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: F43.10
2. Current Diagnoses
--------------------
a. Mental Disorder Diagnosis #1: Antisocial personality disorder
ICD Code: F60.2
Mental Disorder Diagnosis #2: Opioid use disorder
ICD Code: F11.20
Mental Disorder Diagnosis #3: PTSD
ICD Code: F43.10
b. Medical diagnoses relevant to the understanding or management
of the
Mental Health Disorder (to include TBI): Deferred to medical
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: Antisocial personality disorder is responsible
for
contentious interpersonal relationships including
threats, aggression,
assault; failure to accept responsibility; violation of
social norms
and law; impulsive decisions and behaviors; and affective
instability.
In the symptom list below antisocial personality disorder
is
responsible for impaired judgment, disturbance of
motivation and mood,
difficulty establishing and maintaining effective
social/work
relationships, difficulty adapting to stressful
circumstances, and
impaired impulse control.
Opioid use disorder has been in institutional remission
June 2018, and
is not at this time contributing to the symptom picture.
Substance
use is well known to have deleterious effects on mood,
cognition, and
behavior. When active, however, these symptoms likely
take a
predominant role.
PTSD is responsible for the remaining symptoms below,
which include
depressed mood, chronic sleep impairment, and flat
affect.
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 occasional
decrease in work
efficiency and intermittent periods of inability to
perform
occupational tasks, although generally functioning
satisfactorily,
with normal routine behavior, self-care and conversation
b. For the indicated occupational and social impairment, is it
possible to
differentiate which impairment is caused by each mental
disorder?
[X] Yes [ ] No [ ] Not Applicable (N/A)
If yes, list which occupational and social impairment is
attributable
to each diagnosis: As noted above regarding symptoms,
Antisocial
personality disorder is primary and PTSD is secondary.
c. If a diagnosis of TBI exists, is it possible to differentiate
which
occupational and social impairment indicated above is caused
by the TBI?
[ ] Yes [ ] No [X] Not Applicable (N/A)
SECTION II:
-----------
Clinical Findings:
------------------
1. Evidence Review
------------------
Evidence reviewed (check all that apply):
[X] VA e-folder
[X] CPRS
2. Recent History (since prior exam)
------------------------------------
a. Relevant social/marital/family history:
The veteran last completed a PTSD review DBQ 06/20/17, and
he reported
that since that exam he has moved from Columbus to
Marysville. The
veteran currently is in residential programming at
Chillicothe VA,
hoping for placement in the DOM.
The veteran denied his family situation since last exam.
Socially, the veteran said he is getting along well with
other
residents here. His girlfriend and mother visited him
here. He said
he is made some acquaintances in the programming as well
as a couple
friends.
b. Relevant occupational and educational history:
The veteran denied changes in education since last exam.
He has
completed a GED and some college, and has a license to
work with fuel
and chemicals for shipping.
The veteran denied employment since May 2017. He worked
in landscaping
prior and occasionally for his mother after that. His
mother's
business is sales of retail and bank machines. He said
his mother
arranged his hours to suit him.
c. Relevant mental health history, to include prescribed
medications and
family mental health:
The veteran denied pre-military and military mental health
treatment.
Specifically, he denied a history of hospitalization,
suicide attempt,
outpatient therapy, and prescription of psychotropic
medications prior
to about 2001. CPRS and VBMS were reviewed with the
following relevant
mental health entries.
06/20/17: PTSD review DBQ. MSE: Mood and affect
depressed, otherwise
normal. Examiner opined significant impairment.
06/14/18: Medical certificate. The veteran requested
admission due to
depression, suicidal ideation, overdose attempt on
Seroquel and alcohol
last evening, and hearing voices telling him to kill
himself every day.
UDS was positive for oxycodone, Suboxone, and
cannabinoids. DX:
Cocaine dependence; alcohol abuse; cannabis dependence;
opioid
dependence; PTSD.
06/19/18: Medical certificate. Veteran seen for change in
programming.
MSE: Normal except for dysphoric affect.
d. Relevant legal and behavioral histor
y:
The veteran denied arrest since last exam, however, he has
3 years and
3 months left on parole. As a juvenile, the veteran was
arrested for
trespassing, DUI, domestic dispute. He denied being
remanded to
juvenile detention. During military, the veteran was
arrested for
underage consumption. He also received NJPs for being
late to work (up
to 10 hours), possession of pornography, disrespect to a
commanding
officer, and drinking while on duty. After service, the
veteran has
been arrested for domestic violence 2, aggravated robbery
3, and
theft. He served 10 years in ODRC. While in prison, the
veteran
reported that he ran the inmate "store" providing drugs,
contraband
items, and running gambling schemes. He received over 50
tickets for
institutional rules violations while in prison. He was
released in
September 2016.
e. Relevant substance abuse history:
The veteran reported that historically he has rarely used
alcohol,
perhaps 1-2 times per month and none since June 2018. The
veteran
denied use of illicit drugs since June 2018. In the
period immediately
prior he primarily used narcotics and heroin.
f. Other, if any:
Nothing further.
