Joint Appendix — Joshua E. Bufkin, Petitioner v. Douglas A. Collins, Secretary of Veterans Affairs

No. 23-713

IN THE

Supreme Court of the United States

___________________________________

JOSHUA E. BUFKIN AND NORMAN F. THORNTON,

Petitioners,

v.

DENIS MCDONOUGH,

SECRETARY OF VETERANS AFFAIRS,

Respondent.

___________________________________

ON WRIT OF CERTIORARI TO THE UNITED STATES

COURT OF APPEALS FOR THE FEDERAL CIRCUIT

___________________________________

JOINT APPENDIX

___________________________________

Melanie L. Bostwick

Counsel of Record

ORRICK, HERRINGTON &

SUTCLIFFE LLP

2100 Pennsylvania

Avenue, NW

Washington, DC 20037

(202) 339-8400

mbostwick@orrick.com

Elizabeth B. Prelogar

Solicitor General

Counsel of Record

DEPARTMENT OF JUSTICE

950 Pennsylvania

Avenue, NW

Washington, DC 20530

(202) 514-2217

SupremeCtBriefs@usdoj.gov

Counsel for Petitioners

Counsel for Respondent

PETITION FOR WRIT OF CERTIORARI FILED

DECEMBER 29, 2023

CERTIORARI GRANTED APRIL 29, 2024

i

TABLE OF CONTENTS

Page

Letter from Robert B. Goos, MD, Staff

Psychiatrist, Pueblo VA CBOC (Feb. 27,

2014) (Bufkin RBA489-490) .................................. JA1

Disability Benefits Questionnaire for

Joshua Bufkin (June 17, 2015) (Bufkin

RBA183-194) ......................................................... JA4

Disability Benefits Questionnaire for

Norman Thornton (July 8, 2015)

(Thornton RBA1304-1313) .................................. JA29

Disability Benefits Questionnaire for

Joshua Bufkin (Apr. 19, 2018) (Bufkin

RBA269-278) ....................................................... JA49

Letter from Charles Mellon, MD,

Department of Veterans Affairs, Eastern

Colorado Health Care System, to Joshua

Bufkin (Dec. 23, 2019) (Bufkin RBA42) ............. JA77

JA1

LOCAL TITLE: GENERAL INFORMATION CBCB

STANDARD TITLE: ADMINISTRATIVE NOTE

DATE OF NOTE: FEB 27, 2014@09:00

ENTRY DATE: FEB 27, 2014@09:00:23

AUTHOR: GOOS,ROBERT B

EXP COSIGNER:

INSTITUTION: PUEBLO CBOC

DIVISION: PUEBLO CBOC

URGENCY:

STATUS: COMPLETED

The following letter was prepared for this veteran:

2/27/2014

To whom it may concern,

I am the attending physician for Mr. Joshua Bufkin

at the Pueblo VA clinic. I performed a comprehensive

psychiatric evaluation and have seen him for regular

followup visits over this last year. He suffers from

severe Posttraumatic Stress Disorder. He worked in

the military in intelligence and had planned on

making a career in the military. His wife was

suffering from depression and he was presented by

his superiors with a choice. They said that they could

not afford to have a serviceman’s wife commit

suicide, so he was told he would have to either

divorce her or leave the military. He felt he was

being forced to decide his wife’s fate, to stay in the

service he would have to abandon her and be

responsible if she commited suicide. He chose to

leave the service, but the anger and powerlessness

he felt has never left him. He is hypervigilant for

anything that might endanger him or his family. He

JA2

feels great distrust for others and responds quickly

with anger if he feels any threat. For many years he

slept with a gun next to his bed, but because of

ongoing nightmares, he put it away. He has

avoidance behaviors, and cannot be around people

for long, especially large groups of people. He has

prominent emotional numbing. He startles easily,

has prominent hyperarousal which he can’t shut

down. He can’t have people walking behind him

without tremendous anxiety, fear or anger. Anger is

extremely quick to erupt and he worries about

carrying out this anger in violence. Sleep has been

impaired and he does have nightmares.

