My C and P Exam...Thoughts Please???

[MsAsya]

SECTION I:
---------- 1. Diagnostic Summary
---------------------
Does the Veteran have a diagnosis of PTSD that conforms to DSM-5 criteria based on today's evaluation?
[X] Yes [ ] No
ICD code: F43.10
2. Current Diagnoses
--------------------
a. Mental Disorder Diagnosis #1: Post-traumatic stress disorder
ICD code: F43.10
 
Mental Disorder Diagnosis #2: Cannabis use disorder, mild ICD code: F12.10

b. Medical diagnoses relevant to the understanding or management of the mental health disorder (to include TBI):
No response provided.

3. Differentiation of symptoms
------------------------------
a. Does the Veteran have more than one mental disorder diagnosed?
[X] Yes [ ] No
b. Is it possible to differentiate what symptom(s) is/are attributable to each diagnosis?

[X] Yes [ ] No [ ] Not applicable (N/A)
If yes, list which symptoms are attributable to each diagnosis and discuss whether there is any clinical association between these diagnoses:
Cannabis use disorder accounts for persistent use despite negative consequences and large amounts of time spent using. All other symptoms are due to the PTSD.

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?
[ ] Yes [X] No [ ] Not Applicable (N/A)
If no, provide reason:
Veteran has not had meaningful sobriety from cannabis in some time so it is not possible to determine the level of impairment caused
by her PTSD alone.
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)

 

family mental health (pre-military, military, and post-military):
Veteran first received counseling services as a child, related to DCFS involvement. She reported a history of suicidal ideation and self-destructive behavior around age 7-8. One inpatient
hospitalization
at this time.
Still with suicidal ideation, "I really hate being here," estimated
once per day. Has engaged in reckless behavior, like fast driving. Cites children as deterrent. Also fears not succeeding and being chronically disabled. History of self-injurious behavior (cutting and burning) 4-5 years ago. Cries daily. Limited enjoyment of activities. Able to care for children. Unclear how much assistance she receives from family me
mbers. "I feel like a bad mom." Does not have many friends. Prefers to be alone.
Currently attending therapy once per week. Cannot discuss trauma
because she becomes too distressed. "I constantly remember or think
about ways I could have gotten away or done things differently. I feel like a weak person. I can't protect myself. How can I protect my children?"
Taking medications Seroquel and Lamictal along with sleep aid (Trazodone). Medications not helpful. No adverse side effects. Misses 2 doses per week.

Sleep disrupted by dreams of "being trapped." Weight fluctuates along
with eating.

Prefers not to sleep. Wants to stay alert to surroundings.
Occasionally sees "shadows."

d. Relevant legal and behavioral history (pre-military, military, and post-military):
Juvenile legal involvement for stealing and truancy. History of fighting as a juvenile.

e. Relevant substance abuse history (pre-military, military, and post-military):
1-2 grams cannabis daily. Able to be sober 1-2 years while looking for a job or while pregnant. No problems related to use.

History of alcohol use, which she stopped due to father's history of
alcoholism.

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: 2 rapes by fellow service members

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?
[X] Yes [ ] No

If yes, please describe the markers that may substantiate the stressor.
  Unplanned pregnancy documented 9/4/2008. Delivery 5/4/2009.
  Disclosure of MST to multiple providers, including non-VA providers. Veteran's statement in support of claim dated 8/11/2018.

 

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)
Criterion B: Presence of (one or more) of the following intrusion symptoms
to
associated with the traumatic event(s), beginning after the traumatic event(s) occurred:
[X] Intense or prolonged psychological distress at exposure
internal or external cues that symbolize or resemble an aspect of the traumatic event(s).

Criterion  Persistent avoidance of stimuli associated with the traumatic 
event(s), beginning after the traumatic events(s) occurred, as evidenced by one or both of the following:
[X] Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with
traumatic event(s).
"I Criterion

 Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more)
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] Persistent, distorted cognitions about the cause or
consequences of the traumatic event(s) that lead the
individual to blame himself/herself or others.
[X] Markedly diminished interest or participation in
significant activities.
[X] Feelings of detachment or estrangement from others.
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] Reckless or self-destructive behavior.
[X] Hypervigilance.
[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 #1
5. Symptoms
-----------
For VA rating purposes, check all symptoms that actively apply to the Veteran's diagnoses:
[X] Depressed mood [X] Anxiety
[X] Suspiciousness
[X] Chronic sleep impairment
[X] Flattened affect
[X] Disturbances of motivation and mood [X] Suicidal ideation
6. Behavioral Observations
--------------------------
The Veteran arrived on time and alone for her appointment, and sat calmly in the waiting room until her name was called. She responded promptly, and walked steadily and without assistance. No psychomotor abnormalities, such
as
tics or tremor, were observed. The Veteran displayed fair eye contact and adequate grooming, and was generally cooperative with the evaluation. Her speech was spontaneous and fluent, with soft volume and slowed rate. She provided short responses to questions. The Veteran described her mood as "depressed." Affect was distressed, tearful, and congruent with her
stated
mood. Thought process was linear and organized. Associations were coherent.
Thought content was without delusions or homicidal ideation. Veteran reported
passive suicidal ideation without intent or plan. She has no firearms at home
and cited deterrents for suicide. She planned to meet with her psychiatrist
after her C&P appointment and was not considered an imminent risk of self
harm. The Veteran reported atypcial hallucinations of music and shadows. She did not appear to be responding to internal stimuli during the evaluation.
The Veteran was alert and oriented. Attention was intact via conversation. Intellect was estimated as average. Insight and judgment were thought to be intact.
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

