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ArmyMajor

C and P Exam PTSD/MST Update

Question

I have a pending VA claim for PTSD/MST and I have included the original post that was related to conflicting information from the VA C & P examiner and notes from another VA psychologist that were made a few days later.  The intake psychologist also diagnosed me in April 2018 with depressive disorder. I also included the most recent notes from my VA therapist that I have been seeing since March 2018.  I am also followed by clinical nurse practitioner, which diagnosed with me as having chronic PTSD in December 2018.  Any thoughts of a potential rating would be appreciated.

 

 

Therapist Notes (December 2018)


PTSD SCREEN PC-PTSD-5+I9 PTSD Screening Score: 5 The score for this administration is 5, which indicates a POSITIVE screen for PTSD in the past month.

 PC-PTSD-5+I9 Suicide Screening Score: 1 The results of this administration revealed suicidal ideation over the last 2 weeks, which indicates a POSITIVE primary screen for Risk of Suicide.

PHQ-2+I9 PHQ-2+I9 Depression Screening Score: 2 The score on this administration is 2, which indicates a negative screen on the Depression Scale over the past two weeks.

 PHQ-2+I9 Suicide Screening Score: 1  The results of this administration revealed suicidal ideation over the last 2 weeks, which indicates a POSITIVE primary screen for Risk of Suicide.

AUDIT-C An alcohol screening test (AUDIT-C) was positive (score=9).

 

Posted March 24, 2018 (edited)

 

I was scheduled for an appointment with a VA psychologist and the below are her results, which is seems to conflict the C and P examiner ...... any feedback is appreciated

 VA Psychologist Notes (March 2018)

Military History

Branch (years of service): MST: yes
 

MEASUREMENT BASED CARE:
PHQ-9: 19 (moderate)
GAD-7: 16 (severe)
PCL-5:
AUDIT-C: 5 (above threshold)

 

DIAGNOSTIC IMPRESSIONS:
Anxiety Disorder, unsp
MDD, recurrent, moderate

 

Depression Monitoring (PHQ-9) 2017:
Depression Screen:
PHQ9 Screening
PHQ-9
A PHQ-9 screen was performed. The score was 19 which is suggestive
of moderately severe depression.

 

PTSD Screening:
PTSD Screen:
PTSD Screening
PC PTSD
A PTSD screening test (PC-PTSD) was positive (score=4).

 

+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

 

C & P Examiners Notes (March 2018)

 

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: UNSPECIFIED DEPRESSIVE DISORDER
b. Medical diagnoses relevant to the understanding or management of the
Mental Health Disorder (to include TBI): SEE MEDICAL CHART
3. Differentiation of symptoms
------------------------------
a. Does the Veteran have more than one mental disorder diagnosed?
[ ] Yes [X] No
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] 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 medication

TYPE OF MEDICAL OPINION REQUESTED: Military Sexual Trauma (MST)
OPINION: Military Sexual Trauma (MST)
This examination is being conducted to assist with determining whether the
Veteran experienced an in-service personal assault stressor related to
military sexual trauma (MST) that has resulted in a current PTSD diagnosis.
Please review the claims file and state in your report that it was reviewed.
In your review of the claims file, please pay special attention to signs,
events, or circumstances that may represent markers for the MST stressor
described by the Veteran. Your review is not limited to the evidence
identified on this request form, or tabbed in the claims folder. If
additional testing is required, please obtain it prior to rendering your
opinion.
Based upon your review of the evidence, please provide a medical opinion as
to whether the MST stressor event described by the Veteran is at least as
likely as not (50 percent or greater probability) supported by and consistent
with the in-service marker evidence. Please provide a rationale for the
opinion and list the marker evidence used to arrive at your decision.
NO MARKERS IDENTIFIED. MEDICAL OPINION DOES NOT APPEAR WARRANTED.


In addition:
1. IF YOUR EXAMINATION DETERMINES THE VETERAN HAS A CURRENT DIAGNOSIS OF
PTSD, please provide an opinion as to whether the current PTSD diagnosis is
at least as likely as not (50 percent or greater probability) caused by or a
result of the in-service MST-related marker(s), and provide a rationale.
Please note that only PTSD can be service connected based on circumstantial
marker evidence (38 CFR 3.304(f) (5)).
VETERAN'S SYMPTOMS APPEAR TO BE BEST ACCOUNTED FOR BY A DIAGNOSIS OF
UNSPECIFIED DEPRESSIVE DISORDER. MEDICAL OPINION DOES NOT APPEAR WARRANTED.

