Would anyone be willing to look over my husbands new report and DBQs concerning separate ratings for TBI/PTSD A&A Headaches?

[Vet Dog and wife]

 

Would anyone be willing to look over my husband’s new report and DBQs concerning separate ratings for TBI/PTSD A&A Headaches? we also posted a lot of his VA claim docs too.

 

Thank you all very much for all your prior advice. you have helped my husband so much and we truly appreciate all your help.

Edited May 1, 2019 by Vet Dog and wife
need help

[doc25]

13 minutes ago, Vet Dog and wife said:

Does anyone have an opinion on my husband's recent psychological report and DBQ?

Thank you all on Hadit members

 

Dr P Antoniou (CPsychol)

Chartered Counselling Psychologist (BPS Reg. No. 24434)

Registered Practitioner Psychologist (HCPC Reg. No. PYL6566)

Licensed Psychologist (SEPS Reg. No. 155555)

Scientific Collaborator at European University Cyprus

 

Address: Larnaca, Cyprus

Phone: +

E-mail:

 

Private and Confidential

Report of Psychological Evaluation

DRAFT

 

Patient’s Name: MR. Black

Date of Birth:

Social Security Number:

 

Identifying Information:

 

  MR. Black is a 59-year-old Caucasian male who was self-referred for psychological evaluation on 25/10/2018.  MR. Black was seen on 02/11/2018 for an extensive clinical interview and completed the PTSD Diagnostic Scale for DSM-5 (PDS-5), the Hospital Anxiety and Depression Scale (HADS) and the Medical Symptoms Questionnaire (MSQ). 

MR. Black gathered and brought with him his VA Claims File and numerous medical records to be reviewed as part of his psychological evaluation. Most of the records were obtained from VA Palo Alto, California; VA Capitola, California; VA Varo, Oakland, California; VA San Diego, California; VA Puget Sound Health Care System, Seattle Washington; VA Houston Regional Office; and Grays Harbor Community Hospital, Aberdeen, Washington.  Mr. Black’s current wife provided much information concerning MR. black. MR. Black reported coming to Cyprus approximately two years ago and is currently renting a flat in Larnaca Cyprus with his spouse Mrs. and her 11-year-old son. 

 

Background Information:

MR. Black served in the U.S. Marines from 1977-19--.  Throughout this period MR. Black was a boxer with the Marine Corps and practiced, sparred and fought in boxing and other forms of combat sport for several hours per day.  MR. Black reported being “knocked out numerous times while boxing and sparing” and, as a result, experienced being left dazed, with multiple facial and head traumas, hematuria, hand fractures, burning and numbness of both feet, loss of consciousness, and further down the line, Tension and migraine headaches, loss of memory, disorientation and speech impairments.  MR. Black also reported “being harassed” by his superiors and peers in the Marines due to these impairments and being called names, such as “moron”, “stupid” “Retard”, and “weird”.

Later, not only was he constantly harassed but he was sexually harassed by two sergeants and later beaten, bitten, and choked by one of these sergeants while still in bed. MR. Black was also stalked and threatened with being raped and had his life threatened many times by these two sergeants. MR. Black reported feeling “very embarrassed”, and found it really challenging to talk about these experiences.  MR. Black suffered an additional head injury while serving in the Marines, as he was struck in the head with a pick-axe.

after suffering for many years with little help, in 1998 he was diagnosed with “dementia due to head trauma with mood disorder and post-traumatic stress disorder” by the VA and he was rated with a 100% permanent and total service-connected disability. 

