Comp & Pen for PTSD

Discussion in 'PTSD and Mental Health Conditions' started by gman64, Nov 29, 2016.

?

My rating based on my Comp & pen reults

  1. don't know

  2. 0% to 100%

  3. 100%

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  1. gman64

    gman64 Registered Member

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    Hello everyone I was wondering if I can get some advice on my comp & pen results for PTSD which was on October 27th 2016.


    LOCAL TITLE: C&P MENTAL DISORDERS

    STANDARD TITLE: MENTAL HEALTH C & P EXAMINATION CONSULT

    DATE OF NOTE: OCT 27, 2016@13:00 ENTRY DATE: OCT 27, 2016@13:18:43





    Mental Disorders

    (other than PTSD and Eating Disorders)

    Disability Benefits Questionnaire



    Is this DBQ being completed in conjunction with a VA 21-2507, C&P

    Examination

    Request?

    [X] Yes [ ] No




    SECTION I:

    ----------

    1. Diagnosis

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

    a. Does the Veteran now have or has he/she ever been diagnosed with a mental

    disorder(s)?

    [X] Yes [ ] No



    ICD code: F43.1



    If the Veteran currently has one or more mental disorders that conform to

    DSM-5 criteria, provide all diagnoses:



    Mental Disorder Diagnosis #1: PTSD

    ICD code: F43.1


    Mental Disorder Diagnosis #2: Major Depressive Disorder, Severe

    ICD code: F33.4


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

    Mental Health Disorder (to include TBI):

    No response provided.



    2. Differentiation of symptoms

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

    a. Does the Veteran have more than one mental disorder diagnosed?

    [X] Yes [ ] No



    b. Is it possible to differentiate what symptom(s) is/are attributable to

    each diagnosis?

    [ ] Yes [X] No [ ] Not applicable (N/A)



    If no, provide reason that it is not possible to differentiate what

    portion of each symptom is attributable to each diagnosis and discuss

    whether there is any clinical association between these diagnoses:

    Significant overlap



    c. Does the Veteran have a diagnosed traumatic brain injury (TBI)?

    [ ] Yes [ ] No [X] Not shown in records reviewed



    3. 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] Total occupational and social impairment


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



    If no, provide reason that it is not possible to differentiate what portion of the indicated level of occupational and social impairment

    is attributable to each diagnosis:

    Signficant overlap



    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

    [X] Other (please identify other evidence reviewed):

    Veteran brought in Statement in Support of PTSD and a handwritten

    letter as well.

    This was given to Ricardo Sealy for scanning.



    2. History

    ----------

    a. Relevant Social/Marital/Family history (pre-military, military, and

    post-military):




    Veteran stated that he continues to live with his wife, but in separate

    bedrooms. "It's been rough the past two months, I haven't been speaking

    to anyone.


    I haven't been at work for two weeks, since that incident. It's been

    hell - the anxiety, don't want to be around people. I had time driving

    here, my dad was supposed to drive me here last week. But I had to take

    myself here, since he went on vacation.


    I don't talk to anyone -not at all. Since the incidnet, at work, I

    haven't been able to go back. I feel that people are out to get me."



    b. Relevant Occupational and Educational history (pre-military, military,

    and post-military):



    "I've been struggling at work for the past three months. It was

    something that triggered my episode. I was Dunkin Donuts, and a guy

    threatened this young lady. She kept apologizing, he was going to stab

    her. I had a confrontation with him, I didn't care if I lived or died.

    She grabbed my hand, but when I turned around she was gone.


    I've had that happen a couple of times [witnessing someone being

    threatened]. There was a veteran shouting at the secretary, and I lost

    it. I went home early that day. I was going home early from work about

    4

    times per week.


    The incident at work was when a veteran got mad at me and threatened my

    life. I thought I was going to lose it, come after him. They've been

    calling me to come back to work, but I can't talk to them, I can't go

    back there."






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

    family mental health (pre-military, military, and post-military):



    "I haven't been to work since then [the incident two weeks ago]. They

    have been trying not contact me, but I don't talk to anyone. I last saw

    psychologist in Newington last week. I'm struggling, I take the bus, I

    have anxiety.


    I eat once in a while - lost 25 pounds. I haven't taken a bath in a few

    days. In the same clothes for the past three days. In the last weeks, I

    only sleep for two hours per night. I wake up tired, wiht nightmares

    about my friend.


    Flashbacks - that's why I'm not driving. I had one at a stop sign.

    People blowing horns, then there was a cop on my window. I haven't

    driven since the last day I went to work. I had to drive myself here.


    Suicidal - I think about it every day, my brother had my firearms for

    now. I feel safe to go home today. agreed to call crisis line. Declined

    immediate support, did not want to be walked to the psych ER.


    Mood - anxious, depressed most of the time. I feel like I have no

    Energy to do anything."


