What do you guys think it will be? He left out things that I said. I reported that I have panic attacks everyday and he said weekly or less. WTF?
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: F43.8
2. Current Diagnoses ------------------- a. Mental Disorder Diagnosis #1: Other Specified Trauma- and Stressor-Related Disorder ICD Code: F43.8 Comments, if any: The frequency and intensity of the veteran's current symptoms meet the DSM-5 criteria for a diagnosis of Other Specified Trauma- and Stressor-Related Disorder which is consistent with previous diagnoses from a Review Posttraumatic Stress Disorder DBQ dated December 12, 2016 and a Mental Disorders DBQ dated August 25, 2017.
Mental Disorder Diagnosis #2: Unspecified Schizophrenia Spectrum and Other Psychotic Disorder ICD Code: F29 Comments, if any: The veteran has a history psychotic symptoms including paranoid thoughts and auditory hallucinations. His symptoms are exacerbated by stress. He reported that he benefits from treatment with Risperdone.
b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): Chronic back pain; Chronic knee pain
3. Differentiation of symptoms ----------------------------- a. Does the Veteran have more than one mental disorder diagnosed?
STONE, WILLIAM MIKAEL CONFIDENTIAL Page 13 of 42
[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: The veteran's symptoms of Other Specified Trauma- and Stressor-Related Disorder include intrusive memories, recurring dreams, avoidance behaviors, and anxious hyperarousal.
His symptoms of Unspecified Schizophrenia Spectrum and Other Psychotic Disorder include paranoid ideation, distrust of others, bland affect, and apathy. 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 reduced reliability and productivity
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 relation to his diagnosis of Other Trauma- and Stressor-Related Disorder, the veteran has difficulty concentrating on occupational tasks because he is distracted by intrusive memories. He has recurring nightmares which disturb his sleep resulting in daytime fatigue. His anxiety is triggered by certain stimuli which remind him of his deployments. He has difficulty in public places, such as supermarkets, due to his hypervigilance.
As result of his diagnosis of Unspecified Schizophrenia Spectrum and Other Psychotic Disorder, the veteran is distrustful and suspicious of others which makes it difficult for him to form and maintain interpersonal relationships. He is easily provoked when he feels threatened and he has had verbal outbursts towards which has affected his occupational functioning.
STONE, WILLIAM MIKAEL CONFIDENTIAL Page 14 of 42
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: DESCRIPTION OF MARITAL, FAMILY, AND SOCIAL RELATIONSHIPS: Mr. Stone was married in April 2016. His wife is employed as a clerk at the Post Office. He has a seven-year-old stepson and a six-month-old daughter. He reported that both of the children are in good general health and his stepson is doing well in school. He stated that he gets along well with his stepson. The veteran and his wife go out to eat occasionally. Most of the time he stays at home because he is anxious in public places. His wife socializes with friends from work but the veteran avoids going to social events. He communicates with one friend on social media, otherwise, he has not maintained friendships. The veteran's father is deceased. His mother lives in Texas and she calls to see how the baby is doing. He has not traveled to Texas to visit her recently. His sister lives in Lexington, KY and he talks to her on the holidays. He did not identify any hobbies or past time activities that interest him. He stated that he used to enjoy playing soccer but he lost interest. b. Relevant Occupational and Educational history: MILITARY HISTORY --------------- DATE(S) OF SERVICE: December 12, 2005 to October 11, 2011 BRANCH OF SERVICE: Navy HIGHEST RANK OBTAINED: E4 TYPE OF DISCHARGE: Honorable RANK AT DISCHARGE: E4
STONE, WILLIAM MIKAEL CONFIDENTIAL Page 15 of 42
MILITARY OCCUPATIONAL SPECIALTY: HM Field Medical Service Technician DECORATIONS AND MEDALS AWARDED: Combat Action Ribbon; First Good Conduct Medal; National Defense Service Medal; Afghanistan Campaign Medal; Iraq Campaign Medal; Global War on Terrorism Service Medal; Sea Service Deployment Ribbon; NATO Medal; Rifle Marksmanship Ribbon DID THE VETERAN HAVE COMBAT EXPERIENCE: Yes LOCATION AND DATE OF COMBAT EXPERIENCE: Iraq from August 2009 to October 2009; Afghanistan from December 2010 to July 2011.
