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.
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.