    The PTSD reported developed after veteran and his close friend

    witness a fight at a bar near Andrews AFB in May 1985. They intervened to help

    the ladies, and his friend was shot and killed. Veteran was holding his

    friend in his arms, as he died immediately.




    d. Relevant Legal and Behavioral history (pre-military, military, and

    post-military):



    Nothing in the past year, in terms of legal issues. Veteran's last

    arrest in 2001 for assaulting two police officers.



    e. Relevant Substance abuse history (pre-military, military, and

    post-military):



    No relapses with alcohol or drug use. "I've been close. I almost acted

    on it last week."

    When asked why he didn't, he said that his dog licked my face. Now, his

    service dog doesn't leave his side.



    f. Other, if any:

    No response provided.



    3. Symptoms

    -----------

    For VA rating purposes, check all symptoms that actively apply to the

    Veteran's diagnoses:



    [X] Depressed mood

    [X] Anxiety

    [X] Suspiciousness

    [X] Near-continuous panic or depression affecting the ability to function

    independently, appropriately and effectively

    [X] Chronic sleep impairment

    [X] Disturbances of motivation and mood

    [X] Difficulty in establishing and maintaining effective work and social

    relationships

    [X] Difficulty in adapting to stressful circumstances, including work or

    A work like setting

    [X] Inability to establish and maintain effective relationships

    [X] Suicidal ideation

    [X] Neglect of personal appearance and hygiene

    [X] Intermittent inability to perform activities of daily living,

    including maintenance of minimal personal hygiene


    4. Behavioral observations

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

    Mental Status and Behavioral Observations:


    -ORIENTATION: Alert and oriented x3.

    -PRESENTATION: Appropriately dressed in casual attire and well-groomed.

    -RAPPORT: Cooperative and open with his concerns.



    -MOOD/AFFECT: Mood appeared dysthymic; affect congruent with mood or

    excessively flat.

    -THOUGHTS: Linear and goal-directed.

    -SPEECH: Flatt and sparse in terms of rate, rhythm, and volume.

    -INSIGHT AND JUDGMENT: Fair insight and judgment.



    5. Other symptoms

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

    Does the Veteran have any other symptoms attributable to mental disorders

    that are not listed above?

    [ ] Yes [X] No



    6. Competency

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

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

    [X] Yes [ ] No



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

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

    Veteran meets criteria for PTSD as well as MDD, based on report sympotms and

    chart review. He experienced an incident at work about 2 weeks ago, and

    since that time he has been impaired in his emotional functioning, communication,

    eabilities, and ADLs.
     
  2. Warrior644

    Warrior644 PEB Forum Veteran Registered Member

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    Welcome to the PEB Forum! :)

    As based upon 38 CFR §4.130 Schedule of ratings—Mental disorders, it would seem that your potential DoVA rating should be at the 100% rate due to the following indication:

    "General Rating Formula for Mental Disorders

    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%"

    3. 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] Total occupational and social impairment

    Thus, I quite often comment that "possessing well-informed knowledge is truly a powerful equalizer!"

    Best Wishes!
     
    Last edited: Nov 29, 2016
  3. gman64

    gman64 Registered Member

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    Thanks Warrior644 I haven't been back to work it's been a month now.
     
  4. dotlak

    dotlak PEB Forum Veteran Registered Member

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    I totally agree with Warrior644. Base on your c & p, you should receive 100%. Good luck!
     
  5. gsfowler

    gsfowler Staff Member PEB Forum Veteran

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    100%, more than likley TDRL.

    If you have not, I highly recommend that you apply for SSDI, the probability of approval is very good, could provide more income for your family. You will get expedited processing while still in active duty. https://www.ssa.gov/people/veterans/

    Also consider applying for CRSC if your PTSD is combat related, you could restore all or some of the VA offset to your medical retirement. https://www.dfas.mil/retiredmilitary/disability/crsc.html

    edit: I updated your poll to add the option of 100% only. 0-100% covers any and all ratings :)
     
  6. Warrior644

    Warrior644 PEB Forum Veteran Registered Member

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    Indeed, you are welcome! :)

    Please take care of yourself and I can definitely comprehend your current medical situation since I too have PTSD & severe MDD which yielded a DoVA disability 100% P&T rating. Peace my brother!

    Oh yes, if you feel that you are unable to continue working, you may want to consider applying for SSA SSDI federal disability compensation at this particular point in time. Visit my below URL for additional detailed information about the SSA SSDI process:
    Thus, I quite often comment that "possessing well-informed knowledge is truly a powerful equalizer!"

    Best Wishes!
     
  7. gman64

    gman64 Registered Member

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    Thanks for the input
     
  8. chaplaincharlie

    chaplaincharlie PEB Forum Veteran Registered Member

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    Agree on 100% an TDRL is likely.
     

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