EDUCATION: The veteran obtained a bachelor's degree in business from Mid way University. He has completed courses towards and master's degree in health care administration. EMPLOYMENT: The veteran has been employed as an outpatient surgery technician at the Lexington VAMC since October 2015. His duties included setting up for procedures, getting vital signs from patients, assisting physicians, and cleaning up after procedures. He reported that he recently had an angry outburst towards a coworker. He was subsequently reassigned to the sterilization room where he operates the sterilization equipment and he has less interactions with coworkers. c. Relevant Mental Health history, to include prescribed medications and family mental health: PSYCHIATRIC HOSPITALIZATIONS: The veteran received psychiatric treatment on an inpatient basis at the Lexington VAMC from January 19, 2014 to January 23, 2014. His attending psychiatrist was Dr. Courtney Markham-Abedi. He was admitted with depressed mood, anxiety, and thoughts of suicide. He reported psychotic symptoms which included auditory hallucinations, delusional thoughts, and disorganized behaviors. He reported hearing voices of people giving him directions while driving and he expressed fears that people are following him or talking about him. Prior to this admission, he had been taking his psychiatric medications inconsistently and he was abusing marijuana and synthetic marijuana.
The veteran has been provided with out-patient mental health treatment at the Lexington VAMC from March 2016 to the present. He attends individual and group psychotherapy sessions with his treating psychologist, Dr. Craig Cabezas. CURRENT TREATMENT(S): Anti-depressant SPECIFY MEDICATION: Bupropion 150 mg. per day; Risperidone 1 mg., one and on-half tablets twice per day MEDICATION SIDE EFFECT(S): He reported problems with dizziness and nausea GROUP THERAPY: Yes INDIVIDUAL PSYCHOTHERAPY: Yes EFFECTIVENESS OF THERAPY: Fair COMMENT ON EFFECTIVENESS OF THERAPY: He reported that treatment with
STONE, WILLIAM MIKAEL CONFIDENTIAL Page 16 of 42
antidepressant medication has helped to improve his mood and psychotherapy is helping to improve his coping skills. d. Relevant Legal and Behavioral history: The veteran had no disciplinary infractions during his military service. He reported no history of civilian legal charges. e. Relevant Substance abuse history: The veteran described his alcohol use as occasional. He stated that he will drink at home and he does not go out and drink anywhere and the last time he had a beer was two weeks ago. He denied any problems related to alcohol use and he was never referred for treatment for alcohol abuse. He has a history of occasional marijuana use and he stated that it has helped to reduce his anxiety. He stated that he failed a random drug screen at work, due to recent cannabis use, and he is afraid that he may lose his job. f. Other, if any: The veteran has a history of chronic back pain and knee pain. He is provided with primary medical care by Dr. Wisam Owais at the Lexington VAMC. His current medications include the following: 1) BUPROPION HCL 150MG 12HR SR TAB TAKE ONE TABLET DAILY FOR MOOD OR SMOKING CESSATION 2) BUSPIRONE HCL 10MG TAB TAKE ONE TABLET EVERY MORNING AND TAKE ONE-HALF TABLET AT NOON AND TAKE ONE TABLET AT BEDTIME FOR ANXIETY 3) HYDROXYZINE HCL 25MG TAB TAKE 1 TABLET (25MG) EVERY MORNING AND TAKE 1 TO 2 TABLETS (25-50MG) AT BEDTIME FOR ANXIETY 4) RISPERIDONE 1MG TAB TAKE ONE AND ONE-HALF TABLETS TWICE A DAY FOR MOOD 5) CARBAMAZEPINE 200MG TAB TAKE TWO TABLETS TWICE A DAY FOR MOOD 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)
STONE, WILLIAM MIKAEL CONFIDENTIAL Page 17 of 42
[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).
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 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] 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] Hypervigilance. [X] Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).
