Case Study Mental Evaluation

Case Study Mental Evaluation

Facts Service: 3/65 11/69 8/06 Regional Office (RO) granted service connection (S/C) for posttraumatic stress disorder (PTSD) at 30% from 3/06 7/07 Statement of Case (SOC) raised evaluation to 50% from 3/06 (appeal continued)

Medical opinion dated 5/06: Affect: modulated Mood: sad & sullen Behavior: vacillated b/tw agitation & depression Confused & disoriented Impulsive thoughts & flashbacks Hyperalert & hypervigilant Frequent panic attacks Indecisive, unable to think clearly & unable to concentrate & complete tasks Dx chronic severe PTSD Global Assessment of Functioning (GAF) 49

4/08 VAE Psychiatric Exam Examiner opined PTSD significantly interferes w/ vet s normal daily activities Examiner stated vet s symptoms included: Recurrent, intrusive & distressing memories of Vietnam; Flashbacks w/ intense psychological distress Avoidance & numbing Not taking medication at time of VAE

4/08 VAE Psychiatric Exam Examiner reported vet stated: Feeling anxious, nervous & irritable; Obsessed with thoughts of Vietnam; Difficulty adapting to stressful situations; Increasingly withdrawn; Had trouble even talking to significant other; Relationship significantly harmed by irritability; Trouble sleeping; Daily difficulty concentrating; Hypervigilance; Exaggerated startle response; & Had to quit job as nurse in 2006 because he was so irritable

4/08 VAE Psychiatric Exam Mental status examination: Clear & linear thought process although he reported being disoriented by flashbacks at times Significantly restricted range of affect Concentration adequate for interview although vet reported concentration difficulties w/ reading Memory normal Judgment & insight intact Mood neutral Affect pleasant No evidence of inappropriate behavior, suicidal ideation, or thought disorder Examiner stated vet s symptoms interfered w/ his ability to establish & maintain effective relationships Vet increasingly isolated Symptoms significantly interfered w/ employment functioning DX chronic severe PTSD GAF 47

4/08 VAE Psychiatric Exam 10/08 hearing reiterated previous symptoms & said he had to call his private psychologist for panic attacks about 3 times every 6 months

BVA Analysis Under findings of fact BVA stated: Vet s PTSD is manifested by occupational & social impairment w/ deficiencies in most areas such as work, school, family relations, judgment, thinking or mood, due to symptoms. BVA acknowledged problems w/ concentration, difficulty sleeping, nightmares, panic attacks, flashbacks, intrusive thoughts, irritability, difficulty adapting to stressful situations, difficulty establishing & maintaining relationships; significantly restricted affect; increasingly withdrawn; & significant interference w/ employment

BVA Analysis BVA noted no evidence of: suicidal ideation, obsessional rituals, illogical speech, near continuous panic or depression, impaired impulse control, & neglect of personal hygiene.

BVA Analysis BVA found: Speech was goal oriented, Appropriately dressed, Memory functions appeared normal, Judgment & insight were intact, No evidence of unprovoked irritability w/ periods of violence No psychiatric medication

BVA Analysis BVA GAF scores BVA stated while GAF scores reflect severe symptoms, BVA found vet didn t manifest symptoms that would support 70% evaluation. BVA stressed vet didn t have: obsessional rituals which interfere w/ routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting ability to function independently, appropriately & effectively. BVA denied an increase to 70%.

Before the Court (before the case was briefed) VAGC took one look at this case & agreed to assign 70% rating from 3/06.

38 C.F.R. 4.130 70% Occupational & social impairment, w/ deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere w/ routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting ability to function independently, appropriately & effectively; impaired impulse control (such as unprovoked irritability w/ periods of violence); spatial disorientation; neglecting personal appearance & hygiene; difficulty in adapting to stressful circumstances including work or a worklike setting); inability to establish & maintain effective relationships

38 C.F.R. 4.130 50% Occupational & social impairment w/ reduced reliability & productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- & long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation & mood; difficulty in establishing & maintaining effective work & social relationships

38 C.F.R. 4.130 GAF 41-50 Serious symptoms, (e.g. suicidal ideation, severe obsessional rituals, frequent shoplifting) OR any serious impairment in social, occupational, or school functioning (e.g. no friends, unable to keep job).

NVLSP Screening BVA found as fact vet had social & occupational impairment w/ deficiencies in most areas Exams of 5/06 & 4/08 support 70% evaluation. Assigned GAF scores of 49 then 47. Symptoms very severe especially on 5/06 exam. BVA continued 50% evaluation in spite of GAF scores, in spite of severe symptoms & most importantly in spite of the fact BVA conceded vet suffered social & occupational impairment w/ deficiencies in most areas which is requirement for 70% under 4.130. There is a good chance for reversal here.