1. Diagnostic Summary
Does the Veteran have a diagnosis of PTSD that conforms to DSM-IV criteria based on today's evaluation? YES
2. Current Diagnoses
a. Diagnosis #1: PTSD
Diagnosis #2: Alcohol Dependence in remission
b. Axis III - medical diagnoses (to include TBI):
Chronic pain, diabetes, hyperlipidemia, hypothyroidism, GERD, HTN, sleep apnea
c. Axis IV - Psychosocial and Environmental Problems (describe, if any):
Unemployment, recent death of dog
d. Axis V - Current global assessment of functioning (GAF) score:
3. Differentiation of symptoms
a. Does the Veteran have more than one mental disorder diagnosed? YES
b. Is it possible to differentiate what symptom(s) is/are attributable to each diagnosis? YES
If yes, list which symptoms are attributable to each diagnosis:
The Veteran no longer drinks alcohol.
4. Occupational and Social Impairment
a. <X> Occupational and social impairment with reduced reliability and productivity
SECTION II: CLINICAL FINDINGS:
1. Evidence Review
a. <X> Claims Folder (C-file)
<X> Other, please describe:
Interview, CPRS and Vistaweb review
b. Was pertinent information from collateral sources reviewed? NO
a. Relevant Social/Marital/Family history (pre-military, military, and post-military):
The Veteran reported a generally normal childhood and socialization although he had few friends growing up. He was married once for 6 years and had one daughter, but divorced after his wife cheated. He was married a second time for 4 years, but divorced after his wife cheated. He has been married for the past 3 years which is doing well. He spends his days shopping, cooking, watching TV, doing yardwork, going to church, and sometimes fishing.
b. Relevant Occupational and Educational history (pre-military, military, and post-military):
The Veteran completed the 12th grade. He completed 1.5 years of college with a 3.5 GPA in construction management, but left school when he was unemployed and unable to afford it. The Veteran worked in construction management at 2 different positions for 7 years total, leaving them for better positions, but at his 3rd position which he held for 4-5 years he was laid off as part of a downsizing maneuver. The Veteran did well and was being groomed for a VP position, but did have an argument with a client which he believes may have impacted the decision to let him go. He has been unable to find work and began collecting SSDI for PTSD in 2009.
c. Relevant Mental Health history, to include prescribed medications and family mental health (pre-military, military, and post-military):
The Veteran first began psychiatric care in 2005 and psychotherapy last year. He currently attends group therapy and medications include prazosin and sertraline. He did participate in marital counseling during his second marriage. Family mental health history is positive for suicide and addiction.
d. Relevant Legal and Behavioral history (pre-military, military, and post-military):
One suspension in school for fighting. One Article 15 in 1996 for having a foreign national in his barracks.
e. Relevant Substance abuse history (pre-military, military, and post military):
The Veteran does not smoke. He did smoke marijuana regularly from 2000-05. The Veteran began drinking heavily following Desert Storm until 2009 and would drink 24 beers or more until passing out.
a. Stressor #1: On 2/25/91 the Veteran was on guard duty at Khobar, Saudi Arabia when a SCUD landed and killed 28 soldiers and injured 250 others. The Veteran was later required to remove his protective mask to assess the possibility of chemical agents.
Does this stressor meet Criterion A (i.e., is it adequate to support the diagnosis of PTSD)? YES
Is the stressor related to the Veteran's fear of hostile military or terrorist activity? YES
4. PTSD Diagnostic Criteria
<X> The Veteran experienced, witnessed, or was confronted with an event that involved actual or threateded death or serious injury, or a threat to the physical integrity of self or others.
<X> The Veteran's response involved intense fear, helplessness or horror.
<X> Recurrent and distressing recollections of the event, including images, thoughts, or perceptions
<X> Recurrent distressing dreams of the event
<X> Efforts to avoid thoughts, feelings or conversations associated with the trauma
<X> Efforts to avoid activities, places or people that arouse recollections of the trauma
<X> Markedly diminished interest or participation in significant activities
<X> Feeling of detachment or estrangement from others
<X> Restricted range of affect (e.g., unable to have loving feelings)
<X> Difficulty falling or staying asleep
<X> Irritability or outbursts of anger
<X> Difficulty concentrating
<X> The duration fo the symptoms described above in Criteria B, C, and D is more than 1 month
<X> The PTSD symptoms described above cause clinically significant distress or impairment in social, occupational, or other important areas of functioning
b. Which stressor(s) contributed to the Veterans PTSD diagnosis?:
<X> Stressor #1
<X> Chronic sleep impairment
<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. Other symptoms: NO
Is Veteran capable of managing his or her financial affairs? YES
8. Remarks, if any
The Veteran reported symptoms consistent with a diagnosis of PTSD. He reported a stressor wich would meet diagnostic Criterion A for PTSD and is consistent with the kinds of duties expected of a service member at that time and in those circumstances. There are no pre- or post-military traumas which would account for his symptoms and his entrance physicals on 5/31/88 and 7/7/88 do not show any indications of prior psychiatric history or treatment. It is at least as likely as not that the Veteran has PTSD that was caused by or resulted from military service. The Veteran reported only mild anergia and amotivation as current symptoms of depression. He did report prior depressive episodes beginning after service in Desert Storm, but these are more likely than not manifestations of PTSD rather than a separate medical entity.
After the interview, the psychologist shook my had, thanked me for my service, and said "enjoy your retirement"
Thoughts? Thanks in Advance!