I have MDD & at the very last moment, a diagnosis of Personality Disorder was added to my file. Do I need an independent Medical Advisor? I disagree with the diagnosis. Is there a possibility of getting 0% from the DOD because of this added diagnosis? This new provider that I saw a handful of times went as far as to say that the personality disorder is what caused the depression that I've been dealing with for years. I think I'm screwed.
SECTION I:
----------
1. Diagnosis
------------
a. Does the Veteran now have or has he/she ever been diagnosed with a mental disorder(s)?
[X] Yes [ ] No
If the Veteran currently has one or more mental disorders that conform to
DSM-5 criteria, provide all diagnoses:
Mental Disorder Diagnosis #1: Major depressive disorder with anxious distress
Mental Disorder Diagnosis #2: unspecific personality disorder by history
b. Medical diagnoses relevant to the understanding or management of the
Mental Health Disorder (to include TBI): reports she has hypertension, tachycardia, hyperthyroidism, GERD
2. 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 overlap of symptoms
c. Does the Veteran have a diagnosed traumatic brain injury (TBI)?
[ ] Yes [ ] No [X] Not shown in records reviewed
3. 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 reduced reliability and productivity
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 overlap 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):
Redacted
b. Relevant Occupational and Educational history (pre-military, military, and post-military):
Educational History:
-Veteran graduated High school
-Veteran received good grades in school.
-Difficulties in school with classes: No repeats
College or Technical School: obtained Bachelors
Occupational History:
Primary career field:
Discharge Status:
Medals:
c. Relevant Mental Health history, to include prescribed medications and family mental health (pre-military, military, and post-military):
STRs reviewed:
-------------------Aug 2015 annual questions. no anxiety no depression
************************************************
CPRS/VISTAWEB reviewed: no VA treatment notes
************************************************
Current Private Mental Health Treatment: denies any current
Current Psychiatric Medications:
d. Relevant Legal and Behavioral history (pre-military, military, and post-military):
Legal History: Denies arrest
Behavioral History: Denies any behavioral issues in childhood, as an adolescent, while in the Military or after the Military.
e. Relevant Substance abuse history (pre-military, military, and post-military):
Substance Abuse History:
-Alcohol: occasionally will drink every other week to once a month
-Drugs: denies
-Tobacco: denies
-Caffeine:1 serving every few weeks
-Rehabs or other substance abuse treatment programs attended: denies
f. Other, if any:
No response provided.
3. Symptoms
-----------
For VA rating purposes, check all symptoms that actively apply to the
Veteran's diagnoses:
[X] Depressed mood
[X] Anxiety
[X] Disturbances of motivation and mood
4. Behavioral observations
--------------------------
Typical day:
MENTAL STATUS EXAMINATION: The veteran was well groomed and casually dressed. Veteran was oriented to person, place, and time. Eye contact was good. Veteran was cooperative. Rapport was good. Speech was normal for rhythm, rate, and volume. Veteran mood was ok. Affect was stable and congruent with mood. Veteran denied current suicidal or homicidal ideations.
Thought processes were linear, logical, and goal-directed. Insight, judgment, and reasoning appeared intact. There was no evidence of any perceptual disturbances, paranoia, or delusional thinking.
Review of neurovegetative symptoms over past 4 to 8 weeks:
-depressed mood: has noticed a correlation between menstrual cycle and depressed mood. Reports feeling depressed about
1 week a month
-Sleep: 8-9 hours at night. Falls asleep easily and reports wakes up for unknown reasons . She reports sometimes she will not go back to sleep and other times it takes her 30 mins to fall back asleep.
-Interest: "not really there."
-Guilt/worthlessness: guilty that she being a burden to her husband who sometimes has to take care of her. She reports he has to get her medication or get her up to shower sometimes.
-Energy: ok
-Concentration: "not the best." reports she is easily distracted
-Appetite: fair . she reports she gained weight in the past year. She
reports she gained about 10lbs.
-Psychomotor: wnl
-Suicide screen: denied current suicidal/homicidal ideation, intent or plan. protective factors are husband, mother, sister. wants to improve self. future goals/plans. plans on attending future medical appointments.
-Excessive worry/anxiety: worries that "I won't every be stable enough." , her husband and her being happy, finding work.
- Irritable behavior: sometimes easily annoyed. reports verbal irritability. denies any physical aggression or property destruction.
-ADL's: performs independently
-She reports she was told that becasue of her mental health issues she cannot promote to the next rank.
5. Other symptoms
-----------------
Does the Veteran have any other symptoms attributable to mental disorders that are not listed above?
[ ] Yes [X] No
6. Competency
-------------
Is the Veteran capable of managing his or her financial affairs?
