Anxiety Disorder part III - The NARSUM, Commanders Letter and the Threats. Help!

A

Airforcematt

PEB Forum Regular Member
PEB Forum Veteran
Registered Member
Alright, this is an update for my latest encounters with the medical group. Been going over this with the awesome help of ceilingfan who's given me what I think is some good advice but I'd like to get others read on the situation.

First off - lets talk about the NARSUM

A sanitized version of my NARSUM can be downloaded here
A sanitized version of my Commanders Letter (that I helped write) can be downloaded here

There are several problems with my NARSUM. Let me list them.

  1. The NARSUM was written before my latest Commanders Letter, hence the impact on my ability to function is out of date. In my most current Commanders letter it directly relates my back pain, and my anxiety as issues that contributed to my removal from duties in my AFSC. Thankfully my PEBLO has agreed to hold off submitting this to the MEB until I can talk to my PCM.
  2. Now I have asked my PCM the question before if my Anxiety would be added to my NARSUM and this was the answer
    ----Original Message-----
    From: ***
    Sent: Late last year
    To: USAF1
    Subject: RE: NARSUM question

    Yes, I have spoken with Dr. ************* and he said that anxiety is not a
    boardable condition. Only major depression or psychosis.

    V/R

    Dr. So and So
    Click to expand...
    Now I know that's not a true statement. I have proof from the AFI's - see the direct quotes in the Commanders Letter. Right now I plan on simply asking him and/or sending him an email asking him.

    Does anyone have any further suggestions on how to attack this?

    Would just leaving all this alone till the MEB meets and cover it all in my rebuttal letter be the better course of action

  3. My mental health team and I haven't got along pretty much since I went to a outside provider who diagnosed me with PTSD. I've made no bones about the fact that I think that this is a bigger issue than they are making it out to be and I don't feel comfortable that they are actually trying to help me. I actually feel threatened at every appointment I go to. This all came to a head a few days ago

    I'm being seen by a Psychiatrist for my medication needs and a psychologist for counselling. A few days ago I had a meeting with my psychologist, the first one since I got back from my C&P results. He wanted to know where I was in that process and I explained where I am in the process and that I'm trying to get my NARSUM updated prior to the board. He got a bit frustrated and told me "well, you know that Anxiety isn't a boardable condition..." I responded "Yes, actually it is" he then said "Well, I guess you know psychiatry better than us then" in an cutting, angry tone of voice. I apologized and backpedaled as I was intimidated and, to be quite frank, a bit scared... My Psychiatrist has gotten snippy with me when I talk to him about the fact that I disagree with him but he has remained (fairly) professional about the fact that I'm entitled to my own opinion. I just about lost it when the above happened and have been freaking out over it since then. This are the actions of the person that is supposed to be HELPING me. First you threaten me with legal action for seeing an outside provider then you get angry when I assert that I know what I'm talking about? SMDH...

    This whole MH situation seems to keep on getting worse as time goes on. I have gone from feeling that I could trust my MH team to feeling like the only reason they exist is to try and make SURE that I don't make a "bad statistic" on someone's spreadsheet or powerpoint slide somewhere. I feel like they are physically threatening me - and it's scary as shit. I have an appointment with the base Patient Advocate on Monday, took everything I had to hold it together to make the appt, I called and hung up a couple times before I got the nerve up to actually talk to & make an appointment with him.

    Any advice on how to move forward at this point?



    PS - Know that some of you from my work come to this site for advice. If anyone here from my shop is reading this and you know who I am I ask that you please respect my privacy and don't share this information around. Thanks!
 
Well i can help you from the army point of view partner, If your gonna get something done mental health wise your gonna have to do it with an onpost provider! It took me 18 months i.e. combat records, video tape, commanders letter the works to get the team of mental health providers on the 5th floor to agree! I tried to go off post for counseling and was denied due to the fact that i had been diagnosed with ptsd. They make u do it on post so they can track it and as you know people off post are probably better so they want to keep u where they know that you have to jump through fire to get the right diagnosis. Hope this helps
 
