Am I screwed?
LOCAL TITLE: C&P PTSD, INITIAL EVALUATION STANDARD TITLE: MENTAL HEALTH C & P EXAMINATION CONSULT DATE OF NOTE: JUN 12, 2018@08:30
ENTRY DATE: JUN 13, 2018@07:41:45
AUTHOR: STEARNS,WILLIAM L EXP COSIGNER: URGENCY: STATUS: COMPLETED Initial Post Traumatic Stress Disorder (PTSD) Disability Benefits Questionnaire *
Internal VA or DoD Use Only *
Name of patient/Veteran: REDACTED 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: REDACTED CONFIDENTIAL Page 4 of 13 2. Current Diagnoses -------------------- a. Mental Disorder Diagnosis #1: Major Depressive Disorder, recurrent, moderate, with anxious distress ICD code: F33.1 Comments, if any: Major Depressive Disorder, recurrent, moderate, with anxious distress is less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. Major Depressive Disorder is less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran's service connected conditions. Per Veteran's report, his current depression had onset over 20 years after his release from active duty. Mental Disorder Diagnosis #2: Alcohol use disorder, moderate ICD code: F10.20 Comments, if any: Alcohol use disorder, moderate is less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. Alcohol use disorder is less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran's service connected conditions. Per Veteran's report, he had heavy drinking during the military. He reported about 15 years sobriety until return to heavy drinking after being laid off from work in 2015. b. Medical diagnoses relevant to the understanding or management of the mental health disorder (to include TBI): No response provided. 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? [ ] Yes [X] No [ ] Not applicable (N/A) If no, provide reason: Alcohol use disorder: compulsive use, continued use in the face of consequences, loss of control, preoccupation, craving. It is likely that his alcohol use contributes to and exacerbates his depressive symptoms.
REDACTED CONFIDENTIAL Page 5 of 13 c. Does the Veteran have a diagnosed traumatic brain injury (TBI)? [ ] Yes [ ] No [X] 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 with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation b. For the indicated occupational and social impairment, is it possible to differentiate which impairment is caused by each mental disorder? [ ] Yes [X] No [ ] Not Applicable (N/A) If no, provide reason: It is likely that alcohol use exacerbates his depressive symptoms to a degree to not allow for differentiation of sources of functional impairment. c. If a diagnosis of TBI exists, is it possible to differentiate which occupational and social impairment indicated above is caused by the TBI? [ ] Yes [ ] No [X] Not Applicable (N/A) SECTION II: ----------- Clinical Findings: ------------------ 1. Evidence Review ------------------ Evidence reviewed (check all that apply): [X] VA e-folder [X] CPRS 2. History ---------- a. Relevant social/marital/family history (pre-military, military, and post-military): The Veteran was born and raised in Iowa. His parents divorced when he was 14 years old and he continued to live with his mother remarried. He has 3 brothers and 1 sister as well as many stepsiblings. He has a twin. Growth and development were regarded to be unremarkable. He denied any abuse or neglect during his childhood and described his childhood as "Good." He reported positive relationships and
REDACTED CONFIDENTIAL Page 6 of 13 a good social adjustment while growing up. He denied any social adjustment problems upon entering the military. He separated from his first wife after 6 months and had attempted to have the marriage annulled. He has been with his second wife for 34 years. They have 4 adopted children. A 19-year-old with autism and a 16-year-old remained in the household. He is the custodian conservator for a 19-year-old son who lives outside the household. They also have an 18-year-old adoptive daughter who lives with grandparents. Veteran reported having a ministerial degree and providing pastoral services at a local nursing home on a regular basis. He reported being active in his church and, Iowa and being on the Earning board. He reported being on the advisory Board for habitat for humanity. He indicated he has no male friends that he does things with. He does enjoy going to activities shopping with his wife. Otherwise, he reported that he tends to socially isolate. He went on a cruise with his family 3 years ago and reported being able to relax and enjoy that activity. The Veteran reported being able to complete all ADLs and IADLs on an independent level. He has no difficulty maintaining his personal grooming and hygiene. He reported some anger episodes when driving but denied any face-to-face confrontations. b. Relevant occupational and educational history (pre-military, military, and post-military): The Veteran graduated from high school in 1980, earning above average grades and denying any learning disabilities or disciplinary problems. He worked while attending high school. He reported completing a two-year degree at community college in May, 2018 and aging services management. He has worked for the past 2 years as a cashier at Heidi about 20 hours a week. He reported having been counseled at least monthly about being reviewed or abrasive to customers. He has not been threatened with termination. He had worked for CDS Global for 20 years until being laid off in November, 2015. He reported having no inappropriate behaviors or performance problems on that job. He started college courses after being laid off. c. Relevant mental health history, to include prescribed medications and family mental health (pre-military, military, and post-military): Family Psychiatric History: None.