[X] Yes [ ] No
7. Remarks (including any testing results), if any:
---------------------------------------------------
The following contentions need to be examined:
Anxiety
SECTION I:
----------
1. Diagnosis
------------
a. Does the Veteran now have or has he/she ever been diagnosed with a mental disorder(s)?
[X] Yes [ ] No
If the Veteran currently has one or more mental disorders that conform to
DSM-5 criteria, provide all diagnoses:
Mental Disorder Diagnosis #1: Major depressive disorder with anxious distress
Mental Disorder Diagnosis #2: unspecific personality disorder by history
b. Medical diagnoses relevant to the understanding or management of the
Mental Health Disorder (to include TBI): reports she has hypertension, tachycardia, hyperthyroidism, GERD
2. 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 overlap of symptoms
c. Does the Veteran have a diagnosed traumatic brain injury (TBI)?
[ ] Yes [ ] No [X] Not shown in records reviewed
3. 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 reduced reliability and productivity
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 overlap 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):
Redacted
b. Relevant Occupational and Educational history (pre-military, military, and post-military):
Educational History:
-Veteran graduated High school
-Veteran received good grades in school.
-Difficulties in school with classes: No repeats
College or Technical School: obtained Bachelors
Occupational History:
Primary career field:
Discharge Status:
Medals:
c. Relevant Mental Health history, to include prescribed medications and family mental health (pre-military, military, and post-military):
STRs reviewed:
-------------------Aug 2015 annual questions. no anxiety no depression
************************************************
CPRS/VISTAWEB reviewed: no VA treatment notes
************************************************
Current Private Mental Health Treatment: denies any current
Current Psychiatric Medications:
d. Relevant Legal and Behavioral history (pre-military, military, and post-military):
Legal History: Denies arrest
Behavioral History: Denies any behavioral issues in childhood, as an adolescent, while in the Military or after the Military.
e. Relevant Substance abuse history (pre-military, military, and post-military):
Substance Abuse History:
-Alcohol: occasionally will drink every other week to once a month
-Drugs: denies
-Tobacco: denies
-Caffeine:1 serving every few weeks
-Rehabs or other substance abuse treatment programs attended: denies
f. Other, if any:
No response provided.
3. Symptoms
-----------
For VA rating purposes, check all symptoms that actively apply to the
Veteran's diagnoses:
[X] Depressed mood
[X] Anxiety
[X] Disturbances of motivation and mood
4. Behavioral observations
--------------------------
Typical day:
MENTAL STATUS EXAMINATION: The veteran was well groomed and casually dressed. Veteran was oriented to person, place, and time. Eye contact was good. Veteran was cooperative. Rapport was good. Speech was normal for rhythm, rate, and volume. Veteran mood was ok. Affect was stable and congruent with mood. Veteran denied current suicidal or homicidal ideations.
Thought processes were linear, logical, and goal-directed. Insight, judgment, and reasoning appeared intact. There was no evidence of any perceptual disturbances, paranoia, or delusional thinking.
Review of neurovegetative symptoms over past 4 to 8 weeks:
-depressed mood: has noticed a correlation between menstrual cycle and depressed mood. Reports feeling depressed about
1 week a month
-Sleep: 8-9 hours at night. Falls asleep easily and reports wakes up for unknown reasons . She reports sometimes she will not go back to sleep and other times it takes her 30 mins to fall back asleep.
-Interest: "not really there."
-Guilt/worthlessness: guilty that she being a burden to her husband who sometimes has to take care of her. She reports he has to get her medication or get her up to shower sometimes.
-Energy: ok
-Concentration: "not the best." reports she is easily distracted
-Appetite: fair . she reports she gained weight in the past year. She
reports she gained about 10lbs.
-Psychomotor: wnl
-Suicide screen: denied current suicidal/homicidal ideation, intent or plan. protective factors are husband, mother, sister. wants to improve self. future goals/plans. plans on attending future medical appointments.
-Excessive worry/anxiety: worries that "I won't every be stable enough." , her husband and her being happy, finding work.
- Irritable behavior: sometimes easily annoyed. reports verbal irritability. denies any physical aggression or property destruction.
-ADL's: performs independently
-She reports she was told that becasue of her mental health issues she cannot promote to the next rank.
5. Other symptoms
-----------------
Does the Veteran have any other symptoms attributable to mental disorders that are not listed above?
[ ] Yes [X] No
6. Competency
-------------
Is the Veteran capable of managing his or her financial affairs?
[X] Yes [ ] No
7. Remarks (including any testing results), if any:
---------------------------------------------------
The following contentions need to be examined:
Anxiety
