Increasing rating questions.

[RAM0311]

Good morning everyone,

This is my first post as member, I've read these forums for some time.  But anyways, I'm a former 0311 USMC 2 combat tours in afghanistan, discharged honorably  in 2012.  I initiated my claims and was granted 30% for PTSD with insomnia in 2013, had my re-eval in feb of 2018.  I have been treated with sleep meds and had a few therapy sessions, got back 30%.  I was fearful to appeal because of the horror stories of decreased ratings.  I've read through the different ratings and based on the symptoms it appears I should fall in the 50 percentile range, maybe 70%.   I've been started on SSRI's for my symptoms, I don't seek therapy through the VA because the scheduling is so far out my work schedule is not forgiving and I have to continuously reschedule.  I can post my last C&P exam for reference if that may help if y'all think it is worth investigating an increase.  I read a lot about getting a private medical exam, but I'm not sure where to go, or if that is something my VSO could assist me finding me a good examiner.  The last few years have been very busy between school/work and I have a very ill wife I have to put first.  The years are adding and I feel right now I'm at a good point to get my business taken care of.  I currently have several exams for other items I'm having increased.  I've exhausted my google searches.  I appreciate all your advice, the years of reading in the background of posts has been helpful.

Cheers,

RAM0311

[RAM0311]

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: PTSD

 ICD Code: F43.10

 b. Medical diagnoses relevant to the understanding or management of the

 Mental Health Disorder (to include TBI):

 No response provided.

 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

****************** Page 6 of 19

 tasks only during periods of significant stress, or; symptoms

 controlled by medication

 b. For the indicated level of occupational and social impairment, is it

 possible to differentiate what portion of the occupational and social

 impairment indicated above is caused by each mental disorder?

 [ ] Yes [ ] No [X] No other mental disorder has been diagnosed

 c. If a diagnosis of TBI exists, is it possible to differentiate what

portion

 of the occupational and social impairment indicated above is caused by

the

 TBI?

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

 SECTION II:

 -----------

 Clinical Findings:

 ------------------

 1. Evidence Review

 ------------------

 Evidence reviewed (check all that apply):

 [X] VA e-folder (VBMS or Virtual VA)

 [X] CPRS

 Evidence Comments:

 PCMHI Clinic Note, ***** - "PRESENTING COMPLAINTS:

is a ******-year-old                                                           

 SERVICE CONNECTED % - 40 married veteran who presents with symptoms of

 PTSD, anxiety, concentration

 SUBJECTIVE: The patient discussed continued symptoms of PTSD in his

current

 work environment, most specifically around helicopters. He is continuing

to

 adapt to functioning as a nurse in a demanding medical environment, and is

 enjoying the work."

 ***********************************

 PCMHI Consult Note, ******* - "HISTORY OF PRESENTING ILLNESS: The

 patient is 30% SC for PTSD. PTSD symptoms since first deployment. Current

 symptoms of PTSD include hyperactive startle response, hypervigilance,

 anxiety, "I feel like I am fine in the head, but I have that antsy

 feeling". The patient reports he will stay busy to manage his symptoms

of

 PTSD. He reports daily intrusive thoughts/images of traumatic events in

 combat. He discussed that when he was on deployment he loaded two of his

 friends on medical helicopters. This was an emotional and traumatic

 experience for him. He currently works as an **************** (new

 *****************), and in his role as an ******** he finds himself

 loading patients into medical helicopters. He stated his work

********************* Page 7 of 19

circumstances

 reminds him of combat

 experiences, but he feels it is a form of exposure therapy and while

 difficult is helpful for him.

 The patient stated he has problems with staying focused, and maintaining

 attention. Even though he had these problems in nursing school, he

 graduated with a high GPA. He is able to focus as needed at work.

 After first deployment he had problems with short-term memory "always

like

 a haze or a fog I have going on, sort of like sinus congestion".

 Memory problems only developed after deployment. In nursing school he did

 well because he could focus exclusively on classes. He has a history of

not

 remembering what he is told, if he doesn't make a note of it.

 He also stated he has some compulsive cleaning behavior.

 In February of 20** a close friend from ********* school committed suicide.

 This loss has been emotionally difficult for him."

 *******************************************

 MHBS Consult Note, 01/07/2013 - SM was noted to attend group orientation

 with no follow up.

 2. Recent History (since prior exam)

 ------------------------------------

 a. Relevant Social/Marital/Family history:

 SM is 30% SC for PTSD and was last evaluated for C&P in 2012.

Current

 assessment will review symptom progression since that time.

