C & P for ptsd increase 03/12/2018

[Togore101]

Hello everyone I am new to the site. And I recent submit a the dbq for an increase for my PTSD and I trying to understand it but im just not getting it. So I figured would ask you all. Below is what the examiner put in the record.

 

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

ICD Code: F43.1

2. Current Diagnoses

--------------------

a. Mental Disorder Diagnosis #1: PTSD

ICD Code: F43.1

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 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?

[ ] 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

Evidence Comments:

MENTAL HEALTH OUTPATIENT FOLLOW UP NOTE [excerpts]

DATE OF NOTE: MAR 05, 2018

AUTHOR: ========,NP NURSE PRACTITIONER

CHIEF COMPLAINT: "same old same old"

INTERVAL HISTORY:

Veteran is here for 6 week follow up for PTSD, Alcohol Use Disorder,

unspecified, episodic. At last appointment, low dose venlafaxine was

added, aripiprazole, prazosin, and melatonin were continued.

He reports symptoms are about the same. His wife is pregnant with twins,

so he is trying to minimize arguments at home. He worries he will not be

able to connect with the babies, because he struggled so much with his

daughter and points to her persistence as the reason they are close now.

He see no change in sleep, remains irritable, and more hypervigilant due

To recent car break ins on his street. He has cut down on drinking, and

denies any binges since last appointment. He continues to have fleeting

SI, but denies intent. He often has thoughts of hurting others, but

strongly denies acting on the thoughts. No recent hallucinations. He

does talk to himself when he is trying to work something out, but denies

hearing voices other than his own. It can be embarrassing as coworkers and wife

have caught him.

ASSESSMENT AND TREATMENT PLAN GOALS:

DSM 5 Diagnostic Impression

PTSD

Alcohol Use Disorder, Unspecified, episodic

Goals:

1. Decrease irritability and anger- does not interfere with home or work

life more than one time per month, ongoing, improving

2. Improve feeling of connection with others- enjoying and developing

relationships, ongoing, no change

3. Decrease avoidance of social situations/crowds- can tolerate Wal Mart,

enjoy outings with family, ongoing, no change

4. Improve sleep- no difficulty falling asleep, sleep 6 to 8 hours

nightly, ongoing, worsening

PLAN AND PROGRESS TOWARDS TREATMENT PLAN GOALS:

reviewed records and discussed options

- increasing venlafaxine to 75 mg

- continuing aripiprazole, prazosin, and melatonin

- suggested individual supportive counseling at the Vet Center after Dr.

Bhatia leaves.

- monitoring labs at next appointment

- Will continue to follow closely. RTC 6 weeks/PRN

2. Recent History (since prior exam)

------------------------------------

a. Relevant Social/Marital/Family history:

Last C&P PTSD DBQ May 2016

Lives in Moncks Corner, SC with wife of 9 years and daughter age 4.

Daily routine: Lay down for bed 2100. Will fall asleep 2300. Wake

frequently. "I have to do certain things to calm down. I need my

gun next to me. I have to check the house make sure its locked. Make sure

the alarm is on. If I hear something, it wakes me right up and I have

to check it out." +Nightmares, night sweats. "Sometimes

I'm swinging and yelling and talking in my sleep, so my wife leaves for a different

room. I wake up and she's not there and it freaks me out."

Prescribed

melatonin for sleep, prazosin for nightmares. Abilify for PTSD.

Diagnosed sleep apnea by sleep study in 2013, prescribed CPAP and is

compliant.

Relationship with wife: "We almost got divorced a few times. She

didn't understand what was going on. She started reading up on it. The whole

reason I went to mental health was because of her."

Relationship with daughter: "She is scared of me. She has seen me

Snap a few times. She is on guard. She doesn't know if I'm going

to be up or down. She is my heart. She is the only thing that makes me feel

normal." Will watch cartoons and read books together.

Hobbies: play basketball, go to gym "but now I just sit in the

House watch TV or just in the room." Likes anime.

Support: father "he's been with me through everything."

And is Veteran

too, wife "but there is a wall there where I don't open

up."

b. Relevant Occupational and Educational history:

Working for passport services for 3 years. "Its rough at times.

There's a lot of people in there. They had to move my seat because I'm

too jumpy. They moved it so I'm not around a lot of people. It is hard

to focus. I have to use sticky notes. They have been pretty supportive.

