Mental Health C&P

[sanktuary]

Hey all!  I just downloaded the mental health dbq from the appt i had the other day.  As a precursor the VA for my whole time using the VA has me listed as having GAD, MDD, Panic Attacks w/ Agorophobia and PTSD.  Below is the eval that was just done.  Appreciate your thoughts as this was done by someone in the same field as my condition.  They had scheduled me for 2 exams 1 for PTSD and One for GAD, Panic and Agorophobia.. only did this 1.

        Mental Disorders                     (other than PTSD and Eating Disorders)                        Disability Benefits Questionnaire
    Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination    Request?    [X] Yes  [ ] No    
    Does the Veteran now have or has he/she ever been diagnosed with a mental       disorder(s)?       [X] Yes  [ ] No              ICD code: F41.0

    If the Veteran currently has one or more mental disorders that conform to       DSM-5 criteria, provide all diagnoses:              

Mental Disorder Diagnosis #1: Panic Disorder       ICD code: F41.0
Mental Disorder Diagnosis #2: Agoraphobia       ICD code: F40.0
    b. Medical diagnoses relevant to the understanding or management of the       Mental Health Disorder (to include TBI): n/a       
    2. Differentiation of symptoms    -----------------------------    No response provided.        
3. Occupational and social impairment    ------------------------------------    No response provided.                                      

SECTION II:                                   ----------                               Clinical Findings:                               -----------------    1. Evidence Review    -----------------    Evidence reviewed (check all that apply):        [X] VA e-folder    [X] CPRS
    2. History    ---------    No response provided.        3. Symptoms    ----------    No response provided.        4. Behavioral observations    -------------------------    Duplicate request: Please see the PTSD DBQ completed today.    
                   
                 
Initial Post Traumatic Stress Disorder (PTSD)                        
Disability Benefits Questionnaire                         
   
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: Panic Disorder           ICD code: F41.0
       Mental Disorder Diagnosis #2: Agoraphobia           ICD code: F40.0

    b. Medical diagnoses relevant to the understanding or management of the  mental health disorder (to include TBI): n/a

    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?       [ ] Yes   [X] No   [ ] Not applicable (N/A)                  
If no, provide reason:              The Panic Disorder and Agoraphobia are part of the same problem.  Each feeds the other.
                 
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] Total occupational and social impairment
      
 b. For the indicated occupational and social impairment, is it possible to differentiate which impairment is caused by each mental disorder?       [ ] Yes   [X] No   [ ] Not Applicable (N/A)  
               
If no, provide reason:              Panic Disorder and Agoraphobia exacerbate each other  
               
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
    Evidence Comments:    They are records from the VA clinic.

    2. History    ---------    a. Relevant social/marital/family history (pre-military, military, and       post-military):          Says he is "always at home." He does not go out because of panic attacks. Says he has to prepare himself for weeks to go out. If he does leave the house, it is with his wife.          They started home schooling the children because his wife couldn't leave him at home. Says he has intrusive thoughts of what if he had the          thought of hurting the kids. He is unable to be apart from his wife for  over 10 minutes.  Being home by himself scares him. His wife and younger children are          always in the home now because Veteran won't be alone.  Social impairment is extreme and is affecting his family.                        b. Relevant occupational and educational history (pre-military, military, and post-military):   Graduated from high school, worked at a pizza restaurant and joined the  Army a year later. He was in the infantry.

          After the Army, he has mostly tried to work from home using the  Internet. He would build websites and had a marketing company. He quit          when he was expected to leave the house and go to conferences to  promote the marketing company. He says panic attacks became so          debilitating, he couldn't even work from home.    He is not currently employed. He has credit card debt and no income.  

