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———- 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: Posttraumatic Stress Disorder ICD code: F43.12 Comments, if More likely than not secondary to military combat trauma.
Mental Disorder Diagnosis #2: Persistent Depressive Disorder, with persistent Major Depressive Episode ICD code: F34.1 Comments, if any: More likely than not incurred during active duty military service.
Mental Disorder Diagnosis #3: Alcohol Use Disorder ICD code: F10.20 Comments, if any: More likely than not secondary to diagnoses 1 and 2.
b. Medical diagnoses relevant to the understanding or management of the mental health disorder (to include TBI): Obesity
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 and discuss whether there is any clinical association between these diagnoses: The veteran’s symptoms can be partially differentiated. The symptoms specifically attributable to PTSD include those that reflect a reexperiencing of trauma (for example, nightmares, flashbacks, and intrusive memories), hyper arousal (for example, exaggerated startle reflex and hypervigilance), and avoidance of trauma reminders. Other symptoms are nonspecific and may reflect PTSD and/or depression. These symptoms include irritability, depressed mood, negative cognitions about self and others, sleep disturbance, diminished participation in significant activities, and disconnection from other people.
The veteran’s excessive use of alcohol can be understood as reflective of the avoidance symptoms of PTSD; the effect of the alcohol is to cause intoxication that allows the veteran to temporarily avoid other PTSD symptoms through alcohol “self-medication.”
c. Does the Veteran have a diagnosed traumatic brain injury (TBI)? [ ] Yes [X] No [ ] Not shown in records reviewed
4. Occupational and social impairment ————————————-
a. Which of the following best summarizes the Veteran’s level of occupational
and social impairment with regards to all mental diagnoses? (Check only one) [X] Occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood
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: The impact of the veteran’s mental conditions on social and occupational functioning is interrelated and overlapping, and therefore it is not possible to reliably differentiate the independent impact of each one on the veteran’s functioning.
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
The veteran’s electronic claims file and VA records were reviewed. The veteran’s claims file includes a DD 214 document showing entry into the US Army on November 17, 2009 with an honorable discharge at a rank of E4 on July 22, 2014. The reason for separation is listed as weight control failure. A separation medical examination dated April 20, 2014 is marked “normal” for psychiatric clinical evaluation. In support of the veterans claim for PTSD he provided written statements describing 2 stressful incidents as follows: 1) artillery attack in Afghanistan in January or February 2011, 2) Suicide of best friend on Christmas Day 2013. The veteran’s VA records show that he was seen at the Newburg CBOC by the primary care mental health integration staff on July 27, 2016 at which time he was reporting symptoms including depression, feelings of worthlessness, sleep disturbance, and frustration. The diagnoses listed were “anger, anxiety.” Records do not indicate the veteran followed up this appointments
with additional sessions. The veteran was seen on January 17, 2019 at the Dayton VA Medical Ctr Prime care mental health integration program, where his chief complaint related to depressive symptoms that had begun shortly after his grandfather’s death in 2011. He also reported the loss of 2 friends to suicide in 2012 and 2013. He reported symptoms including anergia, amotivation, depressed mood, irritability, and increased appetite as well as some anxiety symptoms that began in 2014 after separating from the military and included wanting to leave crowded situations and vague hypervigilance symptoms. The veteran reported that his depressive symptoms were his primary concern. He was diagnosed with unspecified depressive disorder (with rule out for major depressive disorder versus persistent depressive disorder) and unspecified anxiety disorder, (with rule out for generalized anxiety disorder versus PTSD). Records show the veteran was scheduled for group treatment following the initial assessment, but did not show, and has not returned to the VA for mental health treatment since then.
a. Relevant social/marital/family history (pre-military, military, and post-military): The veteran reported that he was raised in a small town in Ohio, living with his mother and grandparents until about age 10. His natural father was not in the picture. The veteran’s stepfather entered his life when he was about 8, and later adopted him. The veteran also has 3 younge r sisters. He reported that he was treated very well by his parents and grandparents. He was involved in baseball and other sports, and had no significant academic problems. He graduated high school on time then briefly attended college. The veteran was married to his first wife before entering the military, but she left him when he was deployed to Afghanistan. That marriage never produced children. The veteran and his current wife have been married 7 years, and they have 2 children, ages 4 and 2. The veteran stated the relationship is “shitty” right now because he doesn’t talk to his wife and he pushes her away. He said that she has talked about separating, and it was in January of this year that he finally sought treatment because she threatened to leave and take the children. The veteran stated the children are the only thing that brings a smile to his face.
b. Relevant occupational and educational history (pre-military, military, and post-military): Prior to entering the military, the veteran briefly attended college, and then went to NASCAR tech school in North Carolina, but “it wasn’t for me.” He joined the military approximately at age 22. He was trained in artillery and deployed to Afghanistan in 2011. The veteran’s duty in Afghanistan included providing FOB security, and tell her guard duty. Occasionally, they shot artillery.