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).
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).
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] Markedly diminished interest or participation
in
significant activities.
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] Hypervigilance.
[X] Exaggerated startle response.
[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] Chronic sleep impairment
[X] Flattened affect
[X] Impaired judgment
[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] Impaired impulse control, such as unprovoked irritability
with periods
of violence
5. Behavioral observations
--------------------------
The veteran presented as guarded. We were able to establish
adequate
rapport through time. He initiated conversation and
elaborated on topics,
often to highlight the frequency and severity of symptoms.
He was easily
re-directed, however. He was cooperative in that he answered
all
questions asked. The veteran's mood was neutral and stable.
His affect
was mildly flat and mildly irritable, with limited mobility
in range and
intensity. The veteran seldom smiled and laughed, and seldom
responded to
humor. He was not tearful. There was no hopelessness and
helplessness
evident in his comments. There was no objective evidence of
facial
flushing, vigilance, arousal, tremor, perspiration, or muscle
tension.
Speech, thought processes, orientation, attention, and memory
all were
within expectations. Psychomotor was remarkable for bouncing
a leg.
Given vocabulary, and educational, employment, and military
history, I
estimate his IQ in the average range. The veteran denied
recent changes
in sleep, noting he experiences nightmares about 70% of the
time. He
appeared alert and rested and did not report functional loss
due to sleep
problems. He said his appetite is unchanged with some weight
increase
with abstinence from drugs. Thought content was negative for
objective
signs of psychosis and the veteran denied same. He also
denied suicidal
and homicidal ideation, but added "They call it passive SI.
I'm getting
better at telling people about it."
Given several opportunities, the veteran reported current
symptoms of:
Nightmares; not liking to think about the military event;
staying away
from crowds; inability to interact with people; increased
stress with
work; blaming himself for the event happening; being aware of
his
surroundings; isolating from others; not sleeping well; drug
use.
The veteran reported abilities indicating that he retains
considerable
cognitive capacity (physical capacity is not assessed here).
When home,
he enjoys gardening, growing roses, and mowing his sisters
grass. He told
that he can drive independently. The veteran said he can
perform personal
care independently. The veteran told that he can use a
calendar, clock,
calculator, telephone, and computer. He reported that he can
manage
money, appointments, and medications, as well as shop and pay
bills. For
enjoyment he watches TV on his laptop, works out, watches OSU
football,
and does some light reading. He had good social skills on
exam. Socially,
the veteran said he is getting along well with other
residents here. His
girlfriend and mother visited him here. He said he is made
some
acquaintances in the programming as well as a couple friends.
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:
---------------------------------------------------
****This forensic report is a legal document intended for the
sole use of
VBA in determining the veteran's eligibility for compensation
and pension.
This examination is very different from other psychological
examinations,
such as for treatment, with considerably different criteria
and, thus,
often with considerably different diagnoses and outcomes. As
such, great
caution is needed in interpreting this information and use of
this report
outside its intended purpose by VHA personnel, VSO, and/or
the veteran is
STRONGLY discouraged. This examination does not constitute a
rating
decision. Rating decisions are made solely by the Regional
Office after
all available data have been reviewed and verified. Note
that "The
examiner should not express an opinion regarding the merits
of any claim
or the percentage evaluation that should be assigned for a
disability.
Determination of service connection and disability ratings
for VA benefits
is exclusively a function of VBA" (VHA Directive 1046).
Thus, any
questions or concerns regarding rating decisions should be
directed to the
Regional Office or an Appeals Board.****
The veteran was seen today for this PTSD Review exam. I
verbally provided
the usual informed consent regarding: this being a VBA
assessment, not
treatment; the report becomes a legal document; the forensic
role of VBA;
the potential outcomes of a review exam; and limits to
confidentiality.
A written copy of Informed Consent was offered.
Throughout the interview the veteran inserted nearly every
symptom of PTSD
listed in the DSM 5. He noted often that these symptoms are
severe and
prevent him from interacting with people and working with
others. This
was not particularly consistent with mental status and
functional data.
