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Question
tylerb333
Does this sound or look right to anyone? Denied TDIU...
=========================================================================
Date/Time: 20 Jun 2017 @ 0800
Note Title: C&P MENTAL DISORDER
Location: Chalmers P Wylie VA Outpatnt
Signed By: HOULE,ALLISON C
Co-signed By: HOULE,ALLISON C
Date/Time Signed: 20 Jun 2017 @ 1641
-------------------------------------------------------------------------
LOCAL TITLE: C&P MENTAL DISORDER
STANDARD TITLE: MENTAL HEALTH C & P EXAMINATION CONSULT
DATE OF NOTE: JUN 20, 2017@08:00 ENTRY DATE: JUN 20, 2017@16:41:06
AUTHOR: HOULE,ALLISON C EXP COSIGNER:
URGENCY: STATUS: COMPLETED
*** C&P MENTAL DISORDER Has ADDENDA ***
Review Post Traumatic Stress Disorder (PTSD)
Disability Benefits Questionnaire
Name of patient/Veteran: xxxxxxx
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
2. Current Diagnoses
--------------------
a. Mental Disorder Diagnosis #1: Posttraumatic Stress Disorder
ICD Code: F43.10
Mental Disorder Diagnosis #2: Opioid Use Disorder, Severe, In early
remission, on maintenance therapy
ICD Code: F11.20
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?
[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 are primarily related to his PTSD
since he has not used substances in more than six months.
c. Does the Veteran have a diagnosed traumatic brain injury (TBI)?
[ ] Yes [X] No [ ] 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: The veteran's
impairment is related to his PTSD.
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:
The veteran's electronic medical records (CPRS & VistAWeb) and military
records (VBMS) were reviewed.
The veteran was referred for a compensation and pension examination. The
veteran was informed verbally of the nature and purpose of the examination
and confidentiality limits. He appeared to have a basic understanding of
the purpose of the examination and confidentiality limits. He was provided
with a chance to ask questions about the evaluation procedures. All
questions were answered to reasonable satisfaction or referred to other
resources. He was informed that this examiner is not his treating
clinician
or the legal determiner of compensation or pension benefits. Instead, he
was informed that this examiner is an independent provider of clinical
information and expertise to assist those who review and make legal
compensation and pension claim decisions and would not be participating in
her healthcare. He was given information about the Veteran's 24-hour
Crisis
Line. The veteran indicated understanding of these terms and explicitly
and
freely consented to the evaluation. The judgments of symptoms and opinions
in this evaluation report are offered to a reasonable degree of
psychological certainty and are only based upon the information available
at the time of the evaluation.
This report was dictated using Dragon Naturally Speaking dictation
software. The report has been proofread; however, there still may be some
typographical errors due to the nature of the dictation software.
The veteran began participating in recovery services at the VA in May
2017.
His last group note was dated 5/31/17.
A note dated 2/26/17, by Dr. Laurie Berger, indicates that the veteran
began therapy at the Vet Center in October 2016. He attends therapy on a
weekly basis. He attended six sessions with Dr. Berger when this note was
written.
The veteran was initially evaluated for a C&P exam by Dr. Janine Schroeder
on 3/22/17.
2. Recent History (since prior exam)
------------------------------------
a. Relevant Social/Marital/Family history:
The veteran was born and raised in xxxx. He was raised by
his
mother and father until they divorced when he was 7 years old. The
veteran then lived with his mother until he was 14 years old. The
veteran's mother remarried when he was 11 years old and he reported
that he did not get along well with his stepfather. He went to live
with his father at 14 years of age due to being disrespectful towards
his stepfather. The veteran has one older sister and one younger
brother. The veteran's father did not remarry, but he was in a
relationship with the same woman for 20 years. He reported physical
abuse by his father throughout his adolescent years. He recalled one
incident where he got a black eye after his father hit him. He denied
any Child Protective Services involvement. The veteran describes his
father as emotionally absent. His father died in 2007 from a heart
attack.
The veteran is a 36-year-old, divorced male. He was married in 2001
for
five years and divorced in 2006. The veteran reported that they
divorced due to his drug use. They have a 1X-year-old daughter
together. His ex-wife and daughter live in xxxxx. He
maintained some contact with his daughter, but has not seen her in
several years. The veteran reported that he was involved in a
relationship for a few years following his divorce. They are no longer
in a relationship, but are close friends.