Over several therapy sessions, and with great difficulty MR. Black further discussed several traumatic incidents that he experienced while serving in the Marines.  These include, but are not limited to: being locked up in a gas chamber full of CS gas without a mask and being made to repeatedly go back into chamber to retrieve his caps in the dark, and “feeling like he was going to die”; having experienced someone tossing several large CS teargas grenades into the barracks where MR. Black and other marines were sleeping, and later being blamed for doing this himself; having the Marine Recon special forces instructor spraying water up MR. Black’s nose causing him to choke and cough, and shooting a powerful stream of water at MR. blacks testicle while being told to stand at attention while enduring the pain. In addition, MR Black was told to hold his breath to the point of passing out under water while taking the special forces recon test. On at least two occasions MR. Black came very close to drowning while training and swimming in the ocean. Another incident was when he attacked from behind, with a blow to the head, while still in bed and being held down and repeatedly punched and bitten on the back of the head, neck, ears and back by one of the sergeants that had been harassing MR. Black previously, requiring going to the hospital for treatment due to the bite wounds. MR. Black and another marine where also locked in a sea cargo container “with a very small hole for the two Marines to breathe from and someone sprayed a fire extinguisher in there”. MR Black also perform first-aid and CPR on a man that was sitting next to him on a bus. MR. black had noticed that the man had stopped breathing and yelled for the bus to stop, he then took steps to perform first-aid and CPR with the help of others. the man’s heart stopped eight time. This went on for quit a long time before the ambulance came. The man died shortly after. Mr. Black had been assaulted and battered several times and has witnesses horrible beatings of other Marines.

  Following his honorable discharge from the Marines on 21/04/1980, MR. Black unsuccessfully attempted to find and sustain employment. Due to his debilitating neurological and psychological conditions he was at risk to himself and other people on the job and was responsible for many accidents.  Prior to the Marines, MR. Black worked with his Family’s marine electronic equipment company and landscape business.

Mr. Black had future plans of becoming an engineer like his father, uncles, and grandfather after serving his time in the marines. He currently has no occupation because of his permanent disabilities and is fully financially supported by the VA disability compensation.  It is very unlikely that MR. Black would be capable of sustaining any kind of employment.  MR. Black has been married six times up to this date.  Most of MR. Black’s relationships have failed due to his service-connected disabilities. He reported finding it difficult to develop and maintain relationships of any kind — Romantic, social, or occupational. MR. Black found it hard to show and receive love and affection with friends and family and get along with others at work. MR. Black was often distant in his romantic relationships, most of his partners “did not understand his conditions.” He was unable to find and maintain employment due to constantly getting lost, loosing tools and his other disabilities, he often got in fights and arguments, and missed work due to Migraines. he had and still has frequent outbursts of anger, long bouts of depression, lack of interest in most things, and suffers from a low libido, all these issues where the causes of his failed relationships and lack of employment.

 

Presenting Issues:

 

(a) Physiological:

  MR. Black reported suffering from several physiological problems which are also evident in his medical records.  These are: hypoglycemia; chronic headaches; pancreatitis; arthritis; issues with his heart; daily back and neck pain; gastrointestinal problems; numbness in his hands and feet; hearing impairment and ringing in his ears; erectile dysfunction and diabetes-related symptomatology.  MR. Black’s physiological problems negatively affect his mental health and interfere with his sleep and all aspects of his life quality. MR. Black’s driving license was revoked more than twenty years ago due to his cognitive impairments that affected safe driving. MR. Black reported being hypersensitive to light and sound, feeling fatigue and experiencing frequent headaches (resembling migraines) that often cause him to be homebound. 

 

(b) Psychological:

MR. Black’s diagnosis of traumatic brain injury (TBI) was recently reconfirmed by his Consultant Psychiatrist in Cyprus, Dr Georgios Mikellides, MD, MR.CPsych, CCT, Consultant Psychiatrist.  MR. Black has difficulties with his memory (including acquiring new information); concentrating; problem-solving; speed of information processing; attention; word-finding; decision-making; hearing; planning and organizing.  MR. Black reported that sometimes he finds it difficult to understand what people around him talk about, and this makes him feel “embarrassed” and “upset.”  He has trouble understanding jokes, and abstract statements and concepts. MR. Black is often disoriented to at least two of the four aspects of orientation (person, time, place, situation) and often gets lost even in familiar surroundings.  MR. Black reported that he is unable to use assistive devices such as GPS (Global Positioning System) or his phone to help him in such circumstances.  MR. Black seems to have developed compensatory strategies for social situations which tend to make him appear more functional than he actually is. 

