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Ray_USMC_1968

Question of intrepretation from VHA C&P Examiner's report

Question

I am concerned the "Diagnosis and Rationale" section are going to be the stumbling block for a DRO; in MY opinion, they are contradictory. The examiner wrote out a DBQ that I would have paid an independent examiner to write. The wording the examiner used could not have been any more favorable to my claim, at all! If I had chosen the words to use in my behalf, I would have fallen short of her submitted DBQ. However, the examiner left the diagnosis and rationale sections open to intrepretation. 

Does any one here on this forum have insight that will be helpful in explaining what I am seeing? Basically, am I looking at a blanket denial, or is there the possibility of a "reasonable doubt" situation?

The following is a cut and paste from a C&P for mental health. I am not currently rated for any service-connected disability. I also have a current VHA psychiatrist diagnosis which matches the C&P examiner's diagnosis (Major Depressive Disorder). I read the request for the recent C&P, the rater did request two separate issues to be addressed: 
1) Does the Veteran have a diagnosis of PTSD, Major Depressive Disorder, or other mental disorder that was at least as likely as not (50 percent or greater probability) incurred in or caused by the claimed stressors?
2) Does the Veteran have a diagnosis of PTSD, Major Depressive Disorder, or other mental disorder that clearly and unmistakably existed prior to his military service, and that was at least as likely as not (50 percent or greater probability) aggravated beyond its natural progression by the claimed stressors?

"Taken as a whole, in this examiner's opinion, the evidence available at this time is most supportive of a diagnosis of Major Depressive Disorder With Anxious Distress, and is insufficient to determine whether this condition was incurred during the Veteran's military service, or was aggravated by it. To make such a determination would require evidence regarding his pre-military history which has direct bearing on the question of the onset and etiology of his mental health difficulties, and which was not available to the present examiner."

I claimed 3 stressors, applied for PTSD, or other MH diagnosis. The DBQ was well written, addressing each of the stressors. The examiners tied each of the stressors to DSM-V. Then, as part of her narrative, she included the following: "Consequently, for the purpose of the present examination, the claimed stressors are considered to be corroborated. For the purpose of this examination, the claimed stressors are also considered to be sufficient to cause PTSD as specified by DSM-5 diagnostic criteria, a clinical judgment which is inherently and unavoidably subjective to some extent."

However, instead of a PTSD diagnosis, she chose "Major Depressive Disorder with Anxious Distress." 

Now, I am most concerned about her "Diagnosis and Rationale":  She used the same wording to answer both of the rater's questions. 

"OPINION: It is this examiner's opinion that the Veteran DOES NOT have a diagnosis of PTSD, Major Depressive Disorder, or other mental disorder that was at least as likely as not (50 percent or greater probability) incurred in or caused by the claimed stressors.

RATIONALE: The evidence available is insufficient to determine whether the Veteran's diagnosed mental disorder was incurred during his military service. To make such a determination would require evidence regarding his pre-military history which has direct bearing on the question of the onset and etiology of his mental health difficulties, and which was not available to the present examiner."

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As for the claim being denied it might be denied at the RO level but I doubt it would be denied at BVA.  BVA is strong on good buddy letters.  Before we start thinking about appealing, did the previous C&P's or your VA doctor provide a nexus?  This could be used in your favor.  As long as a doctor provides a nexus you can point this out.  I would request your records and see what the other C&P's said about this.  I would also request your treatment records.   I am hoping that your claim will not be denied and need to go to BVA.

As for personality disorders, the military and VA love to claim personality disorders.  I was diagnosed with about six different ones before the VA settled on PTSD. 

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13 hours ago, Ray_USMC_1968 said:

Thank you to doc25 for your well-reasoned response. 

When I filed my NOD, I indicated a reference to being in sound condition upon enlistment; because I was given a misdiagnosed discharge for "Personality Disorder", during the C&P exam, the examiner and I even discussed this topic. I pointed out to her my pre-enlistment physical documents and explained to her why I disputed the PD disagnosis. She is aware of the paperwork; she SHOULD have known the difference when she filed her DBQ. 

After pursuing this disability claim since July 2016, I can clearly recognize how Veterans get frustrated with "the system." After having 3 separate C&P examinations for the same disability, and not having even one examiner to agree with either of the other two, and none of the 3 to be in agreement with my VHA psychiatrist or Vet Center counselor... The frustration continues to build. 

For me, the frustration is in not having any one at VBA to speak directly with - in not having a warm set of eyes to point out the apparent discrepancy between the documented reality of STR, and connecting the dots between those records and a DBQ. 

If the current examiner has only submitted her DBQ without a medical opinion and rationale, she would have submitted the perfect supporting examination for me... When she submitted the opinion and rationale, she chose to use conflicting terminology. Using her terminology, I feel the DRO will be justified in denying my claim. 

I realize how many other Veterans are in my age group, and I also realize the odds are significantly against me being around another 5 - 7 years while my claim is appealed. This is what makes the frustration level nearly unbearable. 