It is clear to me that in every aspect he meets

criteria for Posttraumatic Stress Disorder and it is

quite disabling for him. He has been coming in for

treatment for the last year but continues

symptomatic and it effects every aspect of his life. It

is my opinion that the primary stressor was this

perceived threat to his wife’s life, this perception

that those in power did not care if his wife lived or

died that has led to his current condition. It disrupts

significantly his interpersonal, social, and certainly

his occupational functioning and will likely do so far

into the future.

Thank you for your consideration of this matter.

If you have any questions about this, I can be

reached at 719-584-5112 or 719-543-7889.

JA3

Sincerely,

Robert B. Goos, MD

Staff Psychiatrist

Pueblo VA CBOC

/es/ Robert B. Goos, M.D.

Psychiatrist

Signed: 02/27/2014 09:01

JA4

** PROGRESS NOTES ***************************

------------------------------------------------------------------------LOCAL TITLE: C&P PSYCH

STANDARD TITLE: PSYCHIATRY C & P

EXAMINATION CONSULT

DATE OF NOTE: JUN 11, 2015@13:00

ENTRY DATE: JUN 17, 2015@11:46:44

AUTHOR: WEBSTER,DAVID C

EXP COSIGNER:

INSTITUTION:

DIVISION: CHEYENNE VAMROC

URGENCY:

STATUS: COMPLETED

Initial Post Traumatic Stress Disorder (PTSD)

Disability Benefits Questionnaire

* Internal VA or DoD Use Only *

Name of patient/Veteran: Bufkin,Joshua E

SECTION I:

----------------1. Diagnostic Summary

-------------------------------Does the Veteran have a diagnosis of PTSD that

conforms to DSM-5 criteria based on today’s

evaluation?

[ ] Yes [X] No

If no diagnosis of PTSD, check all that apply:

JA5

[X] Veteran’s symptoms do not meet the

diagnostic criteria for PTSD under DSM-5

criteria

[X] Veteran has another Mental Disorder

diagnosis. Continue to complete this

Questionnaire and/or the Eating Disorder

Questionnaire:

2. Current Diagnoses

-------------------------------a. Mental Disorder Diagnosis #1: Adjustment

Disorder with Mixed Disturbance of Emotions

and Conduct, Persistent form

ICD code: 309.4

Comments, if any:

This is a very complex case. The veteran

reports a longstanding pattern of

depressed mood, angry outbursts and

rumination about his administrative

separation from the Air Force in 2006,

after being in the military only six months.

The onset of the condition was sometime

shortly after separation in 2006 (as

evidenced by the Air Force psychiatrist

stating the veteran did not have a mental

health condition at the time of discharge),

but the consequences continue to affect

him to the present day (states “I was

meant to be in the military”, and he

continues to be married to the woman who

coerced him to leave the military). The

diagnosis that most accurately describes

this pattern of symptoms is Adjustment

JA6

Disorder with Mixed Disturbance of

Emotions and Conduct, Persistent form.

Veteran’s claim is for PTSD and the

veteran has been diagnosed with PTSD by

a past VA treating psychiatrist who wrote

a letter in support of the veteran’s claim.

However I note the psychiatrist has not

been able to review the military

medical/mental health records (specifically

the treatment document from the Air Force

psychiatrist and the Training Record note,

both of which give specific details of events

leading up to the veteran being granted a

Hardship Discharge) and must rely solely

on the veteran’s report of events. I point

out to VBA that diagnoses are often

changed as additional information becomes

available, and I think it is entirely possible

that if the VA psychiatrist had the

opportunity to review the relevant military

records that would have a significant

impact on their diagnostic deliberations.

