therefore the level of impairment is due to the PTSD.
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): Previous Initial PTSD C&P Exam (May 12, 2014).
Personal history below since that exam.
***I've redacted this but let's just say I've not done well at life despite 3 degrees and federal employment***
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
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 dis tressing 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] 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] Chronic sleep impairment
[X] Flattened affect
[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
[X] Impaired impulse control, such as unprovoked irritability with periods of violence
Casually dressed, neatly groomed. Fully alert and oriented. Speech soft, normal rate, logical and coherant. Affect was very anxious. Mood described as nearly always anxious or irritable. Denies recent suicidal ideation. Memory intact. No agitation or evidence of thought disorder.
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: ---------------------------------------------------
[X] Other (please identify other evidence reviewed): Previous Initial PTSD C&P Exam (May 12, 2014).
MEDICAL OPINION SUMMARY -----------------------
In my opinion, after reviewing his treatment records before and after his previous Initial PTSD Exam (May 2014) and the exam itself that Mr. Carver was misdiagnosed during his previous exam. I believe that there was plenty of evidence in his treatment records that his condition did cause significant impairment of occupational and social functioning prior to his 2014 exam. The symptoms that are indicated in the 2014 exam would meet the DSM-5 criteria for Other Trauma and Stressor Related Disorder. The previous examiner concluded that the in service stressors did meet the DSM-5 stressor criteria for PTSD, and with that, I concur. Since the 2014 exam he has stopped all medication because he was not able to find a time to schedule an appointment with the local VA clinic due to his work schedule. As a result of being off medications, which he found quite helpful, his condition has worsened significantly since the 2014 exam. Through my interview with Mr. Carver, it is my opinion that he meets the full diagnostic criteria for PTSD as a result of his experiences during his Iraq deployments during service. It is my opinion that his Major Depresison is secondary to his PTSD and his previous alcohol use was self medication for, and not the cause of his psychiatric disorders.
RESTATEMENT OF REQUESTED OPINION:
a. Opinion from general remarks: Does the veteran have depression that is more likely than not caused by his alcohol use during service.
b. Indicate type of exam for which opinion has been requested: Mental disorders.
TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR DIRECT SERVICE CONNECTION ]
b. The condition claimed was less likely than not (less than 50% probability) incurred in or caused by the claimed in-service injury, event or illness.
c. Rationale: See medical opinon summary. This question is reversed in my opinion. His previous alcohol use was self medication for his mental disorder(s) and not the cause of them.
Indicate method used to obtain medical information to complete this document:
[X] Review of available records (without in-person or video telehealth examination) using the Acceptable Clinical Evidence (ACE) process because the existing medical evidence provided sufficient information on which to prepare the DBQ and such an examination will likely provide no additional relevant evidence.
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): Previous Psych C&P PTSD Exams (including my exam from June for which this is an addendum.
MEDICAL OPINION SUMMARY -----------------------
In my opinion, coming under consistent mortar fire and seeing death of civilians in Iraq constitutes a hostile military action which resulted in the veteran being afraid. Since that experience, he has PTSD symptoms. I think there is a direct causative effect between being attacked by hostile forces and his symptoms.
RESTATEMENT OF REQUESTED OPINION:
a. Opinion from general remarks: Are the veteran's PTSD symptoms a result of fear of hostile military action?
b. Indicate type of exam for which opinion has been requested: PTSD TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR DIRECT SERVICE CONNECTION ]
a. The condition claimed was at least as likely as not (50% or greater probability) incurred in or caused by the claimed in-service injury, event or illness.
c. Rationale: While deployed to Iraq, his base came under mortar fire frequently. This was a hostile act which resulted in the veteran being afraid. He has PTSD symptoms as a result of that experience.
Question
CarverUSAF
Hello, I've utilized this site many times looking through other people's questions and gaining incite from those. This is the first time I've posted a question myself and I'm not really sure what I'm asking for to begin with. I guess I'm just hoping for a little input. A little background: I've had claims in for 5 years now. My initial C&P exam concluded that my mental issues were the result of alcohol abuse, not PTSD, hence the first of the two C&P exams I'll list here. I guess a good question would be does anyone think the initial C&P will carry more weight than these? I don't have a copy of it and didn't know that was the conclusion until I went to my current claims C&P. The Doc literally stated "WTF" when mentioning it. If anything has given me a little hope it's his attitude towards the initial exam. I guess there are some good people in the system. I have consistently held back when asked about suicidal thoughts and intentions. (Primarily because I've been institutionalized previously against my will and I consider firearms an intrinsic part of my identity, having those and my freedom taken away doesn't present a situation I'd like to repeat.) I understand that if I were more forthcoming I may receive a higher rating? I guess another question would be if there's a doc I trust enough to address those issues with, should I possibly go back for a higher rating? I think I'm on track for 30% and I'd be happy with that considering how hard of a time I've had simply getting appointments, let alone a claim that represented me fairly. At any rate, here are the DBQ's. I have redacted some information I felt wasn't pertinent.
______________________________
LOCAL TITLE: C&P PSYCH
STANDARD TITLE: PSYCHIATRY C & P EXAMINATION CONSULT
DATE OF NOTE: JUN 30, 2017@09:00 ENTRY DATE: JUL 28, 2017@11:04:15
AUTHOR: J*,* EXP COSIGNER: URGENCY: STATUS: COMPLETED
Addendum / Clarification Disability Benefits Questionnaire Name of patient/Veteran: Carver, William Please utilize this form when responding to VBA requests for either addendums or clarifications of prior VHA examination reports. The stressor events in Iraq during the veteran's service included fear of terrorist activity. His mental disorder is not a result of his memory loss.