Stressor #1: Early in his tour while stationed in Bagram, the base was attacked with artillery fire. The veteran stated he was terrified and petrified. He was out smoking near the command post when the shells started hitting. He dove between some barriers and other people dove on top of him. He could hear the shells hitting and recalled turning over to see them flying overhead. After the shelling stopped, the veteran was frozen. His Sgt. slapped him. They had taken many incoming that day, and though nobody was killed in his platoon, the veteran doesn’t know if others on the base were harmed. After that day, he remained always on alert and tried not to think about it.
Stressor #2: Later, he was stationed in Salerno, Afghanistan when another artillery strike occurred. Again, the veteran froze.
Stressor #3: A third incident occurred when he was stationed at COB Zormat – they took incoming artillery and returned artillery in response. Once again, the veteran froze, and was taken aside by his Sgt. who chewed him out, shamed him, and told him to hide his fear. The veteran stated he was afraid to say anything to anyone because he feared he looked like “a xxxxx.” While in Afghanistan, the veteran received word from his wife that she wanted a divorce. The veteran stated that his friend helped him through his distress. In 2013, on Christmas day, his friend committed suicide. The veteran stated that when he heard of this, he was angry, including anger at himself for not seeing the warning signs. Veteran stated that his friend’s suicide has ruined Christmas for him ever since. Post military occupational functioning: The veteran has been unable to maintain employment since his military discharge. In the first few years post discharge he held 4 to 5 different jobs, the longest being less than a year. Then, he found work as a corrections officer in a prison in Kentucky. However, the
veteran’s depression, drinking, calling off work, anxiety, and irritability, resulted in him being terminated after about 2 years. He got into trouble for losing his temper with the captain and cussing her out. In May 2018, he moved to Ohio having landed another job as a corrections officer with a prison in London. He was there less than 6 months before being terminated. Again, he was having difficulty due to anxiety, irritability, depression, poor attendance, and drinking. He briefly worked at the Post Office as a mail carrier after that, but couldn’t get enough sleep, felt depressed, and felt that everyone who worked there was from the military. He couldn’t stand it. The veteran has been unemployed for some months now. He wishes to return to school and earned his bachelor’s degree. Even at school, he had difficulty because people wanted to ask him about his military service and he always wanted to avoid it.
c. Relevant mental health history, to include prescribed medications and family mental health (pre-military, military, and post-military): The veteran stated that he was never the same after his deployment. He has felt fearful, depressed, and worthless. He experienced the loss of his grandfather while he was deployed, and the loss of his friend to suicide in 2013. The veteran stated he sleeps poorly, waking up many times throughout the night, and dreaming about artillery attacks. He has intrusive thoughts about his military trauma and other negative military experiences, and at times has physical symptoms including rapid heart rate, shortness of breath, sweating, and trembling. He drinks excessively as an apparent avoidance technique. He has problems with anger outbursts and irritability. He has hypervigilance, problems concentrating, exaggerated startle reflex, feelings of guilt, feelings of inadequacy and worthlessness, inability to connect with others, and wonders if others would be better off if he were dead. The veteran second-guesses his actions in Afghanistan and thinks he could’ve done better and “I should’ve manned up.” He said he feels worthless. He wonders why he cowered when his base was attacked. He shakes when he hears loud noises, and can’t tolerate fireworks. He rarely does activities unless he must, and generally just wants to be by himself. He sees others as threatening, and feels disconnected from everyone including his wife, with the exception of his children, and more recently, his therapist Dr. Ward. The veteran stated he has lost interest in things he used to enjoy, most notably sports. He overeats and drinks excessively. He avoids his friends because he doesn’t want to talk about the military. He dropped
out of school because people kept asking about his military service. He hates going to his parents home because his mother has erected a “shrine” to him in their living room, and he is to fearful of disappointing his parents to tell them how much he hates it. The veteran sought treatment earlier this year, and has now been working with a psychologist in Spring field, Dr. Ward, for 4-5 months. He stated that Dr. Ward is the one person he feels close to. They recently began EMDR therapy. The veteran has been referred for medication, but is awaiting his first appointment.