When strictly adhering to the diagnostic

requirements for PTSD in the DSM-5 there

are three specific requirements that MUST

be present for a diagnosis of PTSD to be

accurately given. These three basic

requirements are 1) exposure to a PTSD

trauma event that meets the DSM-5

definition, 2) problems due to persistent reexperiencing that trauma event in the form

of intrusive unwanted memories of the

trauma event, recurring nightmares of the

JA7

event, or flashbacks of the event, and 3)

avoidance of stimuli associated with that

event...These are absolute requirements

for a diagnosis of PTSD, unless ALL

THREE are present no diagnosis of PTSD

can accurately be given, and this is clearly

stated in the DSM-5. Therefore, for

example, if a man directly experiences a

PTSD trauma event but does not reexperience the trauma event, he does not

meet the DSM-5 requirements for PTSD.

(NOTE TO VBA RATER…this is why

PTSD symptom checklists such as was

used with this veteran are so often

incorrect, these symptom checklists make

no effort to insure that an actual DSM-5

defined PTSD trauma event occurred, and

are the actual basis of “re-experiencing

trauma memories, avoidance of trauma

memories, etc.)

In the case at hand the veteran submitted

a list of claimed “trauma events” to VBA.

In the exam today when asked about

recurring

intrusive

memories

or

nightmares of trauma events, the veteran

reported he generally slept well and denied

recurring nightmares of any trauma

events. The only “intrusive memories of a

trauma” that he identified was that he was

“always mad at the military for the way

they treated me.” It’s important to note

here that the fact that the other claimed

trauma events submitted by the veteran

(in his report to me today) are not resulting

JA8

in recurrent intrusive memories or

recurring nightmares of these events. This

means that BY DSM-5 DEFINITION he

cannot have PTSD based on these events

(regardless of whether they meet the DSM5 definition of a PTSD trauma event).

Furthermore in regards to his report of

“always being mad at the military for the

way they treated me” (VA mental health

treatment note dated Apr 17, 2015 states

“Mr. Bufkin always thought of his

discharge as a personal affront to his

abilities in the Air Force”) this fails to meet

all three of the DSM-5 requirements for

PTSD. First, no matter how “unfairly” or

“uncaring” or “rejecting” the veteran

perceives the military’s actions to be, these

actions very clearly in no way meet the

DSM-5 definition of a PTSD trauma event

(as defined on page 271 of the DSM-5,

“exposure to actual or threatened death,

serious injury, or sexual violence”).

Secondly, in order to meet the DSM-5

definition of “intrusive memories”, the

memories have to be unwanted. The

veteran very directly states that he wants

to think about these memories, they are

not “intrusive” as defined by the

DSM…finally, in regards to the DSM-5

requirement of “avoidance” the veteran

very clearly states that he makes no effort

to avoid memories of “how the military

treated him.” In fact, as he stated, he does

not “want to forget” these memories and

JA9

instead dwells on them daily to remind

himself of how he was “mistreated” by the

military.

For the sake of thoroughness I will address

the letter in support of PTSD from the VA

psychiatrist. The VA psychiatrist states

“the primary stressor was this perceived

threat to his wife’s life, this perception that

those in power did not care if his wife lived

or died”. In regards to the statement “the

primary stressor was this perceived threat

to his wife’s life” the psychiatrist is

referring to the fact that the veteran’s wife

wanted him to leave the military and in an

attempt to coerce him she began making

suicidal threats and gestures. This is

reported by the veteran today and is

documented in the military medical

records.

It is certainly possible that an actual

suicide attempt could meet the DSM-5

requirements of a PTSD trauma event, but

there is no indication that there was a

suicide attempt in this case. Suicide

threats and gestures, especially when

there is a long history of these behaviors

(which is how the veteran described his

wife’s suicidal threats and gestures to the

Air Force psychiatrist) but no actual

attempts, do not in my opinion represent

the PTSD trauma definition of a significant

“threat to life.” In fact I asked the veteran

if his wife ever made a suicide attempt and

JA10

he stated “no, she never actually cut

herself, she would just make marks on her

arm” in a pretty dismissive manner, which

I interpreted as his recognizing that her

suicidal threats and gestures were

manipulative but not an actual life

threatening event.