Again, I thank everyone who has offered their insight to my posting. Thank you for helping me, and a huge thank you for being here as you continue to help others!!!!

 

Ray

To me, it looks like the presumption of sound condition was completely disregarded. All the examiner needed to know was that if it was or wasn't in your entrance exam. Period. 

The law clearly and unmistakably says what is required. Nothing more, nothing less. 

The longer this drags out, the more $$$ is going into your bank account. 

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@doc25 makes some good points

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Belatedly, I want to thank those who have replied. "Thank you" for your well-reasoned responses to my initial posting. 

In the unlikely event this posting remains active, I have been waiting for the DRO to make a decision based on the DBQ from November 2, 2018. Thus far, no movement. 

It is only MY opinion that says the examiner misdiagnosed me with MDD w/Anxious Distress. I know for the purposes of compensation, VBA doesn't differentiate between PTSD, MDD, Anxiety, or any of the other MH disorders. However, in my case. the DBQ is specific to PTSD and I feel this should have been my diagnosis. It it my theory the examiner makes a clinical opinion/decision but her opinion falls apart when she says under the "Rationale" she needs more information because "the evidence is insufficient to determine whether the diagnosis was incurred during his military service.".

With that said, if any one remains willing to review my DBQ, I have redacted the personal information so I can post the relevant sections. 

As so many other 'learners' on this site (and other sites!!!), I sincerely appreciate any and all feedback, suggestions, advice, admonitions, et al that are offered. My sincere thanks to everyone who takes time to even read my posting. 

Ray

 

LOCAL TITLE: C&P EXAMINATION

STANDARD TITLE: C & P EXAMINATION NOTE

DATE OF NOTE: NOV 02, 2018@10:00 ENTRY DATE: DEC 02, 2018@17:13:49

 

 

Disability Benefits Questionnaire

 

Please use this DBQ to address 1151 requests, or other issues that are not specifically addressed by specific DBQs such as Individual Unemployability (UI).

Initial Posttraumatic Stress Disorder (PTSD)

Disability Benefits Questionnaire

Date of Request: 10/5/2018

Date of Exam: 11/2/2018

Time of Exam: 9:45 AM

Date(s) of Previous Exam(s): 9/20/2017, 5/21/2018

 

Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination Request?

[X] Yes [ ] No

***PLEASE NOTE: This Veteran was seen by other providers in September 2017 and May 2018 for C&P Initial PTSD examinations, the findings of which are documented in detailed reports dated 9/20/2017 and 5/21/2018. In light of his expressed and well-documented concerns that the previous examiners did not fully review, consider, and account for the evidence of record, the present examiner elected to focus the interview solely on information that the Veteran felt might not be adequately covered in his records, and the Veteran readily agreed to this approach. Consequently, only historical information that is new or additional to that summarized in the previous examination reports is presented below. Please see the reports of the previous examinations for historical information that is not reiterated in this report.***

 

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

[X] Veteran's symptoms do not meet the diagnostic criteria for PTSD

under DSM-5 criteria.

[X] Veteran has another Mental Disorder diagnosis that conforms with DSM-5 criteria. Continue to complete this Questionnaire and/or the Eating Disorder Questionnaire.

2. Current Diagnoses

------------------------------

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

a. Mental Disorder Diagnosis #1: Major Depressive Disorder With Anxious Distress ICD Code: F33.9

b. Medical problems relevant to the understanding or management of the mental health disorder(s): See previous C&P Initial PTSD examinations dated 9/20/2017 and 5/21/2018.

 

3. Differentiation of Symptoms

------------------------------

a. Does the Veteran have more than one mental disorder diagnosed?

[ ] Yes [X] No

b. Is it possible to differentiate what symptom(s) is/are attributable to each diagnosis?

[ ] Yes [ ] No [X] Not applicable (N/A)

c. Does the Veteran have a diagnosed traumatic brain injury (TBI)?

[ ] Yes [ ] No [X] Not shown in records reviewed

d. Is it possible to differentiate what symptom(s) is/are attributable to TBI and any non-TBI mental health diagnosis?   

[ ] Yes [ ] No [X] Not applicable (N/A)

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 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

b. For the indicated occupational and social impairment, is it possible to differentiate which impairment is caused by each mental disorder?

[ ] Yes [ ] No [X] Not applicable (N/A)

c. If a diagnosis of TBI exists, is it possible to differentiate which occupational and social impairment indicated above is caused by TBI?

[ ] Yes [ ] No [X] No diagnosis of TBI

 

COMMENTS: The level of functional impairment indicated above is that indicated during the previous C&P Initial PTSD examination dated 5/21/2018. It should be noted that this appears consistent with the level of functioning described during that examination, but inconsistent with the level of symptomatology endorsed.

 

SECTION II:

---------------------

Clinical Findings:

---------------------

1. Evidence Review

------------------------------

Evidence reviewed (check all that apply):

[X] VA e-folder (VBMS and Virtual VA)

[X] CPRS

[X] Other (please identify other evidence reviewed): VistaWeb or JLV

 

2. History

------------------------------

Relevant Family and Social History: See previous C&P Initial PTSD examinations dated 9/20/2017 and 5/21/2018.

