Thoughts on C&P Report for Increase Anxiety/Depression/Panic

[chriscond]

I'm currently rated at 50% for Anxiety Disorder NOS. I have a few issues with some of the things he wrote because some were flat out wrong, but I don't know if I should fuss about it.

 

Is this DBQ being completed in conjunction with a VA 21-2507, C&P 
Examination
   Request?
   [X] Yes  [ ] No
   

                                  SECTION I:
                                  ----------
   1. Diagnosis
   ------------
   a. Does the Veteran now have or has he/she ever been diagnosed with a mental
      disorder(s)?
      [X] Yes  [ ] No
      
      ICD code: F41
      
      If the Veteran currently has one or more mental disorders that conform to
      DSM-5 criteria, provide all diagnoses:
      
      Mental Disorder Diagnosis #1: Generalized Anxiety Disorder
      ICD code: F41

      Mental Disorder Diagnosis #2: Major Depressivve Disorder
      ICD code: F33

      Mental Disorder Diagnosis #3: Panic Disorder
      ICD code: F41

   b. Medical diagnoses relevant to the understanding or management of the
      Mental Health Disorder (to include TBI): Per Veteran, Headaches
      

   2. 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:
            The Veteran's anxiety is secondary to Generalized Anxiety Disorder
            (GAD). Depression and feelings of guilt are secondary to Major
            Depressive Disorder (MDD). Panic Attacks are secondary to Panic
            Disorder. Symptoms of low energy, low concentration, low 
motivation,
            low sex drive, irritability and insomnia are secondary to both GAD
            and MDD.
            
   c. Does the Veteran have a diagnosed traumatic brain injury (TBI)?
      [ ] Yes  [ ] No  [X] Not shown in records reviewed
      
   3. 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?
      [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:
            GAD and MDD both appear to have a significant impact in his level 
of
            dysfunction. They are both complex, overlapping in symptoms and
            interactive in nature.
            
   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)

2. History
   ----------
   a. Relevant Social/Marital/Family history (pre-military, military, and
      post-military):
      
        The Veteran currently lives in Silverdale, Washington, with his partner
        of seven years and her their children.  He stated that his relationship
        with her was, "Rocky...I'm just hard to deal with. She's told me
        multiple times that she wants to leave."  He stated that he'd remained
        emotionally connected to his children.  He has two friends who he has
        rare contact with.  He spends his time reading, listening to music,
        watching tv and on the internet. He explained that he often spent time
        alone in his room because he was anxious and felt disconnected from
        others. He denied having problems with activities of daily living.
        
   b. Relevant Occupational and Educational history (pre-military, military, 
and
      post-military):
      
        The Veteran is currently unemployed. He most recently worked for one
        week in 2009 as a sterile processing tech.  He struggled with anxiety,
        panic attacks and depression which led to him leaving the position. He
        said, "I can become violent sometimes."  He hadn't been employed since
        then.  He said, "My mental health provider recommended me to take care
        of myself."
        
   c. Relevant Mental Health history, to include prescribed medications and
      family mental health (pre-military, military, and post-military):
      
        The Veteran has been in mental health treatment at the VA in Seattle
        since 2013. He's currently prescribed prozac, clonazepam, lithium and
        hydroxyzine.  He said he'd been diagnosed with GAD, MDD and Panic
        Disorder.  He was previously in mental health treatment at the Front
        Street Clinic in Poulsbo, Washington.
        
   d. Relevant Legal and Behavioral history (pre-military, military, and
      post-military):
      
        The Veteran reported that he'd been convicted of a misdemeanor in 2013
        after pushing a police officer. No other history of legal issues were
        reported.
        


   e. Relevant Substance abuse history (pre-military, military, and
      post-military):
      
        The Veteran reported that he most recently consumed alcohol in February
        2013.  He said he abused alcohol "off and on" since 2008.  He's been in
        substance abuse treatment in Silverdale, Washington, "for almost one
        year."  He meets criteria for Alcohol Use Disorder.
        
   f. Other, if any:
      No response provided.
      
   3. 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] 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
      [X] Inability to establish and maintain effective relationships

   4. Behavioral observations
   --------------------------
   See Remarks below.
   
   5. Other symptoms
   -----------------
   Does the Veteran have any other symptoms attributable to mental disorders
   that are not listed above?
   [ ] Yes  [X] No
   
   6. Competency
   -------------
   Is the Veteran capable of managing his or her financial affairs?
   [X] Yes  [ ] No
   
   7. Remarks (including any testing results), if any:
   ---------------------------------------------------
   Clinical Examination: The Veteran was interviewed for approximately 61
   minutes to obtain a psychosocial history, assess clinical symptoms, and
   evaluate quality of life and functional status. The examiner
   Psy.D., is a Washington state licensed clinical psychologist who is
   privileged at the VAMC, Puget Sound, to perform Mental Disorders, PTSD and
   cognitive screening C&P exams.  Limits of confidentiality for this 
assessment
   were reviewed.  It was explained that the resulting report, which includes a
   review of medical records, would be sent to regional office for 
determination
   of benefits.  The Veteran did not express any concerns about this.
   Additionally, the Veteran was informed that if he/she presented as a danger
   to him/herself or others or reported that elders or children were being
   harmed, confidentiality would be breached. 