REDACTED Page 7 of 13 The Veteran denied having any mental health services prior to or during his military service time. Initial mental health contact was an acute psychiatry admission at the Des Moines VA 2/19/17 to 2/23/17. He was admitted on an emergency hold after having called the crisis hotline several times, making suicidal statements. Discharge diagnoses were Anxiety Disorder NOS, Major Depressive Disorder, single episode, and Rule out Alcohol Use Disorder. He had a second acute psychiatry admission 10/31/2017 to 11/10/2017, again for suicidal ideation. Discharge diagnoses were listed as 1. Suicidal Ideation, 2. Major Depressive Disorder, recurrent - moderate without psychotic, features, with anxious features, 3. Alcohol Use Disorder - episodic, 4. Rule out Posttraumatic Stress Disorder, 5. Rule out Personality Disorder NOS. Veteran had a third acute psychiatric admission 11/29/2017 to 12/12/2017 that was prompted by his daughter having witnessed him trying to cut his wrist with a paring knife. Discharge diagnoses were listed as Major Depressive Disorder, recurrent, moderately severe, complicated by suicidal thoughts, Cluster B Borderline Personality traits, r/o BPD, Anxiety Disorder NOS. He has continued with outpatient services including one-to-one psychotherapy for depression. He is prescribed mirtazapine and quetiapine. His most recent psychiatric appointment was on 6/8/2018. Diagnosis at that appointment was listed as Anxiety Disorder Unspecified, Major Depressive Disorder, recurrent, moderate, Alcohol Use Disorder, Personality disorder. Veteran completed a comprehensive psychological evaluation on 11/30/17 while on the acute psychiatric unit. His MMPI-2-RF profile was invalid and could not be meaningfully interpreted. Other components of the evaluation were also considered of questionable validity. Diagnoses were listed as Alcohol Use Disorder (per history/CPRS) and Unspecified Mood Disorder (per history/CPRS) Veteran reported a suicide attempt by overdose on ibuprofen in 1986 when reacting to multiple stressors in the Navy including a fellow Navy seaman having died from an infection after being hospitalized in France. He did not seek mental health services or medical evaluation at the time, stating that he slept off the effects of the medication. Veteran related the onset of his current mental health symptoms as occurring soon after being laid off from work after 23 years 2015. Drinking increased at that time as well as increased depression. He reported onset of self-mutilation, primarily slicing her cutting on his
REDACTED Page 8 of 13 left wrist in December, 2017. He reported feeling some relief from stress when cutting on himself. He estimated that he cuts on his wrist 2-3 times a week and this pattern is related to whether he is intoxicated or not. d. Relevant legal and behavioral history (pre-military, military, and post-military): None. e. Relevant substance abuse history (pre-military, military, and post-military): 1. Caffeine: 10 cups of coffee a day. 2. Tobacco: denied. Quit about 10 years ago. 3. ETOH: The Veteran reported drinking alcohol on a daily basis, estimating consuming about 1.5 L of liquor a week. He reported this pattern of drinking for the past 3 years. He hides his supply of alcohol from his wife. He sometimes drinks before going to work. He reported that prior to 3 years ago he had 15 years of sobriety. He reported heavy alcohol consumption during military service time. He denied alcohol related arrests. 4. Street drugs: denied. f. Other, if any: None. 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: As a teenager Veteran was involved in a motor vehicle accident in which one friend was killed and several friends seriously injured. As a teenager he also witnessed the shooting person. 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 Is the stressor related to personal assault, e.g. military sexual trauma? [ ] Yes [X] No b. Stressor #2: The Veteran described being on a security alert team while on