Relevant Occupational and Educational History: See previous C&P Initial PTSD examinations dated 9/20/2017 and 5/21/2018.

Relevant Mental Health History: Reported that he saw an outpatient VA psychiatrist in Long Beach, California for about six months in 1973-1974. "He was treating me for anxiety. I don't think we talked about depression because I was hiding suicidal thoughts." Reported that he was encouraged to file a disability claim. "When they denied it, I could no longer have outpatient treatment, so I quit going. I tried a couple of times, and because I didn't have my paper or didn't follow through. I think '07 was the first time I tried, but I didn't have my DD 214. The only time I got help was when I got in criminal trouble, was facing legal charges. I was afraid of getting locked up. In 2002, I overdosed on pain medication. Of all the regrets I have is that it didn't work. My wife interrupted me."

Reported that he applied again for VA care in 2014. "I was still working at ********. I was very successful there, but I was having suicidal thoughts. I just wanted it to end. I didn't want to keep feeling the pain. So I called again. I went online and applied. But I didn't have medical records, and I didn't follow through. The next year, I was fired from Expedia, and that continued my depression slide. The VA examiners said being fired precipitated this depression. That isn't accurate. I had already applied before being discharged. It escalated my depression." Reported that he talked to a VSO in 2017, who referred him to the Springfield Vet Center, where he indicated he has been seen since July 2017. Treatment records and multiple written statements submitted in support of his claim document that the Veteran has reported receiving mental health treatment at Long Beach VAMC in 1973-1974. No documentation of the treatment was found in the records available for review. Correspondence dated 7/20/2017 from a mental health counselor who saw him for individual therapy while incarcerated in about 1994-1995 document that issues related to trauma (the details of which were not specified) and suicidal ideation and behavior were addressed. No documentation of the treatment was found in the records available for review. A written statement dated 11/15/2017 documents that he reported receiving outpatient mental health services at Burrell Mental Health in August 1988. No documentation of the treatment was found in the records available for review. Springfield Vet Center treatment records document that he reported undergoing mental health evaluation through Burrell Behavioral Health in January 2018 and with another, unidentified provider in February 2018. No documentation of the evaluations was found in the records available for review.

Available Vet Center records document outpatient counseling received between July 2017 and July 2018 to address issues related to depression, anxiety, and suicidal ideation. The records document that he reported experiencing traumatic stressors during his military service to which he attributed his current difficulties. However, they do not document a detailed assessment of his psychosocial history prior to military service, do not document a detailed assessment of PTSD symptomatology (the PCL was administered, but the specific findings are not documented), and indicate that the focus of treatment was on his symptoms as they related to current psychosocial stressors. 

VA treatment records document that he was seen for an initial mental health evaluation by a psychologist at Mount Vernon CBOC in January 2018. He had contacted the clinic in December 2017, at which time he indicated that he was seeking a PTSD evaluation in support of his claim for service connection. When he was informed that such an evaluation could not be conducted through

VHA as its focus is on treatment services, he indicated that he was interested in treatment for depression and suicidal ideation. During his initial visit, he endorsed symptoms consistent with Major Depressive Disorder. While he attributed the onset of his difficulties to physical abuse by instructors during Marine Corps training, he indicated that he had read about PTSD after his claim was denied in 2017, and agreed that his symptoms did not fully meet criteria for a diagnosis. The records document that he has subsequently been seen for medication management services.

See previous C&P Initial PTSD examinations dated 9/20/2017 and 5/21/2018 for additional information.

Relevant Legal and Behavioral History: See previous C&P Initial PTSD examinations dated 9/20/2017 and 5/21/2018 for additional information.

Relevant Substance Use History: None. See previous C&P Initial PTSD examinations dated 9/20/2017 and 5/21/2018.

Other Relevant History:

Military personnel records document that the Veteran served in the Marine Corps from May 1968 to September 1969, that his MOS was voice radio operator, that he had no combat tours, and that he received an honorable discharge. They also document that he served as a military policeman in the Army National Guard from September 1973 to September 1976. Service treatment records document that he was seen for psychiatric evaluation in June 1969 due to complaints of blurred vision which were believed not to be attributable to any known organic cause (based in part on variations in findings of visual field studies that were suggestive of "functional deficit"). They note that he was disenchanted with the military and was experiencing conflict regarding whether to get out of the Marine Corps or stay in, and that he had begun experiencing symptoms. The records indicate that he described noteworthy educational, emotional, social, and family difficulties in childhood and adolescence; was assigned a diagnosis of "schizoid personality disorder [with] hysterical features," was prescribed anti-anxiety medications in the course of several follow-up appointments; complained of progressively worsening vision; was determined to be unfit for duty; and was discharged with diagnoses of "schizoid personality" and "psychoneurotic conversion reaction."