2. IF YOUR EXAMINATION DETERMINES THAT, IN ADDITION TO PTSD, THE VETERAN HAS
ADDITIONAL MENTAL DISORDERS, please state whether the additional mental
disorders are at least as likely as not (50 percent or greater probability)
secondary to the PTSD, and provide a rationale. For each mental disorder

MEDICAL OPINION DOES NOT APPEAR WARRANTED.


3. IF YOUR EXAMINATION DETERMINES THE VETERAN DOES NOT HAVE PTSD, BUT HAS A
DIFFERENT MENTAL DISORDER(S), please review the service treatment records
(STRs) and service personnel records for in-service direct evidence. Direct
evidence is clear, undisputable proof of an event, injury, or disease. Such
evidence includes, but is not limited to, mental health treatment, mental
health symptoms, or a mental health diagnosis. If direct evidence exists in
the STRs or service personnel records, please provide an opinion as to
whether the mental disorder(s) diagnosed on examination is at least as likely
as not (50 percent or greater probability) caused by or a result of the
direct evidence noted in service. Please provide a rationale for the opinion
and list the evidence used to arrive at your decision. (38 CFR 3.303).


NO DIRECT EVIDENCE LOCATED. OPINION DOES NOT APPEAR WARRANTED

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On the surface, it does not look like service connection (SC) will be granted based on that C&P exam. However, keep in mind the VA reworked the PTSD rules about 5 or 6 years ago so they require a separate doc to perform PTSD examinations. In effect, it takes the decision about SC from the treating providers who know you well and puts it into the hands of a single doc who will see you for an hour tops and try to cobble it all together, often incorrectly. I hope this will change for the better eventually.

At first impression, the results appear to contradict themselves. Your March and December 2018 PTSD score was positive, indicating you have a diagnosis, but the C&P exam indicated it was negative. It is odd that the C&P doctor indicates "no markers identified", "no direct evidence located" and "repeatedly states the opinion was not warranted" when there appears to be some evidence to the contrary. This makes me wonder if they performed a thorough review of your records.

Sometimes a PTSD diagnosis takes time. Your doctors observe you at each visit and evaluate based on your history and current condition.

Keep in mind you will need three things for service connection: 
1. Event/injury from being in service
2. Current diagnosis
3. Medical opinion connecting 1 and 2

I'm not an expert, but I would recommend doing the following:
1. Wait for your award or SSOC letter to arrive in the mail. Thoroughly review it. It will include a "reasons and bases" which will describe how the VA came to their decision.
2. If denied, I would first find out the credentials of the C&P examiner. If it was a Nurse Practitioner, immediately file a notice of disagreement or request reconsideration on the basis that a board certified psychiatrist or psychologist should perform the exam.
3. If granted, compare the rating granted against the table below.

There is also another important factor. The VA will only grant a single mental health rating regardless of the diagnosed disorders.  Just because they deny PTSD doesn't mean they can't SC you for depression. Once service connected, be aware of the variety of criteria which could warrant an increase, should your condition worsen.

If you were to become service connected, according to 4 (a) in the C&P findings, you would match the 10% rating criteria, per the table below.

Quote

General Rating Formula for Mental Disorders

    Rating
Total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 100
Occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. 70
Occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. 50
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.

 

 

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there are no medical records to show my drill sgt harassed me for weeks before stepping up his abuse and me filing a complaint.  There is nothing in my str to show my childhood friend and co-enlistee was raped, tortured, and murdered. I was out in less than three months after her murder. I guess I'd raise all kinds of hell if I received a C&P like this. The VA needs to hand over investigation reports if they want a psychologist to determine if military sexual trauma has occurred.

 

I know enough about the VA to make me wonder why so many people fight for mental health services with them. But my last psychologist isn't with them anymore. She said things like "the client who wishes to be called" as if I'm a liar and in the end, she proved herself to be a liar.  I"m not saying that's why she left the VA but she shouldn't have been there and I'm glad she is no longer working with our Veterans.

 

It doesn't look good with the C&P but hopefully they will grant you depression if nothing else. It's a start and hopefully  acknowledging your trauma will give you strength to continue your fight.  It seems to me the people working with you longest would be give more weight than someone who met with you for an hour but I don't think that's the way it works.