My anxiety, OCD, Imsomnia along with other mental conditions were all put under my depression/PTSD. So tell them to put in under that area, that is what the board and the VA is going to do anyways. I will tell you that the DOD does go crazy when you get diagnosed by a civilian doctor, and the reason is because I have known alot of guys to go out in town a pay a doctor. I was stationed with an E6 marine at my last base that wanted out. So he went out in town and paid a Dr $500 to diagnose him with Bipolar, which is the hardest mental condition that a military Doc will diagnose someone with. Now he is healthy as a bird, out of the Marines, and drawing over $4000 a month, while the rest of us who really are sick have to fight the system to get what we deserve. The best thing you can do is let the DOD diagnose you with the Anxiety or did the VA rate you for those mental conditions. As far as the NMA, I feel for you. I was lucky no one in my command had any experience with Medical Retirements, So I wrote everything and my E7 and CO added a few lines and their signatures. I was 1 of the top Sailors too, so I think that had alot to do with it. Also it helps to have medical conditions that are well documented and if you have had them for a long time. I had my Crohns Disease for 4 years before it got to where it really affected my job, along with my other medical conditions, so they knew that I tried to work thru them. I wish you the best bud, and I dont think that any of us can really help in this situation. Just try not to piss off the DOD docs cause they can screw you. God Bless and I trully wish you the best.
 
No Slack Bayonet said:
Well i can help you from the army point of view partner, If your gonna get something done mental health wise your gonna have to do it with an onpost provider! It took me 18 months i.e. combat records, video tape, commanders letter the works to get the team of mental health providers on the 5th floor to agree! I tried to go off post for counseling and was denied due to the fact that i had been diagnosed with ptsd. They make u do it on post so they can track it and as you know people off post are probably better so they want to keep u where they know that you have to jump through fire to get the right diagnosis. Hope this helps
Click to expand...

I feel you, sadly enough right now it's not exactly like that for me. The MH folks are readily admitting that I have a problem, they are just claiming that it doesn't impact me. It's a bit of a weird place to be.


kiefer82 said:
My anxiety, OCD, Imsomnia along with other mental conditions were all put under my depression/PTSD. So tell them to put in under that area, that is what the board and the VA is going to do anyways. I will tell you that the DOD does go crazy when you get diagnosed by a civilian doctor, and the reason is because I have known alot of guys to go out in town a pay a doctor. I was stationed with an E6 marine at my last base that wanted out. So he went out in town and paid a Dr $500 to diagnose him with Bipolar, which is the hardest mental condition that a military Doc will diagnose someone with. Now he is healthy as a bird, out of the Marines, and drawing over $4000 a month, while the rest of us who really are sick have to fight the system to get what we deserve. The best thing you can do is let the DOD diagnose you with the Anxiety or did the VA rate you for those mental conditions. As far as the NMA, I feel for you. I was lucky no one in my command had any experience with Medical Retirements, So I wrote everything and my E7 and CO added a few lines and their signatures. I was 1 of the top Sailors too, so I think that had alot to do with it. Also it helps to have medical conditions that are well documented and if you have had them for a long time. I had my Crohns Disease for 4 years before it got to where it really affected my job, along with my other medical conditions, so they knew that I tried to work thru them. I wish you the best bud, and I dont think that any of us can really help in this situation. Just try not to piss off the DOD docs cause they can screw you. God Bless and I trully wish you the best.
Click to expand...




Yeah, I know that going to off base providers is frowned on. It's really sad that a few folks like that E-6 can screw up a system. It's nice that your command let you write you own stuff, mine had been taking my inputs and putting their own spin on them - at my unit I feel like I'm being supported. Mental Health though? I feel like they are out to get me :/
 
Any good, honest medical provider isn't going to care if an SM seeks care off post...it's your right do do so. The only justifiable reason military providers should be upset is that going off post costs the military much more money. And, especially in these days of budget cuts, it's part of officers responsibility to keep costs down. With that being said, most providers, who react the way your mental health providers are, merely don't want their bogus diagnosis and attempt to screw you over to be undermined.

Bottom line: if you know you have a condition (and no one knows himself better than you) and your current providers aren't adequately, accurately documenting that condition, then you must seek outside care. This is for many reasons: one, how can you receive the proper care for a condition that a doc won't even acknowledge; two, evidence for the IDES must be present, abundant and accurate; three, this is your future happening right before your eyes.

It's a very delicate situation, I know. But the type of treatment and behavior you are describing above should not be accepted. Besides, if you were to just go with the flow and accept them trying to screw you out of 50% (your command clearly states you can't do your job because of PTSD/anxiety), you'll only regret it later.
 
Many of your concerns can be addressed with an MEB rebuttal. I would do this after first requesting an impartial review (asking for this triggers additional procedural rights).