  MR. Black has severe issues with his memory to the extent that he forgets to eat or drink water, find or cloth himself properly, he forgets to go to the bathroom, and is reliant on the assistance of his wife for taking his medications and other daily tasks.  MR. Black tends to repeat information with a lack of awareness that he has already mentioned it.  Without the daily help of his wife, MR. Black is unable to perform activities of daily living, including maintenance of minimal personal hygiene, dressing properly for the weather, and finding things.  Mr. Black is unable to cook his own food due to being a hazard to himself and others in the kitchen. MR. Black and his wife reported that in the past, on several occasions, he forgot leaving the fire on the stove burning, leaving the tub running flooding the apartment, leaving the gas on unlit, unintentionally putting himself and others at risk at home and had had similar had similar issues at work of endangering himself and others.  MR.Black also doesn’t always pay attention before he crosses the road and has been hit by a car. he often gets lost and much more. He has disorientation to time or place; he has memory loss for names of close relatives and many other cognitive issues.

  MR. Black reported suffering from severe Migraine headaches These headaches occur about three to seven times a month and can last for three hours to three days and completely stop him from functioning at all. His wife said that this has been his typical monthly headache pattern for the last three years and MR. black said it has been the same since serving in the Marines. The severity of Mr. Black’s migraine headaches is also stated in MR. Black’s first wife’s statement, and other statements found in his VA claims file.

 MR. Black and his wife said that sometimes MR. Black’s migraines cause him to get nauseous and sometimes cause him to vomit. they reported that sometimes he becomes so frustrated that he hits himself in the head or bang his head on the wall. 

In order to manage these throbbing migraines, MR. Black stays in the dark, out of the heat, and cannot tolerate loud noises, bright light, sun glare, and talking, or any kind of physical activity.  Before his migraines start to throb, MR. Black often complains of seeing flashes of light, blind spots, wavy zigzag and or double vision. MR. Black reported that sometimes “everything turns completely black for a few moments”.

MR. Black also reported suffering from constant tinnitus, dizziness and blurred vision, and daily tension headaches. Due to many of these symptoms MR. Black cannot take care of himself and is 100% dependent on his spouse’s assistance and supervision for his daily functioning and survival.

 Mr. Black is also service-connected due to PTSD. MR. Black also reported suffering from post-traumatic stress disorder (PTSD) in the Marines and since he left the Marines. His symptoms include recurrent and distressing recollections of the traumatic events; recurrent distressing dreams of the events and night terrors; flashback episodes; intense psychological distress at exposure to internal or external cues that resemble aspects of the traumatic events; physiological reactivity on exposure to internal or external cues that resemble aspects of the traumatic events; efforts to avoid conversations associated with the traumatic events; efforts to avoid people or places that arouse recollections of the traumatic events; reported feelings of detachment from others; sense of a foreshortened future; markedly diminished interest in significant activities; difficulty falling and staying asleep; difficulty concentrating; hypervigilance; exaggerated startle responses; and suicidal ideation, and urinating in bed.  Due to MR. Black’ PTSD-caused night terrors and startle reactions, he has unintentionally injured others in his sleep including his wife.  These symptoms are also evident on the PDS-5 on which MR. Black reported experiencing almost all PTSD symptomatology severely during the last month.

  MR. Black further reported severe symptoms of daily anxiety and panic, which were also highly evident in the psychometric tools he completed (excessive constant anxiety and worry more days than not; restlessness; irritability; being easily fatigued; palpitations; muscle tension; sleep disturbance; frequent panic attacks). 

 MR. Black also reported diminished interest and pleasure in almost all activities most of the day, nearly every day, not feeling cheerful, having a decreased libido, having lost interest in his appearance, feeling worthless and guilty, and having recurrent thoughts of death.  In fact, MR. Black attempted suicide three times in the last 3 months: on 05/11/2018, (he tried drowning himself in the sea) on 23/11/2018 (he jumped in front of a moving truck) and on 05/01/2019 (he tried drowning himself in the sea).  MR. Black was provided emergency aid as soon as he was able to reach out for support.  He was hospitalized in the Psychiatric Unit of Nicosia Hospital between 05/11/2018-20/11/2018 and then again on 24/11/2018-03/12/2018 and all the necessary steps were taken to maintain his safety. MR. black has been dealing with suicidal issues starting while in the Marines.