d. Relevant legal and behavioral history (pre-military, military, and post-military): The veteran has no history of legal problems.
e. Relevant substance abuse history (pre-military, military, and post-military): The veteran has been drinking excessively since his return from Afghanistan. He estimates that he was drinking a bottle of hard liquor per day at his peak. It has decreased somewhat recently as he has been engaged in therapy, but he continues to drink quite heavily. 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: Artillery attacks at Bagram and Salerno, Afghanistan 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 ————————— 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 injury, c) sexual violence, 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 affect 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 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 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 and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., “I am bad,: “No one can be trusted,: “The world is completely dangerous,: “My whole nervous system is permanently ruined”). [X] Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others. [X] Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame). [X] Markedly diminished interest or participation in significant activities. [X] Feelings of detachment or estrangement from others.
Criterion E: Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: [X] Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects. [X] Reckless or self-destructive behavior. [X] Hypervigilance. [X] Exaggerated startle response. [X] Problems with concentration. [X] Sleep disturbance (e.g., difficulty falling or staying asleep or restless
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] Chronic sleep impairment [X] Disturbances of motivation and mood [X] Difficulty in establishing and maintaining effective work and social relationships [X] Difficulty in adapting to stressful circumstances, including work or a worklike setting
6. Behavioral Observations ————————– The veteran arrived on time for his scheduled examination. His identity was confirmed by having him provide his full name and date of birth. The veteran presents as a tall, obese, Caucasian male who appears the stated age. He was dressed casually and exhibited good grooming and hygiene. He had tattoos visible on his lower and upper extremities. His posture, gait, and psychomotor activity were within normal limits. His manner of interaction was cooperative, courteous, and friendly. His speech was normal in rate, rhythm, tone, and volume. His thought processes were clear, logical, coherent, and goal-directed. Veteran reported his mood to be depressed, with affect congruent. He denied suicidal ideation, but admitted to thoughts of death and wondering if others would be better off without him. He denied homicidal ideation as well as auditory and visual hallucinations.
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 ————————————————– In my opinion, the veteran meets DSM 5 diagnostic criteria for posttraumatic stress disorder, which is more likely than not secondary to military trauma. In this veteran’s case, there is a strong component of shame that is also associated with his military service and is foundationally related to his depressive disorder. His experience of freezing during 3 artillery attacks is something that is associated with feelings of overwhelming shame, worthlessness, helplessness, and inadequacy for the veteran. These thoughts and feelings contribute significantly to his depressive condition, and contribute meaningfully to his PTSD symptoms as well. The veteran also experienced significant losses during military service that have likely aggravated his PTSD and depressive conditions. Notably, the veteran’s grandfather died in 2011 when the veteran was deployed to Afghanistan, and his best friend committed suicide on Christmas day in 2013. Both losses were experienced by the veteran as emotionally traumatic and contribute to his symptomatology. The veteran has developed a dysfunctional coping mechanism of excessive alcohol intake in his efforts to suppress negative feelings associated with his traumas. As his excessive alcohol use appears to be largely in the service of avoidance of distress and suppression of intrusive/reexperiencing symptoms, it is my opinion that his alcohol use disorder is secondary to his PTSD and depressive disorders. The veteran’s mental health symptoms have severely impaired his functional capacity. He is socially disengaged and avoidant. He has difficulty expressing himself emotionally, showing empathy, or forming emotional bonds with others. Occupationally, the veteran has exhibited significant dysfunction as he has been unable to maintain employment due to anxiety, depression, avoidance, alcohol abuse, irritability, shame. Hs shame about his reactions of freezing during artillery attacks prompts him to avoid interpersonal interactions as much as possible as he fears that the topic of his military service will arise. Recently, the veteran has begun outpatient mental health treatment in the form of individual counseling, and he is awaiting an appointment for trial of medication.
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SECTION I: ---------- 1. Diagnostic Summary --------------------- Does the Veteran have a diagnosis of PTSD that conforms to DSM-5 criteria based on todays evaluation? [X] Yes [ ] No ICD code: F43.12 2.Current Diagnoses -------------------- a. Mental Disorder Diagnosis #1: Posttraumatic Stress Di...