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LightningFan75

Need Help with an unfavorable C&P for PTSD Secondary to MST

Question

I need some unofficial guidance with my claim for PTSD.  I think I have two uphill battles ahead...I just had my C&P and have received the notes from the exam.  The doctor has completely discounted that the event happened, much less any secondary markers, attributing my trauma to a childhood incident.  His notes contradict themselves on multiple occasions.  He states that I denied any history of alcohol abuse, yet states later in the exam that I disclosed that I started abusing alcohol after the incident.  He also discounted and falsely reported several facts surrounding my time in the service.  He stated I was never in combat, never had foreign service or received any combat medals and to view my DD-214 for more information, yet my DD-214 shows multiple combat medals, foreign service and he his report lists my service dates where i received combat pay and hostile Fire/Imminent Danger pay.

His notes are mostly snippets copied and pasted from my past appointments that support his denial, but he leaves out all of the relevant parts of my session.

He never looked me in the eyes and stared at his clip board the entire time

He said I started therapy after I lost my job and that I lost my job in April, when in fact I was therapy months before I lost my job which was 7/16.  I told him all of this and he reported it wrong.

He also put down: 

On the SIMs, a measure of symptom validity, the score of 37 indicated significant symptom exaggeration/over reporting.

On a PTSD symptom validity screen, the score of 25 indicated significant symptom exaggeration/over reporting.

Basically he's calling into question my integrity and makes no reference to my MH sessions with my provider, who never once questions my honesty in our sessions.

My test scores from my MH sessions are:

PHQ-9 (Depression): 23

PHQ-9 was administered and score indicates severe depression.

(RANGES: 0-4 Minimal; 5-9 Mild; 10-14 Moderate; 15-19 Moderately severe;

20-27 Severe)

GAD-7 (Anxiety): 19

GAD-7 was administered and score indicates severe anxiety. (RANGES: 0-4 Minimal; 5-9 Mild; 10-14 Moderate; 15-21 Severe)

PCL-5 (Posttraumatic distress): 64 (very severe symptoms reported)

PCL-5 was administered and the score is > or equal to cutoff score of 33 and may be consistent with a diagnosis of PTSD..

 

That leads me to my next issue...my MH provider continually throws out the term PTSD in our sessions, has started me on a treatment plan that consists of BOTH MST and PTSD therapy and yet WILL NOT put PTSD as a diagnosis.  Instead I'm diagnosed with:

DIAGNOSES (per chart):

Major depressive disorder, single episode, moderate

Anxiety disorder, unspecified

 

On top of that my VA psychiatrist put contradicting statements in my last exam:

DIAGNOSIS:

Mental Health Diagnoses and Relevant Medical Conditions:

Unspecified Trauma-Stressor-related Disorder r/o PTSD

Significant Psychosocial and Contextual Factors: MST (Sexual assault)

CASE FORMULATION AND RESPONSE TO TREATMENT:

35 y/o female veteran with anxiety, depressive Sx's and significant

clinical

distress since index trauma, in 2011. High suspicion for PTSD. No prior MH treatment.

 

So he in essence ruled out PTSD and then stated he had a high suspicion for PTSD.

 

I apologize that these thoughts may seem all over the place, but my treatment notes are a mess and the C&P examiner added 112 pages to it with mostly copy and paste, so it's hard for me to make sense of and I'm very hesitant to upload personal information.  I just don't know what to do when MH provider says I have PTSD from MST, puts me in treatment but won't diagnose me, and then a C&P appointment with a doctor who acted like he had better things to do and went mostly off my test scores and didn't really listen to a word i said since his notes are riddled with inaccuracies.

 

 

 

 

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if you were a combat veteran they consead the stressors  you have the CIB on your DD 214 That should be good enough evidence you were in combat. 

''yet my DD-214 shows multiple combat medals, foreign service and he his report lists my service dates where i received combat pay and hostile Fire/Imminent Danger pay''.

You may already know this? but here it is again.

You need 3 basic things here called the Clauza Triangle

1.Current Diagnosis.   (No diagnosis, no Service Connection.)

2.In Service Event or Aggravation.

3.Nexus (link- cause and effect- connection) or Doctor’s Statement close to: “The Veteran’s (current diagnosis) is at least as likely due to x Event in military service”

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They've already denied my combat PTSD claim due to the fact that all of my over seas records are missing and they're stating that a DD-214 is not sufficient enough evidence to prove PTSD.  Basically they're telling me that I may have been in combat but it didn't cause any stress on me.  I've asked my MH provider for a letter of nexus and he said he'd "look into it", so I provided him with the VA policy on medical opinions and a sample letter.  Of course I'm now realizing that he hasn't diagnosed me with PTSD so I don't yet meet criteria 1.  Having to relive these events by telling a new person what happened is taking a toll on my sanity and my family and i feel like I'm experiencing it all over again and then told it didn't happen or I'm exaggerating.  I honestly feel like I'm worse now that I've sought treatment than when I just kept it bottled up.  I'm not sure how to convince my MH provider to actually diagnose me with PTSD.  He's agreed I have it, he's agreed I need to go through specialized treatment and yet he won't write it down.  Almost as if he's been told to reduce the number of PTSD diagnosis he gives and instead come back with Depressive Disorder, or Adjustment disorder with Anxiety.

In the US murderers and thieves are innocent until proven guilty but Veterans are just the opposite.  It didn't happen until you can give us iron clad proof.