 

Best of luck to you ArmyMajor

 

I came back to add.. I know there are plenty of abused veterans that didn't file a complaint. There were a few more abused my our drill sergeant but the company commander talked them out of filing a report. That is what the MST program is supposed to be about but if they won't acknowledge investigations than how can we expect them to help those that were too scared to take their stand? those that sought help and then abused and/or ignored by the system?  Psychologist have no business looking at records to decide if a veteran is a liar or not. Especially when the VA fails to hand over all evidence.  Remember these victims had to ask permission to go to sick call. many were denied basic human rights and the MST program is a good start but it is still failing many.

Edited by Pockets
i said assault but i changed to Military sexual trauma

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14 hours ago, ArmyMajor said:

I have a pending VA claim for PTSD/MST and I have included the original post that was related to conflicting information from the VA C & P examiner and notes from another VA psychologist that were made a few days later.  The intake psychologist also diagnosed me in April 2018 with depressive disorder. I also included the most recent notes from my VA therapist that I have been seeing since March 2018.  I am also followed by clinical nurse practitioner, which diagnosed with me as having chronic PTSD in December 2018.  Any thoughts of a potential rating would be appreciated.

 

 

Therapist Notes (December 2018)


PTSD SCREEN PC-PTSD-5+I9 PTSD Screening Score: 5 The score for this administration is 5, which indicates a POSITIVE screen for PTSD in the past month.

 PC-PTSD-5+I9 Suicide Screening Score: 1 The results of this administration revealed suicidal ideation over the last 2 weeks, which indicates a POSITIVE primary screen for Risk of Suicide.

PHQ-2+I9 PHQ-2+I9 Depression Screening Score: 2 The score on this administration is 2, which indicates a negative screen on the Depression Scale over the past two weeks.

 PHQ-2+I9 Suicide Screening Score: 1  The results of this administration revealed suicidal ideation over the last 2 weeks, which indicates a POSITIVE primary screen for Risk of Suicide.

AUDIT-C An alcohol screening test (AUDIT-C) was positive (score=9).

 

Posted March 24, 2018 (edited)

 

I was scheduled for an appointment with a VA psychologist and the below are her results, which is seems to conflict the C and P examiner ...... any feedback is appreciated

 VA Psychologist Notes (March 2018)

Military History

Branch (years of service): MST: yes
 

MEASUREMENT BASED CARE:
PHQ-9: 19 (moderate)
GAD-7: 16 (severe)
PCL-5:
AUDIT-C: 5 (above threshold)

 

DIAGNOSTIC IMPRESSIONS:
Anxiety Disorder, unsp
MDD, recurrent, moderate

 

Depression Monitoring (PHQ-9) 2017:
Depression Screen:
PHQ9 Screening
PHQ-9
A PHQ-9 screen was performed. The score was 19 which is suggestive
of moderately severe depression.

 

PTSD Screening:
PTSD Screen:
PTSD Screening
PC PTSD
A PTSD screening test (PC-PTSD) was positive (score=4).

 

+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

 

C & P Examiners Notes (March 2018)

 

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: UNSPECIFIED DEPRESSIVE DISORDER
b. Medical diagnoses relevant to the understanding or management of the
Mental Health Disorder (to include TBI): SEE MEDICAL CHART
3. Differentiation of symptoms
------------------------------
a. Does the Veteran have more than one mental disorder diagnosed?
[ ] Yes [X] No
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] 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 medication

TYPE OF MEDICAL OPINION REQUESTED: Military Sexual Trauma (MST)
OPINION: Military Sexual Trauma (MST)
This examination is being conducted to assist with determining whether the
Veteran experienced an in-service personal assault stressor related to
military sexual trauma (MST) that has resulted in a current PTSD diagnosis.
Please review the claims file and state in your report that it was reviewed.
In your review of the claims file, please pay special attention to signs,
events, or circumstances that may represent markers for the MST stressor
described by the Veteran. Your review is not limited to the evidence
identified on this request form, or tabbed in the claims folder. If
additional testing is required, please obtain it prior to rendering your
opinion.
Based upon your review of the evidence, please provide a medical opinion as
to whether the MST stressor event described by the Veteran is at least as
likely as not (50 percent or greater probability) supported by and consistent
with the in-service marker evidence. Please provide a rationale for the
opinion and list the marker evidence used to arrive at your decision.
NO MARKERS IDENTIFIED. MEDICAL OPINION DOES NOT APPEAR WARRANTED.