STONE, WILLIAM MIKAEL CONFIDENTIAL Page 18 of 42
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 that occur weekly or less often [X] Chronic sleep impairment [X] Difficulty in establishing and maintaining effective work and social relationships
5. Behavioral observations ------------------------- MENTAL STATUS EXAM ========== GENERAL APPEARANCE: Casually dressed PSYCHOMOTOR ACTIVITY: Unremarkable SPEECH: Monotone ATTITUDE TOWARD EXAMINER: Cooperative AFFECT: Bland MOOD: Depressed ATTENTION: He reported that he has difficulty concentrating because his mind wanders. ORIENTATION: Intact THOUGHT PROCESS: Logical THOUGHT CONTENT: Unremarkable DELUSIONS: None HALLUCINATIONS: None JUDGMENT: Understands outcome of behavior INTELLIGENCE: Average INSIGHT: The veteran understands his treatment recommendations. DOES THE PATIENT HAVE SLEEP IMPAIRMENT? Yes COMMENTS AND DESCRIPTION OF EXTENT SLEEP IMPAIRMENT INTERFERES WITH DAILY ACTIVITY: He reported having difficulty falling asleep because of racing
STONE, WILLIAM MIKAEL CONFIDENTIAL Page 19 of 42
thoughts. He wakes up and has difficulty falling back to sleep. His sleep is disturbed by nightmares most nights. He gets about four to five hours of broken sleep per night and he has difficulty waking up to get to work on time. DOES THE PATIENT HAVE OBSESSIVE/RITUALISTIC BEHAVIOR? No DOES THE PATIENT HAVE PANIC ATTACKS? Yes FREQUENCY, SEVERITY, DURATION AND EFFECTS ON FUNCTIONING: He reported having panic attacks when he feels crowded or closed in IS THERE PRESENCE OF HOMICIDAL THOUGHTS? No IS THERE PRESENCE OF SUICIDAL THOUGHTS? No EXTENT OF IMPULSE CONTROL: Fair EPISODES OF VIOLENCE: No EXAMPLES OF EFFECTS ON MOTIVATION/MOOD OR OTHER COMMENTS: He tends to be irritable and short tempered. He had a verbal outburst at work and was transferred to another job. He has had instances of road rage when he felt someone was tailgating him. He stated that he gets irritated and yells at home but he denied any physical violence. ABILITY TO MAINTAIN MINIMUM PERSONAL HYGIENE? Yes IS THERE PROBLEM WITH ACTIVITIES OF DAILY LIVING: No COMMENTS OR ELABORATION OF ANY ITEMS IN THE MSE OR FOR ITEMS NOT COVERED OR OTHER COMMENTS: The veteran reported depressed mood with lack of interest and pleasure and low motivation. He reported having thoughts that life would be easier for his family if he was not there but he denied any plans or intent for suicide. He stated that he does not want his daughter to grow up without a father. He stated that he has difficulty going outside because he feels that people are watching him and he is hypervigilant in public places. He will wear sunglasses and headphones if he goes out anywhere. MEMORY ----- REMOTE MEMORY: Normal RECENT MEMORY: Normal IMMEDIATE MEMORY: Normal 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: -------------------------------------------------- PCL-5 (Clinician Administered and Scored)
STONE, WILLIAM MIKAEL CONFIDENTIAL Page 20 of 42
Criterion A: Deployments to Iraq and Afghanistan In the past month, how much were you bothered by: 0 = Not at all 1 = A little bit 2 = Moderately 3 = Quite a bit 4 = Extremely Criterion B: INTRUSION symptoms 1. Repeated, disturbing, and unwanted memories of the stressful experience? 3 He has intrusive thoughts intermittently during the day which distract him while he is at work. 2. Repeated, disturbing dreams of the stressful experience? 3 He reported a recurring nightmare and he wakes up in a cold sweat. 3. Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)? 2 He is triggered by certain smells. 4. Feeling very upset when something reminded you of the stressful experience? 2 He becomes anxious but is able to calm himself down. 5. Having strong physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating)? 2 Occasional panic attacks. Criterion C: AVOIDANCE 1. Avoiding memories, thoughts, or feelings related to the stressful experience? 2 He avoids talking about his service but attending a peer support group was helpful to him. 2. Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or situations)? 2 He avoids watching the news because he will be anxious for the rest of the day. Criterion D: Negative alterations in COGNITIONS AND MOOD 1. Trouble remembering important parts of the stressful experience? 