Not sure if they will look at this or if it is even matters. I applied for a CRSC increase because my current rating is 10% crsc(no clue why they even gave me it originally). I just got PTSD rating because during a seizure/tbi c&p I talked to someone and they switched my %'s to TBI w PTSD 100%. I retired a few years ago with a DOD & VA rating of 100%. . What will reviewer think that looks over crsc applications?
1. Diagnostic Summary
---------------------
Does the Veteran have a diagnosis of PTSD that conforms to DSM-5 criteria based on today's evaluation?
[X] Yes [ ] No
ICD code: F43.12
2. Current Diagnoses
--------------------
a. Mental Disorder Diagnosis #1: PTSD
ICD code: F43.12
b. Medical diagnoses relevant to the understanding or management of the
Mental Health Disorder (to include TBI): TBI (see service connected conditions below)
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)?
[X] Yes [ ] No [ ] Not shown in records reviewed
d. 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:
It is difficult if not impossible differentiate what portion of each symptom is attributable to each diagnoses. There is a high degree of overlap and comorbidity between the disorders.
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] 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 [ ] 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 [X] No [ ] No diagnosis of TBI
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:
It is difficult if not impossible differentiate what portion of each symptom is attributable to each diagnoses. There is a high degree of overlap and comorbidity between the disorders.
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?
[X] Yes [ ] 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
[ ] Other:
b. Was pertinent information from collateral sources reviewed?
[ ] Yes [X] No
2. History
----------
16 months deployed to Iraq.
CAB
Mr. XXXXXXXX has not been able to work since he was in the Army.
c. Relevant Mental Health history, to include prescribed medications and family mental health (pre-military, military, and post-military):
Currently treated with anti-seizure medication and stated that he is considering psychiatric medications.
d. Relevant Legal and Behavioral history (pre-military, military, and post-military):
No response provided.
e. Relevant Substance abuse history (pre-military, military, and post-military):
No response provided.
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: Combat. Fear of rockets and IEDs.
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?
[X] Yes [ ] No
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)
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).
[X] Recurrent distressing dreams in which the content and/or effect of the dream are related to the traumatic event(s).
[X] Intense or prolonged psychological distress at exposure to Internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
[X] Marked physiological reactions to internal or external cues that symbolize or resemble an aspect 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).
[X] Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse 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 negative emotional state (e.g., fear, horror, anger, guilt, or shame).
[X] Markedly diminished interest or participation in significant activities.
[X] Feelings of detachment or estrangement from others.
[X] Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings.)
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] Hypervigilance.
[X] Exaggerated startle response.
[X] Problems with concentration.
[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?:
[X] Stressor #1
5. Symptoms
-----------
For VA rating purposes, check all symptoms that actively apply to the
Veteran's diagnoses:
[X] Depressed mood
[X] Anxiety
[X] Suspiciousness
[X] Panic attacks that occur weekly or less often
[X] Chronic sleep impairment
[X] Impairment of short- and long-term memory, for example, retention of
only highly learned material, while forgetting to complete tasks
[X] Flattened affect
[X] Circumstantial, circumlocutory or stereotyped speech
[X] Speech intermittently illogical, obscure, or irrelevant
[X] Impaired abstract thinking
[X] Disturbances of motivation and mood
[X] Difficulty in establishing and maintaining effective work and social
relationship
---------------------
Does the Veteran have a diagnosis of PTSD that conforms to DSM-5 criteria based on today's evaluation?
[X] Yes [ ] No
ICD code: F43.12
2. Current Diagnoses
--------------------
a. Mental Disorder Diagnosis #1: PTSD
ICD code: F43.12
b. Medical diagnoses relevant to the understanding or management of the
Mental Health Disorder (to include TBI): TBI (see service connected conditions below)
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)?
[X] Yes [ ] No [ ] Not shown in records reviewed
d. 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:
It is difficult if not impossible differentiate what portion of each symptom is attributable to each diagnoses. There is a high degree of overlap and comorbidity between the disorders.
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] 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 [ ] 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 [X] No [ ] No diagnosis of TBI
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:
It is difficult if not impossible differentiate what portion of each symptom is attributable to each diagnoses. There is a high degree of overlap and comorbidity between the disorders.
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?
[X] Yes [ ] 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
[ ] Other:
b. Was pertinent information from collateral sources reviewed?
[ ] Yes [X] No
2. History
----------
16 months deployed to Iraq.
CAB
Mr. XXXXXXXX has not been able to work since he was in the Army.
c. Relevant Mental Health history, to include prescribed medications and family mental health (pre-military, military, and post-military):
Currently treated with anti-seizure medication and stated that he is considering psychiatric medications.
d. Relevant Legal and Behavioral history (pre-military, military, and post-military):
No response provided.
e. Relevant Substance abuse history (pre-military, military, and post-military):
No response provided.
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: Combat. Fear of rockets and IEDs.
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?
[X] Yes [ ] No
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)
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).
[X] Recurrent distressing dreams in which the content and/or effect of the dream are related to the traumatic event(s).
[X] Intense or prolonged psychological distress at exposure to Internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
[X] Marked physiological reactions to internal or external cues that symbolize or resemble an aspect 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).
[X] Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse 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 negative emotional state (e.g., fear, horror, anger, guilt, or shame).
[X] Markedly diminished interest or participation in significant activities.
[X] Feelings of detachment or estrangement from others.
[X] Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings.)
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] Hypervigilance.
[X] Exaggerated startle response.
[X] Problems with concentration.
[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?:
[X] Stressor #1
5. Symptoms
-----------
For VA rating purposes, check all symptoms that actively apply to the
Veteran's diagnoses:
[X] Depressed mood
[X] Anxiety
[X] Suspiciousness
[X] Panic attacks that occur weekly or less often
[X] Chronic sleep impairment
[X] Impairment of short- and long-term memory, for example, retention of
only highly learned material, while forgetting to complete tasks
[X] Flattened affect
[X] Circumstantial, circumlocutory or stereotyped speech
[X] Speech intermittently illogical, obscure, or irrelevant
[X] Impaired abstract thinking
[X] Disturbances of motivation and mood
[X] Difficulty in establishing and maintaining effective work and social
relationship
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