Furthermore as noted above, when I asked

the

veteran

about

intrusive

memories/nightmares/flashbacks, he did

not report any recurring intrusive

memories/nightmares/flashbacks about his

wife’s suicidal threats or gestures....Even if

the veteran’s wife’s suicidal threats and

gestures did meet the DSM-5 definition of

a PTSD trauma event, if he is not having

recurring

intrusive

memories

or

nightmares or flashbacks OF THAT

CLAIMED EVENT then he does not meet

the three required elements for a PTSD

diagnosis.

Finally, DSM-5 definition of a PTSD

trauma event is quite specific, and the

psychiatrist’s

statement

that

“this

perception that those in power did not care

if his wife lived or died” is not relevant to

the definition of a PTSD trauma event. I

point out that the veteran did not live with

his wife at that time, she did not live on

base, she did not seek mental health

treatment from the military, reportedly

was

“uncooperative

with

treatment

efforts”, etc., and in effect the military was

JA11

powerless over her actions...even if his

perception of them being “uncaring” was

accurate, it has nothing to do with the

DSM-5 definition of a PTSD trauma event.

Finally, to give context for my conclusions I

will relate key portions of the military

medical documentation relevant to the case

at hand. While the military medical

document is often consistent with the

veteran’s report of events, there are some

key differences which help to clarify the

diagnostic issues.

Here is a summary of history based on

military

records.

Military

administrative/mental

health

records

indicated the veteran joined the Air Force

and did well in basic training. He married

his wife shortly after completing Basic and

entered into his required Individual

Training to become a Security Forces

airman (military police). His wife remained

at her home. He began repeatedly failing

his required training classes, and could not

progress to being assigned to a job if he

could not pass these classes (insteady he

likely would be separated from the

military). His Air Force instructions meet

with him to try and determine why he was

having problems. He requested a meeting

with Air Force mental health which was

arranged. He told the Air Force

psychiatrist (and me today) that his new

wife did not want him to be in the military,

JA12

and that she wanted him to quit and come

home to her. He stated that she had a long

history of making suicidal threats and

gestures, and began making suicidal

threats if he did not leave the Air Force.

Conflict between them over his being in

the military resulted in significant stress

for him, making it difficult for him to

concentrate in his classes, resulting in his

failures in training tests...in addition he

was apprehensive about how his wife

would handle his first duty assignment

once he completed training (he was

scheduled to be stationed in Germany)...In

support of this I note that Military Record

of Administrative Training Action dated

Feb 16, 2006 states after failing a written

measurement for the second time during

his training he was sent to mental health

and ended up being evaluated by Lt Col

Wasileski, Chief of the Behavioral

Evaluation Service who concluded “AB

Bufkin has legitimate and significant

marital problems…impacting his training

performance”…the document goes on to

recommend

that

AB

Bufkin

be

recommended for separation with the

opportunity to return to active duty and to

the course at a later date if his

humanitarian situation were lessened to

the point where he could be effective.”

In contrast to the veteran’s report to his

VA psychiatrist that the Air Force “forced

him to choose between his wife and a

JA13

hardship discharge, the military records

document that he was repeatedly failing

his required training classes. If he could

not pass these classes he could not perform

his job and it would lead to either

reassignment to a much simpler career

field in the Air Force (such as cook), or

more likely to an administrative discharge

for “Inability to adapt...Unsuitability”, or

some similar reason...