 

 

MEDICAL OPINION SUMMARY -----------------------
RESTATEMENT OF REQUESTED OPINION:
a. Opinion from general remarks: Military Sexual Trauma (MST)
b. Indicate type of exam for which opinion has been requested: Psych-PTSD Initial
TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR DIRECT SERVICE CONNECTION ]
a. The condition claimed was at least as likely as not (50% or greater
probability) incurred in or caused by the claimed in-service injury, event or
illness.
c. Rationale: The Veteran meets minimum diagnostic criteria for post-traumatic stress disorder. The current level of severity is moderate. Veteran reported ongoing symptoms despite medications and therapy. It is at least as likely as not that the Veteran's PTSD is due to her reported
military sexual trauma (MST).
It is patently impossible to determine whether or not the veteran's claimed
experiences of MST are factual based only upon the evidence provided in her claims file. To be clear, the veteran has reported that these incidents occurred and there is nothing contained in her service treatment records
that
contradicts her report. There is evidence to support her claim starting with the diagnosis of pregnancy on 9/4/2008. This examiner can see no reason to doubt the veracity of the MST events that she has reported. The
veteran's
ongoing mental health symptoms are consistent with symptoms often reported
by
individuals who have a history of sexual assault, which serves to further substantiate the claimed events. In light of the evidence reviewed today,
and
the veteran's self-report, it is the opinion of this examiner that it is
at
least as likely as not that the MST events reported above did in fact occur.

The Veteran's diagnosis of cannabis use disorder is a separate diagnosis and
is not secondary to the PTSD.

The mental disorders of PTSD and cannabis use disorder affect the Veteran's occupational functioning in terms of her ability to get along with others and maintain concentration. No formal cognitive assessment was performed today, nor has any been documented in records. Veteran did not display any overt cognitive deficits. She reported she is largely independent for activities of daily living, including caring for her three children. She is able to drive
a car.

 

[vetquest]

First, might I say that your cannabis use is hurting your diagnosis.  Noted in the statement:

Veteran has not had meaningful sobriety from cannabis in some time so it is not possible to determine the level of impairment caused by her PTSD alone.

 

Second, your condition is currently noted as having only an occasional decrease in work efficiency.  The mental health percentages are noted below:

Occupational and social impairment with occasional decrease in work efficiency and intermittent
periods of inability to perform occupational tasks (although generally functioning satisfactorily,
with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed
mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep
impairment, mild memory loss (such as forgetting names, directions, recent events) ................ 30
Occupational and social impairment due to mild or transient symptoms which decrease work efficiency
and ability to perform occupational tasks only during periods of significant stress, or;
symptoms controlled by continuous medication ........................................................................... 10
A mental condition has been formally diagnosed, but symptoms are not severe enough either to
interfere with occupational and social functioning or to require continuous medication .............. 0

 

Everything else looks pretty solid.  I wish you luck in this claim.

[GeekySquid]

17 hours ago, MsAsya said:

Mental Disorder Diagnosis #2: Cannabis use disorder, mild ICD code: F12.10

since when is smoking pot a mental health disorder per the DSM? I knew it was once a substance abuse disorder, but now its a mental disorder?

 

17 hours ago, MsAsya said:

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:
Cannabis use disorder accounts for persistent use despite negative consequences and large amounts of time spent using. All other symptoms are due to the PTSD.

you are a big ole pot head

depending on your state and the rater, this may or may not create a reason for a lower rating. If you live in a state with legal pot, it is unlikely to be very harmful to your rating.

The rating attaches your PTSD to MST and the examiner firmly believes you despite there being no "reported" nexus events except the unintended pregnancy. The examiner clearly states this is well within "normal" for MST victims.

I am not a rater, but considering the recent OIG demand that all MST cases from 2017 on be re-evaluated because the VA got them wrong (meaning low-balled), I would suspect no more than a 50% rating. I say that because you seem to be fairly functional in normal spaces even if you basically just don't like being around people and could easily fit the 30% criteria rating.

 

18 hours ago, MsAsya said:

5. Symptoms
-----------
For VA rating purposes, check all symptoms that actively apply to the Veteran's diagnoses:
[X] Depressed mood [X] Anxiety
[X] Suspiciousness
[X] Chronic sleep impairment
[X] Flattened affect
[X] Disturbances of motivation and mood [X] Suicidal ideation

these symptoms are by no means unusual in today's world, much less for someone with PTSD or MST events.

The suicidal ideation may be the "worst" or most concerning issue to take up with your counselor.

I wish you luck and hope your therapy sessions bring you relief and help you "get past" the MST. It is a horrible crime and I am saddened every time a service member is harmed by another service member.