MR. Black did not report any resent use of substances.

 

Diagnostic Formulation and Diagnoses:

 

Based on MR. Black’s self-reported information as well as his medical records, he satisfies the DSM-5 and ICD-10 criteria for the following psychological and neurological diagnoses:

 

309.81 (F43.10)     Post-Traumatic Stress Disorder, Sever

 (S06.30) Major Neurocognitive Disorder due to TBI, severe;

300.4  (F34.1) Persistent Depressive Disorder with Anxious Distress, severe

300.2  (F41.1) Generalized Anxiety Disorder

V62.29 (Z56.9) Other Problem Related to Employment

V15.49 (Z91.49)     Other Personal History of Psychological Trauma

V15.59 (Z91.5) Personal History of Self-harm

V69.9  (R29.818)    Problem Related to Lifestyle

 

Pharmacology Treatment Plan:

MR. Black is currently on, or has recently been on the following medication for the management of his neurological and psychological symptoms:

 

001. Lekap 100mg when required

002. Mirtazapine 15mg daily

003. Atodel 1mg daily

004. Lorazepam 2mg when required

005. Algofen 500mg daily

006. Ompranyt 20mg daily

007. Zocor 10mg daily

008. Kratium 5mg daily

009. Priacin 10mg daily

010. Brufen 400mg when required

011. Stilnox 10mg when required

012. Enidap 100mg when required

013. Zyprexa Velotab 5mg daily

014. Nitredon 5mg daily

015. Prazosin 1mg when required

016. Zoldipem

017. Omeprazole 20mg when required

018. Ibuprofen

019. Trazodone

 

Summary and Conclusion:

MR. Black has been diagnosed with TBI due to the blow to the head with a pickaxe and the excessive blows to the head while serving in the Marines (re: report of Psychological Consultation by A. Goodman, Ph.D., and Psychiatric Report by Dr Georgios Mikellides, MD, MR.CPsych, CCT, Consultant Psychiatrist).

MR. Black also satisfies the criteria for PTSD due to the traumatic incidents that took place in the Marines.

It is of my professional opinion that it is more likely than not that the PTSD is not secondary to the TBI. 

The extensive evidence from MR. Black’s medical records and VA Claims File support separating the TBI from the PTSD and rating them separately. 

Some symptoms of PTSD and TBI overlap, but most of MR. Black symptoms are distinct and separate justifying separate 100% disability ratings for his PTSD and TBI in accordance with VA standards. 

It is more likely than not that MR. Black’ headaches and cognitive deficits are attributed to his TBI, as they are post-concussive in nature, and therefore separate from his stressor-induced psychological disabilities.

In agreement with all other professionals in the care of MR. Black, it is of my professional judgment that the incident with the pickaxe, harassment, and assaults have also had a significant effect in contributing to MR. Black’ PTSD and TBI.

Mr. Black’s TBI is separate from his PTSD, distinguishing the symptoms of PTSD and depression, from the symptoms of cognitive disorder and headaches due to TBI

Mr. Black’s TBI results from in-service combat sports, boxing and getting hit in the head with the pick-axe and being assaulted and beat about the head. The residuals of his TBI include such issues as his headaches, cognitive deficits, memory issues, difficulty focusing, dizziness, issues with processing information, blurred vision, and several other issues — many which are listed in his records.)

Mr. Black’s PTSD with major depressive disorder is caused by the many stressors Mr. Black had experienced during his time in the Marines to include getting hit in the head with the pick-ax, getting assaulted and harassed; the incidence with the sea-cargo container, the gas chamber, and the teargas grenades in the barracks, his fights inside and outside the ring; witnessing assaults and death, performing CPR, Having his life threatened and believing he would die on several occasions, almost suffocating to death, almost drowning, and witnessing violence.

As I stated above, some symptoms of MR Black’s PTSD and TBI that overlap, but most of his symptoms are distinct and separate justifying separate 100% disability ratings for his PTSD and TBI, therefore, it is more likely than not that MR. Black’s headaches and cognitive deficits are attributed to his TBI. Mr. X headaches and cognitive deficits are post-concussive in nature and therefore separate and distinct from his stressor-induced psychiatric disabilities.