The veteran reported that he has spends time with three friends from
high school. The veteran stated that he enjoys gardening.
b. Relevant Occupational and Educational history:
The veteran reported that he did not enjoy school and did not want to
do the work. He frequently skipped school to go skating. He stated that
he would "have a few beers and smoked pot" when he skipped school. He
reported being suspended several times for truancy, fighting, and
disrespect towards teachers. He was never held back a grade. He was
expelled his junior year of high school due to nonattendance. He
earned
his GED in 1997.
The veteran worked for his father from 1997 until 1999 doing ironwork.
The veteran enlisted in the Navy in October 1999. He reported several
disciplinary issues while in the service related to going AWOL, being
late, and underage drinking. He reported that the sexual assault
occurred in the summer of 2001. The veteran received a general under
honorable conditions discharge in September 2001 for misconduct.
The veteran worked in Virginia Beach beginning in September 2001 doing
ironwork. He worked at a company for one year and was fired due to not
showing up for work and using alcohol and drugs. He then worked for
Roofing Services Incorporated from September 2002 until August 2003.
The veteran then earned his tanker men certification, z card, and AB
certification to work on tugboats. He worked on boats from September
2003 until March 2005. At that time his wife left him and he moved
back
to Ohio to be closer to his family. The veteran continued working on
boats in Ohio until the summer of 2005 when he got fired. The veteran
was incarcerated from 2006 until 2016. After his release from prison,
he worked with friends doing landscaping and painting. He began
working
at ABS Money Systems in January 2017, a company that his mother owns.
The veteran reported that he was working 30-40 hours per week for the
first two months. He stated that his hours have declined significantly
since March and he is currently working 5-6 hours per week. He stated
that his work has declined due to his mental health symptoms. However,
according to the initial C & P exam, "he is unable to do a lot for her
because she works serving ATM machines in banks and with his record he
isn't allowed to work in banks." He also reported that his employment
since the military has been "short-lived due to his drug and alcohol
use."
c. Relevant Mental Health history, to include prescribed medications and
family mental health:
The veteran reported that he was diagnosed with ADHD during childhood
and received treatment. The veteran reported a suicide attempt in 2001
after he was discharged from the military. He began attending
treatment
at the Vet Center in October 2016. He reported that he attends
individual therapy twice per week with Dr. Berger. The veteran
described his mood as "anxious, paranoid, and depressed." He stated
that he feels as though he "can't get a break." He reported having
passive thoughts of suicide, but stated that he does not have a plan
or
intention to kill himself. He stated "I couldn't do that to my
family."
He stated that he has had difficulty dealing with his emotions since
he
is no longer using substances and does not have an escape. He stated
"I
don't have the coping skills." He described having difficulty sleeping
and stated that he does not sleep every night. He stated that he is
not
feel safe in his bed.
d. Relevant Legal and Behavioral history:
The veteran reported that he had several misdemeanor offenses as a
juvenile, including truancy, driving without a license, and theft. He
reported that he was arrested for selling drugs at 18 years of age and
was placed on probation for one year. According to the previous exam,
he was arrested numerous times from June 1998 to September 1999. The
veteran was convicted of armed robbery for robbing three pharmacies
with a weapon. He served a 10-year prison sentence beginning in
October
2006 and was released in September 2016. He is currently on parole for
five years.
e. Relevant Substance abuse history:
The veteran reported that he first drank alcohol at 10 years of age.
He
began regularly drinking alcohol during high school. He began smoking
marijuana at 15 years of age on the weekends. He also experimented
with
mushrooms and pain/anxiety medication that he took from his father.
The
veteran's alcohol use increased significantly while in the military.
He
denied using any drugs while in the service. After his discharge from
the service, he continued using alcohol and marijuana. In 2002, he
began using narcotic pain medication. He also began using heroin and
reported that he eventually used heroin intravenously. The veteran
reported using substances throughout his time in prison. He reported
that he has been clean from drugs and alcohol since October 2016. He
has maintained sobriety using Suboxone. He currently attends AA
meetings approximately once per week. He attends substance abuse
groups
at the VA twice per month.
f. Other, if any:
No response provided.
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)
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
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).
Criterion
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, 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] 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] 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] Disturbances of motivation and mood
[X] Difficulty in establishing and maintaining effective work and social
relationships
5. Behavioral observations
--------------------------
The veteran arrived 10 minutes late for his appointment and was pleasant
upon meeting. The veteran was oriented to person, place, situation, and
time. His grooming and hygiene were adequate. He made appropriate eye
contact and presented with a depressed mood with a congruent affect. His
speech was within normal limits for tone, volume, and rate. His thoughts
were logical, linear, and goal-directed. He did not evidence any
psychotic
symptoms, including responding to auditory or visual hallucinations and
delusional beliefs.