REDACTED CONFIDENTIAL Page 9 of 13 board ship when a fellow sailor had to have a weapon taken from him. The Veteran reported that the person was almost shot prior to giving up his weapon. The Veteran also described having been on a flight deck holding the phone line between ships, having an emergency breakaway, and the Veteran being fearful that he would be pulled over the side of the ship. 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 Is the stressor related to personal assault, e.g. military sexual trauma? [ ] Yes [X] No c. Stressor #3: The Veteran reported having had a friend die in the bombing barracks in Beirut in 1983. 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 Is the stressor related to personal assault, e.g. military sexual trauma? [ ] Yes [X] No 4. PTSD Diagnostic Criteria --------------------------- Note: Please check criteria used for establishing the current PTSD diagnosis. Do NOT mark symptoms below that are clearly not attributable to the Criterion 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 Criterion 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
REDACTED CONFIDENTIAL Page 10 of 13 injury, c) sexual violence, 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 [X] Learning that the traumatic event(s) occurred to a close family member or close friend; cases of actual or threatened death must have been violent or accidental; or, experiencing repeated or extreme exposure to aversive details of the traumatic events(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse); this does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related. 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] No criterion in this section met. 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] No criterion in this section met. 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] No criterion in this section met. 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] No criterion in this section met. Criterion F: [X] No criterion in this section met.
REDACTED CONFIDENTIAL Page 11 of 13 Criterion G: [X] No criterion in this section met. Criterion H: [X] No criterion in this section met. Criterion I: Which stressor(s) contributed to the Veteran's PTSD diagnosis?: [X] No criterion in this section met. 5. Symptoms ----------- For VA rating purposes, check all symptoms that actively apply to the Veteran's diagnoses: [X] Depressed mood [X] Anxiety [X] Chronic sleep impairment [X] Mild memory loss, such as forgetting names, directions or recent events 6. Behavioral Observations -------------------------- 1. General Appearance: Adequately groomed, appropriately dressed. 2. Psychomotor Activity/Mannerisms/Behaviors: Unremarkable. 3. Orientation: alert and fully oriented. 4. Speech: Spontaneous, coherent, goal directed. 5. Attitude Toward Examiner: Cooperative. 6. Affect: Appropriate. 7. Mood: ANXIETY: Veteran denied any phobias or panic attacks. He reported feeling nervous or on edge much of the time. He tends to worry excessively and to ruminate over perceived failures. He easily becomes annoyed or irritable. He easily becomes defensive and tends to respond with verbal attacks. DEPRESSION: credibly denied thought of harm to self or others. He noted that his cutting of his wrists is not with suicidal intent. He described low mood most days and having feelings of worthlessness and hopelessness. He reported sleeping about 2 hours at night. He reported dreams of sometimes being attacked or chased but these were not related to his military experiences. He reported having a sleep study scheduled within the next 2 weeks. MANIC: No symptoms or episodes. 8. Obsessive/Ritualistic Behavior: None. 9. Attention: No disturbance during the interview. He reported being forgetful at times and sometimes difficulty remembering details of conversations. 10. Memory: Able to recall remote and recent events during interview.