Mr. Black in fact sufferers from Total occupational and social impairment due PTSD.

Mr. Black also sufferers from Total occupational and social impairment due TBI.

Also noted on 04/22/1980 upon discharge from the Marines, MR. Black was given a 0% rating for occipital area scar, skull code 7805 (according to his service medical records, his scar is from a blow from a pick-axe which more likely than not also contributed to his TBI, Headaches, and PTSD.

MR. Black’s migraines are more likely than not secondary to his TBI due to MR Black’s boxing, combat sports, assaults, and getting hit in the head with the pickaxe. all of which are major contributors to his cognitive issues. It is my professional opinion that Mr. Black’s headaches are due to multiple TBIs. In addition, it is common knowledge that headaches are one of the main symptoms of TBI.

MR. Black comes across as a very kind and proud man, with eagerness to protect his family and/or anyone “being bullied”. However, MR. Black’s neurological and psychological conditions negatively affect all areas of his daily life to the extent that he is a hazard to himself and others without supervision.  MR. Black suffers from total social and occupational impairments due to his PTSD and TBI, which are both service-related.  It is more likely than not that these impairments are permanent. His TBI, headaches, PTSD, and other disabilities have been an issue since serving in the Marines.

It is of my understanding that these extremely difficult symptoms triggered his suicidal behavior.  MR. Black immediately requires constant support, guidance and supervision as he is a catastrophically disabled veteran.

MR. Black is engaging with psychological therapy twice a week in order to minimize suicidal risk and stabilize the symptoms of PTSD. 

Respectfully submitted by:

Dr P Anton

Date:

 

 

Records Reviewed:

For the purpose of writing this report the following records were reviewed:

001. 02/29/1996: Medical Record of VA Palo Alto Health Care System Emergency Room – Nursing Service

002. 12/09/1997-06/09/1998: Records from the Santa Cruz Vet Center

003. 03/04/1998: Western Medical Associates Report of Evaluation of V D. Lov (M.D., M.P.H.), Associate Professor of Clinical Medicine, Stanford University

004. 03/17/1998-08/13/1998: Outpatient treatment reports from VA Outpatient Clinic Monterey

006. 04/28/1998: Psychiatric evaluation by R. G. Gill

007. 07/17/1998: Vet. Center Psychological Evaluation Report from P. Muj, Ph.D.

008. 07/29/1998: Rating Decision of the Department of Veteran Affairs Oakland Regional Office

009. 08/10/1998: Statement from N.

010. 08/10/1998: Statement from D.

011. 08/10/1998: Statement from M.

012. 08/27/1998: Statement from J.

013. 09/18/1998: Statement from G.A.

014. 10/13/1998: Statement from S.K.

015. 10/13/1998: Statement from A.

016. 10/13/1998: Statement from R. G.

017. 04/29/1999-08/04/1999: Reports from the Brain Injury Recovery Unit at VA Medical Center Palo Alto

018. 08/20/1999: Report of Psychological Consultation of A. Goodman (Ph.D.), Licensed Psychologist

019. 08/25/1999-08/26/1999: VA Examinations

020. 09/02/1999: Compensation and Pension Exam Report of VAMC Palo Alto

021. 09/09/1999: Vets report of an inadequate C&P exam

022. 09/09/1999: C&P exam: Dr, Neurologist

023. 09/09/1999: C&P exam: Dr, Psychologist

024. 09/09/1999: Private Physician Report of Exam by Dr, Ph.D.