In addition:
1. IF YOUR EXAMINATION DETERMINES THE VETERAN HAS A CURRENT DIAGNOSIS OF
PTSD, please provide an opinion as to whether the current PTSD diagnosis is
at least as likely as not (50 percent or greater probability) caused by or a
result of the in-service MST-related marker(s), and provide a rationale.
Please note that only PTSD can be service connected based on circumstantial
marker evidence (38 CFR 3.304(f) (5)).
VETERAN'S SYMPTOMS APPEAR TO BE BEST ACCOUNTED FOR BY A DIAGNOSIS OF
UNSPECIFIED DEPRESSIVE DISORDER. MEDICAL OPINION DOES NOT APPEAR WARRANTED.

2. IF YOUR EXAMINATION DETERMINES THAT, IN ADDITION TO PTSD, THE VETERAN HAS
ADDITIONAL MENTAL DISORDERS, please state whether the additional mental
disorders are at least as likely as not (50 percent or greater probability)
secondary to the PTSD, and provide a rationale. For each mental disorder

MEDICAL OPINION DOES NOT APPEAR WARRANTED.


3. IF YOUR EXAMINATION DETERMINES THE VETERAN DOES NOT HAVE PTSD, BUT HAS A
DIFFERENT MENTAL DISORDER(S), please review the service treatment records
(STRs) and service personnel records for in-service direct evidence. Direct
evidence is clear, undisputable proof of an event, injury, or disease. Such
evidence includes, but is not limited to, mental health treatment, mental
health symptoms, or a mental health diagnosis. If direct evidence exists in
the STRs or service personnel records, please provide an opinion as to
whether the mental disorder(s) diagnosed on examination is at least as likely
as not (50 percent or greater probability) caused by or a result of the
direct evidence noted in service. Please provide a rationale for the opinion
and list the evidence used to arrive at your decision. (38 CFR 3.303).


NO DIRECT EVIDENCE LOCATED. OPINION DOES NOT APPEAR WARRANTED

It appears you'll be rated at 10% according to the criteria the examiner provided. The problem with this C&P exam is that NO RATIONALE is being provided other than OPINION DOES NOT APPEAR WARRANTED.

That's a half ass exam, to be honest. The examiner also failed to use one of these five phrases the Ratings schedulers need to see to grant a claim. [Don't be surprised if it gets kicked back to the examiner for an addendum and it shows in Ebenefits that it went back to gathering of information.]

1. "due to" (100% probability)

2."more likely than not" (greater than 75% probability)

3."at least as likely as not" (equal to or greater than 50% probability)

4. "less likely than not" (less than 50% probability)

5. "not due to" (100% improbability)

If you get the 10% SC granted all you will need to do is keep going to mental health to build on the medical evidence for an "increase". You're symptoms will become worse within the next 1-2 years. You can still appeal if you wish to do so.

If you get denied for this claim, appeal it and file your NOD immeadiately. 

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The C&P appears to contradict everything you are saying about your medical care.  This is not good.  Right now file a FIOA to get your VA medical records.  This is the form you need to fill out.

https://www.va.gov/vaforms/medical/pdf/vha-10-5345-fill.pdf

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If he/she had a MST/ PTSD dx from the VA,THAT ARE  UNSPECIFIC , then VA Dr's  must Decide. usually ?MST is Related to PTSD Caused from the trauma.

This C&P Can be of Inadequacy and another one Re- scheduled.

Then he/she needs to get in therapy asap, talk to a therapist, then maybe work on this claim.

These type claims should be treated with respect and in total consideration to the MST Victim

 Usually if no records are found to connect it to military service, the Veterans lay statement must be strong and able to proof with markers as to the trauma that took place rather that trauma was  Rape or  some type of sexual act that was improper from another individual such as a co military personal that caused the trauma. even sexual harassment.

  a person don't have to be rape to  claim MST  So the This Veteran can write out a statement in detail to describe what happen or what causes the trauma , any VA psychologist  can take that statment to be the truth.

MST Victims some times never come forward For years, rather that's their choice or to embarrassed or what ever their reason ,When they do come forward and ask for Help the VA will help them, when applying for a MST CLAIM and if no medical records found, then a strong lay statment from this Veteran should be considered. what happen time and location /if it happen on military insulation/or private ect,,ect,, and dates in his/her statment...and this can be corroborated from witness or from police reports or military   or buddy statements  someone that was there to witness the fact or the trauma. any type of information to help substantiate the claim  and usually that is found in markers and the veterans symptoms. and the severity! of them.

I would think the main thing to do for this Veteran is get help with the VA MH Dept see an MST Coordinator   and seek VA counseling/Therapy.

Edited by Buck52
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