Some patterns of thought developed throughout the interview,
such as when
the veteran noted that when people try to enforce rules or
consequences
for his behavior he makes threats and blames them for causing
him to use
substances. He noted that all his criminal behavior and drug
use is due
to the military assault, even though he also reported that
alcohol and
drug use began at an early age, as did arrest. For example,
the veteran
said that the traumatic event in service caused and or
heightened his drug
use in response, but he also commented that "I figured out
when I was
younger that using drugs and alcohol makes problems like that
go away."
The veteran noted that he was found to have steroids in his
jacket while
at Bay Pines. He subsequently was discharged from the
program. He then
interpreted that as "people make me fail. That (being
discharged from Bay
Pines) put me in a bad place and made me attempt suicide.
They deny my
individual unemployability because they say I'll get better
with
treatment, then the treatment kicks me out and I'm worse
now." This
behavior and thinking is quite consistent with personality
disorder.
The veteran was diagnosed with PTSD in prior C&P exams, the
diagnosis has
been carried forward by treatment providers, and by his
report continues
with sufficient symptoms for the diagnosis. Thus the
diagnosis of PTSD
continues, as likely as not due to events in military
service. Antisocial
personality disorder was present well before military
service, so it is
less likely as not caused by military events, and there is no
evidence
that this disorder was exaggerated by military events. Also,
alcohol and
illicit drug use clearly was present prior to enrollment in
military, so
it is less likely as not caused by military service. There
is no evidence
that the veteran's substance use was due to events in
military service nor
has it progressed beyond the normal course for this disorder.
Put another
way, even if the military event had not occurred it is likely
that the
resulting pattern of substance use would have been present.
Moreover,
while there is some equivalence in the literature about the
direction of
causality when both mental disorder and substance use are
present, DSM 5
does not acknowledge any substance use disorder as "due to
mental
illness," yet there are numerous "substance-induced" mental
disorders.
INDIVIDUAL UNEMPLOYABILITY
The veteran retains considerable residual mental function
(physical
limitations, if any, are not assessed nor considered here).
The veteran
can perform personal care independently. He has a driver's
license and
drives independently. The veteran can use a calendar, clock,
calculator,
telephone, and computer. He can manage money, appointments,
and
medications, as well as pay bills. There is no mental
disorder that
prevents him from attending to, learning, and persisting to
complete
simple and complex tasks. There is no cognitive dysfunction
that would
prevent same. His performance on mental status in attention,
concentration, memory, abstraction, and thought processes
were within
expectations for age. The veteran reported limited
socialization. Yet,
he dated, married, and maintains a current relationship
(after divorcing).
He maintains some contact with family. Moreover, the veteran
was a quite
bright, capable, pleasant, cooperative gentleman on exam, and
his social
skills here were excellent. He reported isolating at home,
not liking to
be around people, and having difficult relationships through
time. The
veteran is not a member of any clubs/organizations. Indeed,
personality
disorder is predictive of contentious interpersonal
relationships and the
affective instability and impulsive decisionmaking/behavior
of the
personality disorder may interfere with motivation and
concentration.
Question
tylerb333
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: F43.10 2. Current Diagnoses -------------------- a. Mental Disorder Diagnosis #1: Antisocial personality disorder ICD Code: F60.2 Mental Disorder Diagnosis #2: Opioid use disorder ICD Code: F11.20 Mental Disorder Diagnosis #3: PTSD ICD Code: F43.10 b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): Deferred to medical 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: Antisocial personality disorder is responsible for contentious interpersonal relationships including threats, aggression, assault; failure to accept responsibility; violation of social norms and law; impulsive decisions and behaviors; and affective instability. In the symptom list below antisocial personality disorder is responsible for impaired judgment, disturbance of motivation and mood, difficulty establishing and maintaining effective social/work relationships, difficulty adapting to stressful circumstances, and impaired impulse control. Opioid use disorder has been in institutional remission June 2018, and is not at this time contributing to the symptom picture. Substance use is well known to have deleterious effects on mood, cognition, and behavior. When active, however, these symptoms likely take a predominant role. PTSD is responsible for the remaining symptoms below, which include depressed mood, chronic sleep impairment, and flat affect. 