Claims records document that in the time since his discharge from the Marine Corps, the Veteran has filed claims for mental health conditions including "nervous condition," "psychoneurotic conversion reaction," schizoid personality disorder, "depressive neurosis," major depressive disorder, and PTSD. The records indicate that his claims have been denied for reasons including evidence that the claimed condition existed prior to service, lack of a current clinical diagnosis of the claimed condition, lack of evidence linking his current clinical diagnosis to his military service, and the claimed condition not being subject to service connection.

The report of the Veteran's initial examination for service connection dated 5/7/1974 is considered to be of limited value, as the examiner noted that the C file was not available for review, and thus based his conclusions solely on the Veteran's self-report. However, it is noteworthy that the examiner did not document any significant symptoms or functional impairments at that time, although his diagnostic impression was "anxiety neurosis." The report of the C&P Initial PTSD examination dated 9/20/2017 documents that the examiner assigned diagnoses of unspecified personality disorder and documented no PTSD symptoms other than exposure to a traumatic stressor, and attributed all of the documented symptoms to the aforementioned diagnoses.

The report of the C&P Initial PTSD examination dated 5/21/2018 documents that the examiner assigned diagnoses of major depressive disorder and unspecified personality disorder, and noted symptoms meeting all criteria for PTSD except Criterion A (stating that the reported stressors were "distressing and upsetting" but did not "meet criteria as a traumatic event"). Additionally, the report documents that the examiner noted that the Veteran endorsed a "high number of extreme symptoms that were not fully consistent with presentation or history," and noted that he denied any history of significant childhood trauma or educational, emotional, behavioral, social, or family problems prior to his military service.

During the present interview, the Veteran discussed at some length his concerns and frustrations about his previous C&P examinations and denials of his claims of service connection for PTSD and other mental disorders. "It seems as though they have ignored that I was treated for anxiety and depression in service. When I checked into the hospital for my medical board, on the first page of the writeup it shows moderately depressed. That's a pretty strong indicator that somebody knew I was depressed." Reported that he was prescribed Darvon, Librium, and Valium in service. "That was a pretty good indicator that I was depressed. When the Marine Corps threw me out in 1969, it reaffirmed what that gunnery sergeant told me, that I was worthless. I have maintained that the Marine Corps should have hospitalized me. They threw me out instead of treating me. They gave me a personality disorder discharge for schizoid personality."

"In my first C&P exam back in 1974, the C&P examiner said he didn't even have my records. The most recent examiner said being beaten was not a personal assault. The examiner said it didn't qualify as a traumatic event. I'm not doing fine, or I wouldn't be here. The phrase I use to describe me is I feel like a whipped puppy. The episode in Marine Corps basic training defined me for the rest of my life. I feel like a dog that's been beaten down, doing everything I can to please everybody. Every job I've had, every endeavor I've got into is hoping it doesn't blow up in my face. I'm not gonna say my life has been a continual downslide since the Marine Corps. I have had good times. I have shot myself in the foot every time I've been a success. I'm not worthy of anything. Any success that would come to me would be a fluke because I'm not worthy of it. That started in the Marine Corps."

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: "-Redacted-" Please see his written statements submitted in support of his claim and the reports of previous C&P initial PTSD examinations dated 9/20/2017 and 5/21/2018 for further details.

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: In written statements submitted in support of his claim, three former service members who were in the same platoon as the Veteran attested to witnessing incidents similar in nature to those he described.

b. Stressor #2: "-Redacted-" Please see his written statements submitted in support of his claim and the reports of previous C&P initial PTSD examinations dated 9/20/2017 and 5/21/2018 for further details.

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: In a written statement submitted in support of his claim, a former service member who was in the same as the Veteran attested to witnessing incidents similar in nature to those he described.

c. Stressor #3: "-Redacted-" Please see his written statements submitted in support of his claim and the reports of previous C&P initial PTSD examinations dated 9/20/2017 and 5/21/2018 for further details.

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: In written statements submitted in support of his claim, three former service members who were in the same platoon as the Veteran attested to experiencing incidents similar in nature to those he described.

4. PTSD Diagnostic Criteria
---------------------------

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).

[X] Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s).

[X] Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings).

[X] Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).

[X] Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).

Criterion 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 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 or others.

[X] Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame).

[X] Markedly diminished interest or participation in significant activities.

[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] Hypervigilance.

[X] Problems with concentration.

[X] Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).

Criterion F:

[X] Duration of the symptoms described above in Criteria B, C, D, and E is more than 1 month.

Criterion G:

[X] The 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.

Criterion I: Which stressor(s) contributed to the Veteran's PTSD diagnosis?:

[X] Stressor #1

[X] Stressor #2

[X] Stressor #3

COMMENTS: The symptoms indicated above are those endorsed during the previous C&P Initial PTSD examination dated 5/21/2018. It should be noted that insufficient information to substantiate these symptoms was found in the most recent available treatment records.

