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82n17rddairbornevet757

My C&P exam states total occupation and social impairment

Question

My C&P exam states total occupation and social impairment. Does this guarantee that I will receive 100% for PTSD. Also my claim (increase) is currently in Prep for Decision. My claim has been in this stage since about mid-December. I only have one claim submitted right now and that is this claim for PTSD. How long do you think it will be before my claim is completed.

Thanks

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Posted (edited)

Not even close to a guarantee.  There is a lot more stuff you have to have.since you apparently are already sc, you have to show your symptoms are worse.  What were your symptoms when benefits were awarded?  Are you working?  Does this c and p exam conflict with other medical exams??  

Is the doctor qualified..and does he give a rationale for his opinion?  

Any of these, above, can put your claim off track.  

Worse, many times VA does not even bother to read our evidence, so we get denied even when we have the evidence.  

Edited by broncovet

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I Totally Agree with broncovet!!!🤔

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Good info from @broncovet

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Good info and the originator did not specify many other details if they could post the report we could give a better guess 

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Here is most of my exam.

 

 

Is this DBQ being completed in conjunction with a VA 21-2507, C&P
Examination
Request?
[X] Yes [ ] No
SECTION I:
----------
1. Diagnostic Summary
---------------------
Does the Veteran now have or has he/she ever been diagnosed with PTSD?
[X] Yes [ ] No
ICD Code: F43.10
2. Current Diagnoses
--------------------
a. Mental Disorder Diagnosis #1: Post-Traumatic Stress Disorder with Panic Attacks
ICD Code: F43.10
Comments, if any: The Veteran's Panic Attacks symptoms within the
context of his Post-Traumatic Stress Disorder with Panic Attacks are
the
following:
1) Heart racing
2) Sweating
3) Sensations of shortness of breath
4) Feelings of choking
5) Chest discomfort/ tightness
6) Nausea and abdominal distress
7) Feeling unsteady and lightheaded
😎 Chills and hot flashes
9) Fear of losing control
10) Fear of dying
11) Feelings of being detached from reality (being detached from
oneself)
NOTE: He noted that he has experienced coughing when having Panic
Attacks since July 24,2018.
Mental Disorder Diagnosis #2: Unspecified Depressive Disorder
ICD Code: F32.9
Comments, if any: The Veteran has displayed the following symptoms of
an
Unspecified Depressive Disorder across the past year:
1) Depressed mood
2) Reduced interest and pleasure in many activities
3) Sleep disruption
4) Irritability
5) Fatigue
6) Problems with concentration
7) Significant impairment in social and occupational functioning
associated with the Veteran's Unspecified Depressive Disorder
symptoms
😎 See suicide assessment section in relevant mental health history
section of this DBQ PTSD Review examination for information pertaining
to the Veteran's suicide ideation
9) Periods of experiencing Feelings of Hopelessness
b. Medical diagnoses relevant to the understanding or management of the
Mental Health Disorder (to include TBI): Deferred
3. Differentiation of symptoms
a. Does the Veteran have more than one mental disorder diagnosed?
[X] Yes [ ] No
b. Is it possible to differentiate what symptom(s) is/are attributable to
each diagnosis?
[ ] Yes [X] No [ ] Not applicable (N/A)
If no, provide reason: The symptoms of each of the psychiatric
disorders that the Veteran has been diagnosed with cannot be
differentiated without undue speculation at this time.
c. Does the Veteran have a diagnosed traumatic brain injury (TBI)?
[ ] Yes [ ] No [X] Not shown in records reviewed
4. Occupational and social impairment
-------------------------------------
a. Which of the following best summarizes the Veteran's level of
occupational
and social impairment with regards to all mental diagnoses? (Check only
one)
[X] Total occupational and social impairment
b. For the indicated occupational and social impairment, is it possible to
differentiate which impairment is caused by each mental disorder?
[ ] Yes [X] No [ ] Not Applicable (N/A)
If no, provide reason: The portion of the level of occupational and
social impairment attributable to each psychiatric disorder that the
Veteran has been diagnosed with having cannot be distinguished
without undue speculation. 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
2. Recent History (since prior exam)
------------------------------------
a. Relevant social/marital/family history:
He reports that since July 24, 2018 he has experienced a low interest
in communicating with members of his family of origin contributing to
impairment in these relationships with this impairment associated in