c. Relevant mental health history, to include prescribed medications and family mental health (pre-military, military, and post-military):          
Veteran states that he was "fearless" before he went to Korea. Says he "changed completely" after the death of his friend, Hicks, in 1996. In  the STR, there is a note about his having a Mental Status Exam in 1996  at a Mental Health Clinic. No details are available. Veteran says he  did not return for treatment because "everybody picks on you" if you get treatment.  Veteran had many incidents which caused him to feel anxious in the          Army. In basic training, a recruit had a heart attack and was berated.    In the Korea DMZ, he was fired upon. Also, the camp was threatened that          North Korea was making inroads into the DMZ. The soldiers were told  that they had 15 second lifespan.   Veteran states that his first "big panic attack" occurred in 1997, shortly after he left the Army. Says he went to a VA in Atlanta, no  record is available. He was fearful of having cancer or a heart attack.  Veteran was admitted to inpatient psychiatry at the VA in   2004. He was fearful that he had mouth cancer. He declined medication,          fearing that medications would cause problems.  Because he refused meds, he was in psycyhotherapy at the  VA  from 2005 to 2011. Veteran's symptoms only worsened. He avoids  situations that cause panic attacks so his world has become very  restricted.           He is not currently in treatment.   He went to exposure therapy in 2017 at UNC which helped a  very small amount. He is now able to be alone for 10-20 minutes.          He says he gets panic attacks when he takes medication, fears addiction, fears being suicidal.   

              e. Relevant substance abuse history (pre-military, military, and  post-military):          
Says he does not drink alcohol. "Alcohol about killed me in the military."                       
f. Other, if any:       No response provided.    
     
3. Stressors    -----------    Describe one or more specific stressor event(s) the Veteran considers traumatic (may be pre-military, military, or post-military):    
   
a. Stressor #1: In Basic Training, a soldier had a heart attack. Says anxiety started that day.                    
Does this stressor meet Criterion A (i.e., is it adequate to support  the diagnosis of PTSD)?          [ ] Yes  [X] No                    
Is the stressor related to the Veteran's fear of hostile military or  terrorist activity?          [ ] Yes  [X] No                    
Is the stressor related to personal assault, e.g. military sexual trauma?          [ ] Yes  [X] No    
         
b. Stressor #2: In Korea, a soldier stepped on a mine and lost his foot. Veteran was told that he was lucky because that mine had been there for          decades.                    
Does this stressor meet Criterion A (i.e., is it adequate to support  the diagnosis of PTSD)?          [X] Yes  [ ] No                    
Is the stressor related to the Veteran's fear of hostile military or  terrorist activity?          [ ] Yes  [X] No                    
Is the stressor related to personal assault, e.g. military sexual trauma?          [ ] Yes  [X] No  
           
c. Stressor #3: He was on bridge duty in Korea, He came under gunfire one night. He started to run to get ammunition but was called back. .
Does this stressor meet Criterion A (i.e., is it adequate to support  the diagnosis of PTSD)?          [X] Yes  [ ] No                    
Is the stressor related to the Veteran's fear of hostile military or  terrorist activity?          [X] Yes  [ ] No                  
 Is the stressor related to personal assault, e.g. military sexual trauma?          [ ] Yes  [X] No              
d. Additional stressors: If additional stressors, describe (list using the above sequential format):          
North Korea threatened to attack the DMZ. They were shown satellite  photos of the enemy digging into the DMZ. They were put on lockdown.

                        4. PTSD Diagnostic Criteria    --------------------------    
Note: Please check criteria used for establishing the current PTSD diagnosis.    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 #7 - Other symptoms.  The diagnostic criteria    for PTSD, referred to as Criterion A-H, are from the Diagnostic and    Statistical Manual of Mental Disorders, 5th edition (DSM-5).          
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)                  
[X] Witnessing, in person, the traumatic event(s) as they  occurred to others

       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).

       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).                   [X] Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects,  situations) that arouse 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 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] Problems with concentration.                  
[X] Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).

       Criterion F:                          [X] Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month.

       Criterion G:                          [X] The disturbance causes 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.