5. Symptoms
---------------------------

For VA rating purposes, check all symptoms that actively apply to the Veteran's diagnoses:

[X] Depressed mood

[X] Anxiety

[X] Chronic sleep impairment

[X] Mild memory loss, such as forgetting names, directions or recent events

[X] Disturbances of motivation and mood

[X] Difficulty in establishing and maintaining effective work and social relationships

[X] Suicidal ideation

COMMENTS: The symptoms indicated above are those endorsed during the previous C&P Initial PTSD examination dated 5/21/2018.

6. Behavioral Observations (Redacted)

7. Other Symptoms
---------------------------

Does the Veteran have any other symptoms attributable to PTSD and other mental disorders that are not listed above?

[X] Yes [ ] No If yes, describe:

Low self-esteem, unstable self-image, chronic feelings of emptiness, self-dramatization, and self-focus. These symptoms were noted during the previous C&P examination dated 5/21/2018, and have previously been attributed to personality disorder and Major Depressive Disorder.

8. Competency
---------------------------

Is the Veteran capable of managing his or her financial affairs?

[X] Yes [ ] No

If no, explain: Not applicable.

9. Remarks, (including any testing results) if any:

The request for the present examination included several questions and requested medical opinions which overlap substantially in their content, and can essentially be framed as follows:

1) Does the Veteran have a diagnosis of PTSD, Major Depressive Disorder, or other mental disorder that was at least as likely as not (50 percent or greater probability) incurred in or caused by the claimed stressor of experiencing and witnessing physical assaults during his service in the Marine Corps?

2) Does the Veteran have a diagnosis of PTSD, Major Depressive Disorder, or other mental disorder that clearly and unmistakably existed prior to his military service, and that was at least as likely as not (50 percent or greater probability) aggravated beyond its natural progression by the claimed stressor of experiencing and witnessing physical assaults during his service in the Marine Corps?

Written statements from fellow Veterans who were in the same platoon attest to having experienced and witnessed incidents similar in nature to those described by the Veteran, lending support to his account. Consequently, for the purpose of the present examination, the claimed stressors are considered to be corroborated. For the purpose of this examination, the claimed stressors are also considered to be sufficient to cause PTSD as specified by DSM-5 diagnostic criteria, a clinical judgment which is inherently and unavoidably subjective to some extent.

The question of whether the Veteran has a current mental health condition which was caused or aggravated by the claimed stressors is difficult to address. This is due in part to significant advances in the conceptualization, assessment, and diagnosis of PTSD and other mental disorders in the years since the late 1960s, when the Veteran served in the military. Taken as a whole, in this examiner's opinion, the evidence available at this time is most supportive of a diagnosis of Major Depressive Disorder With Anxious Distress, and is insufficient to determine whether this condition was incurred during the Veteran's military service, or was aggravated by it. To make such a determination would require evidence regarding his pre-military history which has direct bearing on the question of the onset and etiology of his mental health difficulties, and which was not available to the present examiner.

OPINION 1: It is this examiner's opinion that the Veteran DOES NOT have a diagnosis of PTSD, Major Depressive Disorder, or other mental disorder that was at least as likely as not (50 percent or greater probability) incurred in or caused by the claimed stressor of experiencing and witnessing physical assaults during his service in the Marine Corps.

RATIONALE: The evidence available is insufficient to determine whether the Veteran's diagnosed mental disorder was incurred during his military service. To make such a determination would require evidence regarding his pre-military history which has direct bearing on the question of the onset and etiology of his mental health difficulties, and which was not available to the present examiner.

OPINION 2: It is this examiner's opinion that the Veteran DOES NOT have a diagnosis of PTSD, Major Depressive Disorder, or other mental disorder that clearly and unmistakably existed prior to his military service, and that was at least as likely as not (50 percent or greater probability) aggravated beyond its natural progression by the claimed stressor of experiencing and witnessing physical assaults during his service in the Marine Corps.

RATIONALE: The evidence available is insufficient to determine whether the Veteran's diagnosed mental disorder was aggravated by his military service. To make such a determination would require evidence regarding his pre-military history which has direct bearing on the question of the onset and etiology of his mental health difficulties, and which was not available to the present examiner.