part with his Post-Traumatic Stress Disorder with Panic Attacks and
Unspecified Depressive Disorder.
The Veteran reported that since July 24,2018 he has infrequently
communicated with members of his family of origin contributing to
social impairment in these relationships with this impairment
attributed partly to his Post-Traumatic Stress Disorder with Panic
Attacks and Unspecified Depressive Disorder.
He noted that at times small issues since July 24,2018 have lead to
him
respond in an irritable and impatient manner towards members of his
family of origin in excess of what would be expected given the issues
in question contributing to impairment in his relationships with
members of his family of origin and this impairment is associated
partly with his Post-Traumatic Stress Disorder with Panic Attacks and
Unspecified Depressive Disorder.
The Veteran noted that often since July 24,2018 he has withdrawn from
interacting with members of his family of origin contributing to
impairment in these relationships and this impairment is associated in
part with his Post-Traumatic Stress Disorder with Panic Attacks and
Unspecified Depressive Disorder.
He indicated that he has tended to keep his conversations brief and
not
in depth when communicating with members of his family of origin since
July 24,2018 contributing to impairment in these family relationships
and this impairment is associated in part with his Post-Traumatic
Stress Disorder with Panic Attacks and Unspecified Depressive
Disorder.
He noted that he has rarely attended social gatherings with members of
his family of origin since July 24,2018 and then has stayed at these
gatherings only briefly with this impairment associated partly with
his
Post-Traumatic Stress Disorder with Panic Attacks and Unspecified
Depressive Disorder and when he has attended these social gatherings
he
has attended them briefly. He noted that for many social gatherings
his family of origin has contacted the Veteran's wife and she has
attended these gathering with their children and herself without
the
Veteran with this social impairment associated in part with his
Post-Traumatic Stress Disorder with Panic Attacks and Unspecified
Depressive Disorder since July 24,2018.
Overall since July 24,2018 the Veteran reported experiencing moderate
to high levels of impairment in his relationships with members of his
family of origin associated with his Post-Traumatic Stress Disorder
with Panic Attacks and Unspecified Depressive Disorder.
The Veteran reported that his current and only marriage began 7 years
ago.
The Veteran noted that frequently since July 24,2018 that he has
responded in an irritable and impatient manner towards his spouse in
excess of what would be expected given the issues in question
contributing to impairment in the Veteran's relationship with his
spouse and this impairment is associated in part with his
Post-Traumatic Stress Disorder with Panic Attacks and Unspecified
Depressive Disorder.
The Veteran noted that he has has experienced a low interest in
attending social outings with his spouse since July 24,2018
contributing to impairment in this relationship and this impairment is
associated in part with his Post-Traumatic Stress Disorder with Panic
Attacks and Unspecified Depressive Disorder.
The Veteran noted that since July 24,2018 he has often declined and
made excuses to his wife in order to not attend social outings that
she
has invited him to with this social impairment associated in part with
the Veteran's Post-Traumatic Stress Disorder with Panic Attacks
and
Unspecified Depressive Disorder.
He reported that since July 24,2018 he has rarely attended social
outings with his spouse contributing to impairment in this
relationship
and this impairment is attributed in part to the Veteran's
Post-Traumatic Stress Disorder with Panic Attacks and Unspecified
Depressive Disorder.
The Veteran noted that he has has experienced a reduced interest in
participating and low participation in pleasurable activities in the
Veteran's home with his spouse since July 24,2018 contributing to
impairment in this relationship and this impairment is associated in
part with his Post-Traumatic Stress Disorder with Panic Attacks and
Unspecified Depressive Disorder.
The Veteran noted that since July 24,2018 he has experienced problems
with completing tasks that the Veteran's spouse expects him to
complete
contributing to impairment in this relationship and this impairment is
attributed in part to his Post-Traumatic Stress Disorder with Panic
Attacks and Unspecified Depressive Disorder. He noted that this has
included from not recalling at times that his wife has asked him to
complete tasks and his wife has become upset with him on these
occasions with this impairment in his marriage associated in part with
his Post-Traumatic Stress Disorder with Panic Attacks and Unspecified
Depressive Disorder. He noted that at times his wife has completed
