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I need some unofficial guidance with my claim for PTSD. I think I have two uphill battles ahead…I just had my C&P and have received the notes from the exam. The doctor has completely discounted that the event happened, much less any secondary markers, attributing my trauma to a childhood incident. His notes contradict themselves on multiple occasions. He states that I denied any history of alcohol abuse, yet states later in the exam that I disclosed that I started abusing alcohol after the incident. He also discounted and falsely reported several facts surrounding my time in the service. He stated I was never in combat, never had foreign service or received any combat medals and to view my DD-214 for more information, yet my DD-214 shows multiple combat medals, foreign service and he his report lists my service dates where i received combat pay and hostile Fire/Imminent Danger pay.
His notes are mostly snippets copied and pasted from my past appointments that support his denial, but he leaves out all of the relevant parts of my session.
He never looked me in the eyes and stared at his clip board the entire time
He said I started therapy after I lost my job and that I lost my job in April, when in fact I was therapy months before I lost my job which was 7/16. I told him all of this and he reported it wrong.
He also put down:
On the SIMs, a measure of symptom validity, the score of 37 indicated significant symptom exaggeration/over reporting.
On a PTSD symptom validity screen, the score of 25 indicated significant symptom exaggeration/over reporting.
Basically he’s calling into question my integrity and makes no reference to my MH sessions with my provider, who never once questions my honesty in our sessions.
My test scores from my MH sessions are:
PHQ-9 (Depression): 23
PHQ-9 was administered and score indicates severe depression.
(RANGES: 0-4 Minimal; 5-9 Mild; 10-14 Moderate; 15-19 Moderately severe;
GAD-7 (Anxiety): 19
GAD-7 was administered and score indicates severe anxiety. (RANGES: 0-4 Minimal; 5-9 Mild; 10-14 Moderate; 15-21 Severe)
PCL-5 (Posttraumatic distress): 64 (very severe symptoms reported)
PCL-5 was administered and the score is > or equal to cutoff score of 33 and may be consistent with a diagnosis of PTSD..
That leads me to my next issue…my MH provider continually throws out the term PTSD in our sessions, has started me on a treatment plan that consists of BOTH MST and PTSD therapy and yet WILL NOT put PTSD as a diagnosis. Instead I’m diagnosed with:
DIAGNOSES (per chart):
Major depressive disorder, single episode, moderate
Anxiety disorder, unspecified
On top of that my VA psychiatrist put contradicting statements in my last exam:
Mental Health Diagnoses and Relevant Medical Conditions:
Unspecified Trauma-Stressor-related Disorder r/o PTSD
Significant Psychosocial and Contextual Factors: MST (Sexual assault)
CASE FORMULATION AND RESPONSE TO TREATMENT:
35 y/o female veteran with anxiety, depressive Sx’s and significant
distress since index trauma, in 2011. High suspicion for PTSD. No prior MH treatment.
So he in essence ruled out PTSD and then stated he had a high suspicion for PTSD.
I apologize that these thoughts may seem all over the place, but my treatment notes are a mess and the C&P examiner added 112 pages to it with mostly copy and paste, so it’s hard for me to make sense of and I’m very hesitant to upload personal information. I just don’t know what to do when MH provider says I have PTSD from MST, puts me in treatment but won’t diagnose me, and then a C&P appointment with a doctor who acted like he had better things to do and went mostly off my test scores and didn’t really listen to a word i said since his notes are riddled with inaccuracies.
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I need some unofficial guidance with my claim for PTSD. I think I have two uphill battles ahead...I just had my C&P and have received the notes from the exam. The doctor has completely discounted that the event happened, much less any secondary markers, attributing my trauma to a childhood in...