Comp & Pen for PTSD

My rating based on my Comp & pen reults

  • don't know

  • 0% to 100%

  • 100%


Results are only viewable after voting.

gman64

Registered Member
#1
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, [email protected]:00 ENTRY DATE: OCT 27, [email protected]: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.
 

Warrior644

PEB Forum Veteran
Registered Member
#2
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[email protected]:00 ENTRY DATE: OCT 27, [email protected]: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.
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:

gsfowler

Staff Member
PEB Forum Veteran
#5
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 :)
 

Warrior644

PEB Forum Veteran
Registered Member
#6
Thanks Warrior644 I haven't been back to work it's been a month now.
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!