tasks that she had asked him to complete since July 24, 2018 and this
impairment is associated in part with his Post-Traumatic Stress
Disorder with Panic Attacks and Unspecified Depressive Disorder.
He reported that since July 24,2018 often he has physically withdrawn
from interacting with his spouse contributing to impairment in this
relationship with this impairment associated with the Veteran's
Post-Traumatic Stress Disorder with Panic Attacks and Unspecified
Depressive Disorder.
The Veteran reported often since July 24,2018 he has not been
attentive
to what his spouse was saying to him contributing to impairment in
their relationship with this impairment associated in part with his
Post-Traumatic Stress Disorder with Panic Attacks and Unspecified
Depressive Disorder.
Overall the past year the Veteran reported experiencing a high level
of impairment in his relationship with his spouse associated with his
Post-Traumatic Stress Disorder with Panic Attacks and Unspecified
Depressive Disorder.
The Veteran noted that he has 2 children ages 5 and 8.
The Veteran reported that across the past year he has experienced
irritability and impatience when interacting with his children
contributing to impairment in these relationships with his children
with this impairment attributed in part to his Post-Traumatic Stress
Disorder with Panic Attacks and Unspecified Depressive Disorder.
He reported that across the past year often he has physically
withdrawn
from interacting with his children contributing to impairment in this
relationship with this impairment associated in part with the
Veteran's
Post-Traumatic Stress Disorder with Panic Attacks and Unspecified
Depressive Disorder.
He reported that he has not participated in as many social activities
especially away from his home as he expects himself since July 24,2018
with his children contributing to impairment in his relationships
with
his children across this period with this impairment associated in
part
with his Post-Traumatic Stress Disorder with Panic Attacks and
Unspecified Depressive Disorder. He noted that since July 24,2018 he
has had his wife take his children to social outings instead of him
attending them with them often as an outcome of impairment in his
social functioning associated in part with his Post-Traumatic Stress
Disorder with Panic Attacks and Unspecified Depressive Disorder
He noted that since July 24,2018 when he has attempted to attend
social
outings where large groups area gathered he has experienced high
levels
of anxiety and not been able to enjoy the event he is attending with
this social impairment associated in part with his Post-Traumatic
Stress Disorder with Panic Attacks and Unspecified Depressive
Disorder.
Overall since July 24,2018 the Veteran reported experiencing moderate
impairment in his relationships with his children associated with his
Post-Traumatic Stress Disorder with Panic Attacks and Unspecified
Depressive Disorder.
He noted that the few friends he has have stopped visiting him and he
still has one friend who calls him occasionally to check on him since
July 24,2018 with this social impairment associated in part with his
Post-Traumatic Stress Disorder with Panic Attacks and Unspecified
Depressive Disorder.
The Veteran noted that since July 24,2018 he has often tried to limit
the number of people and how long he interacts with them in social
situations out of concern that extended interactions with others will
lead people to perceive that he is abnormal for displaying symptoms of
his Post-Traumatic Stress Disorder with Panic Attacks and Unspecified
Depressive Disorder in his interactions with them.
He indicated that he has had a preference to be at home as much as he
could since July 24,2018 year with this social impairment associated in
part with his Post-Traumatic Stress Disorder with Panic Attacks and
Unspecified Depressive Disorder.
The Veteran reported that since July 24,2018 he has experienced a low
level of trust of others that has contributed to impairment in his
social relationships with this impairment associated in part with his
Post-Traumatic Stress Disorder with Panic Attacks and Unspecified
Depressive Disorder.
The Veteran noted that since July 24,2018 he has declined and made
excuses to his friends in order to not attend social gatherings and
outings that they have invited him to with this social impairment
associated in part with the Veteran's Post-Traumatic Stress
Disorder with Panic Attacks and Unspecified Depressive Disorder.
The Veteran indicated that he has experienced discomfort when in
locations where large crowds are gathered or where he is exposed to
people he is unfamiliar with since July 24,2018 leading to him
avoiding
placing himself in these types of social settings with this
social impairment associated in part with his Post-Traumatic Stress
Disorder with Panic Attacks and Unspecified Depressive Disorder.
He noted that he has not attended any social outings with any friend