 

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Buck has great advise, and i certainly am not an expert on PTSD/TBI stuff, but one thing I know that applies here. If the examiner is completely bogus as you indicate call immediately and tell the C&P manager that you totally disagree with his report and the reasons why. Do it today! Ask where you can send your confirming arguments in writing. They should re-schedule you again. Have a copy of your comments that you sent in and show them to the new examiner when you get one.

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Yes, he is calling into question your integrity and I would use that to impeach him.  You have combat medals and foreign service so I would bring this up in your letter where he ignored this.  Take your emotion out of it and explain it like you would if you were doing it for another veteran. 

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Posted (edited)
7 hours ago, LightningFan75 said:

I need some unofficial guidance with my claim for PTSD.  I think I have two uphill battles ahead...I just had my C&P and have received the notes from the exam.  The doctor has completely discounted that the event happened, much less any secondary markers, attributing my trauma to a childhood incident.  His notes contradict themselves on multiple occasions.  He states that I denied any history of alcohol abuse, yet states later in the exam that I disclosed that I started abusing alcohol after the incident.  He also discounted and falsely reported several facts surrounding my time in the service.  He stated I was never in combat, never had foreign service or received any combat medals and to view my DD-214 for more information, yet my DD-214 shows multiple combat medals, foreign service and he his report lists my service dates where i received combat pay and hostile Fire/Imminent Danger pay.

His notes are mostly snippets copied and pasted from my past appointments that support his denial, but he leaves out all of the relevant parts of my session.

He never looked me in the eyes and stared at his clip board the entire time

He said I started therapy after I lost my job and that I lost my job in April, when in fact I was therapy months before I lost my job which was 7/16.  I told him all of this and he reported it wrong.

He also put down: 

On the SIMs, a measure of symptom validity, the score of 37 indicated significant symptom exaggeration/over reporting.

On a PTSD symptom validity screen, the score of 25 indicated significant symptom exaggeration/over reporting.

Basically he's calling into question my integrity and makes no reference to my MH sessions with my provider, who never once questions my honesty in our sessions.

My test scores from my MH sessions are:

PHQ-9 (Depression): 23

PHQ-9 was administered and score indicates severe depression.

(RANGES: 0-4 Minimal; 5-9 Mild; 10-14 Moderate; 15-19 Moderately severe;

20-27 Severe)

GAD-7 (Anxiety): 19

GAD-7 was administered and score indicates severe anxiety. (RANGES: 0-4 Minimal; 5-9 Mild; 10-14 Moderate; 15-21 Severe)

PCL-5 (Posttraumatic distress): 64 (very severe symptoms reported)

PCL-5 was administered and the score is > or equal to cutoff score of 33 and may be consistent with a diagnosis of PTSD..

 

That leads me to my next issue...my MH provider continually throws out the term PTSD in our sessions, has started me on a treatment plan that consists of BOTH MST and PTSD therapy and yet WILL NOT put PTSD as a diagnosis.  Instead I'm diagnosed with:

DIAGNOSES (per chart):

Major depressive disorder, single episode, moderate

Anxiety disorder, unspecified

 

On top of that my VA psychiatrist put contradicting statements in my last exam:

DIAGNOSIS:

Mental Health Diagnoses and Relevant Medical Conditions:

Unspecified Trauma-Stressor-related Disorder r/o PTSD

Significant Psychosocial and Contextual Factors: MST (Sexual assault)

CASE FORMULATION AND RESPONSE TO TREATMENT:

35 y/o female veteran with anxiety, depressive Sx's and significant

clinical

distress since index trauma, in 2011. High suspicion for PTSD. No prior MH treatment.

 

So he in essence ruled out PTSD and then stated he had a high suspicion for PTSD.

 

I apologize that these thoughts may seem all over the place, but my treatment notes are a mess and the C&P examiner added 112 pages to it with mostly copy and paste, so it's hard for me to make sense of and I'm very hesitant to upload personal information.  I just don't know what to do when MH provider says I have PTSD from MST, puts me in treatment but won't diagnose me, and then a C&P appointment with a doctor who acted like he had better things to do and went mostly off my test scores and didn't really listen to a word i said since his notes are riddled with inaccuracies.

Prepare in statement of claim. NOD the decision  and keep up with your original filing date,  you may want to add that in your NOD, if your denied? then Request a DRO Hearing at your local R.O. and do this  

What you can do is find all these inaccurate  statements   from this C&P EXAMINER (if you have the report?) copy and past them Over to a new sheet or email them to yourself ....then correct each inaccuracies with your evidence

Do this sorta-like a break down Of the exam...> copy and past all the report  then in between his inaccuracies  and add your evidence , mark your evidence as exabit A   B  C  ect,,ect,ect,,,  see exabit A on page 2  see exabit B on page 3 ect,,,ect,,   this will show the rater how the examiner screwed up   also this might get you another C&P With a different Dr.

while preparing this, up at the top of the page describe what your sending in   and say something like the examiner was not accurate in his report as this evidence will show different .

I have sent in his report with my break down of his inaccuracies.

you need a PTSD Diagnose form your VA MH Clinic Dr' 

Remember evidence is what wins our claims.

The DRO can make a decision on the spot  if he reads all the inaccuracies  the examiner mention.

someone or other members may be able to explain this better that I can.

Note* if your denied and you NOD (Notice of Disagreement)

Do not select the HLR lane  With this New AMA System, you can not submit new & Relevant Evidence in this lane.

Use the supplemental lane as your course of Action.

 

 

 

 

 

 

Edited by Buck52

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