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


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:


Mental Health Diagnoses and Relevant Medical Conditions:

Unspecified Trauma-Stressor-related Disorder r/o PTSD

Significant Psychosocial and Contextual Factors: MST (Sexual assault)


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


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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Remember, under VA Policy you are not locked in to PTSD.  You can receive the same ratings for Depression as you do for PTSD.

With MH issues it is the impact of the issue on your Life.  Not the "name" of the issue.  The VA should (yea I know...) automatically rate for any other MH issue that is diagnosed other than PTSD as part of the same claim.

So your current therapist records are viable no mater what the diagnosis is.  As long as the records document the impact on work and lifestyle you should be fine.


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Since my last post I think I've pretty much become persona non grata to the entire Orlando MH staff with the exception of my PTSD therapist who has been purposely remaining out of it in order to keep treating me with objectivity, which I can appreciate.  The chief of MH and the AO's no longer return my calls and the MST coordinator is vehemently sticking to the story of "the VA does NOT write nexus letters".  My primary provider went so far as to state that since I didn't report the incident that there is nothing in my record to prove that it happened so he can't give an opinion.  He stopped responding when I reminded him that his job was to help me and that the VA mandated that statements from someone you served with backing up the events and witnessing changes in behavior, etc. are as good as reporting and should be counted as such.  He stopped responding to my messages.  At this point I'm honestly ready to call the IG and let them explain why they're causing they're veterans anxiety and demeaning them when they ask for help.


The bright spot in this is that I started my prolonged exposure on Thursday and even though it was just informational to begin with, the notes were uploaded to MHV and it looks like my PTSD doc dropped the r\o and may have inadvertently given connection?  Below is the excerpt...can I upload this and use it as evidence of diagnosis and SC along with my buddy letter?

VA Notes
Source: VA
Last Updated: 04 Nov 2019 @ 0707


Sorted By: Date/Time (Descending)

VA Notes from January 1, 2013 forward are available 3 calendar days after they have been completed
and signed by all required members of your VA health care team. If you have any questions about your
information please visit the FAQs or contact your VA health care team.


Date/Time: 31 Oct 2019 @ 1425

Signed By:
Co-signed By:
Date/Time Signed: 31 Oct 2019 @ 1540


DATE OF NOTE: OCT 31, 2019@14:25 ENTRY DATE: OCT 31, 2019@14:25:19


Time in session (in minutes): 70
Session Number: 1
Face-to-face session


PTSD clinical team
Primary (focus of treatment): Unspecified Trauma-Related Disorder


A PCL-5 was performed and was positive. The score was 64.
A PHQ-9 screen was performed. The score was 18 which is suggestive of
moderately severe depression.



Veteran completed session 1 of Prolonged Exposure therapy for PTSD. The
following occurred during the session:
Facilitated a good therapeutic relationship.
Provided psychoeducation and introduced PE treatment for PTSD to
Veteran, including:
-Information about PE as a treatment option.
The following information was given:
-Readiness to engage in treatment.
-Addressing Veteran's questions or concerns about treatment.
Veteran expressed the following concerns: Veteran discussed fear associated
with imaginal exposures. Her fears were validated and discussed within the
context of the rationale for treatment.
Presented treatment rationale, focusing on describing factors that
maintain trauma-related fears and symptoms (i.e., avoidance and
unhelpful thoughts and beliefs). Also, described key therapeutic
elements of PE: imaginal and in-vivo exposure procedures. Veteran's
response to rationale involved: The Veteran was able to discuss
acknowledgement of the rationale for treatment.


INDEX TRAUMA to be addressed in PE is related to:
Sexual assault while in the military


Veteran is to complete the following practice items between sessions:
Listen to audiotape of therapy session one time.
Read "Rationale for Treatment" handout and note questions.


Next session planned for agreed upon date/time of: November 5, 2019


Veteran reports:
Significant pain or changes in pain.
Pain level reported = 5, on 0-10 scale with 0 indicating no pain
and 10 most pain imaginable.
Location(s): Back, wrist, shoulder.


Veteran receiving treatment for pain: Yes



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On 10/23/2019 at 10:54 AM, SameOldSong said:

I found a link to a snippet that might be of interest on the "r/o PTSD" commentary:


It discusses the refusal to put PTSD on medical records in the Veterans Health system.


I think that's the email referenced in an IG report I read....where of course they found no evidence that the providers heeded the "suggestion".  However that article is my story almost verbatim...my MH primary even told my they didn't have time to diagnose PTSD. 

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On 10/23/2019 at 11:30 AM, Hyrb said:

Remember, under VA Policy you are not locked in to PTSD.  You can receive the same ratings for Depression as you do for PTSD.

With MH issues it is the impact of the issue on your Life.  Not the "name" of the issue.  The VA should (yea I know...) automatically rate for any other MH issue that is diagnosed other than PTSD as part of the same claim.

So your current therapist records are viable no mater what the diagnosis is.  As long as the records document the impact on work and lifestyle you should be fine.


While that's true, my C&P examiner was clever enough to tie EVERY....SINGLE...Mental diagnosis I have to childhood trauma, negating service connection for all of it.  So one doctor, who never served, who I had never met before and talked to for 90 minutes and never looked me in the eyes, falsifying ALL of what I said, took away all of my SC issues with one stroke of the keyboard.  While I did write a scathing letter of impeachment, I have yet to hear whether it was received or if the appointment is still being used in my claim.  My file is flagged for hardship but they're still dragging their feet.  I have a claim in for IU as well, but they sent a request back to my outside examiner for migraines for clarification on Oct 2nd and still haven't received a response.  He's 12 days past his deadline and they've put no pressure on him to close it out.  They just don't care...I feel like as long as you're not suicidal they get to check off a box and move on.  Yet they don't see that what they're doing is causing veterans to lose everything and BECOME suicidal.  It's all about reacting and putting out fires instead of preventing it from happening.  I'm just fortunate I have a husband who loves me and would do anything to make sure I'm ok...and 2 dumb dogs that are natural service dogs, who can sense my panic attacks well before they hit me.

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