since July 24,2018 and this impairment is associated partly with his
Post-Traumatic Stress Disorder with Panic
Attacks and Unspecified Depressive Disorder.
The Veteran indicated that as an outcome of often declining his
friends' invitations to attend social outings that many of his
friends
have stopped inviting him to attend social outings with this social
impairment associated partly with his Post-Traumatic Stress Disorder
with Panic Attacks and Unspecified Depressive Disorder since July
24,2018.
The Veteran reported that since July 24,2018 he has experienced
irritability and impatience when interacting with others in social
situations contributing to impairment in this area of his life and
this
impairment is associated with the Veteran's Post-Traumatic Stress
Disorder with Panic Attacks and Unspecified Depressive Disorder.
Overall he reported that in the area of friendships that since July
24,2018 he has experienced high levels of social impairment associated
with his Post-Traumatic Stress Disorder with Panic Attacks and
Unspecified Depressive Disorder.
b. Relevant occupational and educational history:
He indicated that he is currently attempting online college courses
for the fall 2018 semester.
He noted that he stopped participating in his current online college
courses as an outcome of the occupational impairment he has been
experiencing associated in part with his Post-Traumatic Stress
Disorder
with Panic Attacks and Unspecified Depressive Disorder
The Veteran reported that he has experienced problems with
concentration where he has had to often re-read information in his
current college courses contributing to impairment in his academic
performance and this impairment is associated in part with the
Veteran's Post-Traumatic Stress Disorder with Panic Attacks and
Unspecified Depressive Disorder.
He reported that he has experienced problems with concentration that
has contributed to him taking longer than expected to complete written
assignments in his current college courses with this impairment
associated in part with his Post-Traumatic Stress Disorder with Panic
Attacks and Unspecified Depressive Disorder.
The Veteran noted that he did not submit some of his work assignment,
submitted some assignments late and submitted work assignments that
were not completed in a thorough manner contributing to impairment in
his academic performance in his current college courses and this
impairment is associated in part with his Post-Traumatic Stress
Disorder with Panic Attacks and Unspecified Depressive Disorder.
He reported that overall across his current college courses attended
he
has experienced a high level of impairment in his academic performance
as an outcome of him experiencing Post-Traumatic Stress Disorder with
Panic Attacks and Unspecified Depressive Disorder.
He noted that in September of 2018 he was terminated from his work
position as an IT Specialist with Newport News Shipyard which he had
held for 14 months approximately as an outcome of experiencing
occupational impairment associated with his Post-Traumatic Stress
Disorder with Panic Attacks and Unspecified Depressive Disorder.
The Veteran reported that he was assigned a new supervisor in August
of
2018 who did not accommodate the occupational impairment he was
experiencing associated with his Post-Traumatic Stress Disorder with
Panic Attacks and Unspecified Depressive Disorder where his previous
supervisor had accommodated greatly this occupational impairment.
He noted that he found himself since July 24, 2018 withdrawing from
interacting with his co-workers to avoid displaying irritibility and
anger when interacting with them including on occasions when he was
suppose to be collaborating with them on work assignments and this
occupational impairment was associated in part with his Post-Traumatic
Stress Disorder with Panic Attacks and Unspecified Depressive Disorder
He noted that he experienced his co-workers making negative comments
that the Veteran was odd and he was like the "shipyard
shooter" with
his new supervisor allowing them to make these comments that
contributed to his distress and a worsening of his problems with mood
at work associated with his Post-Traumatic Stress Disorder with Panic
Attacks and Unspecified Depressive Disorder
He noted that since July 24, 2018 in his work position as an IT
Specialist with Newport News Shipyard he was required to obtain a
letter from his psychiatrist that noted that he was not at risk of
harming himself or others as an outcome of the occupational impairment
he was manifesting associated with his Post-Traumatic Stress Disorder
with Panic Attacks and Unspecified Depressive Disorder including him
with Panic Attacks and Unspecified Depressive Disorder including him
displaying anger outburts when interacting with others in this
setting.
The Veteran reported that he had experienced problems with
concentration that had lead to him taking longer than expected to
complete work tasks contributing to occupational impairment since July