REDACTED CONFIDENTIAL Page 12 of 13 11. Thought Process and content: No hallucinations, delusions or signs of thought disorder. 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 -------------------------------------------------- The Veteran is a 56 year old male seen for a psychological evaluation on 6/12/18 regarding his application for a service connected disability rating for a mental condition to include PTSD. Veteran arrived on time for the interview, reporting that he drove himself to the facility. He was informed of the purpose of the evaluation and provided verbal consent to participate. He was interviewed for approximately 55 minutes. He was cooperative with the interview and responded to all questions. There were no indications of malingering or symptom exaggeration. The Veteran was informed of the Veterans Crisis Line number: 1-800-273-TALK (8255). /es/ WILLIAM L. STEARNS, PSY.D. Licensed Psychologist Signed: 06/13/2018 07:41 END OF MY HEALTHEVET PERSONAL INFORMATI
LOCAL TITLE: C&P PTSD, INITIAL EVALUATION STANDARD TITLE: MENTAL HEALTH C & P EXAMINATION CONSULT DATE OF NOTE: JUN 12, 2018@08:30
ENTRY DATE: JUN 13, 2018@07:41:45
AUTHOR: STEARNS,WILLIAM L EXP COSIGNER: URGENCY: STATUS: COMPLETED Initial Post Traumatic Stress Disorder (PTSD) Disability Benefits Questionnaire *
Internal VA or DoD Use Only *
Name of patient/Veteran: REDACTED 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: REDACTED CONFIDENTIAL Page 4 of 13 2. Current Diagnoses -------------------- a. Mental Disorder Diagnosis #1: Major Depressive Disorder, recurrent, moderate, with anxious distress ICD code: F33.1 Comments, if any: Major Depressive Disorder, recurrent, moderate, with anxious distress is less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. Major Depressive Disorder is less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran's service connected conditions. Per Veteran's report, his current depression had onset over 20 years after his release from active duty. Mental Disorder Diagnosis #2: Alcohol use disorder, moderate ICD code: F10.20 Comments, if any: Alcohol use disorder, moderate is less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. Alcohol use disorder is less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran's service connected conditions. Per Veteran's report, he had heavy drinking during the military. He reported about 15 years sobriety until return to heavy drinking after being laid off from work in 2015. b. Medical diagnoses relevant to the understanding or management of the mental health disorder (to include TBI): No response provided. 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? [ ] Yes [X] No [ ] Not applicable (N/A) If no, provide reason: Alcohol use disorder: compulsive use, continued use in the face of consequences, loss of control, preoccupation, craving. It is likely that his alcohol use contributes to and exacerbates his depressive symptoms.
REDACTED CONFIDENTIAL Page 5 of 13 c. Does the Veteran have a diagnosed traumatic brain injury (TBI)? [ ] Yes [ ] No [X] 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 with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation b. For the indicated occupational and social impairment, is it possible to differentiate which impairment is caused by each mental disorder? [ ] Yes [X] No [ ] Not Applicable (N/A) If no, provide reason: It is likely that alcohol use exacerbates his depressive symptoms to a degree to not allow for differentiation of sources of functional impairment. c. If a diagnosis of TBI exists, is it possible to differentiate which occupational and social impairment indicated above is caused by the TBI? [ ] Yes [ ] No [X] Not Applicable (N/A) SECTION II: ----------- Clinical Findings: ------------------ 1. Evidence Review ------------------ Evidence reviewed (check all that apply): [X] VA e-folder [X] CPRS 2. History ---------- a. Relevant social/marital/family history (pre-military, military, and post-military): The Veteran was born and raised in Iowa. His parents divorced when he was 14 years old and he continued to live with his mother remarried. He has 3 brothers and 1 sister as well as many stepsiblings. He has a twin. Growth and development were regarded to be unremarkable. He denied any abuse or neglect during his childhood and described his childhood as "Good." He reported positive relationships and
REDACTED CONFIDENTIAL Page 6 of 13 a good social adjustment while growing up. He denied any social adjustment problems upon entering the military. He separated from his first wife after 6 months and had attempted to have the marriage annulled. He has been with his second wife for 34 years. They have 4 adopted children. A 19-year-old with autism and a 16-year-old remained in the household. He is the custodian conservator for a 19-year-old son who lives outside the household. They also have an 18-year-old adoptive daughter who lives with grandparents. Veteran reported having a ministerial degree and providing pastoral services at a local nursing home on a regular basis. He reported being active in his church and, Iowa and being on the Earning board. He reported being on the advisory Board for habitat for humanity. He indicated he has no male friends that he does things with. He does enjoy going to activities shopping with his wife. Otherwise, he reported that he tends to socially isolate. He went on a cruise with his family 3 years ago and reported being able to relax and enjoy that activity. The Veteran reported being able to complete all ADLs and IADLs on an independent level. He has no difficulty maintaining his personal grooming and hygiene. He reported some anger episodes when driving but denied any face-to-face confrontations. b. Relevant occupational and educational history (pre-military, military, and post-military): The Veteran graduated from high school in 1980, earning above average grades and denying any learning disabilities or disciplinary problems. He worked while attending high school. He reported completing a two-year degree at community college in May, 2018 and aging services management. He has worked for the past 2 years as a cashier at Heidi about 20 hours a week. He reported having been counseled at least monthly about being reviewed or abrasive to customers. He has not been threatened with termination. He had worked for CDS Global for 20 years until being laid off in November, 2015. He reported having no inappropriate behaviors or performance problems on that job. He started college courses after being laid off. c. Relevant mental health history, to include prescribed medications and family mental health (pre-military, military, and post-military): Family Psychiatric History: None.