No Slack Bayonet said:
Well i can help you from the army point of view partner, If your gonna get something done mental health wise your gonna have to do it with an onpost provider!
Click to expand...
I don't doubt that No Slack Bayonet ran into the troubles he described. However, this is not the case uniformly. Last week, I had a FPEB where the only record supporting an unfit finding was an off post provider. We were able to get a 30% rating based on the letter from the provider (and this was all done after the MEB and IPEB). My point is that there is no hard and fast rule that military providers have to be the source of evidence.


kiefer82 said:
My anxiety, OCD, Imsomnia along with other mental conditions were all put under my depression/PTSD. So tell them to put in under that area, that is what the board and the VA is going to do anyways.
Click to expand...
Again, I don't doubt that this was kiefer82's experience. However, this is not always the case.

All mental health conditions are rated under the same criteria. So, for many cases, whatever they call it will not be all that important. The significance of a PTSD diagnosis is often only important in addressing combat related nature of the disability.

kiefer82 said:
I will tell you that the DOD does go crazy when you get diagnosed by a civilian doctor, and the reason is because I have known alot of guys to go out in town a pay a doctor. I was stationed with an E6 marine at my last base that wanted out. So he went out in town and paid a Dr $500 to diagnose him with Bipolar, which is the hardest mental condition that a military Doc will diagnose someone with. Now he is healthy as a bird, out of the Marines, and drawing over $4000 a month, while the rest of us who really are sick have to fight the system to get what we deserve. The best thing you can do is let the DOD diagnose you with the Anxiety or did the VA rate you for those mental conditions.
Click to expand...

Sometimes local providers and commands can get excited/pissed about civilian providers. However, by and large, I have not seen the PEBs really care whether a provider is civilian or military. It is much more common these days than in the past to have a civilian provider. The important thing about a civilian providers opinion (and the same holds true for military providers) is that the opinion is based on demonstrable evidence or bases for conclusions and that the opinion is consistent with the factual situation.

Whether the condition is anxiety or PTSD (which is a subset of anxiety disorders under the DSM-IV), does not matter so much. The main point to be concerned about is whether a combat related finding is properly addressed.
 
Jason Perry said:
...Sometimes local providers and commands can get excited/pissed about civilian providers. However, by and large, I have not seen the PEBs really care whether a provider is civilian or military. It is much more common these days than in the past to have a civilian provider. The important thing about a civilian providers opinion (and the same holds true for military providers) is that the opinion is based on demonstrable evidence or bases for conclusions and that the opinion is consistent with the factual situation...
Click to expand...

From my experiences, it's less likely than not that the aforementioned red color & bold highlighted statement systematically occurs on a regular basis.

Case in point is the DoVa C&P Examination performed by certain behavioral health clinicians. They provide numerous subjective opinions which are contradictory and/or not supportive of factual objective evidence. Then, in my opinion, their non-evidence supportive opinions are used to make a "minimized" subjective opinion which correlates with the general rating formula as outlined in the VASRD. :(

Unfortunately to that end, I am noticing a major trend which doesn't favor military service members and military veterans upon their eligibility for DoVA disability compensation. Thus, I assume the potential remedy for this type of unacceptable practice is via a rebuttal or an appeal.

Best Wishes!
 
Warrior644 said:
From my experiences, it's less likely than not that the aforementioned red color & bold highlighted statement systematically occurs on a regular basis.

Case in point is the DoVa C&P Examination performed by certain behavioral health clinicians. They provide numerous subjective opinions which are contradictory and/or not supportive of factual objective evidence. Then, in my opinion, their non-evidence supportive opinions are used to make a "minimized" subjective opinion which correlates with the general rating formula as outlined in the VASRD. :(

Unfortunately to that end, I am noticing a major trend which doesn't favor military service members and military veterans upon their eligibility for DoVA disability compensation. Thus, I assume the potential remedy for this type of unacceptable practice is via a rebuttal or an appeal.

Best Wishes!
Click to expand...

I am not sure if you are tracking my point. If the exam is way off from what the commander, the member, and the medical records state, then it can be rejected in favor of the other evidence. My point is that any one piece of evidence is not dispositive. Evidence will carry more weight if it matches up with other evidence. That is what you will ideally have in most cases. But, sometimes you will have less or poor evidence. Yes, in those cases where you don't get a favorable outcome, appealing/rebutting is how you challenge it.
 
Jason Perry said:
I am not sure if you are tracking my point. If the exam is way off from what the commander, the member, and the medical records state, then it can be rejected in favor of the other evidence. My point is that any one piece of evidence is not dispositive. Evidence will carry more weight if it matches up with other evidence. That is what you will ideally have in most cases. But, sometimes you will have less or poor evidence. Yes, in those cases where you don't get a favorable outcome, appealing/rebutting is how you challenge it.
Click to expand...

Case in point understood. Thus, appreciate the clarification via detailed feedback.

Best Wishes!
 