24, 2018 in his position as an IT Specialist with Newport News
Shipyard
with this impairment attributed partly to the Veteran's
Post-Traumatic
Stress Disorder with Panic Attacks and Unspecified Depressive Disorder.
He reported often having to re-read information in order to understand
the information being read as an outcome of experiencing problems with
concentration contributing to impairment in his occupational
functioning since July 24, 2018 in his position as an IT Specialist
with Newport News Shipyard with this impairment associated in part
with his Post-Traumatic Stress Disorder with Panic Attacks and Unspecified
Depressive Disorder.
He indicated that he frequently delayed completing work assignments
since July 24, 2018 in his work position as an IT Specialist with
Newport News Shipyard contributing to impairment in his occupational
functioning with this impairment associated in part with the
Veteran's
Post-Traumatic Stress Disorder with Panic Attacks and Unspecified
Depressive Disorder.
The Veteran reported at times not attending to what others were saying
since July 24, 2018 in his position as an IT Specialist with Newport
News Shipyard with this problem with concentration contributing to
impairment in his occupational functioning and this impairment was
associated in part with his Post-Traumatic Stress Disorder with Panic
Attacks and Unspecified Depressive Disorder. He reported that at
times
since July 24, 2018 in his work position as an IT Specialist with
Newport News Shipyard he had to ask others to repeat what they have
stated to him with this occupational impairment associated partly with
his Post-Traumatic Stress Disorder with Panic Attacks and Unspecified
Depressive Disorder. He noted that in an attempt to compensate for
this occupational impairment from his problems with concentration he
had written down information told to him.
He indicated that since July 24, 2018 in his most recent work position
which was as an IT Specialist with Newport News Shipyard he had
manifested irritability and anger in the form of verbal outbursts when
interacting with his co-workers that had contributed to impairment in
his occupational functioning and this impairment was attributed partly
to the Veteran's Post-Traumatic Stress Disorder with Panic Attacks
and
Unspecified Depressive Disorder.
He indicated that since July 24, 2018 his position as an IT Specialist
with Newport News Shipyard had attended work late and called out sick,
and left work early at times because of triggers in his environment
that would worsen his Post-Traumatic Stress Disorder with Panic Attack
symptoms contributing to impairment in the Veteran's occupational
functioning with this impairment associated in part with his
Post-Traumatic Stress Disorder with Panic Attacks and Unspecified
Depressive Disorder.
He noted that since July 24, 2018 in his position as an IT Specialist
with Newport News Shipyard he had experienced Panic Attacks after
being
exposed to certain triggers in his work environment and then left work
for the remainder of the day at times contributing to occupational
impairment and this impairment is associated in part with his
Post-Traumatic Stress Disorder with Panic Attacks and Unspecified
Depressive Disorder.
He reported that as a result of his problems with excessive absences
including calling out sick, showing up late and leaving early since
July 24, 2018 in his work position as an IT Specialist with Newport
News Shipyard often at the end of his tenure in this position he took
unpaid leave as he had used up all his leave time with this
occupational impairment associated in part with his Post-Traumatic
Stress Disorder with Panic Attacks and Unspecified Depressive
Disorder.
He reported that since July 24, 2018 in his position as an IT
Specialist with Newport News Shipyard regularly he had not attended
meetings that he was suppose to attend contributing to impairment in
his occupational functioning and this impairment is associated in part
with his Post-Traumatic Stress Disorder with Panic Attacks and
Unspecified Depressive Disorder. He noted that his new supervisor
complained about the Veteran not attending these meetings that he was
suppose to attend and this occupational inpairment was associated in
part with his Post-Traumatic Stress Disorder with Panic Attacks and
Unspecified Depressive Disorder.
Overall the Veteran reported experiencing since July 24, 2018 a high
level of occupational impairment in his most recent work position
which
was as an IT Specialist with Newport News Shipyard attributed to the
Veteran's Post-Traumatic Stress Disorder with Panic Attacks and
Unspecified Depressive Disorder.
He noted that his work position as an IT Specialist with Newport News
Shipyard is the 3rd work postion he has been terminated from in the
past 2 years as an outcome occupational impairment he had been
experienced associated with his Post-Traumatic Stress Disorder with