Military medical records clearly show this

is not a case of “Air Force could not afford

to have a serviceman’s wife commit suicide

at the veteran states”, rather it was a case

of the Air Force intervening with an

airman who was unable to pass required

training classes...military mental health

records indicated he was failing his classes

due to marital stressors (A letter from Air

Force Psychiatrist Lt Col Wasileski dated

Jan 27, 2006 in summary says that the

veteran’s wife has a very long history of

serious mental health problems including

making suicidal threats as well as a

history of non-fatal self-injurious behaviors

and has been uncooperative with her

medical providers…spouse does not want

him in the military...veteran’s problems

are directly related to this, no other mental

health diagnoses), but the fact remains

that he was failing required training

classes and therefore unable to progress in

the military, causing the military to take

action. Finally, in the same letter which

JA14

recommends the veteran be separated from

the service, the psychiatrist states “AB

Bufkin reviewed the contents of this letter,

and fully concurs with its statements. AB

Bufkin believes it is in the best interest of

his family and the USAF that he be

separated from the service.” Based on this

the veteran was granted a Hardship

Discharge six months after he entered the

Air Force. This is a non-prejudicial

discharge, as opposed to possible negative

discharges that could have been used such

as

“Personality

Disorder”

or

“Unsuitability.”

To summarize the military records, the

veteran wanted to be in the Air Force, his

newly married wife did not want him to be

in the Air Force and attempted to coerce

him with threats of suicide, as a

consequence

of

this

conflict

his

performance in the Air Force deteriorated

and he did not pass required training

classes. He requested to speak to mental

health and explained what was happening,

and subsequently was granted a nonprejudicial discharge with his consent six

months after entering the military.

Given the above, from a diagnostic

standpoint one might wonder why the

veteran continues to be consumed with

rage at the Air Force for his discharge.

More to the point, one has to wonder why

the veteran is angry at the Air Force

JA15

rather than his wife, since she actively

campaigned and ultimately was successful

in getting him to separate from the Air

Force…. Given the fact that the veteran’s

intense, explosive anger is a very

significant factor in his life, the underlying

cause of the anger is a key diagnostic issue.

In my opinion it is more likely than not

that the veteran’s very understandable

anger towards his wife for coercing him to

leave the military is viewed by the veteran

as “unacceptable”, and he has displaced it

onto the military instead. In addition as

noted earlier by one of his treatment

providers, the veteran always thought of

his discharge as a personal affront to his

abilities in the Air Force, making it a

“narcissistic injury” leading to “outrage.”

This makes it fairly easy to “rationalize”

that his anger is caused by the military

“bad treatment of him.” Unfortunately to

maintain his marriage and avoid the

conflict that anger towards his wife would

cause, he must continue to avoid the fact

that his wife coerced him to quit the

military by continuing to direct his

thoughts/anger at the Air Force. This likely

explains why he dwells obsessively on

being treated “badly” by the military, and

why he resists treatment efforts to get him

to stop dwelling on this…

Finally, the last key symptom is the

veteran’s “hypervigilance/paranoia.” He

reports that he must be on guard for

JA16

attempts at “being attacked.” Superficially

this sounds like the PTSD symptom of

hypervigilance…however,

PTSD

hypervigilance is geared to protecting

oneself from a re-occurrence of the trauma

event. Therefore, people with PTSD from

tornados are hypervigilant for signs of

another tornado, people with PTSD from a

serious car accident are hypervigilant

while in cars, people with PTSD from a

personal assault (such as a combat

veteran) are hypervigilant of another

personal assault, etc…In the veteran’s case

there are no claimed PTSD trauma events

involving a personal assault and he denies

ever being assaulted. Beyond this in

describing why he is on guard the veteran

stated that “if you are nice to people, they

will take advantage of you”, this has more

of an defensive personality trait quality to

it. I also note when I inquired about

interpersonal conflict in the work setting

the veteran stated that generally he did

not have problems with males “because

they avoid me due to my anger” but he was

often angry with female co-workers who

were “sexually suggestive” towards him by

making sexual commits, making sexually

suggestive movements with their fingers,

or touching him in a sexual manner…this

again

had

an

odd

somewhat

narcissistic/paranoid quality to it.

