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ArmyMajor

C and P Exam PTSD/MST More Information

Question

 

I have included all of the information to include the opinions of three different VA psychologist/psychiatrist, clinical nurse practitioner and therapist opinions.  The clinical nurse practitioner most recent diagnosis was chronic PTSD and depressive disorder by psychiatrist, medical doctor (April 2018)

 

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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12 hours ago, Berta said:

I agree- perhaps the examiner had no real expertise in this type of claim to catch any markers

Markers are important for PTSD claims as well as MST claims.

I have a friend who says he has PTSD. He wanted me to agree with that because I worked in a PTSD combat group

at a vet center long ago and most of the local vets I know have PTSD and also my husband had it.

Every time my friend  brings this up ( he is a retiree) he never seems to have any valid stressor at all.

And I see no markers in his behavior, nor did he mention anything in  over 20 of service not only to the Military but over 20 with the Federal Government, that would suggest any MH issue due to his service.

I suggested many times that he see the local VSOs and file a claim but it seemed he wanted me to file the claim- I dont file claims.....

I told him I believed any VSO , who is also a veteran -I am a civilian, could draw him out better than I could to find a provable stressor.

In your case, do you have any buddy statements, or anything in your 201 Military Personnel file that could help prove the MST? But that still leaves the marker issue-----Mstmale is correct.

These claims should be handled by someone with MST claim experience. Have you googled the examiner's name?

Also somewhere here is the VA's link to finding out if a VA doctor is a contractor- and with their name , maybe more pops up as to their expertise.

https://cck-law.com/news/military-sexual-trauma-mst-service-connection/

This site above fromwell respected  Vet lawyers has some excellent info that might help- and we do have MST male and female survivors here at hadit, who have won their claims.

I do not doubt you at all, and suggest you pursue this as much as you can- and try to seek a better C & P exam ...particularly if you can prove this examiner was not qualified to do the C & P exam.

 

 

 

Bertha, how do you go about obtaining a new C & P exam in a case such as this.  The C & P examiner was a clinical psychologist and I will continue to work with my VSO.  Thanks to you and others that have provided support in this case.  This has been one the hardest things that I have ever had to do.

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1 hour ago, ArmyMajor said:

Bertha, how do you go about obtaining a new C & P exam in a case such as this.  The C & P examiner was a clinical psychologist and I will continue to work with my VSO.  Thanks to you and others that have provided support in this case.  This has been one the hardest things that I have ever had to do.

When you filed the claim there was a section on the form to add the markers you had. I'd simply ask your vso to make those corrections and see if they will just reconsider it. What did you write down as proof? Did your vso even ask you? Has your claim already been decided? You still need proof of the markers. Get your military service records. 

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I had two different notifications for two different threads on this same subject-

I answered minutes ago in the other thread-

This post says:

10 hours ago, ArmyMajor said:

Vync, thank you for the information, there are markers that are contained in my record.  I requested an immediate transfer from the unit and another marker is that I requested to retire, ilo of staying in the military.  Of course, I had buddy statements to validate the change in my well-being and overall change in myself.  I thank you in advance and your post has been extremely helpful.  I hope that they look at the overwhelming evidence that has been provided through several therapy sessions and not just with short visit with the C & P examiner.

 

These indicate markers that something happened to you-

Does the VA have the documentation of proof of what is in your service records to verify  the above?

I am sure many here missed that older thread- it pays to stay in the same thread, same topic-

In any event the post I made this AM in the other thread should help you get another C & P exam.

 

 

 

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12 hours ago, ArmyMajor said:

Vync, thank you for the information, there are markers that are contained in my record.  I requested an immediate transfer from the unit and another marker is that I requested to retire, ilo of staying in the military.  Of course, I had buddy statements to validate the change in my well-being and overall change in myself.  I thank you in advance and your post has been extremely helpful.  I hope that they look at the overwhelming evidence that has been provided through several therapy sessions and not just with short visit with the C & P examiner.

This could be grounds for an new C&P exam given the examiner failed to thoroughly go through your claims file and find the markers.

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Posted (edited)

 As of August this past year the VA was still proving to process MST claims improperly.https://cck-law.com/news/va-mishandled-military-sexual-trauma-mst-claims-va-oig-reports/

 

If you are denied or low balled please don't take it personally.  It isn't easy but I doubt it's easy for those that were approved the first time around.  Its hard tapping into those old emotions while trying to get strangers to understand the destruction. It's hard no matter what but some of us are required to fight longer and we are not alone.

 

 

Edited by Pockets

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