Panic Attacks and Unspecified Depressive Disorder. He noted that he
had worked for Ferguson in as a Service Desk Position during the
month of November 2016 and was terminated from this work position as
result of his impairment when having to interact with others
associated
with his Post-Traumatic Stress Disorder with Panic Attacks and
Unspecified Depressive Disorder. Similarly he was terminated from his
work position with
Sentara as an IT Specialist which he held from January 2017 - March
2017 as a result of occupational impairment he had been experienced
associated with his Post-Traumatic Stress Disorder with Panic Attacks
and Unspecified Depressive Disorder including impairment when
interacting with others.
Given the current severity of the Veteran's Post-Traumatic Stress
Disorder with Panic Attacks and Unspecified Depressive Disorder it
would be expected that if he was currently employed he would display
in
many work settings high levels of occupational impairment when engaged
in both sedentary, and physical work tasks associated with this
disorder.
His problems with irritability, anger, sense of disconnect and anxiety
when interacting with others associated with his Post-Traumatic Stress
Disorder with Panic Attacks and Unspecified Depressive Disorder would
probably make it difficult for him to work in a setting where he would
have to work closely with other co-workers and/or have to communicate
directly with customers face to face on a regular basis contributing
to
high levels of occupational impairment in these types of work
settings.
Veteran's problems with concentration associated with his
Post-Traumatic Stress Disorder with Panic Attacks and Unspecified
Depressive Disorder would be expected to contribute to high levels of
impairment in his job performance in certain sedentary and physical
job
tasks that require sustained attention. It would be expected that he
would have because of his problems with concentration experience high
levels of occupational impairment when completing repetitive job
tasks,
attempting to meet strict work deadlines, completing tasks that are
detailed in nature, completing multiple tasks in short periods of time
and tasks that require him to communicate with others regularly
The Veteran's experiences problems with motivation in regards to
beginning and following through on completing tasks with this
impairment associated with his Post-Traumatic Stress Disorder with
Panic Attacks and Unspecified Depressive Disorder that would be
expected to contribute to moderate to high levels of impairment in his
occupational functioning if he was tasked to complete many sedentary
and physical work tasks that require sustained effort.
He reported that his Post-Traumatic Stress Disorder with Panic Attacks
and Unspecified Depressive Disorder worsens including his
hypervigilence and irritability when he is in settings where there are
large groups of people in attendance along with avoidance of placing
himself in this type of setting so this would interfere with his
ability to work in settings where he would be exposed to large groups
regularly contributing to a high level of occupational impairment in
this type of work setting
Relevant mental health history, to include prescribed medications and
family mental health:
The Veteran Hampton VAMC CPRS coversheets notes that he is currently
prescribed psychotropic medication to help him manage his problems
with
Post-Traumatic Stress Disorder with Panic Attacks and Unspecified
Depressive Disorder.
He reported that since July 24,2018 at times he has skipped showering
and brushing his teeth for days at a time and his wife and oldest
child
age 8 have commented on his poor hygiene on these occasions with this
impairment associated in part with his Post-Traumatic Stress Disorder
with Panic Attacks and Unspecified Depressive Disorder.
The Veteran reported that he has experienced Panic Attacks 2-3 times a
week since July 24,2018 with this impairment associated in part with
his Post-Traumatic Stress Disorder with Panic Attacks and Unspecified
Depressive Disorder including when driving his vehicle.
He noted that since July 24,2018 he has avoided driving himself on
bridges and through tunnels including avoiding going to certain
locations as a result of this avoidance behavior with this impairment
associated in part with his Post-Traumatic Stress Disorder with Panic
Attacks and Unspecified Depressive Disorder. He noted that because
his
anxiety levels have been so high while driving at times since July
24,2018 including him experiencing Panic Attacks he has taken a bus to
different locations at times with this associated with impairment from
his Post-Traumatic Stress Disorder with Panic Attacks and Unspecified
Depressive Disorder noting that today he took a bus to today's DBQ
PTSD
Review examination and that when possible he had taken a bus to work
in
his most recent work position as a IT Specialist at Newport News
Shipyard but he could not always to this as result of having to drive