This leads me to conclude that there are

some underlying personality traits that

JA17

drive

some

of

the

veteran’s

behaviors/thoughts,

particularly

his

suspicious, almost “paranoid” attitude (as

well as given his very short time in the

military his “over-identification” as a “bred

to be warrior” so to speak) . However, the

veteran denies any evidence of a

personality disorder during childhood, and

the Air Force psychiatrist specifically

denied that the veteran had Axis I or Axis

II conditions at the time of her

examination. Therefore I conclude that it is

likely that the veteran has some

personality “traits” that do not quite rise to

the level of personality disorder, but do

fuel his “paranoia”. As often is the case

with

personality

traits,

these

behaviors/attitudes/thoughts are often not

caused by “conscious decisions” but are

instead below the level of the patient’s

awareness...

b. Medical diagnoses relevant to the understanding

or management of the Mental Health Disorder (to

include TBI): no contributing factors

3. Differentiation of symptoms

------------------------------------------a. Does the Veteran have more than one mental

disorder diagnosed?

[ ] Yes [X] No

c. Does the Veteran have a diagnosed traumatic

brain injury (TBI)?

[ ] Yes [ ] No [X] Not shown in records reviewed

JA18

4. 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

deficiencies in most areas, such as work,

school, family relations, judgment, thinking

and/or mood

b. For the indicated level of occupational and social

impairment, is it possible to differentiate what

portion of the occupational and social impairment

indicated above is caused by each mental

disorder?

[ ] Yes [ ] No [X] No other mental disorder

has been diagnosed

c. If a diagnosis of TBI exists, is it possible to

differentiate what portion of the occupational and

social impairment indicated above is caused by

the TBI?

[ ] Yes [ ] No [X] No diagnosis of TBI

SECTION II:

-----------------Clinical Findings:

-----------------------1. Evidence review

--------------------------In order to provide an accurate medical opinion, the

Veteran’s claims folder must be reviewed.

JA19

a. Medical record review:

-----------------------------------Was the Veteran’s VA e-folder (VBMS or Virtual VA)

reviewed?

[X] Yes [ ] No

Was the Veteran’s VA claims file (hard copy paper Cfile) reviewed?

[ ] Yes [X] No

If yes, list any records that were reviewed but

were not included in the Veteran’s VA claims file:

If no, check all records reviewed:

[ ] Military service treatment records

[ ] Military service personnel records

[ ] Military enlistment examination

[ ] Military separation examination

[ ] Military post-deployment questionnaire

[ ] Department of Defense Form 214

Separation Documents

[X] Veterans Health Administration medical

records (VA treatment records)

[ ] Civilian medical records

[ ] Interviews with collateral witnesses

(family and others who have known the

Veteran before and after military service)

[ ] No records were reviewed

[X] Other:

included past and current mental health

treatment notes from the Denver VA

b. Was pertinent information from collateral

sources reviewed?

JA20

[X] Yes

[ ] No

If yes, describe:

lay statesments from the veteran’s wife and

mother concerning “changes” after leaving the

military

2. History

--------------a. Relevant Social/Marital/Family history (premilitary, military, and post-military):

Pre-military: family - parents divorced when

he was 18, two siblings…father was an Army

drill

instructor

and

was

very

authoritarian…but

veteran

denies

any

physical or sexual abuse

Post-military:

social

married,

no

children…veteran reports his marriage is

strained due to his irritability, and he has no

friends…he enjoys working on cars but notes

he gets very angry and has cost himself a lot

of money breaking parts when working by

himself on car…also reports that he is

frequently selling his car and buying a new

car trying to make himself happier but this

doesn’t work…

b. Relevant Occupational and Educational history

(pre-military, military, and post-military):

Pre-military: school - high school graduate, no

problems

Military: Air Force Sep 2005 to Mar

2006//Rank E-2//MOS Security Forces Helper

JA21

(still in initial stages of his training at time of

separation)//deployed to combat zone – none

Married after he entered the Air Force,

veteran stated his wife did not want him to

stay in the Air Force and began making

suicidal threats/gestures if he didn’t come

home…conflict/distress over this resulted in

his poor school performance and he started

repeatedly failing required training classes.

