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PSTD/MST Claim with Conflicting VA Feedback


Question

This post is in regards to a follow up visit with a VA psychologist.  I will include the entire VA notes from the two separate visits at VA within two weeks of each other .I was scheduled for an appointment with a VA psychologist after my C and P exam and the below are her results, which seems to conflict the C and P examiner.  In addition, I am scheduled to meet with a psychiatrist and therapist at VA  for counseling and prescription of meds.  Any feedback would be great.

 

Second Visit with VA Psychologist Results:

Military History

Branch (years of service): MST: yes
 

MEASUREMENT BASED CARE:
PHQ-9: 19 (moderate)
GAD-7: 16 (severe)
PCL-5:
AUDIT-C: 5 (above threshold)

 

DIAGNOSTIC IMPRESSIONS:
Anxiety Disorder, unsp
MDD, recurrent, moderate

 

Depression Monitoring (PHQ-9) 2017:
Depression Screen:
PHQ9 Screening
PHQ-9
A PHQ-9 screen was performed. The score was 19 which is suggestive
of moderately severe depression.

 

PTSD Screening:
PTSD Screen:
PTSD Screening
PC PTSD
A PTSD screening test (PC-PTSD) was positive (score=4).

 

+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

 

C and P Exam Notes from VA Clinical Psychologist

 

SECTION I:
----------
1. Diagnostic Summary
---------------------
Does the Veteran have a diagnosis of PTSD that conforms to DSM-5 criteria
based on today's evaluation?
[ ] Yes [X] No
If no diagnosis of PTSD, check all that apply:
[X] Veteran's symptoms do not meet the diagnostic criteria for PTSD under
DSM-5 criteria
[X] Veteran has another Mental Disorder diagnosis. Continue to complete
this Questionnaire and/or the Eating Disorder Questionnaire:
2. Current Diagnoses
--------------------
a. Mental Disorder Diagnosis #1: UNSPECIFIED DEPRESSIVE DISORDER
b. Medical diagnoses relevant to the understanding or management of the
Mental Health Disorder (to include TBI): SEE MEDICAL CHART
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 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 medication

TYPE OF MEDICAL OPINION REQUESTED: Military Sexual Trauma (MST)
OPINION: Military Sexual Trauma (MST)
This examination is being conducted to assist with determining whether the
Veteran experienced an in-service personal assault stressor related to
military sexual trauma (MST) that has resulted in a current PTSD diagnosis.
Please review the claims file and state in your report that it was reviewed.
In your review of the claims file, please pay special attention to signs,
events, or circumstances that may represent markers for the MST stressor
described by the Veteran. Your review is not limited to the evidence
identified on this request form, or tabbed in the claims folder. If
additional testing is required, please obtain it prior to rendering your
opinion.
Based upon your review of the evidence, please provide a medical opinion as
to whether the MST stressor event described by the Veteran is at least as
likely as not (50 percent or greater probability) supported by and consistent
with the in-service marker evidence. Please provide a rationale for the
opinion and list the marker evidence used to arrive at your decision.
NO MARKERS IDENTIFIED. MEDICAL OPINION DOES NOT APPEAR WARRANTED.


In addition:
1. IF YOUR EXAMINATION DETERMINES THE VETERAN HAS A CURRENT DIAGNOSIS OF
PTSD, please provide an opinion as to whether the current PTSD diagnosis is
at least as likely as not (50 percent or greater probability) caused by or a
result of the in-service MST-related marker(s), and provide a rationale.
Please note that only PTSD can be service connected based on circumstantial
marker evidence (38 CFR 3.304(f) (5)).
VETERAN'S SYMPTOMS APPEAR TO BE BEST ACCOUNTED FOR BY A DIAGNOSIS OF
UNSPECIFIED DEPRESSIVE DISORDER. MEDICAL OPINION DOES NOT APPEAR WARRANTED.

2. IF YOUR EXAMINATION DETERMINES THAT, IN ADDITION TO PTSD, THE VETERAN HAS
ADDITIONAL MENTAL DISORDERS, please state whether the additional mental
disorders are at least as likely as not (50 percent or greater probability)
secondary to the PTSD, and provide a rationale. For each mental disorder

MEDICAL OPINION DOES NOT APPEAR WARRANTED.


3. IF YOUR EXAMINATION DETERMINES THE VETERAN DOES NOT HAVE PTSD, BUT HAS A
DIFFERENT MENTAL DISORDER(S), please review the service treatment records
(STRs) and service personnel records for in-service direct evidence. Direct
evidence is clear, undisputable proof of an event, injury, or disease. Such
evidence includes, but is not limited to, mental health treatment, mental
health symptoms, or a mental health diagnosis. If direct evidence exists in
the STRs or service personnel records, please provide an opinion as to
whether the mental disorder(s) diagnosed on examination is at least as likely
as not (50 percent or greater probability) caused by or a result of the
direct evidence noted in service. Please provide a rationale for the opinion
and list the evidence used to arrive at your decision. (38 CFR 3.303).


NO DIRECT EVIDENCE LOCATED. OPINION DOES NOT APPEAR WARRANTED.

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It looks like you were examined by a doctor that disagrees with your treatment.  Keep going to your exams at the VA and build a history of treatment.  As stated in my remand a tie goes to the runner and this looks like you have two different opinions or a tie.  A history of treatment should override a C&P.

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The above medical treatment is unlikely to get you Service connected.  Reason:  There is no nexus.  If there was a nexus elsewhere in your medical records that "may" suffice for sc.  The doc needs to state that your depression is at least as likely as not due to an event(s) which occurred in military service to get SC for it.  This doc did not do so.  

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