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 occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation b. For the indicated occupational and social impairment, is it possible to differentiate which impairment is caused by each mental disorder? [X] Yes [ ] No [ ] Not Applicable (N/A) If yes, list which occupational and social impairment is attributable to each diagnosis: As noted above regarding symptoms, Antisocial personality disorder is primary and PTSD is secondary. c. If a diagnosis of TBI exists, is it possible to differentiate which occupational and social impairment indicated above is caused by the TBI? [ ] Yes [ ] No [X] Not Applicable (N/A) SECTION II: ----------- Clinical Findings: ------------------ 1. Evidence Review ------------------ Evidence reviewed (check all that apply): [X] VA e-folder [X] CPRS 2. Recent History (since prior exam) ------------------------------------ a. Relevant social/marital/family history: The veteran last completed a PTSD review DBQ 06/20/17, and he reported that since that exam he has moved from Columbus to Marysville. The veteran currently is in residential programming at Chillicothe VA, hoping for placement in the DOM. The veteran denied his family situation since last exam. Socially, the veteran said he is getting along well with other residents here. His girlfriend and mother visited him here. He said he is made some acquaintances in the programming as well as a couple friends. b. Relevant occupational and educational history: The veteran denied changes in education since last exam. He has completed a GED and some college, and has a license to work with fuel and chemicals for shipping. The veteran denied employment since May 2017. He worked in landscaping prior and occasionally for his mother after that. His mother's business is sales of retail and bank machines. He said his mother arranged his hours to suit him. c. Relevant mental health history, to include prescribed medications and family mental health: The veteran denied pre-military and military mental health treatment. Specifically, he denied a history of hospitalization, suicide attempt, outpatient therapy, and prescription of psychotropic medications prior to about 2001. CPRS and VBMS were reviewed with the following relevant mental health entries. 06/20/17: PTSD review DBQ. MSE: Mood and affect depressed, otherwise normal. Examiner opined significant impairment. 06/14/18: Medical certificate. The veteran requested admission due to depression, suicidal ideation, overdose attempt on Seroquel and alcohol last evening, and hearing voices telling him to kill himself every day. UDS was positive for oxycodone, Suboxone, and cannabinoids. DX: Cocaine dependence; alcohol abuse; cannabis dependence; opioid dependence; PTSD. 06/19/18: Medical certificate. Veteran seen for change in programming. MSE: Normal except for dysphoric affect. d. Relevant legal and behavioral histor y: The veteran denied arrest since last exam, however, he has 3 years and 3 months left on parole. As a juvenile, the veteran was arrested for trespassing, DUI, domestic dispute. He denied being remanded to juvenile detention. During military, the veteran was arrested for underage consumption. He also received NJPs for being late to work (up to 10 hours), possession of pornography, disrespect to a commanding officer, and drinking while on duty. After service, the veteran has been arrested for domestic violence 2, aggravated robbery 3, and theft. He served 10 years in ODRC. While in prison, the veteran reported that he ran the inmate "store" providing drugs, contraband items, and running gambling schemes. He received over 50 tickets for institutional rules violations while in prison. He was released in September 2016. e. Relevant substance abuse history: The veteran reported that historically he has rarely used alcohol, perhaps 1-2 times per month and none since June 2018. The veteran denied use of illicit drugs since June 2018. In the period immediately prior he primarily used narcotics and heroin. f. Other, if any: Nothing further. 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). 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). 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] Markedly diminished interest or participation in significant activities. 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] Hypervigilance. [X] Exaggerated startle response. [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] Chronic sleep impairment [X] Flattened affect [X] Impaired judgment [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] Impaired impulse control, such as unprovoked irritability with periods of violence 5. Behavioral observations -------------------------- The veteran presented as guarded. We were able to establish adequate rapport through time. He initiated conversation and elaborated on topics, often to highlight the frequency and severity of symptoms. He was easily re-directed, however. He was cooperative in that he answered all questions asked. The veteran's mood was neutral and stable. His affect was mildly flat and mildly irritable, with limited mobility in range and intensity. The veteran seldom smiled and laughed, and seldom responded to humor. He was not tearful. There was no hopelessness and helplessness evident in his comments. There was no objective evidence of facial flushing, vigilance, arousal, tremor, perspiration, or muscle tension. Speech, thought processes, orientation, attention, and memory all were within expectations. Psychomotor was remarkable for bouncing a leg. Given vocabulary, and educational, employment, and military history, I estimate his IQ in the average range. The veteran denied recent changes in sleep, noting he experiences nightmares about 70% of the time. He appeared alert and rested and did not report functional loss due to sleep problems. He said his appetite is unchanged with some weight increase with abstinence from drugs. Thought content was negative for objective signs of psychosis and the veteran denied same. He also denied suicidal and homicidal ideation, but added "They call it passive SI. I'm getting better at telling people about it." Given several opportunities, the veteran reported current symptoms of: Nightmares; not liking to think about the military event; staying away from crowds; inability to interact with people; increased stress with work; blaming himself for the event happening; being aware of his surroundings; isolating from others; not sleeping well; drug use. The veteran reported abilities indicating that he retains considerable cognitive capacity (physical capacity is not assessed here). When home, he enjoys gardening, growing roses, and mowing his sisters grass. He told that he can drive independently. The veteran said he can perform personal care independently. The veteran told that he can use a calendar, clock, calculator, telephone, and computer. He reported that he can manage money, appointments, and medications, as well as shop and pay bills. For enjoyment he watches TV on his laptop, works out, watches OSU football, and does some light reading. He had good social skills on exam. Socially, the veteran said he is getting along well with other residents here. His girlfriend and mother visited him here. He said he is made some acquaintances in the programming as well as a couple friends. 