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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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LightningFan75, you are caught in a system that does not want to diagnose PTSD.  Tying everything to childhood trauma is a cop out that the VA uses.  Did they evaluate you for depression?  If they diagnose you with depression you are entitled to the same benefits that they give for PTSD.  Before giving me a diagnosis of PTSD they made five or six other diagnoses that were not nice.  

Have you tried playing their game and going along in treatment.  If you stay in treatment and they say you need it they have a hard time denying you have something connected to service.  Continue to see your provider that is treating you and don't alienate him.  I understand wanting to get the VA to provide your nexus but they will not do that.  If you push them you will see the same results you are seeing in the rest of the department.  Before I got my diagnosis I had to spend two weeks in a lock down ward and quit drinking alcohol.  

Being persona non gratia is hard to deal with.  I once made an offhand remark to a doctor who was being obnoxious and got flagged.  They required a psyhc doctor to be at all of my medical appointments after that for about a year.

As far as being suicidal talk to your MH provider about that if you are. 

I know about waiting, it was ten years before I got my PTSD rating and ten years after I lost my job due to my SC disability before I got TDIU.

Just remember Do Not let the jerks win.  If you alienate all of your providers or quit trying they have won.

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They have diagnosed me with depressive disorder but my C&P exam did a pretty good job of denying that one as well:

-A diagnosis of PTSD was less likley than not incurred in or caused by the MST reported by the Vet.

-A diagnosis of insomnia was less likley than not proximately due to or the result of her service connected tinnitus.

-Her current diagnosis of adjustment disorder was less likley than not incurred in or caused by active duty service.

-Her current diagnosis of Mixed Anxiety and Depressed Mood was less likley than not incurred in or caused by active duty service.

In terms of PTSD, although the Vet reports a period of sexual harassment and a rape in her active duty service, the STRs were silent for circumstantial markers, as as MH assessment/treatment in active duty. Her other stressors described in the stressor section would not meet category A standards for qualified incidents. In reviewing post service treatment records, her first MH contact came in 4/2019, and was precipitated by a job loss secondary to verbal altercation, prior to which she was functioning fine until a poor performance eval came about before the verbal altercation, MH treatment notes only describe self report of the MST and self report of the Vet's interpretation of more recent psychological difficulties; MH providers have not given a PTSD diagnosis and allude to such a condition only from self report of symptoms; in VBMS, there are many buddy statements from her husband and former co-workers, these do not provide evidence for a MH condition that arose from active duty, and only relate recent struggles with chronic migraines and back issues. In speaking with the Vet today, she did not disclose her hx of childhood sexual abuse as she did in the 12/2018 MH c and p exam, her scores on symptom validity screens (see behav obs scnt) were far above normal limits, indicating unreliability of self report, and she described fears of abandonment and anger in the context of having problematic romantic relationships she got into in the past to fill a void.

He basically said because I didn't tell him I was assaulted as a child that I'm not reliable in self reporting and exaggerating my symptoms now so my issues did not occur during my time in the service.  He also read all of my IU buddy statements but not the one from my shipmate that was relevant to this claim.  My goal wasn't to alienate my MH provider but i found it very unprofessional for him to respond the way he did to my request.  It's all just very frustrating.

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You got caught up in one of the VA's cudgel's for denying claims.  I am saying this for others who may read this post.  You should only self report things that happen after you join the service.  It is not dishonest, it is just protecting you from allowing the VA to claim pre-existing, especially in mental health.  Your having a tough childhood did not make you unfit for service.  If you have issues after service it is most likely due to service.  Yes, he is claiming since you did not report this a second time you are not viewed as a valid self reporter.  This is very tough to get by.  

As far as your migraines and Back issues do you have in-service evidence in you STR's?  You might be able to get SC for these and then go after depression as a secondary to migraine and back pain.

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That's just it.  His "exam" didn't even approach past trauma, so unless I were to have jumped up and said "hey before we start you should know x", it would not have been a fluid self report.  So by not approaching the exam the same my answers were different.  Only AFTER the exam did he go through my past C&P and notice it and then call me out.  

Anyway, to be honest I'm about to give them what they want and stop fighting.  It's putting a strain on my marriage and both my own and my husbands health.  They're dragging their feet on the IU claim and we're starting to fall behind on everything.  My file is flagged for hardship yet they still give a decision date of April...by then we'll be too far gone to keep the house and I won't know what to do.  Everything we worked so hard to build gone because I can't keep a job and the VA doesn't care.  The last thing they told me very coldly was...we can help with homeless shelters if you lose your home.  My husband's been through losing his house and bankruptcy and has always prided himself in being financially responsible and now it looks like he's going to have to go through it all again.

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I have SC for my back at 20% and 10% and migraines at 50%.  Both have made it impossible to do my job since it is very physical which is why I'm claiming IU...unfortunately they recently sucked my PTSD claim into the IU which pushed everything back again.

 

I also just received a notification for yet a 3rd Psych C&P appointment.  This time through VES instead of at the VA.  I consulted my PTSD therapist about it and, after some research, he's saying somewhere along the line in my treatments or C&P exams, a doctor put down that my assault happened in Dubai.  I never told anyone that it happened there...I did say that my assignment at the time was Dubai but I've made it clear where it actually happened.

I don't know if this exam is because I wrote a letter to impeach the examining doctor from my last one, or if it's because now they think I'm lying since a doctor was incorrect in quoting me.  Either way this is going to be difficult to get through and i have no idea how to get the record straight...almost like a clean slate.

My therapist also, said he would write me a letter but he didn't say what he would put in it.

And the rabbit hole keeps getting deeper.

On 11/4/2019 at 7:14 PM, vetquest said:

You got caught up in one of the VA's cudgel's for denying claims.  I am saying this for others who may read this post.  You should only self report things that happen after you join the service.  It is not dishonest, it is just protecting you from allowing the VA to claim pre-existing, especially in mental health.  Your having a tough childhood did not make you unfit for service.  If you have issues after service it is most likely due to service.  Yes, he is claiming since you did not report this a second time you are not viewed as a valid self reporter.  This is very tough to get by.  

As far as your migraines and Back issues do you have in-service evidence in you STR's?  You might be able to get SC for these and then go after depression as a secondary to migraine and back pain.

  

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