       Criterion I: Which stressor(s) contributed to the Veteran's PTSD  diagnosis?:                                      
[X] Stressor #3

    5. Symptoms    ----------    For VA rating purposes, check all symptoms that actively apply to the Veteran's diagnoses:          
[X] Anxiety       [X] Suspiciousness       [X] Panic attacks more than once a week       [X] Chronic sleep impairment       [X] Disturbances of motivation and mood

    6. Behavioral Observations    -------------------------    Veteran is alert, fully oriented, dressed in clean, casual clothing.    Mood is anxious.    Affect is constricted. He becomes tearful when talking about the loss of his    friend and the effect his anxiey has on his family.    He denied suciidal thinking.    He avoids eye contact. Speaks in a tremulous voice.

    7. Other symptoms    ----------------    Does the Veteran have any other symptoms attributable to PTSD (and other    mental disorders) that are not listed above?       [ ] Yes   [X] No          

8. Competency    ------------
    Is the Veteran capable of managing his or her financial affairs?       [X] Yes   [ ] No          

9. Remarks, (including any testing results) if any    -------------------------------------------------       Active duty service dates:       Branch: Army  
       DBQ PSYCH Mental disorders:      

The Veteran is claiming service connection for agoraphobia, anxiety and insomnia. Please examine the Veteran for a chronic disability related to       his  or her claimed condition and indicate the current level of severity.

       If more than one mental disorder is diagnosed please comment on their  relationship to one another and, if possible, please state which symptoms are attributed to each disorder.
       **************************************************************************       **
       DBQ PSYCH PTSD Initial:       The Veteran is claiming service connection for PTSD due to the claimed stressor of Inicident at Korean DMZ. Please examine the Veteran for a  chronic disability related to his or her claimed condition and indicate the current level of severity.

       If more than one mental disorder is diagnosed please comment on their  relationship to one another and, if possible, please state which symptoms are attributed to each disorder.
       If your examination determines that the Veteran does not have diagnosis of PTSD and you diagnose another mental disorder, please provide an opinion as  to whether it is at least as likely as not that the Veteran's diagnosed mental disorder is a result of an in-service stressor related event.

       Response: The Veteran has many symptoms of PTSD and has had events that could cause PTSD. However, the more appropriate diagnosis for this Veteran is Panic Disorder along with Agoraphobia. Panic Disorder and PTSD have  many overlapping symptoms. This Veteran happens to have incurred a trauma  but his presentation more closely resembles Panic Disorder.       There is scant evidence to demonstrate that the anxiety started in the Army, namely the note that a Mental Status Examination took place at a  Mental Health Clinic with no details provided. This corresponds to the Veteran's report that he was evaluated after his close friend died.       His first panic attack occurred within a year of his departure from the       Army.      

In my opinion, the Veteran's Panic Disorder and Agoraphobia were incurred while he was serving in the Army. 

[Berta]

57 minutes ago, sanktuary said:

The Veteran is claiming service connection for PTSD due to the claimed stressor of Inicident at Korean DMZ

I agree that stressor# 3 three would be the best one to prove....and easiest.

D you have proof of the incident yet?

The C & P diagnoses Panic Disorder and Agoraphobia, not PTSD, but that does not matter-the comp is the same ratings  for Almost al MH issues.

 

[sanktuary]

Hello Berta, 

  Yes I actually was awarded an AAM for this.  It is all in the military records.  I guess I am not worried what they actually classify my issues as!  I was diagnosed with multiple mental health issues over the past 20 yrs ( Major Depressive Disorder, Generalized Anxiety Disorder, Panic attacks with Agoraphobia as well as PTSD)

The Agoraphobia to me is the most debilitating.  I just wanted any thoughts on how this looks as far as rating may go.  I understand also that all of the MH issues are rated as one, and the most severe is the rating they use. 

I do appreciate everyone's help on this new journey for me through this whole new level of bureaucracy and red tape. 

[Berta]

Do you have any SC ratings now?

Ratings are based on how the disability affects/impacts  your ability to work- (I thought the examiner would make a statement to that affect but I dont see it there in the C & P exam.)

 

 

 

[sanktuary]

 

Do you have any SC ratings now?