I've had good supervisors." Was counselled about days missing

for work; "I had a blow up at my co-workers so they spoke to me about

that." Miss 2-3 days per month. "When I get to work, I drive around the

Building and if I see something I don't like, I just go home."

Military history: E4, MP, Separated 2014, Honorable, Served about 6

years.

c. Relevant Mental Health history, to include prescribed medications and

family mental health:

Mental health treatment with prescriber and therapist. No history of

hospitalizations. Was in group therapy "but I didn't like it."

d. Relevant Legal and Behavioral history:

"When I was in Japan I got us into trouble because of my alcohol

abuse. I got into a car accident and hit 3 cars." Was sent to ADAP for

anger and PTSD. A month ago got into a physical altercation with sister's

boyfriend "I laid hands on him. So then I went to a hotel room and stayed there and

then I went on a drink binge."

e. Relevant Substance abuse history:

Alcohol - "I abused it really bad. My PCM said it was affecting

My liver." Was drinking4-5 25 oz beers, drink a bottle of liquor over

The weekend. Now will drink 1-2 beers.

Tobacco - 2-3/day

Denies other substances.

f. Other, if any:

Current reported symptoms:

Anger: "I black out and become very violent. I knock TVs off

walls. My wife was ready to leave me."

Triggers: "foggy day and rain." "Ignorant and stupid

people."

Social avoidance.

"If a car is behind me too long, I start to think he is following

me. There is a particular truck that I know and he gets too close to me. I

got sick of it and one day I followed him home. I didn't do

anything, but I blacked out mad. I knew I needed help."

Flashbacks - "I was shopping with my wife, and this guy had a

turban on his head and I thought I was back there. Its constant, its all the

time."

Hygiene - "My wife got on my because I went a week without washing

And I didn't even realize it."

Suicide - "I thought about driving into traffic at the light. One

Time I sped up and got on railroad tracks when a train was coming. I

thought, what am I doing? I went into store parking lot." Reports

this occurred 2 weeks ago. "I keep a picture of my daughter in the car

to keep me from [doing it]."

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] Dissociative reactions (e.g., flashbacks) in which the

individual feels or acts as if the traumatic event(s)

were recurring. (Such reactions may occur on a continuum,

with the most extreme expression being a complete loss of

awareness of present surroundings).

[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] Reckless or self-destructive behavior.

[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] Mild memory loss, such as forgetting names, directions or recent

events

[X] Flattened affect

[X] Impaired judgment

[X] Disturbances of motivation and mood

[X] Difficulty in adapting to stressful circumstances, including work or

a

worklike setting

[X] Suicidal ideation

[X] Impaired impulse control, such as unprovoked irritability with

periods

of violence

[X] Neglect of personal appearance and hygiene

5. Behavioral observations

--------------------------

Veteran was open and forthright with no evidence of exaggeration or

feigning symptoms. Affect blunted. Minimal eye contact. Speech regular

rate, tone, volume. Thought process linear, logical, goal directed.

Thought content absent for delusions, hallucinations, paranoia or HI.

Endorses SI with no active plan, but drove car onto train tracks last

week. Discussed safety, crisis line, Veteran has MHC appointment next

week. Veteran reports safety to return home today.

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 score 72, indicating probable diagnosis of PTSD.

Veteran continues to meet criteria for PTSD. He reports social

withdrawal, sleep problems, memory problems, irritability, anger that is both verbal

and physical, suicidal thoughts. He has work accommodations because of

his PTSD symptoms. He misses several days of work a month because of his

symptoms.

[Buck52]

I would think you should get a 100% S.C. Rating. 

or a 70% and infer to TDIU if this  disability keeps you from finding marginal employment of any kind including sedentary work.

jmo

[Grumpbox]

@Togore101 Tell us a little more about your background, job (MOS), length of service, discharge type, previous/current diagnosis/illness/injuries???

I am with @Buck52 so far on what I've read, but might could offer some insight if I knew the answers to the questions above....

 

Standing by....

