Hello, I was able to obtain notes from my C&P exam for PTSD. It is a tad confusing. From your personal experience, can anyone "guestimate" what is being said here and what type of rating this may lead to? SECTION I: ---------- 1. Diagnostic Summary --------------------- Does the Veteran have a diagnosis of PTSD that conforms to DSM-5 criteria based on today's evaluation? [ ] Yes [X] No If no diagnosis of PTSD, check all that apply: [X] Veteran's symptoms do not meet the diagnostic criteria for PTSD under DSM-5 criteria [X] Veteran has another Mental Disorder diagnosis. Continue to complete this Questionnaire and/or the Eating Disorder Questionnaire: 2. Current Diagnoses -------------------- a. Mental Disorder Diagnosis #1: Posttraumatic Stress Disorder ICD code: 309.81 Comments, if any: Cluster B traits (Narcisstic) b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): Back/shoulder/ankle pains (chronic) 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 [X] No [ ] 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 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 ------------------ In order to provide an accurate medical opinion, the Veteran's claims folder must be reviewed. a. Medical record review: ------------------------- Was the Veteran's VA e-folder (VBMS or Virtual VA) reviewed? [X] Yes [ ] No Was the Veteran's VA claims file (hard copy paper C-file) reviewed? [ ] Yes [X] No If yes, list any records that were reviewed but were not included in the Veteran's VA claims file: If no, check all records reviewed: [ ] Military service treatment records [ ] Military service personnel records [ ] Military enlistment examination [ ] Military separation examination [ ] Military post-deployment questionnaire [ ] Department of Defense Form 214 Separation Documents [ ] Veterans Health Administration medical records (VA treatment records) [ ] Civilian medical records [ ] Interviews with collateral witnesses (family and others who have known the Veteran before and after military service) [ ] No records were reviewed [X] Other: Reviewed files in VBMS. b. Was pertinent information from collateral sources reviewed? [X] Yes [ ] No If yes, describe: -Reviewed the vet's statement in support of claim detailing his traumatic exposure event dated 03/25/16. -Reviewed a letter from the Police Department confirming the vet's presence during the claimed stressor (dated 03/27/09). 2. History ---------- a. Relevant Social/Marital/Family history (pre-military, military, and post-military): Mr. XXXXXX was born and raised in Rochester, NY by his mother. He stated that his father was not involved in his rearing. He described his relationship with his mother as being "strained" due to her history of using illicit drugs and other behaviors commonly associated with chronic abuse. He reported that, due to her behavior and limitations, he had been living on his own since the age of 15. He expressed that he did not have a relationship with his mother for apprx 15- 20 years and that now she is trying to rebuild their relationship. He denied having much of a relationship with his father. He stated that the extent of his relationship with his father is limited to requests for financial favors. He has 1 full sister, 4 half sisters via his mother and 18 known siblings via his father. He described his relationship with his siblings via his mother as variable. He stated that he speaks to his oldest and second to youngest sister on a regular basis. He expressed that his relationship is very close with his second to youngest sister("that's my baby"). He reported that he speaks with his youngest 2 brothers via his father "off and on." He described his overall childhood as being "rough" in association with his mother's behavior, physical and sexual abuse by his stepfather, as well as a lack of his father being present in his life. Mr. XXXXXX reported that he has friends primarily in NY. He denied talking to people as much as he used to. He added that as he ages, he is "starting to learn myself" and as a result, he has been a bit more distant. He further clarified that due to his irritability, he avoids going around people so that he doesn't get upset with them. He stated that he maintains contact with his friends via phone and social media. He communicated that he does not see his friends often. In his leisure time, the vet stated that he enjoys helping people repair their credit or otherwise helping people in other domains. Mr. XXXXXX denied a history of ever being married. He denied being in a romantic relationship. He added that "I am very difficult to get along with...primarily because I have trust and abandonment issues." He has 7 children via 4 different mothers. He expressed having longstanding concerns about "subjecting" his children to the same upbringing he had, which did not consist of having a mother and a father in the home. He described his relationship with his oldest son as being "strained" and "good" with the remainder of his children. He stated that 2 of his sons live relatively locally (in the state of GA). His children range in age from 3-19 y/o. Mr. XXXXXX reported that he lives by himself. He denied having any pets. b. Relevant Occupational and Educational history (pre-military, military, and post-military): Mr. XXXXXX's highest level of education is 2 Master's degrees (MBA in Finance and an MA in Accounting). He stated that his Accounting degree was from XXXXXXX in 2013 and his Finance degree was from XXXXXXXXXX University in 