0 2. Having strong negative beliefs about yourself, other people, or the world (for example, having thoughts such as: I am bad, there is something seriously wrong with me, no one can be trusted, the world is completely dangerous)? 2 He has difficulty trusting others and he is less sociable. 3. Blaming yourself or someone else for stressful experience or what happened after it? 0 4. Having strong negative feelings such as fear, horror, anger, guilt, or shame? 2 He is guarded and fearful. 5. Loss of interest in activities that you used to enjoy? 2 He lost interest in preferred activities such as playing soccer. He plays video games to pass the time 6. Feeling distant or cut off from other people? 3 He has not maintained friendships and he does not socialize. 7. Trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)? 2 He reported decreased pleasure in social activities. Criterion E: Alterations in AROUSAL AND REACTIVITY 1. Irritable behavior, angry outbursts, or acting aggressively? 2
STONE, WILLIAM MIKAEL CONFIDENTIAL Page 21 of 42
Verbal outbursts. 2. Taking too many risks or doing things that could cause you harm? 1 History of impulsive spending. 3. Being "superalert" or watchful or on guard? 3 He is hypervigilant in public places. 4. Feeling jumpy or easily startled? 2 He is startled by unexpected loud noises. 5. Having difficulty concentrating? 2 Difficulty concentrating because his mind wanders. 6. Trouble falling or staying asleep? 2 Four to five hours of broken sleep per night. PCL-5 Score: 39 Cluster B (items 1-5) : 12 Cluster C (items 6-7) : 4 Cluster D (items 8-14): 11 Cluster E (items 15-20): 12
Interpretive Statement: PCL-5 has a total score range of 0-80, with higher scores indicating greater PTSD symptom severity. 0-10: no or minimal symptoms reported 11-20: mild symptoms reported 21-40: moderate symptoms reported 41-60: severe symptoms reported 61-80: very severe symptoms reporte
Question
timmybob123
What do you guys think it will be? He left out things that I said. I reported that I have panic attacks everyday and he said weekly or less. WTF?
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: F43.8
2. Current Diagnoses ------------------- a. Mental Disorder Diagnosis #1: Other Specified Trauma- and Stressor-Related Disorder ICD Code: F43.8 Comments, if any: The frequency and intensity of the veteran's current symptoms meet the DSM-5 criteria for a diagnosis of Other Specified Trauma- and Stressor-Related Disorder which is consistent with previous diagnoses from a Review Posttraumatic Stress Disorder DBQ dated December 12, 2016 and a Mental Disorders DBQ dated August 25, 2017.
Mental Disorder Diagnosis #2: Unspecified Schizophrenia Spectrum and Other Psychotic Disorder ICD Code: F29 Comments, if any: The veteran has a history psychotic symptoms including paranoid thoughts and auditory hallucinations. His symptoms are exacerbated by stress. He reported that he benefits from treatment with Risperdone.
b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): Chronic back pain; Chronic knee pain
3. Differentiation of symptoms ----------------------------- a. Does the Veteran have more than one mental disorder diagnosed?
STONE, WILLIAM MIKAEL CONFIDENTIAL Page 13 of 42
[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: The veteran's symptoms of Other Specified Trauma- and Stressor-Related Disorder include intrusive memories, recurring dreams, avoidance behaviors, and anxious hyperarousal.
His symptoms of Unspecified Schizophrenia Spectrum and Other Psychotic Disorder include paranoid ideation, distrust of others, bland affect, and apathy. 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 reduced reliability and productivity
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 relation to his diagnosis of Other Trauma- and Stressor-Related Disorder, the veteran has difficulty concentrating on occupational tasks because he is distracted by intrusive memories. He has recurring nightmares which disturb his sleep resulting in daytime fatigue. His anxiety is triggered by certain stimuli which remind him of his deployments. He has difficulty in public places, such as supermarkets, due to his hypervigilance.