   Clinical Measures: The Veteran completed psychological evaluations to assess
   for the presence of anxiety and mood disorders.  Specifically, the Veteran
   completed self-report measures to for PTSD (PCL-5), depression (PHQ-9), and
   alcohol use (Audit-C).  

   The PTSD Symptom Scale Interview (PSSI) was completed as a structured
   interview for PTSD and further assessment of other anxiety disorders and
   depression was completed as well. 


   RESULTS OF DIAGNOSTIC INSTRUMENTS:
   The Veteran scored  58/80 on the PCL-5, indicating significant symptoms of
   PTSD (below 38 indicates subclinical symptoms of PTSD). 

   He scored 18/27 on the PHQ-9 (indicating moderately severe depressive
   symptoms).  PHQ-9 scores from 5-9 represent mild depression, 10-14 moderate,
   15-19 moderately severe, and 20 or above severe (Kroenke, Spitzer, &
   Williams, 2001).

   The Veteran score 12/40 on the AUDIT-C, indicating alcohol use appears to be
   a concern for the Veteran at this time. 


   MENTAL STATUS

   APPEARANCE AND BEHAVIOR:  The Veteran drove to the evaluation with his
   partner.  Presented as cordial. Was casually dressed and well-groomed. Eye
   contact was good.  Hygiene and dress were adequate and appropriate on all
   accounts.  Level of activity was normal.  Veteran was cooperative and
   talkative during the interview process.  

   ORIENTATION AND CONSCIOUSNESS:  The Veteran appeared fully oriented to time,
   place, person, purpose.  

   MEMORY LOSS OR IMPAIRMENT:  The Veteran did not display any obvious signs of
   memory problems across the interview, as evidenced by his ability to track
   questions and produce response from immediate, short term, long term and
   episodic memory.   

   SPEECH:  Speech was normal in volume and pace; verbalizations were relevant,
   logical, well-organized, and coherent.  Veteran could articulate thoughts.
   At times, the Veteran was off-topic due to heightened emotions.

   THOUGHT PROCESS AND CONTENT: There was no significant impairment in
   organization of thinking or communication; thinking was goal-directed and
   focused.   

   FUND OF KNOWLEDGE AND COGNITIVE FUNCTIONING:   At least average intellectual
   abilities, as evidenced by the Veteran's use of language, fund of knowledge
   and academic achievement.

   MOOD:  Mood appeared to be anxious and irritable. 

   AFFECT:  The Veteran presented with an expansive affect which was 
appropriate
   in nature.  

   MOTIVATION AND ENERGY:  Motivation for improvement is good.

   IMPULSE CONTROL:  No impairment based on behavior during the evaluation.  

   PSYCHOSIS:  Veteran denied hallucinations and prominent delusions and did 
not
   present with any obvious signs of psychosis across the interview.

   ACTIVITIES OF DAILY LIVING AND SELF-CARE:  Based on the Veteran's report, he
   performs most basic activities of daily living, including meeting basic
   requirements for nutrition, shelter, and hygiene and grooming.  He denied
   experiencing any notable problems with ADLs.



   DIAGNOSTIC FORMULATION
   The Veteran experiences persistent anxiety in response to a wide range of
   issues in his life. He discussed that "little things" often trigger his
   anxiety. He often spends time in isolation while he feels disconnected from
   others. He struggles with low attention, low energy, insomnia and low
   motivation on a regular basis.  He's depressed on a daily basis.  He
   experiences panic attacks multiple times per week.  He also reported low sex
   drive and a fluctuating appetite. Stressors were identified as, "Chores, my
   family, being around people."  He meets criteria for Major Depressive
   Disorder, Generalized Anxiety Disorder and Panic Disorder.


   RISK ASSESSMENT
   At the time of the evaluation, the Veteran denied feeling hopelessness or
   experiencing suicidal ideation. He reported experiencing passive thoughts of
   suicide several days per week. On occasion, he experiences more intense
   thoughts of harming himself, although he denied having a plan. 


   DISCUSSION
   In summary, this is a 32-year-old male Veteran who presents for evaluation 
of
   Mental Disorder.  

   After carefully reviewing the Veteran's electronic medical records,
   psychometric data, and interviewing the Veteran, it is my opinion that the
   Veteran meets DSM-V criteria for Generalized Anxiety Disorder, Major
   Deprssive Disorder and Panic Disorder. It's believed that his current
   psychiatric symptoms are a continuation of the mental disorder that had been
   diagnosed in the past.

   The Veteran's psychiatric symptoms include persistent anxiety,
   depression,irritability, feeling emotionally empty, feeling distant from
   others, lacking drive and motivation, panic attacks, disturbance in sleep 
and
   a low sex drive.  

