Diagnostic Summary
Does the veteran have a diagnosis of PTSD that conforms to DSM-IV criteria based on today's evaluation? Yes
Current Diagnoses
Diagnosis #1: Post Traumatic Stree Disorder/Chronic, Moderate to Severe Axis 1
Diagnosis#2 Panic Disorder with Agoraphobia - Axis 1
Diagnosis#3 Depressive Disorder Not Otherwise Specified - Axis 1
GAF score: 35
Comments: Major impairment in several areas
Does the veteran have more then one Mental disorder diagnosed? Yes
Occupational and social impairment
Occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgement, thinking and/or mood. (Is checked)
Is it possible to differentiate what portion of the occupational and social impairment indicated above is caused by each mental disorder?
PTSD: 70%, Panic Disorder with Agorophobia 10% and Depressive Disorder NOS: 20%
In the section for Stressors:
Does this (there are several stressors listed - all combat related that I would rather not post the details ) meet Criterion A - Yes
Are the stressors related to the Vet's fear of hostile military or terrorist activity? Yes
Which stressor contributed t othe Veterans PTSD diagnosis? All the stressors are checked.
Symptoms (the following are checked):
Depressed mood, anxiety , suspiciousness, panic attacks more then once a week, chronic sleep impairment, difficulty in understanding complex commands, disturbances of motivation and mood, Difficulty in establishing and maintaining effective work and social relationships, Difficulty in adapting to stressful circumstances, including work or worklike setting, impaired impulse control, such as unprovoked irritability with periods of violence, disorientation to time and place, intermittent inability to perform activies of daily living.
Other Symptoms:
Other symptoms are listed for each listed Disorder but I believe they are a bit personal.
Is the Vet capable of managing his or her financial affairs?
Yes.
Remarks: A diagnosis of PTSD is made. It has been determined that the veteran's claimed stressors are related to the veterans fear of in-service hostile military or terrorist activity. Rationale: His stressors/traumas are eligible for PTSD definition of traumas and he further met all of the other criteria of DSMIV for PTSD.
He had gone to a Civilian Psych (via Tri-Care as he's retired 22 years) over a year ago - that Dr was the first to diagnos him with PTSD - had to threaten him with leaving (which I would NEVER do....no matter how bad it gets but at the time he did not need to know this) to get him to go . He's been seeing a VA therapist since that time who also diagnozed him with PTSD - her initial exam of him is much like the above....but her recents comments have just been things like: has much less anger, clear speach, calm, coherent, Pt aware of person, place, time and situation. Casually dressed and adequately groomed, in fair mood with congruent effect. Complexity of Illness/Level of Impairment: moderate and stable at this time. YET they increased the doseage amount of medication that had been perscribed. To be honest....I personally have not seen much change for the better since he has been going to therapy....the medication has helped with his anger/outbursts a little but other things have remained the same or gotten worse:(
Looking at the VA's rating table for MH problems - I would think he would get a 70% rating if all they considered was the C&P........but with some of the things his current therapist is stating I think it might be lower.
To be perfectly honest though.....I just wish I could have my husband back to his former self.
Thanks in advance for any thoughts or answers to my questions.
Edited by USMC5811, 23 July 2012 - 05:45 PM.