[Togore101]

I was in the Air Force six years. my MOS MP (Security Forces). Depolyed Iraq 2010. My current rating is 90% s/c. Honorable discharge. Going for increase in combat related PTSD. Injuries are below

nequal leg length (acquired)	0%	Service Connected		06/04/2014
post traumatic stress disorder with mood disorder NOS		Active Psychosis/GW Mental
left hip strain, claimed as nonallopathic lesions of pelvic region	10%	Service Connected		06/04/2014
congenital foot deformity condition		Not Service Connected
bilateral hearing loss condition		Not Service Connected
plantar fasciitis, bilateral feet, claimed as plantar fasciitis, left foot	10%	Service Connected		06/04/2014
scar, painful, residuals, right side of nose, claimed as laceration to face condition	10%	Service Connected		06/04/2014
right wrist strain, claimed as right wrist pain	10%	Service Connected		06/04/2014
scar, facial	0%	Service Connected		06/04/2014
intervertebral disc syndrome (IVDS), claimed as low back degenerative disk disorder, nonallopathic lesions of lumbar region and sacral regions	20%	Service Connected		06/04/2014
pseudofolliculitis barbae	0%	Service Connected		06/04/2014
obstructive sleep apnea (OSA), claimed as sleep apnea with CPAP	50%	Service Connected		06/04/2014
chipped toe and toe hallux limitus conditions		Not Service Connected
PTSD (post traumatic stress disorder)	50%	Service Connected	PTSD - Combat	07/06/2015
left wrist strain	10%	Service Connected		06/04/2014
radiculopathy, involvement of the sciatic nerve, left lower extremity	20%	Service Connected		06/04/2014
radiculopathy, involvement of the sciatic nerve, right lower extremity	10%	Service Connected		06/04/2014
tinnitus	10%	Service Connected		06/04/2014

[Guest L]

@Togore101 I am not seeing 100- PTSD in my opinion....due to the following observations in the DBQ: You are handling day to day activities well - working, taking care of finances, interacting with daughter... spouse is pregnant...so you are having a close intimate relationship. 

Just my thought:

" Goals:

1. Decrease irritability and anger- does not interfere with home or work

life more than one time per month, ongoing, improving

2. Improve feeling of connection with others- enjoying and developing

relationships, ongoing, no change

3. Decrease avoidance of social situations/crowds- can tolerate Wal Mart,

enjoy outings with family, ongoing, no change

4. Improve sleep- no difficulty falling asleep, sleep 6 to 8 hours

nightly, ongoing, worsening

[Grumpbox]

@Togore101 Thanks for replying with everything!  Both @L and Buck add value to this conversation and estimate of their side for your award.  Likewise, one will never know how the VA makes its final determination.  I've seen more extreme cases than this get denied, and I've seen lesser cases awarded 100% P&T.  It ALL DEPENDS ON THE RATING OFFICIAL. 

As L points out, you've got some things against you that the rating official may use to deny your claim.  Alternatively, the suicidal tendencies point to the more extreme.  One thing I will say that could hurt the approval of this claim is your current employment status.  I am not saying you should quit work.  I am just saying that the VA looks at this as one that can maintain a certain lifestyle. VA's Rationale: if he can work - then why should he get an increase in an award?  Meaning: No sign of his condition worsening.

Also, keep in mind, now that you've open the Pandora's Box for an increase, the VA will snoop in every condition you have and could schedule other exams for these conditions.  Its a slipper-slope you've got to navigate for an increase. Really watch your drinking.  Don't ever let it cause you a domestic or violation of other laws.  You do that and the VA will more than likely make life rough on you.  Be sure and stay in treatment and stay with your prescribed meds.  If you're not seeking help, the VA sees it has: He doesn't need help!

You've got a little wait in front of you now for the outcome of this claim.  What's done is done, so try and make the best of things until the VA prompts you for a decision.  After that, you''ll know what steps to take next.  No sense in worrying over things you have no control over.  I've been there and drove myself (and family) crazy!  A few elders on here finally convinced me to "LET IT GO" and occupy myself otherwise until the results were in for my decision.  My best advice for now: Let go and let higher powers dictate what is meant to be.  

 

GB

[Togore101]

I read over it several times and I seen were they could deny the claim for an increase but im hoping for the best. @Grumpbox I definitely been trying not to pay any attention to it right now but something also tells me to look LOL, but i have gotten better with it. @L @Buck52 @Grumpbox thank you all for taking a look and i appreciate the feedback. I will let you guys know the outcome when i get it. Eben saying it will be between May and July. You all have a good day.