I have just started this process.  As of now I have no listed SC's and have completed exams ( if you call some of them exams ) for the knee, tinnitus, ptsd, panic /agoraphobia

Ratings are based on how the disability affects/impacts  your ability to work- (I thought the examiner would make a statement to that affect but I dont see it there in the C & P exam.)

Hey Berta, the only thing this apparently says is Criterion G ( along with all of the other Criterion in the A-I list) and the part in the beginning where she stated "  [X] Total occupational and social impairment " and at the end where she stated " In my opinion, the Veteran's Panic Disorder and Agoraphobia were incurred while he was serving in the Army.

I guess you have seen a lot more of these than myself.   She basically shifted the PTSD to Panic and Agoraphbia, even though the criterion for PTSD was met.  She stated she felt the Panic and Agoraphobia were more present, i guess.  But nothing really more on the work front outside of her saying that I do not have a job and haven't in years.

 

Thanks Again 

Edited August 6, 2018 by sanktuary
format

[Berta]

You are right- she did check Total occupational and social impairment- I missed that-Sorry!

That usually warrants, with proof of the stressor, a 100% rating. I just don't like to even guess on ratings, however,

because we never know what VA will do.

One thing to think about- agoraphobia and a panic disorder can often completely prevent sustainable employment.

Vets with PTSD are often employed throughout their lifetimes, and rated for SC PTSD .

It depends on a lot of factors. My husband was employed as a Nuke (Nuclear Power Plant Operator

for 20 years -before his combat PTSD got to him. When I met he had relocated to another area  and I met him at a vet center and he again had a very good job, also after we  moved to NY ,he worked at the local VAMC and attended Corning College at the same time.30% SC PTSD .

But he had a major stroke when he was 45 ,significant other PTSD problems, and requested a higher MH rating. He was at 30% for PTSD since 1983.

They awarded 100% SC PTSD P & T  after he died.

My point is that every type of  MH issue is different and the examiner thought the agoraphobia was not only due to your service (they often don't make that nexus statement and it is great that she did) but also ,the examiner felt the prime MH disability you have was the Panic /agoraphobia disorder....

I think this is a good exam, and will award comp to you- but I hope others chime in..

 

 

 

 

 

[FMFDOC25]

On 8/4/2018 at 11:37 AM, sanktuary said:

Hey all!  I just downloaded the mental health dbq from the appt i had the other day.  As a precursor the VA for my whole time using the VA has me listed as having GAD, MDD, Panic Attacks w/ Agorophobia and PTSD.  Below is the eval that was just done.  Appreciate your thoughts as this was done by someone in the same field as my condition.  They had scheduled me for 2 exams 1 for PTSD and One for GAD, Panic and Agorophobia.. only did this 1.

        Mental Disorders                     (other than PTSD and Eating Disorders)                        Disability Benefits Questionnaire
    Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination    Request?    [X] Yes  [ ] No    
    Does the Veteran now have or has he/she ever been diagnosed with a mental       disorder(s)?       [X] Yes  [ ] No              ICD code: F41.0

    If the Veteran currently has one or more mental disorders that conform to       DSM-5 criteria, provide all diagnoses:              

Mental Disorder Diagnosis #1: Panic Disorder       ICD code: F41.0
Mental Disorder Diagnosis #2: Agoraphobia       ICD code: F40.0
    b. Medical diagnoses relevant to the understanding or management of the       Mental Health Disorder (to include TBI): n/a       
    2. Differentiation of symptoms    -----------------------------    No response provided.        
3. Occupational and social impairment    ------------------------------------    No response provided.                                      

SECTION II:                                   ----------                               Clinical Findings:                               -----------------    1. Evidence Review    -----------------    Evidence reviewed (check all that apply):        [X] VA e-folder    [X] CPRS
    2. History    ---------    No response provided.        3. Symptoms    ----------    No response provided.        4. Behavioral observations    -------------------------    Duplicate request: Please see the PTSD DBQ completed today.    
                   