Review Post Traumatic Stress Disorder (PTSD) Disability Benefits Questionnaire
Name of patient/Veteran: Carver,*
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 ICD Code: F43.10
2. Current Diagnoses --------------------
a. Mental Disorder Diagnosis #1: PTSD ICD Code: F43.10 Mental Disorder Diagnosis #2: Major Depression ICD Code: F33.1
b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): Sleep Apnea
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?
[X] Yes [ ] No [ ] Not applicable (N/A)
If yes, list which symptoms are attributable to each diagnosis and discuss whether there is any clinical association between these diagnoses: Major Depression: Depressed Mood, including anhedonia, apathy, and previous suicidal ideation. Remainder are due to PTSD or both.
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 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?
[X] Yes [ ] No [ ] No other mental disorder has been diagnosed
If yes, list which portion of the indicated level of occupational and social impairment is attributable to each diagnosis:
In my opinion, the depression is secondary to his PTSD, therefore the level of impairment is due to the PTSD.
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): Previous Initial PTSD C&P Exam (May 12, 2014).
Personal history below since that exam.
***I've redacted this but let's just say I've not done well at life despite 3 degrees and federal employment***
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
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 dis tressing 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] 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] Chronic sleep impairment
[X] Flattened affect
[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
[X] Impaired impulse control, such as unprovoked irritability with periods of violence
5. Behavioral observations --------------------------
Casually dressed, neatly groomed. Fully alert and oriented. Speech soft, normal rate, logical and coherant. Affect was very anxious. Mood described as nearly always anxious or irritable. Denies recent suicidal ideation. Memory intact. No agitation or evidence of thought disorder.
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: ---------------------------------------------------
See medical opinion
****************************************************************************
Medical Opinion Disability Benefits Questionnaire Name of patient/Veteran: Carver, *
ACE and Evidence Review -----------------------
Indicate method used to obtain medical information to complete this document: [
X] In-person examination 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): Previous Initial PTSD C&P Exam (May 12, 2014).
MEDICAL OPINION SUMMARY -----------------------
In my opinion, after reviewing his treatment records before and after his previous Initial PTSD Exam (May 2014) and the exam itself that Mr. Carver was misdiagnosed during his previous exam. I believe that there was plenty of evidence in his treatment records that his condition did cause significant impairment of occupational and social functioning prior to his 2014 exam. The symptoms that are indicated in the 2014 exam would meet the DSM-5 criteria for Other Trauma and Stressor Related Disorder. The previous examiner concluded that the in service stressors did meet the DSM-5 stressor criteria for PTSD, and with that, I concur. Since the 2014 exam he has stopped all medication because he was not able to find a time to schedule an appointment with the local VA clinic due to his work schedule. As a result of being off medications, which he found quite helpful, his condition has worsened significantly since the 2014 exam. Through my interview with Mr. Carver, it is my opinion that he meets the full diagnostic criteria for PTSD as a result of his experiences during his Iraq deployments during service. It is my opinion that his Major Depresison is secondary to his PTSD and his previous alcohol use was self medication for, and not the cause of his psychiatric disorders.
RESTATEMENT OF REQUESTED OPINION:
a. Opinion from general remarks: Does the veteran have depression that is more likely than not caused by his alcohol use during service.
b. Indicate type of exam for which opinion has been requested: Mental disorders.
TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR DIRECT SERVICE CONNECTION ]
b. The condition claimed was less likely than not (less than 50% probability) incurred in or caused by the claimed in-service injury, event or illness.
c. Rationale: See medical opinon summary. This question is reversed in my opinion. His previous alcohol use was self medication for his mental disorder(s) and not the cause of them.
___________________________________________________________________________
LOCAL TITLE: C&P PSYCH
STANDARD TITLE: PSYCHIATRY C & P EXAMINATION CONSULT
DATE OF NOTE: DEC 01, 2017@09:00 ENTRY DATE: DEC 01, 2017@08:35:06
AUTHOR: J*,* EXP COSIGNER: URGENCY: STATUS: COMPLETED
Medical Opinion Disability Benefits Questionnaire
Name of patient/Veteran: Carver, *
ACE and Evidence Review -----------------------
Indicate method used to obtain medical information to complete this document:
[X] Review of available records (without in-person or video telehealth examination) using the Acceptable Clinical Evidence (ACE) process because the existing medical evidence provided sufficient information on which to prepare the DBQ and such an examination will likely provide no additional relevant evidence.
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): Previous Psych C&P PTSD Exams (including my exam from June for which this is an addendum.
MEDICAL OPINION SUMMARY -----------------------
In my opinion, coming under consistent mortar fire and seeing death of civilians in Iraq constitutes a hostile military action which resulted in the veteran being afraid. Since that experience, he has PTSD symptoms. I think there is a direct causative effect between being attacked by hostile forces and his symptoms.
RESTATEMENT OF REQUESTED OPINION:
a. Opinion from general remarks: Are the veteran's PTSD symptoms a result of fear of hostile military action?
b. Indicate type of exam for which opinion has been requested: PTSD TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR DIRECT SERVICE CONNECTION ]
a. The condition claimed was at least as likely as not (50% or greater probability) incurred in or caused by the claimed in-service injury, event or illness.
c. Rationale: While deployed to Iraq, his base came under mortar fire frequently. This was a hostile act which resulted in the veteran being afraid. He has PTSD symptoms as a result of that experience.
______________________________________________________________________
Thanks in advance and for being patient with me not really knowing what I'm wanting to ask.
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Berta
This C & P exam, in my opinion, will get you a PTSD rating. The only thing I would wonder ,is if, for some very strange reason, the VA questioned the service trauma or your incountry MOS.
CarverUSAF
So, my claim has gone 100 mph the last two days and this morning ebenefits updated to show this
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