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    • By Johnny Adams
      Good Morning,
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    • By JaeT.21
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    • By asknod
      Fifty years in the making. Five filings since 1971. Welcome home, Bob.  A truly fitting Christmas present.
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    • By rightstrivinsissy
      Hello Hadit Helpers, 
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    • By duffman88
      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: F43.12
      2.Current Diagnoses -------------------- a. Mental Disorder Diagnosis
      #1: Posttraumatic Stress Disorder ICD code: F43.12 Comments, if More likely than not secondary to military combat trauma.
      Mental Disorder Diagnosis #2: Persistent Depressive Disorder, with persistent Major Depressive Episode ICD code: F34.1 Comments, if any: More likely than not incurred during active duty military service.
      Mental Disorder Diagnosis #3: Alcohol Use Disorder ICD code: F10.20 Comments, if any: More likely than not secondary to diagnoses 1 and 2.
      b. Medical diagnoses relevant to the understanding or management of the mental health disorder (to include TBI): Obesity
      3. Differentiation of symptoms ------------------------------ a. Does the Veteran have more than one mental disorder diagnosed? [X] Yes [ ] No
      b. Is it possible to differentiate what symptom(s) is/are attributable to each diagnosis? [X] Yes [ ] No [ ] Not applicable (N/A)
      If yes, list which symptoms are attributable to each diagnosis and discuss whether there is any clinical association between these diagnoses: The veteran's symptoms can be partially differentiated. The symptoms specifically attributable to PTSD include those that reflect a reexperiencing of trauma (for example, nightmares, flashbacks, and intrusive memories), hyper arousal (for example, exaggerated startle reflex and hypervigilance), and avoidance of trauma reminders. Other symptoms are nonspecific and may reflect PTSD and/or depression. These symptoms include irritability, depressed mood, negative cognitions about self and others, sleep disturbance, diminished participation in significant activities, and disconnection from other people.
      The veteran's excessive use of alcohol can be understood as reflective of the avoidance symptoms of PTSD; the effect of the alcohol is to cause intoxication that allows the veteran to temporarily avoid other PTSD symptoms through alcohol "self-medication."
      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 deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood
      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: The impact of the veteran's mental conditions on social and occupational functioning is interrelated and overlapping, and therefore it is not possible to reliably differentiate the independent impact of each one on the veteran's functioning.
      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:
      The veteran's electronic claims file and VA records were reviewed. The veteran's claims file includes a DD 214 document showing entry into the US Army on November 17, 2009 with an honorable discharge at a rank of E4 on July 22, 2014. The reason for separation is listed as weight control failure. A separation medical examination dated April 20, 2014 is marked "normal" for psychiatric clinical evaluation. In support of the veterans claim for PTSD he provided written statements describing 2 stressful incidents as follows: 1) artillery attack in Afghanistan in January or February 2011, 2) Suicide of best friend on Christmas Day 2013. The veteran's VA records show that he was seen at the Newburg CBOC by the primary care mental health integration staff on July 27, 2016 at which time he was reporting symptoms including depression, feelings of worthlessness, sleep disturbance, and frustration. The diagnoses listed were "anger, anxiety." Records do not indicate the veteran followed up this appointments
      with additional sessions. The veteran was seen on January 17, 2019 at the Dayton VA Medical Ctr Prime care mental health integration program, where his chief complaint related to depressive symptoms that had begun shortly after his grandfather's death in 2011. He also reported the loss of 2 friends to suicide in 2012 and 2013. He reported symptoms including anergia, amotivation, depressed mood, irritability, and increased appetite as well as some anxiety symptoms that began in 2014 after separating from the military and included wanting to leave crowded situations and vague hypervigilance symptoms. The veteran reported that his depressive symptoms were his primary concern. He was diagnosed with unspecified depressive disorder (with rule out for major depressive disorder versus persistent depressive disorder) and unspecified anxiety disorder, (with rule out for generalized anxiety disorder versus PTSD). Records show the veteran was scheduled for group treatment following the initial assessment, but did not show, and has not returned to the VA for mental health treatment since then.
      2. History
      a. Relevant social/marital/family history (pre-military, military, and post-military): The veteran reported that he was raised in a small town in Ohio, living with his mother and grandparents until about age 10. His natural father was not in the picture. The veteran's stepfather entered his life when he was about 8, and later adopted him. The veteran also has 3 younge r sisters. He reported that he was treated very well by his parents and grandparents. He was involved in baseball and other sports, and had no significant academic problems. He graduated high school on time then briefly attended college. The veteran was married to his first wife before entering the military, but she left him when he was deployed to Afghanistan. That marriage never produced children. The veteran and his current wife have been married 7 years, and they have 2 children, ages 4 and 2. The veteran stated the relationship is "shitty" right now because he doesn't talk to his wife and he pushes her away. He said that she has talked about separating, and it was in January of this year that he finally sought treatment because she threatened to leave and take the children. The veteran stated the children are the only thing that brings a smile to his face.
      b. Relevant occupational and educational history (pre-military, military, and post-military): Prior to entering the military, the veteran briefly attended college, and then went to NASCAR tech school in North Carolina, but "it wasn't for me." He joined the military approximately at age 22. He was trained in artillery and deployed to Afghanistan in 2011. The veteran's duty in Afghanistan included providing FOB security, and tell her guard duty. Occasionally, they shot artillery.
      Military trauma:
      Stressor #1: Early in his tour while stationed in Bagram, the base was attacked with artillery fire. The veteran stated he was terrified and petrified. He was out smoking near the command post when the shells started hitting. He dove between some barriers and other people dove on top of him. He could hear the shells hitting and recalled turning over to see them flying overhead. After the shelling stopped, the veteran was frozen. His Sgt. slapped him. They had taken many incoming that day, and though nobody was killed in his platoon, the veteran doesn't know if others on the base were harmed. After that day, he remained always on alert and tried not to think about it.
      Stressor #2: Later, he was stationed in Salerno, Afghanistan when another artillery strike occurred. Again, the veteran froze.
      Stressor #3: A third incident occurred when he was stationed at COB Zormat - they took incoming artillery and returned artillery in response. Once again, the veteran froze, and was taken aside by his Sgt. who chewed him out, shamed him, and told him to hide his fear. The veteran stated he was afraid to say anything to anyone because he feared he looked like "a xxxxx." While in Afghanistan, the veteran received word from his wife that she wanted a divorce. The veteran stated that his friend helped him through his distress. In 2013, on Christmas day, his friend committed suicide. The veteran stated that when he heard of this, he was angry, including anger at himself for not seeing the warning signs. Veteran stated that his friend's suicide has ruined Christmas for him ever since. Post military occupational functioning: The veteran has been unable to maintain employment since his military discharge. In the first few years post discharge he held 4 to 5 different jobs, the longest being less than a year. Then, he found work as a corrections officer in a prison in Kentucky. However, the