                 
Initial Post Traumatic Stress Disorder (PTSD)                        
Disability Benefits Questionnaire                         
   
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: Panic Disorder           ICD code: F41.0
       Mental Disorder Diagnosis #2: Agoraphobia           ICD code: F40.0

    b. Medical diagnoses relevant to the understanding or management of the  mental health disorder (to include TBI): n/a

    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?       [ ] Yes   [X] No   [ ] Not applicable (N/A)                  
If no, provide reason:              The Panic Disorder and Agoraphobia are part of the same problem.  Each feeds the other.
                 
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] Total occupational and social impairment
      
 b. For the indicated occupational and social impairment, is it possible to differentiate which impairment is caused by each mental disorder?       [ ] Yes   [X] No   [ ] Not Applicable (N/A)  
               
If no, provide reason:              Panic Disorder and Agoraphobia exacerbate each other  
               
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
    Evidence Comments:    They are records from the VA clinic.

    2. History    ---------    a. Relevant social/marital/family history (pre-military, military, and       post-military):          Says he is "always at home." He does not go out because of panic attacks. Says he has to prepare himself for weeks to go out. If he does leave the house, it is with his wife.          They started home schooling the children because his wife couldn't leave him at home. Says he has intrusive thoughts of what if he had the          thought of hurting the kids. He is unable to be apart from his wife for  over 10 minutes.  Being home by himself scares him. His wife and younger children are          always in the home now because Veteran won't be alone.  Social impairment is extreme and is affecting his family.                        b. Relevant occupational and educational history (pre-military, military, and post-military):   Graduated from high school, worked at a pizza restaurant and joined the  Army a year later. He was in the infantry.

          After the Army, he has mostly tried to work from home using the  Internet. He would build websites and had a marketing company. He quit          when he was expected to leave the house and go to conferences to  promote the marketing company. He says panic attacks became so          debilitating, he couldn't even work from home.    He is not currently employed. He has credit card debt and no income.  

c. Relevant mental health history, to include prescribed medications and family mental health (pre-military, military, and post-military):          
Veteran states that he was "fearless" before he went to Korea. Says he "changed completely" after the death of his friend, Hicks, in 1996. In  the STR, there is a note about his having a Mental Status Exam in 1996  at a Mental Health Clinic. No details are available. Veteran says he  did not return for treatment because "everybody picks on you" if you get treatment.  Veteran had many incidents which caused him to feel anxious in the          Army. In basic training, a recruit had a heart attack and was berated.    In the Korea DMZ, he was fired upon. Also, the camp was threatened that          North Korea was making inroads into the DMZ. The soldiers were told  that they had 15 second lifespan.   Veteran states that his first "big panic attack" occurred in 1997, shortly after he left the Army. Says he went to a VA in Atlanta, no  record is available. He was fearful of having cancer or a heart attack.  Veteran was admitted to inpatient psychiatry at the VA in   2004. He was fearful that he had mouth cancer. He declined medication,          fearing that medications would cause problems.  Because he refused meds, he was in psycyhotherapy at the  VA  from 2005 to 2011. Veteran's symptoms only worsened. He avoids  situations that cause panic attacks so his world has become very  restricted.           He is not currently in treatment.   He went to exposure therapy in 2017 at UNC which helped a  very small amount. He is now able to be alone for 10-20 minutes.          He says he gets panic attacks when he takes medication, fears addiction, fears being suicidal.   

              e. Relevant substance abuse history (pre-military, military, and  post-military):          
Says he does not drink alcohol. "Alcohol about killed me in the military."                       
f. Other, if any:       No response provided.    
     