What licenses or qualifications must the alternative source have in order for counseling notes to be used as evidence in an appeal?
 
mushiee6 said:
What licenses or qualifications must the alternative source have in order for counseling notes to be used as evidence in an appeal?
Click to expand...

Technically, anything relevant that is submitted should be considered. If your spouse, child, neighbor, or friend submits a statement, this is called "lay testimony." That said, for VA exams, the regulations sometimes state qualifications for examiners for certain conditions. For mental health, the qualifications are:

(1) Board-certified psychiatrists.
(2) Psychiatrists who have successfully completed an accredited psychiatry residency and
who are appropriately credentialed and privileged.
(3) Licensed doctoral-level psychologist.
(4) Non-licensed doctoral-level psychologists working toward licensure under close
supervision by a board-certified, or board-eligible, psychiatrist or a licensed doctoral-level
psychologist.
(5) Psychiatry residents under close supervision by a board-certified, or board-eligible,
psychiatrist or a licensed doctoral-level psychologist.
(6) Psychology interns or residents under close supervision by a board-certified, or boardeligible, psychiatrist or a licensed doctoral-level psychologist. NOTE: Close supervision means
that the supervising psychiatrist or psychologist met with the Veteran and conferred with the
examining mental health professional in providing the diagnosis and the final assessment. The
supervising psychiatrist or psychologist co-signsthe examination report.

(Here is a link: http://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=2780)

Obviously, the more credentials the treatment provider has, the more weight it will carry. That is, if you have a note from an Masters level therapist, and a note from a Board Certified doctor who is well known in the field (perhaps authored scholarly articles, holds a chair at a prestigious medical school, etc.) the doctors opinion will likely carry more weight. But, I think you also have to look at the basis for the opinions/statements in the counseling notes. So, if the Masters level therapist has treated the patient for years, has reviewed all the previous records, etc., and the doctor has only met for 20 minutes with the patient and the records were not available, then there is a basis to argue that the therapists opinion should hold more weight.

But, to answer your question, there is no technical requirement for credentials for providers of counseling notes.
 
usaf1,

Rebuttal and IMR are valid options that you should strongly consider if you aren't able to fix NARSUM by just informally speaking to the doctor. However, I don't think that IMR is a reliable safety net, in your situation, for correcting NARSUM; nor, do I think you should not seek outside care based on the idea... "I can just do an IMR." I say this mainly because an IMR will probably be carried out by another local behavioral health professional at your MTF--of which you feel are not properly diagnosing. In other words, I would be very suspect, at best, that an IMR carried out within your BH department would do any good. Nonetheless, as mentioned above, I would still request rebuttal and IMR, so at the very least the PEB will see that you disagree.

With all that being said, if you are able to get an outside psychiatrist or psychologist to concur with the VA C&P and your command that in fact you do have anxiety and that it hinders job performance, then you would be more than good.
 
Thanks for all the feedback guys, I feel like we've covered this thing from several angles and that's helped me wrap my brain around this. Right now I'm setup for a appt with my Doc in the next few days and I'm going to informally try and ask for changes to my NARSUM and ask him to push for a Mental Health NARSUM as well. My PCM has been great through this whole process, hopefully things go well with him :)

Open to any more feedback/suggestions on how to attack this :)
 
ceilingfan said:
With all that being said, if you are able to get an outside psychiatrist or psychologist to concur with the VA C&P and your command that in fact you do have anxiety and that it hinders job performance, then you would be more than good.
Click to expand...


One thing I wanted to mention but forgot to in my last post. My MH team here has no problem saying I have an Anxiety disorder, they are just saying that I can't be boarded for it :/
 
usaf1 said:
One thing I wanted to mention but forgot to in my last post. My MH team here has no problem saying I have an Anxiety disorder, they are just saying that I can't be boarded for it :/
Click to expand...

And they would be wrong....Not sure why they would be so confused about this point.

AFI 48-123:

5.3.12.2. Mental conditions requiring MEB:
5.3.12.2.1. Conditions that are expected to have persistent duty impairment (more
than 1 year despite treatment).
5.3.12.2.2. Conditions associated with recurrent duty impairment (2 or more episodes
of impairment in 12 months).
5.3.12.2.3. Conditions which require continuing psychiatric support (e.g. weekly
psychotherapy in order to function) beyond one year.
5.3.12.2.4. Conditions requiring use of lithium, anticonvulsants, or antipsychotics for
mood stabilization.
5.3.12.2.5. Individuals who experience recurrent depression or anxiety disorders,
require psychiatric medication for greater than one year, who have been hospitalized
for a psychiatric condition, require an evaluation by a military mental health provider.
 