      veteran's depression, drinking, calling off work, anxiety, and irritability, resulted in him being terminated after about 2 years. He got into trouble for losing his temper with the captain and cussing her out. In May 2018, he moved to Ohio having landed another job as a corrections officer with a prison in London. He was there less than 6 months before being terminated. Again, he was having difficulty due to anxiety, irritability, depression, poor attendance, and drinking. He briefly worked at the Post Office as a mail carrier after that, but couldn't get enough sleep, felt depressed, and felt that everyone who worked there was from the military. He couldn't stand it. The veteran has been unemployed for some months now. He wishes to return to school and earned his bachelor's degree. Even at school, he had difficulty because people wanted to ask him about his military service and he always wanted to avoid it.
      c. Relevant mental health history, to include prescribed medications and family mental health (pre-military, military, and post-military): The veteran stated that he was never the same after his deployment. He has felt fearful, depressed, and worthless. He experienced the loss of his grandfather while he was deployed, and the loss of his friend to suicide in 2013. The veteran stated he sleeps poorly, waking up many times throughout the night, and dreaming about artillery attacks. He has intrusive thoughts about his military trauma and other negative military experiences, and at times has physical symptoms including rapid heart rate, shortness of breath, sweating, and trembling. He drinks excessively as an apparent avoidance technique. He has problems with anger outbursts and irritability. He has hypervigilance, problems concentrating, exaggerated startle reflex, feelings of guilt, feelings of inadequacy and worthlessness, inability to connect with others, and wonders if others would be better off if he were dead. The veteran second-guesses his actions in Afghanistan and thinks he could've done better and "I should've manned up." He said he feels worthless. He wonders why he cowered when his base was attacked. He shakes when he hears loud noises, and can't tolerate fireworks. He rarely does activities unless he must, and generally just wants to be by himself. He sees others as threatening, and feels disconnected from everyone including his wife, with the exception of his children, and more recently, his therapist Dr. Ward. The veteran stated he has lost interest in things he used to enjoy, most notably sports. He overeats and drinks excessively. He avoids his friends because he doesn't want to talk about the military. He dropped
      out of school because people kept asking about his military service. He hates going to his parents home because his mother has erected a "shrine" to him in their living room, and he is to fearful of disappointing his parents to tell them how much he hates it. The veteran sought treatment earlier this year, and has now been working with a psychologist in Spring field, Dr. Ward, for 4-5 months. He stated that Dr. Ward is the one person he feels close to. They recently began EMDR therapy. The veteran has been referred for medication, but is awaiting his first appointment.
      d. Relevant legal and behavioral history (pre-military, military, and post-military): The veteran has no history of legal problems.
      e. Relevant substance abuse history (pre-military, military, and post-military): The veteran has been drinking excessively since his return from Afghanistan. He estimates that he was drinking a bottle of hard liquor per day at his peak. It has decreased somewhat recently as he has been engaged in therapy, but he continues to drink quite heavily. 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: Artillery attacks at Bagram and Salerno, Afghanistan 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
      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 associated with the traumatic event(s), beginning after the traumatic event(s) occurred: [X] Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). [X] Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s). [X] Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s). [X] Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
      Criterion Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic events(s) occurred, as evidenced by one or both of the following: [X] Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). [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 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] Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others. [X] Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame). [X] 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] Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects. [X] Reckless or self-destructive behavior. [X] Hypervigilance. [X] Exaggerated startle response. [X] Problems with concentration. [X] Sleep disturbance (e.g., difficulty falling or staying asleep or restless 
      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] 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
      6. Behavioral Observations -------------------------- The veteran arrived on time for his scheduled examination. His identity was confirmed by having him provide his full name and date of birth. The veteran presents as a tall, obese, Caucasian male who appears the stated age. He was dressed casually and exhibited good grooming and hygiene. He had tattoos visible on his lower and upper extremities. His posture, gait, and psychomotor activity were within normal limits. His manner of interaction was cooperative, courteous, and friendly. His speech was normal in rate, rhythm, tone, and volume. His thought processes were clear, logical, coherent, and goal-directed. Veteran reported his mood to be depressed, with affect congruent. He denied suicidal ideation, but admitted to thoughts of death and wondering if others would be better off without him. He denied homicidal ideation as well as auditory and visual hallucinations.
      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 -------------------------------------------------- In my opinion, the veteran meets DSM 5 diagnostic criteria for posttraumatic stress disorder, which is more likely than not secondary to military trauma. In this veteran's case, there is a strong component of shame that is also associated with his military service and is foundationally related to his depressive disorder. His experience of freezing during 3 artillery attacks is something that is associated with feelings of overwhelming shame, worthlessness, helplessness, and inadequacy for the veteran. These thoughts and feelings contribute significantly to his depressive condition, and contribute meaningfully to his PTSD symptoms as well. The veteran also experienced significant losses during military service that have likely aggravated his PTSD and depressive conditions. Notably, the veteran's grandfather died in 2011 when the veteran was deployed to Afghanistan, and his best friend committed suicide on Christmas day in 2013. Both losses were experienced by the veteran as emotionally traumatic and contribute to his symptomatology. The veteran has developed a dysfunctional coping mechanism of excessive alcohol intake in his efforts to suppress negative feelings associated with his traumas. As his excessive alcohol use appears to be largely in the service of avoidance of distress and suppression of intrusive/reexperiencing symptoms, it is my opinion that his alcohol use disorder is secondary to his PTSD and depressive disorders. The veteran's mental health symptoms have severely impaired his functional capacity. He is socially disengaged and avoidant. He has difficulty expressing himself emotionally, showing empathy, or forming emotional bonds with others. Occupationally, the veteran has exhibited significant dysfunction as he has been unable to maintain employment due to anxiety, depression, avoidance, alcohol abuse, irritability, shame. Hs shame about his reactions of freezing during artillery attacks prompts him to avoid interpersonal interactions as much as possible as he fears that the topic of his military service will arise. Recently, the veteran has begun outpatient mental health treatment in the form of individual counseling, and he is awaiting an appointment for trial of medication.
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    • Enough has been said on this topic. This forum is not the proper forum for an attorney and former client to hash out their problems. Please take this offline
    • Peggy toll free 1000 last week, told me that, my claim or case BVA Granted is at the RO waiting on someone to sign off ,She said your in step 5 going into step 6 . That's good, right.?
      • 7 replies
    • I took a look at your documents and am trying to interpret what happened. A summary of what happened would have helped, but I hope I am interpreting your intentions correctly:


      2003 asthma denied because they said you didn't have 'chronic' asthma diagnosis


      2018 Asthma/COPD granted 30% effective Feb 2015 based on FEV-1 of 60% and inhalational anti-inflamatory medication.

      "...granted SC for your asthma with COPD w/dypsnea because your STRs show you were diagnosed with asthma during your military service in 1995.


      First, check the date of your 2018 award letter. If it is WITHIN one year, file a notice of disagreement about the effective date. 

      If it is AFTER one year, that means your claim has became final. If you would like to try to get an earlier effective date, then CUE or new and material evidence are possible avenues. 

       

      I assume your 2003 denial was due to not finding "chronic" or continued symptoms noted per 38 CFR 3.303(b). In 2013, the Federal Circuit court (Walker v. Shinseki) changed they way they use the term "chronic" and requires the VA to use 3.303(a) for anything not listed under 3.307 and 3.309. You probably had a nexus and benefit of the doubt on your side when you won SC.

      It might be possible for you to CUE the effective date back to 2003 or earlier. You'll need to familiarize yourself with the restrictions of CUE. It has to be based on the evidence in the record and laws in effect at the time the decision was made. Avoid trying to argue on how they weighed a decision, but instead focus on the evidence/laws to prove they were not followed or the evidence was never considered. It's an uphill fight. I would start by recommending you look carefully at your service treatment records and locate every instance where you reported breathing issues, asthma diagnosis, or respiratory treatment (albuterol, steroids, etc...). CUE is not easy and it helps to do your homework before you file.

      Another option would be to file for an increased rating, but to do that you would need to meet the criteria for 60%. If you don't meet criteria for a 60% rating, just ensure you still meet the criteria for 30% (using daily inhaled steroid inhalers is adequate) because they are likely to deny your request for increase. You could attempt to request an earlier effective date that way.

       

      Does this help?
    • Thanks for that. So do you have a specific answer or experience with it bouncing between the two?
    • Tinnitus comes in two forms: subjective and objective. In subjective tinnitus, only the sufferer will hear the ringing in their own ears. In objective tinnitus, the sound can be heard by a doctor who is examining the ear canals. Objective tinnitus is extremely rare, while subjective tinnitus is by far the most common form of the disorder.

      The sounds of tinnitus may vary with the person experiencing it. Some will hear a ringing, while others will hear a buzzing. At times people may hear a chirping or whistling sound. These sounds may be constant or intermittent. They may also vary in volume and are generally more obtrusive when the sufferer is in a quiet environment. Many tinnitus sufferers find their symptoms are at their worst when they’re trying to fall asleep.

      ...................Buck
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