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
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.
Question
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.
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Vync
In my opinion, it looks like you might qualify for an increase to a minimum of 70% and... §4.130 Schedule of ratings—Mental disorders.
chriscond
Just to clarify some things, since a few of the responses have mentioned it. I am already receiving SSDI based SOLELY on my S/C anxiety/depressive disorder. I've been receiving SSDI since 2010. Actual
Berta
"The VA is aware of my SSDI award." "I am already receiving SSDI based SOLELY on my S/C anxiety/depressive disorder. I've been receiving SSDI since 2010. " If they were aware of it when the
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