As result of his diagnosis of Unspecified Schizophrenia Spectrum and Other Psychotic Disorder, the veteran is distrustful and suspicious of others which makes it difficult for him to form and maintain interpersonal relationships. He is easily provoked when he feels threatened and he has had verbal outbursts towards which has affected his occupational functioning.
STONE, WILLIAM MIKAEL CONFIDENTIAL Page 14 of 42
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: DESCRIPTION OF MARITAL, FAMILY, AND SOCIAL RELATIONSHIPS: Mr. Stone was married in April 2016. His wife is employed as a clerk at the Post Office. He has a seven-year-old stepson and a six-month-old daughter. He reported that both of the children are in good general health and his stepson is doing well in school. He stated that he gets along well with his stepson. The veteran and his wife go out to eat occasionally. Most of the time he stays at home because he is anxious in public places. His wife socializes with friends from work but the veteran avoids going to social events. He communicates with one friend on social media, otherwise, he has not maintained friendships. The veteran's father is deceased. His mother lives in Texas and she calls to see how the baby is doing. He has not traveled to Texas to visit her recently. His sister lives in Lexington, KY and he talks to her on the holidays. He did not identify any hobbies or past time activities that interest him. He stated that he used to enjoy playing soccer but he lost interest. b. Relevant Occupational and Educational history: MILITARY HISTORY --------------- DATE(S) OF SERVICE: December 12, 2005 to October 11, 2011 BRANCH OF SERVICE: Navy HIGHEST RANK OBTAINED: E4 TYPE OF DISCHARGE: Honorable RANK AT DISCHARGE: E4
STONE, WILLIAM MIKAEL CONFIDENTIAL Page 15 of 42
MILITARY OCCUPATIONAL SPECIALTY: HM Field Medical Service Technician DECORATIONS AND MEDALS AWARDED: Combat Action Ribbon; First Good Conduct Medal; National Defense Service Medal; Afghanistan Campaign Medal; Iraq Campaign Medal; Global War on Terrorism Service Medal; Sea Service Deployment Ribbon; NATO Medal; Rifle Marksmanship Ribbon DID THE VETERAN HAVE COMBAT EXPERIENCE: Yes LOCATION AND DATE OF COMBAT EXPERIENCE: Iraq from August 2009 to October 2009; Afghanistan from December 2010 to July 2011.
EDUCATION: The veteran obtained a bachelor's degree in business from Mid way University. He has completed courses towards and master's degree in health care administration. EMPLOYMENT: The veteran has been employed as an outpatient surgery technician at the Lexington VAMC since October 2015. His duties included setting up for procedures, getting vital signs from patients, assisting physicians, and cleaning up after procedures. He reported that he recently had an angry outburst towards a coworker. He was subsequently reassigned to the sterilization room where he operates the sterilization equipment and he has less interactions with coworkers. c. Relevant Mental Health history, to include prescribed medications and family mental health: PSYCHIATRIC HOSPITALIZATIONS: The veteran received psychiatric treatment on an inpatient basis at the Lexington VAMC from January 19, 2014 to January 23, 2014. His attending psychiatrist was Dr. Courtney Markham-Abedi. He was admitted with depressed mood, anxiety, and thoughts of suicide. He reported psychotic symptoms which included auditory hallucinations, delusional thoughts, and disorganized behaviors. He reported hearing voices of people giving him directions while driving and he expressed fears that people are following him or talking about him. Prior to this admission, he had been taking his psychiatric medications inconsistently and he was abusing marijuana and synthetic marijuana.