3. Stressors    -----------    Describe one or more specific stressor event(s) the Veteran considers traumatic (may be pre-military, military, or post-military):    
   
a. Stressor #1: In Basic Training, a soldier had a heart attack. Says anxiety started that day.                    
Does this stressor meet Criterion A (i.e., is it adequate to support  the diagnosis of PTSD)?          [ ] Yes  [X] No                    
Is the stressor related to the Veteran's fear of hostile military or  terrorist activity?          [ ] Yes  [X] No                    
Is the stressor related to personal assault, e.g. military sexual trauma?          [ ] Yes  [X] No    
         
b. Stressor #2: In Korea, a soldier stepped on a mine and lost his foot. Veteran was told that he was lucky because that mine had been there for          decades.                    
Does this stressor meet Criterion A (i.e., is it adequate to support  the diagnosis of PTSD)?          [X] Yes  [ ] No                    
Is the stressor related to the Veteran's fear of hostile military or  terrorist activity?          [ ] Yes  [X] No                    
Is the stressor related to personal assault, e.g. military sexual trauma?          [ ] Yes  [X] No  
           
c. Stressor #3: He was on bridge duty in Korea, He came under gunfire one night. He started to run to get ammunition but was called back. .
Does this stressor meet Criterion A (i.e., is it adequate to support  the diagnosis of PTSD)?          [X] Yes  [ ] No                    
Is the stressor related to the Veteran's fear of hostile military or  terrorist activity?          [X] Yes  [ ] No                  
 Is the stressor related to personal assault, e.g. military sexual trauma?          [ ] Yes  [X] No              
d. Additional stressors: If additional stressors, describe (list using the above sequential format):          
North Korea threatened to attack the DMZ. They were shown satellite  photos of the enemy digging into the DMZ. They were put on lockdown.

                        4. PTSD Diagnostic Criteria    --------------------------    
Note: Please check criteria used for establishing the current PTSD diagnosis.    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 #7 - Other symptoms.  The diagnostic criteria    for PTSD, referred to as Criterion A-H, are from the Diagnostic and    Statistical Manual of Mental Disorders, 5th edition (DSM-5).          
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)                  
[X] Witnessing, in person, the traumatic event(s) as they  occurred to others

       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).

       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).                   [X] Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects,  situations) that arouse 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 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] Problems with concentration.                  
[X] Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).

       Criterion F:                          [X] Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month.

       Criterion G:                          [X] The disturbance causes 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.


       Criterion I: Which stressor(s) contributed to the Veteran's PTSD  diagnosis?:                                      
[X] Stressor #3

    5. Symptoms    ----------    For VA rating purposes, check all symptoms that actively apply to the Veteran's diagnoses:          
[X] Anxiety       [X] Suspiciousness       [X] Panic attacks more than once a week       [X] Chronic sleep impairment       [X] Disturbances of motivation and mood

    6. Behavioral Observations    -------------------------    Veteran is alert, fully oriented, dressed in clean, casual clothing.    Mood is anxious.    Affect is constricted. He becomes tearful when talking about the loss of his    friend and the effect his anxiey has on his family.    He denied suciidal thinking.    He avoids eye contact. Speaks in a tremulous voice.

    7. Other symptoms    ----------------    Does the Veteran have any other symptoms attributable to PTSD (and other    mental disorders) that are not listed above?       [ ] Yes   [X] No          

8. Competency    ------------
    Is the Veteran capable of managing his or her financial affairs?       [X] Yes   [ ] No          

9. Remarks, (including any testing results) if any    -------------------------------------------------       Active duty service dates:       Branch: Army  
       DBQ PSYCH Mental disorders:      

The Veteran is claiming service connection for agoraphobia, anxiety and insomnia. Please examine the Veteran for a chronic disability related to       his  or her claimed condition and indicate the current level of severity.

       If more than one mental disorder is diagnosed please comment on their  relationship to one another and, if possible, please state which symptoms are attributed to each disorder.
       **************************************************************************       **
       DBQ PSYCH PTSD Initial:       The Veteran is claiming service connection for PTSD due to the claimed stressor of Inicident at Korean DMZ. Please examine the Veteran for a  chronic disability related to his or her claimed condition and indicate the current level of severity.

       If more than one mental disorder is diagnosed please comment on their  relationship to one another and, if possible, please state which symptoms are attributed to each disorder.
       If your examination determines that the Veteran does not have diagnosis of PTSD and you diagnose another mental disorder, please provide an opinion as  to whether it is at least as likely as not that the Veteran's diagnosed mental disorder is a result of an in-service stressor related event.

