The way I read 38 C.F.R. §4.130, DC 9411, governs PTSD ratings I fall under the Total occupational and social impairment = %100. would I be right in saying this?
initial evaluation for post traumatic stress disorder PTSD disability benefits questionnaire
SECTION I:
----------
1. Diagnostic Summary
---------------------
Does the Veteran have a diagnosis of PTSD that conforms to DSM-IV criteria
based on today's evaluation?
[X] Yes [ ] No
ICD code: 309.81
2. Current Diagnoses
--------------------
a. Diagnosis #1: PTSD
ICD code: 309.81
Indicate the Axis category:
[X] Axis I [ ] Axis II
Comments, If any: The claimant has severe PTSD
Diagnosis #2: major depressive disorder with psychotic features
ICD code: 296.34
Indicate the Axis category:
[X] Axis I [ ] Axis II
Comments, If any:_______
Diagnosis #3: Inosmina with twitching (movan's Syndrome)
ICD code: 336.0
Indicate the Axis category:
[X] Axis I [ ] Axis II
Comments, If any:_______
Diagnosis #4: panic disorder without agoraphobia
ICD code: 300.01
Indicate the Axis category:
[X] Axis I [ ] Axis II
Comments, If any:_______
If additional diagnoses, describe (using above format alcohol dependence 303.00
b. Axis III - medical diagnoses (to include TBI): GERD; osteoarthritis;
prostatitis
c. Axis IV - Psychosocial and Environmental Problems (describe, if any): Stressors associated with severe PTSD and psychiatric discharge from the military
treatment
d. Axis V - Current global assessment of functioning (GAF) score: 51
3. 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?
[X] Yes [ ] No [ ] Not applicable (N/A)
If yes, list which symptoms are attributable to each diagnosis: terrifying
nightmares and flashbacks, hypervigilance, hyperarousal, social avoidance, avoidance of triggering memories. panic attacks severe are to panic disorder. alcohol dependence is the direct results of his attempts to cope with his traumatic memories. the claimant's major depressive disorder explains the claimants' feeling of sadness and despair, his sense of hopelessness, and his intense suicidal ideation.
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] 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?
[X] Yes [ ] No [ ] No other mental disorder has been diagnosed
If yes, list which portion of the indicated level of occupational and
social impairment is attributable to each diagnosis:
100% of the indicated level of occupational and social impairment
is attributable to PTSD. The abuse of alcohol is determined to be
a means of managing the trauma related symptoms.
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
------------------
a. Records reviewed (check all that apply):
[X] Claims folder (C-file):
[X] Yes
[ ] No
b. Was pertinent information from collateral sources reviewed?
[ ] Yes [X] No
2. History
----------
e. Relevant Substance abuse history (pre-military, military, and
post-military):
The Veteran was vague regarding his current consumption of alcohol.
He
stated that he now drinks less than he used to. He stated that he
used
to binge (6-7 drinks on a Saturday night). He reported his last binge
to have been a month and a half prior to this examination. He gave a
history of blackouts, but none in the past two years. He denied the
use of tobacco products, or other substances.
f. Sentinel Event(s) (other than stressors):
No response provided.
g. Other, if any:
No response provided.
3. Stressors
------------
a. Stressor #1: The Veteran reported that while on a mission during
Operation
Desert Storm, he and his team were on patrol and came upon a tank
that
looked as if as enemy soldier was sitting in the commander's seat.
He
did not respond to their orders and when they approached the tank, saw
that about half of his head had been blown away. Brain matter was
splattered. This image comes to mind most frequently for the Veteran.
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
4. PTSD Diagnostic Criteria
---------------------------
a. Please check criteria used for establishing the current PTSD diagnosis.
The diagnostic criteria for PTSD, referred to as Criteria A-F, are from
the Diagnostic and Statistical Manual of Mental Disorders, 4th edition
(DSM-IV).
Criterion A: The Veteran has been exposed to a traumatic event where both
of the following were present:
[X] The Veteran experienced, witnessed or was confronted with an event
that involved actual or threatened death or serious injury, or a
threat to the physical integrity of self or others.
[X] The Veteran's response involved intense fear, helplessness or
horror.