025. 09/09/1999: Report of Psychological Evaluation by Palo Alto Brain Injury Unit

026. 08/02/2001-08/20/2006: Medications Medical Documentation of San Francisco VAMC

027. 03/11/2001-04/04/2012: Progress Notes Medical Documentation of San Francisco VAMC

028. 06/26/2001-06/15/2005: Consult Requests Medical Documentation of San Francisco VAMC

029. 10/16/2002-06/21/2005: Lab Results Medical Documentation San Francisco VAMC

030. 12/07/2004: Imaging Report by zwan Asla (M.D.), Staff Radiologist

031. 03/09/2004-05/20/2005: Problem List Medical Documentation of San Francisco VAMC

032. 02/06/2006: VA Puget Sound Patient Annual Information Review Medical Record and Health History Questionnaire

033. 09/20/2007: Report of handy (M.D.) Community Hospital, WA

034. 05/01/2008: Medical Record of Terry Daven (RN) Harbors Home Health

036. 06/21/2010-07/20/2010: Progress Notes (Nursing Notes) of VA San Diego HCS

037. 06/11/2012: Rating Decision of the Department of Veterans Affair Houston Regional Office

038. 12/21/2018: Headaches (including migraine headches) Disability Benefits Questionnaire of Georgios Mikellides (M.D., MR.CPsych, CCT), Consultant Psychiatrist, Honorary Assistant Professior at University of Nicosia, Special Scientist at University of Cyprus

039. 12/21/2018: Psychiatric Report of Georgio ellides (M.D., MR.CPsych, CCT), Consultant Psychiatrist, Honorary Assistant Professor at University of Nicosia, Special Scientist at University of Cyprus

040. 12/28/2018: Examination for housebound status or permanent need for regular aid and attendance of Michalis Kit (M.D.), General Physician

041. Notes, History, and information acquired from patient’s spouse

042. Photographs showing the veteran boxing and sparring

 

Statement of Qualifications:

Dr P Anton is an accredited practitioner with a Chartered Membership with the British Psychological Society (CPsychol).   She holds a Bachelor of Science in Psychology from the University of Essex, UK (2007), a Master of Science in Psychotherapy Studies from the University of Kent, UK (2010) and a Professional Doctorate in Counselling Psychology from the Glasgow Caledonian University, UK (2014).  After her graduation, Dr Anton held the position of the Team Leader of the Psychological Service at CEA.; an inclusive service in Scotland offering advice, support and psychological therapy to people affected by abuse.  Alongside this role, she worked at the University of Glasgow in the position of a Counselling Psychologist and Clinical Supervisor.

Dr Anton returned to Cyprus in 2017 and established her own clinical practice alongside with a collaboration with private Universities to offer lectures in undergraduate and postgraduate psychology and to serve as a Research Supervisor.  Dr Anton holds is a registered practitioner with the Health and Care Professions Council, a licensed counselling psychologist with Cyprus SEPS, a member of the European Federation of Psychologists’ Association and an Associate Member of the Cyprus Association of Cognitive Behavioral Psychotherapists.      

 

 

 

 

Wow. That's like the golden ticket for a VA claim.

Dr. Anton mentions that PTSD/TBI overlap with your husband. The rater will need to determine which condition will be rated 100%.

[broncovet]

The problem with this is he is apprently already 100 percent sc for a mental health disorder.  So, the only way "up" from there is SMC.  

Mental health disorders are rated "grouped together" when one has more than one disorder.  So if he had ptsd and bipolar, he would get only a single 100 percent max.  

Im guessing you are seeking SMC for TBI.  Read this over to see if it applies:

https://cck-law.com/news/special-monthly-compensation-series-smct/

Also possible is SMC S or SMC L Aid and attendance if they apply.  

[Vet Dog and wife]

New DBQs

 

Edited March 15, 2019 by Vet Dog and wife
New DBQs

[Vet Dog and wife]

Thank you so much for your replies.

Also do you think the DBQ will suffice?

we want to make sure that the DBQ are complete and correctly filled out 

Thank you

Edited February 18, 2019 by Vet Dog and wife

[Vet Dog and wife]

Dear Broncovet,

I was unable to open that link, but I added several DBQs. do you think these should suffice for A&A and separate ratings for TBI and PTSD and headaches secondary to his TBI?

as always, thank you very much for your help 

[Oceanbound]

The VA is going to (already determined) to lock you out and stick you in PTSD and max at 100%. Personal disorder, depressive disorder, anxiety disorder, personal harm are all going to fall under one, otherwise its pyramiding. 

 Your exam was done by a shrink.

VA hasn't giving you P & T yet?