   These issues appear to have a moderate to severe impact in his ability to
   work a full-time job.  He often isolates while he has minimal trust in
   others.  He's likely to have difficulties working with co-workers, while


   agitation is easily triggered.  More severe symptoms, compared to a few 
years
   ago, were noted as irritability, scattered thinking and panic attacks.  It's
   believed that he's unable to adapt to mild stress in a work environment.

   For the purpose of this evaluation, the severity of the impairment is
   believed to be best classified as, "Occupational and social impairment with
   deficiencies in most areas, such as work, school, family relations, 
judgment,
   thinking and/or mood."

   The Veteran is competent for VA purposes. He is capable of managing his
   benefit payments and financial affairs in his own best interest.

------

My issues with his report: Should I leave it alone or request it to be fixed?

He said I told him my most recent alcohol use was in February 2013. No, I specifically said February of this year. Then he said I have been in alcohol treatment for 1 year currently, NO, i was in alcohol treatment in 2013. So he got those mixed up.
He said I drove to the appointment with my partner. NO-I specifically told him my mom drove me to the appointment because I cannot handle driving long distances.
Stuff about the hygiene and ADL's-NO, I specifically told him I sometimes do not want to eat or get out of bed. I also told him my girlfriend keeps track of when I shower because I'm not able to gauge how frequently I do it and she told me I've showered 3-4 times in the last 6-8 weeks.
That's about it that I can tell from first read through...I dunno how big of a deal those things are but still.
To me, at first glance, looks like he is saying that I couldn't work a full time job and probably not even a part time job. Or maybe I'm reading it wrong. I'll wait for some of you guys to chime in.

[burnedoutvet]

I honestly wouldn't even worry about anything until after the decision...you can always file a new claim...I've had times where I've had C&Ps and I didn't even have to attend because they just reviewed my evidence...I've had times where they've done C &Ps for the same issue and one examiner recorded something different from the other. 

[chriscond]

On 4/8/2018 at 6:41 AM, burnedoutvet said:

I honestly wouldn't even worry about anything until after the decision...you can always file a new claim...I've had times where I've had C&Ps and I didn't even have to attend because they just reviewed my evidence...I've had times where they've done C &Ps for the same issue and one examiner recorded something different from the other. 

Yeah, the details he messed up seem minor but still pertinent. Oh and he said he interviewed me for 61 minutes but my mom timed it and it was no longer than 25 minutes. Thanks for the reply.

[Buck52]

Not sure what increase you may get but based off this c&p exam I would say you may get a 70% increase

here is the general formula rating criteria for PTSD.

 

General Rating Formula for Mental Disorders

	Rating
Total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name.	100
Occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships.	70
Occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships.	50
Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events).	30
Occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication.	10
A mental condition has been formally diagnosed, but symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication.	0

 

 

[Vync]

In my opinion, it looks like you might qualify for an increase to a minimum of 70%

 

Quote

3. 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

and...

Quote

3. 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] 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
      [X] Inability to establish and maintain effective relationships

 

 

§4.130   Schedule of ratings—Mental disorders. 

Quote

General Rating Formula for Mental Disorders

	Rating
Total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name.	100
Occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships.	70
Occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships.	50
Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events).	30
Occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication.	10
A mental condition has been formally diagnosed, but symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication.	0

 

[chriscond]

Thanks for the reply guys. I had a C&P done by my Prviate provider and they checked a few of the boxes in the 100% category and put a GAF of 32 (i know they dont use those anymore). She also said I wouldn't be able to pursue work.

From what I gathered from the VAs doctor report is that I wouldn't be able to work either. I re-read it today and him staying "he would be unable to adapt to mild stress in a work environment" seems like a pretty big statement to make.

I agree with the 70% increase at the minimum with maybe a slight chance of 100% (if they base it on the DBQ's AND my treatment notes). 

I'll have to respond back when I get a decision. Hopefully it's sometime this month.

[Vync]

The GAF scores used to be used by the VA, but when the new DSM-V was released, they kind of did away with them. Some docs still like to note them. If you ever get any printouts of VA appointment, it might even say "new GAF required", but they may have taken that out already.

The way the VA reads the MH criteria exams is a bit weird due to all of the options, and's, and or's.

"Occupational and Social Impairment" tends to be the easiest gauge of one's disability picture, but you are right that they have to look at the big picture based on symptoms and other factors.

Because you are unemployed, a 100% rating might be possible if you fit the picture of "Total Social Occupational and Impairment".

When veterans are no longer able to work, many may opt to apply for SSDI to supplement their income. However, I noticed you indicated not having a job for about 8 or 9 years. I'm not completely certain, but there might be a limitation in how long you can apply. Other veterans here are more knowledgeable about SSDI. I thought I might recommend that as a possible option for you.

Worst case, if you win an increase to 70%, you could always file for IU, which would pay like 100% and you could appeal or request an increase again.

I hope you get good news later this month! Good luck!