2008. He described his performance in school as "easier as I got older." He added that he does not "even know how he got through high school." He denied a history of ever being diagnosed with a learning disability. He denied a history of experiencing any on-going behavioral issues with his peers/instructors. Mr. XXXXXX served in the Army Reserves from 1996-2004 as a supply, then civil affairs tech. He then served in the Air Force Reserves from 2006-present as a finance technician. He denied a history of disciplinary infractions while in service. He reported a history of deployment to only stateside locations. His highest rank in service is E-7. While in the reserves, the vet's civilian employment is with the XXXXXXXXXXXXXXXXXXX (since 02/2016) as an accountant. From 2008-2014, he worked as a contractor for XXXXXXXXXXX (senior functional analyst) followed by XXXXXXXXXXXX (senior staff consultant). Prior to 2008, the vet reported that he worked for XXXXXXXXXXXXas a technical support coordinator. He described his performance across jobs as being "fine." He added that his time actually working on the job has been patchy due to the reserves frequently sending him on long-term TDYs. c. Relevant Mental Health history, to include prescribed medications and family mental health (pre-military, military, and post- military): Mr. XXXXXX reported a history of MH treatment in 2009 after he witnessed a young man get killed by the police. He stated that he saw someone in MH a few times, but eventually told them he was "OK" out of fear of damaging his career as well as "embarrassment." STRs are positive for MH encounters subsequent to the vet's reported trauma. It appears that he was initially seen on 02/16/09 apprx 2 weeks after he had been exposed to the trauma and was experiencing both sleep disturbances and ruminative thoughts about the incident. Although he was diagnosed with Insomnia, his encounter noted "suggestive of an Acute Stress Disorder at this time." Another diagnosis listed in the vet's STRs is Observation for Suspected Mental Condition, which was rendered around the same time as his Insomnia diagnosis. He has a history of being prescribed with Zoloft (depression/panic attacks) and Ambien (sleep). He denied a history of psychiatric hospitalizations or ER visits for MH reasons. Mr. XXXXXX reported that he participated in MH treatment in 02/2015 at Bolling AFB with respect to his sleep issues. He stated that he last saw a MH professional via his company's EAP for 3 sessions in 03/2016. He was last seen for MH treatment on 08/15/16 (psychiatry encounter). Per the encounter, the vet's chief complaint was anxiety and his only listed diagnosis was "panic attacks by history." He described his current symptoms as involving sleeping difficulties (with both going to sleep and staying asleep), challenging interpersonal relationships, increased irritation/aggravation, avoidance of situations that are likely to anger him, avoidance of thinking about his traumatic exposure (via "staying busy"), detachment from others/dislike of being around people including his children and crying spells/emotional outbursts. d. Relevant Legal and Behavioral history (pre-military, military, and post-military): The vet reported a history of getting arrested 2x (falsely accused of selling stolen property and criminal mischief). He denied having a record because each of the charges were dropped. He reported that he is currently involved in a lawsuit against a company that attempted to say he abandoned his civilian job as opposed to leaving for military duty, as was reportedly the case. e. Relevant Substance abuse history (pre-military, military, and post-military): Unremarkable. The vet reported a family history of substance abuse involving his mother (poly-drug abuse), father (crack- cocaine) and sister (alcohol and drugs). f. Other, if any: No response provided. 3. Stressors ------------ Describe one or more specific stressor event(s) the Veteran considers traumatic (may be pre-military, military, or post-military): a. Stressor #1: The vet reported that he was involved in an incident where a young man was killed in front of him while he was on TDY to Robins AFB. He stated that he attempted to assist the man after he was shot, but then the police reportedly trained their guns on his chest and he was ordered to get down on the ground. He added that it took the ambulance over 30 minutes to arrive and that he was lying on the ground next to the man as he died. He stated that whenever he hears about police shootings, he gets re-traumatized. He stated that he feels responsible for not being able to save the young man or get through to him about going home. Does this stressor meet Criterion A (i.e., is it adequate to support the diagnosis of PTSD)? [X] Yes [ ] No Is the stressor related to the Veteran's fear of hostile military or terrorist activity? [ ] Yes [X] No If no, explain: The vet reported that he was given a USAF Commendation Medal for Act of Courage given his involvement in the situation and that he hates it because he was not in fact helping the police, but trying to help the young man with the gun via diffusing the situation. He stated that he is fearful of how he could have been shot by the young man or the police. He added that he can still remember hearing each of the gun shots and the sounds of the young man getting hit with the bullets and listening to him trying to breath on the ground just before dying. Is the stressor related to personal