       Response: The Veteran has many symptoms of PTSD and has had events that could cause PTSD. However, the more appropriate diagnosis for this Veteran is Panic Disorder along with Agoraphobia. Panic Disorder and PTSD have  many overlapping symptoms. This Veteran happens to have incurred a trauma  but his presentation more closely resembles Panic Disorder.       There is scant evidence to demonstrate that the anxiety started in the Army, namely the note that a Mental Status Examination took place at a  Mental Health Clinic with no details provided. This corresponds to the Veteran's report that he was evaluated after his close friend died.       His first panic attack occurred within a year of his departure from the       Army.      

In my opinion, the Veteran's Panic Disorder and Agoraphobia were incurred while he was serving in the Army. 

My interpretation of the all of the medical evidence presented leans more towards what the Ratings Schedulars tend to do. Because Pyramiding of disability conditions is not allowed, such as mental disorders, they may end up service-connecting PTSD with Panic Disorder and Agoraphobia. Either way, the rating criteria is the same for all mental disorders, so I wouldn't be surprised if they combined it like that. It looks like the evidence weighs in your favor for a 70% or 100% rating, as follows:

100% rating: This rating will have the majority of the following circumstances and symptoms:

The Ability to Care for Yourself: This individual cannot take care of himself at all. Constant or near-constant hospitalization and one-on-one supervision is required.

Medications: This individual requires psychiatric medication at all times.

Symptoms: Some or all of the following symptoms will be present.

– Regular or constant delusions or hallucinations and the inability to tell fact from fiction
– Completely inappropriate behavior (like drooling, mumbling, shouting, etc.)
– There is constant danger of hurting self or others (including suicidal tendencies)
– Significant memory loss, including not being able to remember names of close friends, family, or self, and other important information
– The individual cannot understand the idea of time or place
– The individual cannot properly reason, think or communicate logically
– Constant anxiety, fear, suspicion

The Ability to Work: This individual cannot work at all.

Social Relationships: This individual cannot participate in any relationships. In other words, they cannot interact or build a relationship with another person. Family members may care for them, but it is only a one-way relationship. They cannot seek, invite, or encourage any relationships.

70% rating: This rating will have the majority of the following circumstances and symptoms:

The Ability to Care for Yourself: This individual cannot take care of himself most of the time. He is in the hospital or a care facility or is being taken care of by family members all of the time, and requires one-on-one supervision 50% of the time. This person cannot take care of his own personal hygiene.

Medications: This individual requires psychiatric medication at all times.

Symptoms: Some or all of the following symptoms will be present.

– There is the regular possibility of hurting self or others (including suicidal tendencies)
– This individual often cannot communicate logically
– This individual is actively psychotic, but may have intermittent contact with reality
– Obssessive-compulsive behavior that causes repetitive physical actions that interfere completely with daily necessary activities
– Severe, constant anxiety
– Mood often changes radically, without warning.
– Almost constant severe depression or panic, with the inability to function at all in stressful situations
– This individual cannot control impulsive actions like anger, violence, etc.
– Often disoriented to time and place

The Ability to Work: This individual may not be able to work at all or may be severely under-employed (such as a former intelligence analyst now working part time as a custodian).

Social Relationships: This individual cannot participate in any relationships most of the time. In other words, they cannot interact or build a relationship with another person. Family members may care for them, but it is normally only a one-way relationship. They cannot seek, invite, or encourage any relationships the majority of the time.

The only problem I see is the way  the Nexus of opinion was written. It doesn't state "due to" (100% probability); "more likely than not (greater than 50% probability); or "at least as likely as not"(equal to or greater than 50% probability) incurred in service.

I wouldn't be surprised if your claim goes to Preparation for Decision, then back to Gathering of Evidence so the correction can be made. Usually when that happens it takes a few days up to two weeks for the examiner to make the correction then it will to back to Preparation for Decision. It's just an addendum the examiner will have to do. You'll see it in your VA notes.

Best wishes on your claim.