his children to school.
The Veteran reported that across the past 31 days he has experienced
problems initiating sleep where it has taken him approximately 1-3 or
more to initiate sleep each night. He reported that since July 24,
2018 year at times not been able to initiate sleep.
He indicated that he has experienced problems maintaining sleep across
the past 31 days where he has awakened up throughout the night and it
has taken him 10-15 minutes to return to sleep typically but that on
some occasions he has not been able to return to sleep for the
remainder of the night. He indicated that he has attained 4 hours or
less of sleep per night on average across the past 31 days with this
sleep not being continuous nor restorative.
The Veteran reported that when deployed to Iraq and Afghanistan he
experienced mortar attacks that were directed to areas he was located
on his FOB with these experiences serving as some of the trauma
events/stressors associated with his current Post-Traumatic Stress
Disorder with Panic Attacks.
He noted that he ha experienced Panic Attacks 2-3 times a week since
July 24, 2018 with
impairment associated with his Post-Traumatic Stress Disorder with
Panic Attacks and Unspecified Depressive Disorder.
1) Are you feeling hopeless about the present or future? He reported
that he has felt hopeless about the present and the future at times in
the past month.
1a) If yes, have you had thoughts about taking your life? The Veteran
reported that he has had thoughts of taking his life in his lifetime
1b) If yes, when did you have these thoughts? He noted that yesterday
was the most recent time he had thoughts of completing suicide.
2) Do you have a plan to take your life? The Veteran reported no
history of having any suicide plan in his lifetime.
3) Have you ever had a suicide attempt? The Veteran reported no
history of having any suicide attempt.
4) The Veteran reported having no family history of suicide among any
first-degree relative.
5) The following socio-demographic factors are present that may place
the patient at an elevated risk for suicide: male.
6) The following current psychosocial stressors are present that may
increase the Veteran's risks for suicide in the following areas:
marital problems and health problems.
7) The Veteran indicated that he does not own a firearm nor has access
to one at the current time.
😎 He indicated that he is not sure if would be willing to utilize
the
Veterans Crisis Line if he felt that he might act on any suicide
ideation in the future.
9) The Veteran reported that since July 24, 2018 he has consumed 1
pint
of liquor per occasion on Fridays and Saturdays and some weekdays.
10) The Veteran noted that his responsibility to his children is a
barrier to him acting on any suicide ideation.
11) Does the patient have the available means for carrying out his/her
plan for committing suicide?
Not applicable he has no history of having any suicide plan in his
lifetime.
Considering the above assessment information the examiner concludes
that currently the Veteran is at a low risk for self-harm.
Homicidal Ideations or Plans: none reported in the past year. He
noted
that he has not been in an physical altercation with anyone since July
24, 2018.
He reported that he has displayed aggression towards objects since
July
24, 2018 in the form of slammed doors, punch holes in walls and thrown
objects within his reach with this impairment associated in part with
his Post-Traumatic Stress Disorder with Panic Attacks and Unspecified
Depressive Disorder.
3. PTSD Diagnostic Criteria
---------------------------
Please check criteria used for establishing the current PTSD diagnosis. The
diagnostic criteria for PTSD, are from the Diagnostic and Statistical Manual
of Mental Disorders, 5th edition (DSM-5). The stressful event can be due to
combat, personal trauma, other life threatening situations (non-combat
related stressors). 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 #6 - "Other
symptoms".
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 thetraumatic
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 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.
[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] 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 sleep
Criterion F:
[X] The duration of the symptoms described above in Criteria
B, C, and D are more than 1 month.
Criterion G:
[X] The PTSD 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.
4. Symptoms
-----------
For VA rating purposes, check all symptoms that actively apply to the
Veteran's diagnoses:
[X] Depressed mood
[X] Anxiety
[X] Suspiciousness
[X] Panic attacks more than once a week
[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] Difficulty in adapting to stressful circumstances, including work or
a
worklike setting
[X] Inability to establish and maintain effective relationships
 

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