The veteran has been provided with out-patient mental health treatment at the Lexington VAMC from March 2016 to the present. He attends individual and group psychotherapy sessions with his treating psychologist, Dr. Craig Cabezas. CURRENT TREATMENT(S): Anti-depressant SPECIFY MEDICATION: Bupropion 150 mg. per day; Risperidone 1 mg., one and on-half tablets twice per day MEDICATION SIDE EFFECT(S): He reported problems with dizziness and nausea GROUP THERAPY: Yes INDIVIDUAL PSYCHOTHERAPY: Yes EFFECTIVENESS OF THERAPY: Fair COMMENT ON EFFECTIVENESS OF THERAPY: He reported that treatment with
STONE, WILLIAM MIKAEL CONFIDENTIAL Page 16 of 42
antidepressant medication has helped to improve his mood and psychotherapy is helping to improve his coping skills. d. Relevant Legal and Behavioral history: The veteran had no disciplinary infractions during his military service. He reported no history of civilian legal charges. e. Relevant Substance abuse history: The veteran described his alcohol use as occasional. He stated that he will drink at home and he does not go out and drink anywhere and the last time he had a beer was two weeks ago. He denied any problems related to alcohol use and he was never referred for treatment for alcohol abuse. He has a history of occasional marijuana use and he stated that it has helped to reduce his anxiety. He stated that he failed a random drug screen at work, due to recent cannabis use, and he is afraid that he may lose his job. f. Other, if any: The veteran has a history of chronic back pain and knee pain. He is provided with primary medical care by Dr. Wisam Owais at the Lexington VAMC. His current medications include the following: 1) BUPROPION HCL 150MG 12HR SR TAB TAKE ONE TABLET DAILY FOR MOOD OR SMOKING CESSATION 2) BUSPIRONE HCL 10MG TAB TAKE ONE TABLET EVERY MORNING AND TAKE ONE-HALF TABLET AT NOON AND TAKE ONE TABLET AT BEDTIME FOR ANXIETY 3) HYDROXYZINE HCL 25MG TAB TAKE 1 TABLET (25MG) EVERY MORNING AND TAKE 1 TO 2 TABLETS (25-50MG) AT BEDTIME FOR ANXIETY 4) RISPERIDONE 1MG TAB TAKE ONE AND ONE-HALF TABLETS TWICE A DAY FOR MOOD 5) CARBAMAZEPINE 200MG TAB TAKE TWO TABLETS TWICE A DAY FOR MOOD 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)
STONE, WILLIAM MIKAEL CONFIDENTIAL Page 17 of 42
[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).
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 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] 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] Hypervigilance. [X] Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).
STONE, WILLIAM MIKAEL CONFIDENTIAL Page 18 of 42
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 that occur weekly or less often [X] Chronic sleep impairment [X] Difficulty in establishing and maintaining effective work and social relationships
5. Behavioral observations ------------------------- MENTAL STATUS EXAM ========== GENERAL APPEARANCE: Casually dressed PSYCHOMOTOR ACTIVITY: Unremarkable SPEECH: Monotone ATTITUDE TOWARD EXAMINER: Cooperative AFFECT: Bland MOOD: Depressed ATTENTION: He reported that he has difficulty concentrating because his mind wanders. ORIENTATION: Intact THOUGHT PROCESS: Logical THOUGHT CONTENT: Unremarkable DELUSIONS: None HALLUCINATIONS: None JUDGMENT: Understands outcome of behavior INTELLIGENCE: Average INSIGHT: The veteran understands his treatment recommendations. DOES THE PATIENT HAVE SLEEP IMPAIRMENT? Yes COMMENTS AND DESCRIPTION OF EXTENT SLEEP IMPAIRMENT INTERFERES WITH DAILY ACTIVITY: He reported having difficulty falling asleep because of racing
STONE, WILLIAM MIKAEL CONFIDENTIAL Page 19 of 42
thoughts. He wakes up and has difficulty falling back to sleep. His sleep is disturbed by nightmares most nights. He gets about four to five hours of broken sleep per night and he has difficulty waking up to get to work on time. DOES THE PATIENT HAVE OBSESSIVE/RITUALISTIC BEHAVIOR? No DOES THE PATIENT HAVE PANIC ATTACKS? Yes FREQUENCY, SEVERITY, DURATION AND EFFECTS ON FUNCTIONING: He reported having panic attacks when he feels crowded or closed in IS THERE PRESENCE OF HOMICIDAL THOUGHTS? No IS THERE PRESENCE OF SUICIDAL THOUGHTS? No EXTENT OF IMPULSE CONTROL: Fair EPISODES OF VIOLENCE: No EXAMPLES OF EFFECTS ON MOTIVATION/MOOD OR OTHER COMMENTS: He tends to be irritable and short tempered. He had a verbal outburst at work and was transferred to another job. He has had instances of