Criterion B: The traumatic event is persistently reexperienced in 1 or
more of the following ways:
[X] Recurrent and distressing recollections of the event, including
images, thoughts or perceptions
[X] Recurrent distressing dreams of the event
[X] Intense psychological distress at exposure to internal or external
cues that symbolize or resemble an aspect of the traumatic event
Criterion C: Persistent avoidance of stimuli associated with the trauma
and numbing of general responsiveness (not present before
the
trauma), as indicated by 3 or more of the following:
[X] Efforts to avoid thoughts, feelings or conversations associated
with the trauma
[X] Markedly diminished interest or participation in significant
activities
[X] Feeling of detachment or estrangement from others
[X] Restricted range of affect (e.g., unable to have loving feelings)
Criterion D: Persistent symptoms of increased arousal, not present before
the trauma, as indicated by 2 or more of the following:
[X] Difficulty falling or staying asleep
[X] Irritability or outbursts of anger
[X] Difficulty concentrating
[X] Hypervigilance
[X] Exaggerated startle response
Criterion E:
[X] The duration of the symptoms described above in Criteria B, C and
D
is more than 1 month.
Criterion F:
[X] The PTSD symptoms described above cause clinically significant
distress or impairment in social, occupational, or other important
areas of functioning.
b. Which stressor(s) contributed to the Veterans PTSD diagnosis?:
[X] Stressor #1
5. Symptoms
-----------
For VA rating purposes, check all symptoms that apply to the Veterans
diagnoses:
[X] Depressed mood
[X] Anxiety
[X] Chronic sleep impairment
[X] Mild memory loss, such as forgetting names, directions or recent
events
[X] Disturbances of motivation and mood
[X] Difficulty in establishing and maintaining effective work and social
relationships
6. Other symptoms
-----------------
Does the Veteran have any other symptoms attributable to PTSD (and other
mental disorders) that are not listed above?
[ ] Yes [X] No
7. Competency
-------------
Is the Veteran capable of managing his or her financial affairs?
[X] Yes [ ] No
8. Remarks, if any
The Veteran should seek additional inpatient treatment designed specifically to address his severe PTSD symptoms. the inpatient treatment should be followed by intensive outpatient psychotherapy and psychotropic medication management.
initial evaluation for post traumatic stress disorder PTSD disability benefits questionnaire
SECTION I:
----------
1. Diagnostic Summary
---------------------
Does the Veteran have a diagnosis of PTSD that conforms to DSM-IV criteria
based on today's evaluation?
[X] Yes [ ] No
ICD code: 309.81
2. Current Diagnoses
--------------------
a. Diagnosis #1: PTSD
ICD code: 309.81
Indicate the Axis category:
[X] Axis I [ ] Axis II
Comments, If any: The claimant has severe PTSD
Diagnosis #2: major depressive disorder with psychotic features
ICD code: 296.34
Indicate the Axis category:
[X] Axis I [ ] Axis II
Comments, If any:_______
Diagnosis #3: Inosmina with twitching (movan's Syndrome)
ICD code: 336.0
Indicate the Axis category:
[X] Axis I [ ] Axis II
Comments, If any:_______
Diagnosis #4: panic disorder without agoraphobia
ICD code: 300.01
Indicate the Axis category:
[X] Axis I [ ] Axis II
Comments, If any:_______
If additional diagnoses, describe (using above format alcohol dependence 303.00
b. Axis III - medical diagnoses (to include TBI): GERD; osteoarthritis;
prostatitis
c. Axis IV - Psychosocial and Environmental Problems (describe, if any): Stressors associated with severe PTSD and psychiatric discharge from the military
treatment
d. Axis V - Current global assessment of functioning (GAF) score: 51
3. 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?
[X] Yes [ ] No [ ] Not applicable (N/A)
If yes, list which symptoms are attributable to each diagnosis: terrifying
nightmares and flashbacks, hypervigilance, hyperarousal, social avoidance, avoidance of triggering memories. panic attacks severe are to panic disorder. alcohol dependence is the direct results of his attempts to cope with his traumatic memories. the claimant's major depressive disorder explains the claimants' feeling of sadness and despair, his sense of hopelessness, and his intense suicidal ideation.
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] 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?