Jason Perry said:
And they would be wrong....Not sure why they would be so confused about this point.

AFI 48-123:

5.3.12.2. Mental conditions requiring MEB:
5.3.12.2.1. Conditions that are expected to have persistent duty impairment (more
than 1 year despite treatment).
5.3.12.2.2. Conditions associated with recurrent duty impairment (2 or more episodes
of impairment in 12 months).
5.3.12.2.3. Conditions which require continuing psychiatric support (e.g. weekly
psychotherapy in order to function) beyond one year.
5.3.12.2.4. Conditions requiring use of lithium, anticonvulsants, or antipsychotics for
mood stabilization.
5.3.12.2.5. Individuals who experience recurrent depression or anxiety disorders,
require psychiatric medication for greater than one year, who have been hospitalized
for a psychiatric condition, require an evaluation by a military mental health provider.
Click to expand...


110% Agreed Jason. More to follow after I talk with my PCM about it.
 
usaf1 said:
I'm being seen by a Psychiatrist for my medication needs and a psychologist for counselling. A few days ago I had a meeting with my psychologist, the first one since I got back from my C&P results. He wanted to know where I was in that process and I explained where I am in the process and that I'm trying to get my NARSUM updated prior to the board. He got a bit frustrated and told me "well, you know that Anxiety isn't a boardable condition..." I responded "Yes, actually it is" he then said "Well, I guess you know psychiatry better than us then" in an cutting, angry tone of voice. I apologized and backpedaled as I was intimidated and, to be quite frank, a bit scared... My Psychiatrist has gotten snippy with me when I talk to him about the fact that I disagree with him but he has remained (fairly) professional about the fact that I'm entitled to my own opinion. I just about lost it when the above happened and have been freaking out over it since then. This are the actions of the person that is supposed to be HELPING me. First you threaten me with legal action for seeing an outside provider then you get angry when I assert that I know what I'm talking about? SMDH...

  1. This whole MH situation seems to keep on getting worse as time goes on. I have gone from feeling that I could trust my MH team to feeling like the only reason they exist is to try and make SURE that I don't make a "bad statistic" on someone's spreadsheet or powerpoint slide somewhere. I feel like they are physically threatening me - and it's scary as shit. I have an appointment with the base Patient Advocate on Monday, took everything I had to hold it together to make the appt, I called and hung up a couple times before I got the nerve up to actually talk to & make an appointment with him.

    PS - Know that some of you from my work come to this site for advice. If anyone here from my shop is reading this and you know who I am I ask that you please respect my privacy and don't share this information around. Thanks!
Click to expand...


I just got a call from the MH folks. I have been setup with a new Psychologist and will no longer be seeing my old one. Patient Advocate talked to someone very high up the food chain and that person directed the change be made. Step in the right direction I think, we'll see how it goes. Still pending my PCM appt to talk to him about my NARSUM being out of date.
 
usaf1 said:
I just got a call from the MH folks. I have been setup with a new Psychologist and will no longer be seeing my old one. Patient Advocate talked to someone very high up the food chain and that person directed the change be made. Step in the right direction I think, we'll see how it goes. Still pending my PCM appt to talk to him about my NARSUM being out of date.
Click to expand...
Nice
 
ceilingfan said:
Nice
Click to expand...

Yep it is - thanks for pushing me that direction through PM's - very likely would not have got the nerve up to talk to the patient advocate without your 1on1 encouragement man.
 
Update time.

Alright, first the good news. Had an appt with my PCM and talked to him about the changes. He is going to add some things to the job impact section based on my inability to currently work in my career field and the fact I've been assigned to an admin job outside my shop.

Secondly, when I started talking about Anxiety it went from helpful and cordial to a bit tense of an issue, he re-iterated that I was not being boarded for my Anxiety and I think he thought I was trying to sneak something by him. I told him I was just confused about the process moving forward and I wanted to know what I needed to do to get a MH NARSUM addendum completed by my MH doc as they don't agree that it's a boardable condition. He told me that when my package went to the SGH after the board that the SGH would review it and go from there.

I went home and proceeded to flip out a little bit. Now that I've calmed down a bit I am trying to formulate an action plan moving forward. The patient advocate told me to let him know how the meeting with my PCM went, I think at this point I'm going to write up a letter detailing the various regulations that state that my mental health issues need to be addressed and requesting the patient advocate help me ascertain why this has not happened and why they keep running from it. Based on the conversation I had with him before there is a good chance that I may be sitting down with the SGH to talk this out, we'll see how tomorrow plays out. I'm writing up a copy of the letter now, will post it for your guys thoughts shortly.
 
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