 SM reports having gotten married in 20**. They have no children;

"Just

 my animals...******************." He reports purchasing his

first

 home with his wife in 20**. SM denies engagement in hobbies or

 interests but generally reports walking his dogs or frequenting the

gym

 in his leisure time.

 b. Relevant Occupational and Educational history:

 SM reports graduating from nursing school in 20** and began working in

 the ********************). He reports continuing to work in the

 ED and explained, "I do pretty good. Working as a coreman and

then

 dealing with what happened in Afghanistan, it makes my job now

 rewarding. There are times when I have patients that remind me of

 losing *********, especially when having to load or unload patients. It is

 overwhelming to a certain point, but I work through it."

******************** CONFIDENTIAL Page 8 of 19

 c. Relevant Mental Health history, to include prescribed medications and

 family mental health:

 SM denies contiuous engagement in mental health since 20** and

 explained, "I really devoted all of my time to getting my

education

 once I got out, but when finishing up school I had a professor to

 encourge me to see someone. I did briefly but then in 20***, I was

 working a lot because we were purchasing a home. I do pretty good

until

 I have long periods of time where I am not doing anything. I am still

 really overly startled, especially being in a residential area. I hear

 everything, people dropping things and loud noises really startle

me."

 SM denies engagement in medication management but has been

 intermittently engaged in psychotherapy; "I was just seen in

January,

 but requested another appointment because I'm coming into another

wave

 where I have been feeling more anxious. 20** I had a number of

guys

 that were in my unit to die...two suicides, one *******************

 Regarding re-experiencing symptoms and alterations in cognitions, SM

 explained, "There is not a day that goes by that I do not think

about

 it...the bad events of course and how I changed as a person. I think

 about what if I would not have gone over there...would some of my

views

 be different. I think about what could have been different,

especially

 when ***** got injured. I was always the point man. I always did the

 sweep and this day someone else took over for me, that is when ***

 stepped on the IED. That never happened on my missions.

 Nightmares are not very common but I recently had a nightmare of a

 helicopter but theatre was at home. I have also had dreams where

 someone was standing over me, staring at me. "

 SM reports ongoing difficulties with hyperarousal; "I am always

keyed

 up but there have been times lately where I am more anxious. I'm

not

 sure why. I really don't know why but it tends to be really bad

when I

 do not have anything to do. It is really an issue with my sleep. My

 mind just goes and goes. I really want to go off the Ambien but if I

 don't take it, I do not go to sleep. Even with the Ambien I am

still

************ CONFIDENTIAL Page 9 of 19

 waking up. I am generally getting 3-4 hours." Regarding

hypervigilence

 he explained, "I watch people sitting in their cars. If they are

 pulling off the same time as me, I seem to need to watch to determine

 if I need to chnage my path...a little weird but that is just me.

I'm

 not as overly alert when I am working because I am busy and it helps

to

 keep me distracted. I am most alert on my days off, when I don't

have

 that distractions."

 SM reports ongoing avoidance and explained, "I have to keep my

mind

 busy, so working in the ******* works in my favor. It is very high pace,

 which is how I like to do things. My take on the memories has been, as

 long as it is stashed away, it doesn't exist...that's kind of

my thing.

 I don't generally talk about me, it is easier that way. I do not

really

 avoid anywhere in particular but helicopter bring up a lot of anxiety.

 I am trying to address that. When I hear one, I try to go outside and

 look at it. I am planning to do a ride with our crisis team to help

 with that too."

 With regard to other changes in mood he explained, "I get along

well

 with everyone but I don't have any close friends. Last year, I got

with

 all of my brothers as we laid*********to rest and that was very

 therapeutic to me. I think I am really socially awkward. I am just not

 comfortable, I don't know what to even talk about. I want to

connect to

 people and I keep people laughing at work, but I just have a hard time

 with getting close, other than my wife. I am in good communication

with

 my family. I talk to my dad a couple times a week, sometimes I can be

a

 bit short with my mom. I deal with angry patients all the time. I

don't

 let myself get upset or lash out...I just take a moment and hold it

 in."

 d. Relevant Legal and Behavioral history:

 SM denies

 e. Relevant Substance abuse history:

 SM denies

*********** CONFIDENTIAL Page 10 of 19

 f. Other, if any:

 No response provided.

 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)

 [X] Witnessing, in person, the traumatic event(s) as they

 occurred to others

 [X] Learning that the traumatic event(s) occurred to a close

 family member or close friend; cases of actual or

 threatened death must have been violent or accidental;

or,

 experiencing repeated or extreme exposure to aversive

 details of the traumatic events(s) (e.g., first

responders

 collecting human remains; police officers repeatedly

 exposed to details of child abuse); this does not apply

to

 exposure through electronic media, television, movies, or

 pictures, unless this exposure is work related.

 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] Marked physiological reactions to internal or external

 cues that symbolize or resemble an aspect of the

traumatic

 event(s).

 Criterion Persistent avoidance of stimuli associated with the

traumatic

 event(s), beginning after the traumatic events(s) occurred,

***************** CONFIDENTIAL Page 11 of 19

 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).