On a brief mental status exam he was able to freely recall two of three
words presented after a brief delay. He was able to recall six digits
forward and three digits backward. He was able to complete a serial seven
subtraction task with no errors to seven places. He was able to spell the
word WORLD forwards and backwards. He was able to complete a two-digit
addition and subtraction tasks. He was able to compare an apple and
banana
and was able to reason abstractly when comparing a poem and a statue. His
response to the proverb "don't cry over spilled milk" was good. He was
not
able to provide a response to the proverb "people in glass houses should
not throw stones."
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:
---------------------------------------------------
The veteran was administered a psychological measurement that is useful
for interpreting the veracity of other data provided by an examinee
during
a psychological or neuropsychological examination. This assessment can
assist in evaluating and making a clinical opinion regarding the veracity
of an examinee's purported symptoms. Research has determined that this
tool is a useful instrument to administer in order to screen for possible
feigning of PTSD symptoms. The following results should be interpreted in
light of the fact that the measurement that was chosen is a screening
tool
and not designed as a definitive measure of whether or not an individual
is feigning mental illness. The Veteran's total score was not elevated
beyond the cut-off score. Therefore, his PTSD symptoms are considered to
be credible.
The veteran was administered the Minnesota Multiphasic Personality
Instrument-2-Restructred Form (MMPI-2-RF), which is a self-report
psychological assessment used to identify a variety of psychological
syndromes. The veteran was provided a quiet, private room to complete the
testing. It appears the veteran understood the items and responded to the
items in a consistent manner. The veteran over-reported psychological
dysfunction, which is evidenced by a considerably larger than average
number of infrequent responses. The veteran also possibly overreported
symptoms associated with non-credible memory complaints. Although there
is
evidence of over reporting of symptoms, the profile is considered valid
and will be interpreted.
Overall, the veteran endorsed considerable emotional distress that is
likely perceived as a crisis. The veteran reported feeling sad and
dissatisfied with his currently circumstances. He reported a lack of
positive emotional experiences, a lack of energy, and a lack of interest
in activities. He also reported experiencing various negative emotional
experiences including anxiety, anger, and fear. The veteran also reported
a significant history of antisocial behavior. This behavior includes
involvement with the criminal justice system, difficulty with authority
figures, conflictual interpersonal relationships, impulsivity, juvenile
delinquency, and substance abuse. The veteran also endorsed various
unusual thought and perceptual processes.
The veteran endorsed a diffuse pattern of cognitive difficulties
including
memory complaints. He also reported past suicidal ideation and feelings
of
helplessness. The veteran endorsed feelings of anxiety, being anger
prone,
and experiencing multiple fears that restrict his activity inside and
outside of the home. He also reported being unassertive and shy. The
veteran endorsed not enjoying social events and avoiding social
situations. He also reported disliking being around people. On a scale of
personality pathology, the veteran endorsed being self-critical and
guilt-prone. He also endorsed being pessimistic and feeling depressed.
The veteran is currently diagnosed with Posttraumatic Stress Disorder and
Opioid Use Disorder, Severe, In early remission, on maintenance therapy.
The veteran currently lives alone and is not involved in a romantic
relationship. He maintains phone contact with his daughter. He has a
close
relationship with his mother, sister, and two friends. He is currently
working for his mother's company. He reported experiencing symptoms of
PTSD. He is attempting to cope with his emotions without the use of
drugs.
The veteran has been employed numerous times and has been fired for
tardiness or alcohol and drug use. He is currently working 5-6 hours per
week for his mother's company. According to the previous C&P exam, he is
not able to work many hours due to not being permitted to work inside of
a
bank due to his felony record. The veteran reported that he was "working"
during his 10 years in prison selling drugs. He denied having any
difficulties while in prison. The veteran is capable of following
instructions and performing simple tasks. He is able to concentrate on a
simple task and respond appropriately to coworkers and supervisors.
/es/ ALLISON C HOULE, PHD
C&P Psychologist
Signed: 06/20/2017 16:41
06/20/2017 ADDENDUM STATUS: COMPLETED
The veteran presented for his appointment. The report from the C&P Exam was
completed in Capri by Allison Houle, PhD; procedure code 99456 and 96101.
/es/ ALLISON C HOULE, PHD
C&P Psychologist
Signed: 06/20/2017 16:42
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