Any thoughts?

[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 July 21, 2018 by tylerb333

[Buck52]

This examiner didn't do you any favors..You might get  30% if not denied?...I don't think it will be a high rating like 70%or 100% or inferred to IU...

I would say this will be a low rating if your rated at all? hopefully I 'm wrong here.

at the end of this exam the examiner was pretty harsh in is/her statements.

[Guest L]

@Buck52 - I agree- especially with the second paragraph stating the patient/client inserted every symptom in the DSM-V under PTSD along with NOT exacerbated by service and behaviors and drug use was prior to military service. 

I recall replying to your recent post, and respectfully submit that I am not being disrespectful, but employment on a continuous basis would be great for your overall situation mental & financial. 

You  have a lot of POSITIVES in the situation above, handles your own finances, able to groom et al , relationships, GED all things you are able to perform and engage in a meaningful way. 

These POSITIVES cancel out the symptomatology of a PTSD higher level rating. 

 

[Buck52]

L quoted

''I recall replying to your recent post, and respectfully submit that I am not being disrespectful, but employment on a continuous basis would be great for your overall situation mental & financial. ''

Not so sure what you mean by this.?

I can't work I am unable to work  or I would be working,  I am on TDIU-/W/ P&T WITH SMC  S & K  been that way for the last  17 or 19 on TDIU  Depending on the date for my EED ,

My  Award letter is 2003 and was paid Retro back to 1999.when I first filed for Increase from 50%

IF I COULD WORK BELIEVE ME I'D BE WORKING

FYI I have no claim/claims in at this time.

[Guest L]

Confused but I will bite.........The comment was to the original posting @tylerb333   You replied to HIS THREAD......I agreed with YOU.

Reading slower is a good thing at times.

 

His situation, felony convictions hapering his success in moving on.

Doing anything at this point especially with the poor C & P would be more beneficial, especially improving his finances. Working two low paying jobs or school et al. 

Work is  a therapeutic tool, the the original posting asking about rating decision that from the above post looks like a very poor shot at an increase. 

Free advice from my years of experience. 

[Buck52]

Okay   I got ya  just mis understood...so Roger That L