assault, e.g. military sexual trauma? [ ] Yes [X] No 4. PTSD Diagnostic Criteria --------------------------- Please check criteria used for establishing the current PTSD diagnosis. Do NOT mark symptoms below that are clearly not attributable to the Criteria A stressor/PTSD. Instead, overlapping symptoms clearly attributable to other things should be noted under #7 - Other symptoms. The diagnostic criteria for PTSD, referred to as Criteria A-H, are from the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5). Criterion A: Exposure to actual or threatened a) death, b) serious injury, c) sexual violation, 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 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). Criterion C: Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic events(s) occurred, 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 D: 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 to the individual to blame himself/herself or others. [X] Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame). [X] Markedly diminished interest or participation in significant activities. 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] Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects. [X] Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep). Criterion F: [X] Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month. Criterion G: [X] The disturbance causes 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. Criterion I: Which stressor(s) contributed to the Veteran's PTSD diagnosis?: No response provided. 5. Symptoms ----------- For VA rating purposes, check all symptoms that actively apply to the Veteran's diagnoses: [X] Anxiety [X] Chronic sleep impairment [X] Memory loss for names of close relatives, own occupation, or own name [X] Disturbances of motivation and mood 6. Behavioral Observations -------------------------- Mr. XXXXXX presented as a 37 year-old African-American man of average height and build. He was casually dressed and neatly groomed, he appeared his stated age. He arrived to his appointment 20 minutes late. He readily greeted this examiner and accompanied her to her office. No gait abnormalities were observed. He was alert and oriented in all spheres and clearly understood the undersigned's role and the purpose of the current examination. The vet cooperated well with the current exam. He maintained an affable demeanor and readily engaged in dialogue. He responded to all questions asked of him, and his speech was normal in rate, volume, and intensity. His thinking, as evidenced in his speech, seemed logical and organized. His mood appeared euthymic and he exhibited a broad range of affect. Mr. XXXXXX expressed clear future orientation and denied having thoughts of wanting to harm himself or others. He stated that he has had "dark moments" and that he is able to feel better when he thinks about "tomorrow." Sleep: 3-4 hrs a night, reported that he frequently thinks about an incident involving a man being shot and killed by police in front of him. Interest Level: "Low" Guilt: Increased about situation with the young man Energy: I don't have a lot of energy and my body aches all the time, I've put on 25 lbs because I don't exercise like I used to Concentration: It's hard to concentrate on 1 particular thing, stated that he looks forward to TDYs because it get's him away from work (he isn't interested in doing his work, which reportedly affects his productivity) Appetite: "It fluctuates" Psychomotor Agitation/Retardation: No 7. Other symptoms ----------------- Does the Veteran have any other symptoms attributable to PTSD (and other mental disorders) that are not listed above? [ ] Yes [X] No 8. Competency ------------- Is the Veteran capable of managing his or her financial affairs? [X] Yes [ ] No 9. Remarks, (including any testing results) if any -------------------------------------------------- On the basis of the current examination, including the diagnostic interview and review of records, Mr. XXXXXX has been diagnosed with PTSD. He reported symptoms that were consistent with each criterion listed for diagnosis. He also expressed experiencing both anxiety and depression, which are both symptoms of PTSD. As such, additional diagnoses are not warranted at this time. The vet did not communicate his experience of "panic attacks" and so a panic attack diagnosis or specifier was not added. His potential history of panic attacks warrants further evaluation. Of note, the vet appeared to evidence symptoms/social history that seemed somewhat consistent with a disordered personality. He expressed having challenging relationship with friends, family, co-workers and supervisors. Although a clear conclusion could not be reached at the close of the current exam, further evaluation re" the presence of a Personality Disorder (with Narcissistic features) is also warranted (though, given the nature of personality disorders, military service would not have played a causal role in its development). Mr. XXXXXX's STR's were positive for sleep disturbances, both anxiety and depressive symptoms, as well as documented responses to trauma exposure. In consideration of the available information, it is the opinion of the undersigned that the vet's current diagnosis of PTSD is at least likely as not related to, or was incurred during, his military service. NOTE: VA may request additional medical information, including additional examinations if necessary to complete VA's review of the Veteran's application.