REDACTED Page 7 of 13 The Veteran denied having any mental health services prior to or during his military service time. Initial mental health contact was an acute psychiatry admission at the Des Moines VA 2/19/17 to 2/23/17. He was admitted on an emergency hold after having called the crisis hotline several times, making suicidal statements. Discharge diagnoses were Anxiety Disorder NOS, Major Depressive Disorder, single episode, and Rule out Alcohol Use Disorder. He had a second acute psychiatry admission 10/31/2017 to 11/10/2017, again for suicidal ideation. Discharge diagnoses were listed as 1. Suicidal Ideation, 2. Major Depressive Disorder, recurrent - moderate without psychotic, features, with anxious features, 3. Alcohol Use Disorder - episodic, 4. Rule out Posttraumatic Stress Disorder, 5. Rule out Personality Disorder NOS. Veteran had a third acute psychiatric admission 11/29/2017 to 12/12/2017 that was prompted by his daughter having witnessed him trying to cut his wrist with a paring knife. Discharge diagnoses were listed as Major Depressive Disorder, recurrent, moderately severe, complicated by suicidal thoughts, Cluster B Borderline Personality traits, r/o BPD, Anxiety Disorder NOS. He has continued with outpatient services including one-to-one psychotherapy for depression. He is prescribed mirtazapine and quetiapine. His most recent psychiatric appointment was on 6/8/2018. Diagnosis at that appointment was listed as Anxiety Disorder Unspecified, Major Depressive Disorder, recurrent, moderate, Alcohol Use Disorder, Personality disorder. Veteran completed a comprehensive psychological evaluation on 11/30/17 while on the acute psychiatric unit. His MMPI-2-RF profile was invalid and could not be meaningfully interpreted. Other components of the evaluation were also considered of questionable validity. Diagnoses were listed as Alcohol Use Disorder (per history/CPRS) and Unspecified Mood Disorder (per history/CPRS) Veteran reported a suicide attempt by overdose on ibuprofen in 1986 when reacting to multiple stressors in the Navy including a fellow Navy seaman having died from an infection after being hospitalized in France. He did not seek mental health services or medical evaluation at the time, stating that he slept off the effects of the medication. Veteran related the onset of his current mental health symptoms as occurring soon after being laid off from work after 23 years 2015. Drinking increased at that time as well as increased depression. He reported onset of self-mutilation, primarily slicing her cutting on his
REDACTED Page 8 of 13 left wrist in December, 2017. He reported feeling some relief from stress when cutting on himself. He estimated that he cuts on his wrist 2-3 times a week and this pattern is related to whether he is intoxicated or not. d. Relevant legal and behavioral history (pre-military, military, and post-military): None. e. Relevant substance abuse history (pre-military, military, and post-military): 1. Caffeine: 10 cups of coffee a day. 2. Tobacco: denied. Quit about 10 years ago. 3. ETOH: The Veteran reported drinking alcohol on a daily basis, estimating consuming about 1.5 L of liquor a week. He reported this pattern of drinking for the past 3 years. He hides his supply of alcohol from his wife. He sometimes drinks before going to work. He reported that prior to 3 years ago he had 15 years of sobriety. He reported heavy alcohol consumption during military service time. He denied alcohol related arrests. 4. Street drugs: denied. f. Other, if any: None. 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: As a teenager Veteran was involved in a motor vehicle accident in which one friend was killed and several friends seriously injured. As a teenager he also witnessed the shooting person. 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 Is the stressor related to personal assault, e.g. military sexual trauma? [ ] Yes [X] No b. Stressor #2: The Veteran described being on a security alert team while on