[X] Yes [ ] No [ ] No other mental disorder has been diagnosed
If yes, list which portion of the indicated level of occupational and
social impairment is attributable to each diagnosis:
100% of the indicated level of occupational and social impairment
is attributable to PTSD. The abuse of alcohol is determined to be
a means of managing the trauma related symptoms.
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
------------------
a. Records reviewed (check all that apply):
[X] Claims folder (C-file):
[X] Yes
[ ] No
b. Was pertinent information from collateral sources reviewed?
[ ] Yes [X] No
2. History
----------
e. Relevant Substance abuse history (pre-military, military, and
post-military):
The Veteran was vague regarding his current consumption of alcohol.
He
stated that he now drinks less than he used to. He stated that he
used
to binge (6-7 drinks on a Saturday night). He reported his last binge
to have been a month and a half prior to this examination. He gave a
history of blackouts, but none in the past two years. He denied the
use of tobacco products, or other substances.
f. Sentinel Event(s) (other than stressors):
No response provided.
g. Other, if any:
No response provided.
3. Stressors
------------
a. Stressor #1: The Veteran reported that while on a mission during
Operation
Desert Storm, he and his team were on patrol and came upon a tank
that
looked as if as enemy soldier was sitting in the commander's seat.
He
did not respond to their orders and when they approached the tank, saw
that about half of his head had been blown away. Brain matter was
splattered. This image comes to mind most frequently for the Veteran.
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
4. PTSD Diagnostic Criteria
---------------------------
a. Please check criteria used for establishing the current PTSD diagnosis.
The diagnostic criteria for PTSD, referred to as Criteria A-F, are from
the Diagnostic and Statistical Manual of Mental Disorders, 4th edition
(DSM-IV).
Criterion A: The Veteran has been exposed to a traumatic event where both
of the following were present:
[X] The Veteran experienced, witnessed or was confronted with an event
that involved actual or threatened death or serious injury, or a
threat to the physical integrity of self or others.
[X] The Veteran's response involved intense fear, helplessness or
horror.
Criterion B: The traumatic event is persistently reexperienced in 1 or
more of the following ways:
[X] Recurrent and distressing recollections of the event, including
images, thoughts or perceptions
[X] Recurrent distressing dreams of the event
[X] Intense psychological distress at exposure to internal or external
cues that symbolize or resemble an aspect of the traumatic event
Criterion C: Persistent avoidance of stimuli associated with the trauma
and numbing of general responsiveness (not present before
the
trauma), as indicated by 3 or more of the following:
[X] Efforts to avoid thoughts, feelings or conversations associated
with the trauma
[X] Markedly diminished interest or participation in significant
activities
[X] Feeling of detachment or estrangement from others
[X] Restricted range of affect (e.g., unable to have loving feelings)
Criterion D: Persistent symptoms of increased arousal, not present before
the trauma, as indicated by 2 or more of the following:
[X] Difficulty falling or staying asleep
[X] Irritability or outbursts of anger
[X] Difficulty concentrating
[X] Hypervigilance
[X] Exaggerated startle response
Criterion E:
[X] The duration of the symptoms described above in Criteria B, C and
D
is more than 1 month.
Criterion F:
[X] The PTSD symptoms described above cause clinically significant
distress or impairment in social, occupational, or other important
areas of functioning.
b. Which stressor(s) contributed to the Veterans PTSD diagnosis?:
[X] Stressor #1
5. Symptoms
-----------
For VA rating purposes, check all symptoms that apply to the Veterans
diagnoses:
[X] Depressed mood
[X] Anxiety
[X] Chronic sleep impairment
[X] Mild memory loss, such as forgetting names, directions or recent
events
[X] Disturbances of motivation and mood
[X] Difficulty in establishing and maintaining effective work and social
relationships
6. Other symptoms
-----------------
Does the Veteran have any other symptoms attributable to PTSD (and other
mental disorders) that are not listed above?
[ ] Yes [X] No
7. Competency
-------------
Is the Veteran capable of managing his or her financial affairs?
[X] Yes [ ] No
8. Remarks, if any
The Veteran should seek additional inpatient treatment designed specifically to address his severe PTSD symptoms. the inpatient treatment should be followed by intensive outpatient psychotherapy and psychotropic medication management.