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: --------------------------------------------------- ****This forensic report is a legal document intended for the sole use of VBA in determining the veteran's eligibility for compensation and pension. This examination is very different from other psychological examinations, such as for treatment, with considerably different criteria and, thus, often with considerably different diagnoses and outcomes. As such, great caution is needed in interpreting this information and use of this report outside its intended purpose by VHA personnel, VSO, and/or the veteran is STRONGLY discouraged. This examination does not constitute a rating decision. Rating decisions are made solely by the Regional Office after all available data have been reviewed and verified. Note that "The examiner should not express an opinion regarding the merits of any claim or the percentage evaluation that should be assigned for a disability. Determination of service connection and disability ratings for VA benefits is exclusively a function of VBA" (VHA Directive 1046). Thus, any questions or concerns regarding rating decisions should be directed to the Regional Office or an Appeals Board.**** The veteran was seen today for this PTSD Review exam. I verbally provided the usual informed consent regarding: this being a VBA assessment, not treatment; the report becomes a legal document; the forensic role of VBA; the potential outcomes of a review exam; and limits to confidentiality. A written copy of Informed Consent was offered. Throughout the interview the veteran inserted nearly every symptom of PTSD listed in the DSM 5. He noted often that these symptoms are severe and prevent him from interacting with people and working with others. This was not particularly consistent with mental status and functional data. Some patterns of thought developed throughout the interview, such as when the veteran noted that when people try to enforce rules or consequences for his behavior he makes threats and blames them for causing him to use substances. He noted that all his criminal behavior and drug use is due to the military assault, even though he also reported that alcohol and drug use began at an early age, as did arrest. For example, the veteran said that the traumatic event in service caused and or heightened his drug use in response, but he also commented that "I figured out when I was younger that using drugs and alcohol makes problems like that go away." The veteran noted that he was found to have steroids in his jacket while at Bay Pines. He subsequently was discharged from the program. He then interpreted that as "people make me fail. That (being discharged from Bay Pines) put me in a bad place and made me attempt suicide. They deny my individual unemployability because they say I'll get better with treatment, then the treatment kicks me out and I'm worse now." This behavior and thinking is quite consistent with personality disorder. The veteran was diagnosed with PTSD in prior C&P exams, the diagnosis has been carried forward by treatment providers, and by his report continues with sufficient symptoms for the diagnosis. Thus the diagnosis of PTSD continues, as likely as not due to events in military service. Antisocial personality disorder was present well before military service, so it is less likely as not caused by military events, and there is no evidence that this disorder was exaggerated by military events. Also, alcohol and illicit drug use clearly was present prior to enrollment in military, so it is less likely as not caused by military service. There is no evidence that the veteran's substance use was due to events in military service nor has it progressed beyond the normal course for this disorder. Put another way, even if the military event had not occurred it is likely that the resulting pattern of substance use would have been present. Moreover, while there is some equivalence in the literature about the direction of causality when both mental disorder and substance use are present, DSM 5 does not acknowledge any substance use disorder as "due to mental illness," yet there are numerous "substance-induced" mental disorders. INDIVIDUAL UNEMPLOYABILITY The veteran retains considerable residual mental function (physical limitations, if any, are not assessed nor considered here). The veteran can perform personal care independently. He has a driver's license and drives independently. The veteran can use a calendar, clock, calculator, telephone, and computer. He can manage money, appointments, and medications, as well as pay bills. There is no mental disorder that prevents him from attending to, learning, and persisting to complete simple and complex tasks. There is no cognitive dysfunction that would prevent same. His performance on mental status in attention, concentration, memory, abstraction, and thought processes were within expectations for age. The veteran reported limited socialization. Yet, he dated, married, and maintains a current relationship (after divorcing). He maintains some contact with family. Moreover, the veteran was a quite bright, capable, pleasant, cooperative gentleman on exam, and his social skills here were excellent. He reported isolating at home, not liking to be around people, and having difficult relationships through time. The veteran is not a member of any clubs/organizations. Indeed, personality disorder is predictive of contentious interpersonal relationships and the affective instability and impulsive decisionmaking/behavior of the personality disorder may interfere with motivation and concentration.Edited by tylerb333Link to comment
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