road rage when he felt someone was tailgating him. He stated that he gets irritated and yells at home but he denied any physical violence. ABILITY TO MAINTAIN MINIMUM PERSONAL HYGIENE? Yes IS THERE PROBLEM WITH ACTIVITIES OF DAILY LIVING: No COMMENTS OR ELABORATION OF ANY ITEMS IN THE MSE OR FOR ITEMS NOT COVERED OR OTHER COMMENTS: The veteran reported depressed mood with lack of interest and pleasure and low motivation. He reported having thoughts that life would be easier for his family if he was not there but he denied any plans or intent for suicide. He stated that he does not want his daughter to grow up without a father. He stated that he has difficulty going outside because he feels that people are watching him and he is hypervigilant in public places. He will wear sunglasses and headphones if he goes out anywhere. MEMORY ----- REMOTE MEMORY: Normal RECENT MEMORY: Normal IMMEDIATE MEMORY: Normal 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: -------------------------------------------------- PCL-5 (Clinician Administered and Scored)
STONE, WILLIAM MIKAEL CONFIDENTIAL Page 20 of 42
Criterion A: Deployments to Iraq and Afghanistan In the past month, how much were you bothered by: 0 = Not at all 1 = A little bit 2 = Moderately 3 = Quite a bit 4 = Extremely Criterion B: INTRUSION symptoms 1. Repeated, disturbing, and unwanted memories of the stressful experience? 3 He has intrusive thoughts intermittently during the day which distract him while he is at work. 2. Repeated, disturbing dreams of the stressful experience? 3 He reported a recurring nightmare and he wakes up in a cold sweat. 3. Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)? 2 He is triggered by certain smells. 4. Feeling very upset when something reminded you of the stressful experience? 2 He becomes anxious but is able to calm himself down. 5. Having strong physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating)? 2 Occasional panic attacks. Criterion C: AVOIDANCE 1. Avoiding memories, thoughts, or feelings related to the stressful experience? 2 He avoids talking about his service but attending a peer support group was helpful to him. 2. Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or situations)? 2 He avoids watching the news because he will be anxious for the rest of the day. Criterion D: Negative alterations in COGNITIONS AND MOOD 1. Trouble remembering important parts of the stressful experience? 0 2. Having strong negative beliefs about yourself, other people, or the world (for example, having thoughts such as: I am bad, there is something seriously wrong with me, no one can be trusted, the world is completely dangerous)? 2 He has difficulty trusting others and he is less sociable. 3. Blaming yourself or someone else for stressful experience or what happened after it? 0 4. Having strong negative feelings such as fear, horror, anger, guilt, or shame? 2 He is guarded and fearful. 5. Loss of interest in activities that you used to enjoy? 2 He lost interest in preferred activities such as playing soccer. He plays video games to pass the time 6. Feeling distant or cut off from other people? 3 He has not maintained friendships and he does not socialize. 7. Trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)? 2 He reported decreased pleasure in social activities. Criterion E: Alterations in AROUSAL AND REACTIVITY 1. Irritable behavior, angry outbursts, or acting aggressively? 2
STONE, WILLIAM MIKAEL CONFIDENTIAL Page 21 of 42
Verbal outbursts. 2. Taking too many risks or doing things that could cause you harm? 1 History of impulsive spending. 3. Being "superalert" or watchful or on guard? 3 He is hypervigilant in public places. 4. Feeling jumpy or easily startled? 2 He is startled by unexpected loud noises. 5. Having difficulty concentrating? 2 Difficulty concentrating because his mind wanders. 6. Trouble falling or staying asleep? 2 Four to five hours of broken sleep per night. PCL-5 Score: 39 Cluster B (items 1-5) : 12 Cluster C (items 6-7) : 4 Cluster D (items 8-14): 11 Cluster E (items 15-20): 12
Interpretive Statement: PCL-5 has a total score range of 0-80, with higher scores indicating greater PTSD symptom severity. 0-10: no or minimal symptoms reported 11-20: mild symptoms reported 21-40: moderate symptoms reported 41-60: severe symptoms reported 61-80: very severe symptoms reporte
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