 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, distorted cognitions about the cause or

 consequences of the traumatic event(s) that lead the

 individual to blame himself/herself or others.

 [X] Feelings of detachment or estrangement from others.

 Criterion E: Marked alterations in arousal and reactivity associated with

 the traumatic event(s), beginning or worsening after the

 traumatic event(s) occurred, as evidenced by two (or more)

of

 the following:

 [X] Hypervigilance.

 [X] Exaggerated startle response.

 [X] Sleep disturbance (e.g., difficulty falling or staying

 asleep or restless sleep).

 Criterion F:

 No response provided.

 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] Anxiety

 [X] Suspiciousness

 [X] Chronic sleep impairment

****************** CONFIDENTIAL Page 12 of 19

 5. Behavioral observations

 --------------------------

 SM presented as well-groomed and neatly dressed. He was fully oriented

to

 person, place, time and circumstance. SM was fully engaged and exhibited

 good eye contact throughout the assessment. His mood appeared anxious,

 with constricted affect. Speech was clear and of normal rate and tone.

 Thought processes were congruent and goal directed. There was no

evidence

 of psychosis, delusions or perceptual disturbance. SM denies active

 SI/HI, plan or intent. Overall, judgement and insight appeared intact.

SM

 was made aware of the 24-hour Veterans Crisis Hotline in the event of

 worsening distress. He expressed an understanding.

 6. Other symptoms

 -----------------

 Does the Veteran have any other symptoms attributable to PTSD (and other

 mental disorders) that are not listed above?

 [ ] Yes [X] No

 7. Competency

 -------------

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

 [X] Yes [ ] No

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

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

 Prior to beginning the interview, the undersigned examiner informed the

 veteran of the purpose of the evaluation, the role of the undersigned

 examiner, and the limits of confidentiality. The veteran indicated

 understanding of the aforementioned information.

 Per VA Memorandum titled Information Bulletin: Updated Guidance for the

 Fifth Edition of Diagnostic and Statistical Manual of Mental Disorders

 (DSM-5) use in Compensation and Pension Examinations, dated August 28,

 2014 this examination was conducted using DSM-5 criteria. Of note, the

 DSM-5 no longer requires computation of a GAF score.

 **************************************************************

 DBQ PSYCH PTSD Review

 The following contentions need to be examined:

 post-traumatic stress disorder (PTSD) with sleep disorder

 Active duty service dates:

 Branch: Marine Corps

**************** CONFIDENTIAL Page 13 of 19

 EOD: *******20**

 RAD: *******20**

 DBQ PSYCH PTSD Review:

 Please review the Veteran's electronic folder in VBMS and state that

it

 was

 reviewed in your report.

 The veteran is service connected for post-traumatic stress disorder (PTSD)

 with sleep disorder and requires a routine future exam for this

 disability.

 Please examine the Veteran to determine the current level of severity.

 If more than one mental disorder is diagnosed please comment on their

 relationship to one another and, if possible, please state which symptoms

 are attributed to each disorder.

 

[vetquest]

Yes, please post your C&P, just redact all identifying information.  The Horror stories are mostly that, just horror stories told by the vet reps to reduce their workloads.  I would not get an IMO until you are denied.  If you get an IMO then you appeal straight to the BVA with your IMO.

As to getting an IMO I would look into a website that identifies IMO doctors.  You need one that knows how to write a VA letter.  Without the comment that they have reviewed all of your STR's and the statement that you are as likely as not disabled due to your service the IMO is just a piece of paper.  They also need to add a reasons and basis for their conclusions.  Hopefully you are getting treatment on the outside.  I would file all of these records with your appeal.  You need to show a chronic condition with treatment.

This site shows doctors by state: http://www.independentmedicalexaminer.com/

Good luck and ask as many questions as you can think of. 

[vetquest]

Yes, this is the C&P exam.  Can you post the third exam?

[RAM0311]

I guess I'm not sure which exam you are requesting.  I've had two C&P exams, but no other C&P type exams.  I guess I"ll need clarification to which exam you are requesting,

 

Thanks

[Buck52]

Look at this rating criteria for Mental Disorders

and look at this above exam  check your symptoms .... and see what rating you think you should have.

They rate PTSD by the symptoms!   also I notice this examiner mention you had a sleeping disorder? if you have OSA (Sleep Apnea) request a sleep study from your MH Clinic....you can file for Sleep Apnea Secondary to your S.C. PTSD when Awarded if you do get it Service Connected  and I don't see why that won't.

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.	0

 

[RAM0311]

I have terrible habit of downplaying symptoms, and even worse talking about them.  So I probably am at my own fault for my rating.   I have PTSD with insomnia... Is that something that should be looked at separately. My sleep sucks.  I haven't approached a sleep study.  Or do they get rated together?