Asked to see mental health as a result,

received a mental health evaluation and was

granted a “Hardship” discharge.

Post-military: occupational - employee at the

Denver VA/Pueblo Clinic in IT since

2010…veteran says his technical knowledge is

good but his supervisor tells him his customer

service is affected by his irritability and he

struggles with his motivation at times…states

most of his male co-workers just avoid him but

he gets angry at the sexually suggestive

comments/behaviors his female co-workers

make…reports he had comments about his

irritability at his previous job working for

DOD IT as well, in fact he was told he had to

be careful or he would create a “hostile work

environment”/educational

- has earned

certifications

c. Relevant Mental Health history, to include

prescribed medications and family mental health

(pre-military, military, and post-military):

Pre-military: mental health--family history none//patient history - none…veteran notes

JA22

that he internalized anger when he was young

and it never caused any problems, did well in

school, played sports, socialized with others,

etc. without any evidence of impairment

Military: mental health treatment - reports he

saw a psychiatrist Lt Col who gave him a

choice, divorce his wife or take a hardship

discharge…Military Record of Administrative

Training Action dated Feb 16, 2006 states

after failing a written measurement for the

second time during his training he was sent to

mental health and ended up being evaluated

by Lt Col Wasileski, Chief of the Behavioral

Evaluation Service who concluded “AB Bufkin

has legitimate and significant marital

problems…impacting

his

training

performance”…the document goes on to

recommend that AB Bufkin be recommended

for separation with the opportunity to return

to active duty and to the course at a later date

if his humanitarian situation were lessened to

the point where he could be effective.”

A letter from Lt Col Wasileski dated Jan 27,

2006 in summary says that the veteran’s wife

has a very long history of serious mental

health problems including making suicidal

threats as well as a history of non-fatal selfinjurious

behaviors

and

has

been

uncooperative

with

her

medical

providers…spouse does not want him in the

military and veteran is concerned about how

his wife would react to the stressors of living

abroad (his first duty assignment was

JA23

scheduled to be in Germany) without the

support of her extended family.

Post-military: Mental Health Treatment diagnosed with PTSD by Robert Goos in May

2013 at the Denver VA, currently on

Escitalopram and Lorazepam, getting Alpha

Stimulation treatment as well

d. Relevant Legal and Behavioral history (premilitary, military, and post-military):

Pre-military: legal - none

Military: disciplinary actions - none

Post-military: legal - none

e. Relevant Substance abuse history (pre-military,

military, and post-military):

Pre-military: alcohol/drugs - no problems

Military: alcohol/drugs - no problems

Post-military: alcohol/drugs - no problems

f. Other, if any:

No response provided.

3. Stressors

----------------Describe one or more specific stressor event(s) the

Veteran considers traumatic (may be pre-military,

military, or post-military):

a. Stressor #1: Veteran reports he has constant

thoughts of “being forced by the Air Force to

choose between his wife and his Air Force

career

JA24

Does this stressor meet Criterion A (i.e., is it

adequate to support the diagnosis of PTSD)?

[ ] Yes [X] No

Is the stressor related to the Veteran’s fear of

hostile military or terrorist activity?

[ ] Yes [X] No

Is the stressor related to personal assault, e.g.

military sexual trauma?