REDACTED CONFIDENTIAL Page 9 of 13 board ship when a fellow sailor had to have a weapon taken from him. The Veteran reported that the person was almost shot prior to giving up his weapon. The Veteran also described having been on a flight deck holding the phone line between ships, having an emergency breakaway, and the Veteran being fearful that he would be pulled over the side of the ship. 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 Is the stressor related to personal assault, e.g. military sexual trauma? [ ] Yes [X] No c. Stressor #3: The Veteran reported having had a friend die in the bombing barracks in Beirut in 1983. 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 Is the stressor related to personal assault, e.g. military sexual trauma? [ ] Yes [X] No 4. PTSD Diagnostic Criteria --------------------------- Note: Please check criteria used for establishing the current PTSD diagnosis. Do NOT mark symptoms below that are clearly not attributable to the Criterion 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 Criterion 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
REDACTED CONFIDENTIAL Page 10 of 13 injury, c) sexual violence, 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 [X] Learning that the traumatic event(s) occurred to a close family member or close friend; cases of actual or threatened death must have been violent or accidental; or, experiencing repeated or extreme exposure to aversive details of the traumatic events(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse); this does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related. 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] No criterion in this section met. 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] No criterion in this section met. 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] No criterion in this section met. 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] No criterion in this section met. Criterion F: [X] No criterion in this section met.
REDACTED CONFIDENTIAL Page 11 of 13 Criterion G: [X] No criterion in this section met. Criterion H: [X] No criterion in this section met. Criterion I: Which stressor(s) contributed to the Veteran's PTSD diagnosis?: [X] No criterion in this section met. 5. Symptoms ----------- For VA rating purposes, check all symptoms that actively apply to the Veteran's diagnoses: [X] Depressed mood [X] Anxiety [X] Chronic sleep impairment [X] Mild memory loss, such as forgetting names, directions or recent events 6. Behavioral Observations -------------------------- 1. General Appearance: Adequately groomed, appropriately dressed. 2. Psychomotor Activity/Mannerisms/Behaviors: Unremarkable. 3. Orientation: alert and fully oriented. 4. Speech: Spontaneous, coherent, goal directed. 5. Attitude Toward Examiner: Cooperative. 6. Affect: Appropriate. 7. Mood: ANXIETY: Veteran denied any phobias or panic attacks. He reported feeling nervous or on edge much of the time. He tends to worry excessively and to ruminate over perceived failures. He easily becomes annoyed or irritable. He easily becomes defensive and tends to respond with verbal attacks. DEPRESSION: credibly denied thought of harm to self or others. He noted that his cutting of his wrists is not with suicidal intent. He described low mood most days and having feelings of worthlessness and hopelessness. He reported sleeping about 2 hours at night. He reported dreams of sometimes being attacked or chased but these were not related to his military experiences. He reported having a sleep study scheduled within the next 2 weeks. MANIC: No symptoms or episodes. 8. Obsessive/Ritualistic Behavior: None. 9. Attention: No disturbance during the interview. He reported being forgetful at times and sometimes difficulty remembering details of conversations. 10. Memory: Able to recall remote and recent events during interview.
REDACTED CONFIDENTIAL Page 12 of 13 11. Thought Process and content: No hallucinations, delusions or signs of thought disorder. 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 -------------------------------------------------- The Veteran is a 56 year old male seen for a psychological evaluation on 6/12/18 regarding his application for a service connected disability rating for a mental condition to include PTSD. Veteran arrived on time for the interview, reporting that he drove himself to the facility. He was informed of the purpose of the evaluation and provided verbal consent to participate. He was interviewed for approximately 55 minutes. He was cooperative with the interview and responded to all questions. There were no indications of malingering or symptom exaggeration. The Veteran was informed of the Veterans Crisis Line number: 1-800-273-TALK (8255). /es/ WILLIAM L. STEARNS, PSY.D. Licensed Psychologist Signed: 06/13/2018 07:41 END OF MY HEALTHEVET PERSONAL INFORMATI
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