[ ] Yes [X] No

4. PTSD Diagnostic Criteria

---------------------------------------No response provided

5. Symptoms

------------------For VA rating purposes, check all symptoms that

actively apply to the Veteran’s diagnoses:

[X] Depressed mood

[X] Anxiety

[X] Suspiciousness

[X] Mild memory loss, such as forgetting names,

directions or recent events

[X] Impaired judgment

[X] Disturbances of motivation and mood

[X] Difficulty in establishing and maintaining

effective work and social relationships

[X] Difficulty

in

adapting

to

stressful

circumstances, including work or a worklike

setting

JA25

6. Behavioral Observations

-------------------------------------MENTAL STATUS EXAM: alert, coherent, fully

oriented, dressed in clean casual clothes, polite and

cooperative in manner, thought processes were

logical and goal oriented, affect was tense/dysphoric,

denied current thoughts of suicide, no evidence of a

formal thought disorder

7. Other symptoms

--------------------------Does the Veteran have any other symptoms

attributable to PTSD (and other mental disorders)

that are not listed above?

[ ] Yes [X] No

8. Competency

--------------------Is the Veteran capable of managing his or her

financial affairs?

[X] Yes [ ] No

9. Remarks, (including any testing results) if any

--------------------------------------------------------------------No remarks provided.

NOTE: VA may request additional medical

information, including additional examinations if

necessary to complete VA’s review of the Veteran’s

application.

*************************************************

Medical Opinion

Disability Benefits Questionnaire

JA26

Name of patient/Veteran: Bufkin,Joshua E

Indicate method used to obtain medical information

to complete this document:

[ ] Review of available records (without in-person or

video telehealth examination) using the

Acceptable Clinical Evidence (ACE) process

because the existing medical evidence provided

sufficient information on which to prepare the

DBQ and such an examination will likely provide

no additional relevant evidence.

[ ] Review of available records in conjunction with a

telephone interview with the Veteran (without inperson or telehealth examination) using the ACE

process because the existing medical evidence

supplemented with a telephone interview

provided sufficient information on which to

prepare the DBQ and such an examination would

likely provide no additional relevant evidence.

[ ] Examination via approved video telehealth

[X] In-person examination

Evidence review

---------------------Was the Veteran’s VA claims file reviewed? Yes

If yes, list any records that were reviewed but

were not included in the Veteran’s VA claims file:

VA medical records (including his treating

VA)

MEDICAL OPINION SUMMARY

-----------------------------------------------

JA27

RESTATEMENT OF REQUESTED OPINION

a. Opinion from general remarks: Does the veteran

have a diagnosis of mental health condition (also

claimed as PTSD, depression, and anxiety) that is at

least as likely as not incurred in or caused by his

wife’s mental health illness which led to his eventual

discharge during the service?

b. Indicate type of exam for which opinion has been

requested: Initial PTSD

TYPE OF MEDICAL OPINION PROVIDED: [

MEDICAL OPINION FOR DIRECT SERVICE

CONNECTION ]

b. The condition claimed was less likely than not

(less than 50% probability) incurred in or caused by

the claimed in-service injury, event or illness.

c. Rationale: 1) The veteran does not meet the

DSM-5 diagnostic requirements for PTSD. I

explained this is great detail in my exam report and

refer the VBA rater to the narrative of the

Diagnostic section for the unavoidably long

explantation.

2) Veteran does in fact currently have symptoms of

depression/anxiety which I have diagnosed as

Chronic Adjustment Disorder. However, based on

the military mental health documentation this

condition was not present while the veteran was in

the military. The onset was sometime after leaving

the military, and could have presented as quickly as

JA28

within days of leaving the military...the question

about whether the symptoms are “caused by wife’s

mental health illness” requires a detailed

explanation. In military medical notes the veteran

reported his wife had “Bipolar Disorder.” In the

veteran’s VA mental health treatment notes he has

referred to his wife as “having Bipolar Disorder” or

“being Depressed.” However in my exam I

specifically asked if the veteran’s wife had ever been

diagnosed or treated for Bipolar Disorder and he

said no (!!??) I realize this seemingly contradicts his

earlier reports to others but this is exactly what he

told me...I can only assume either the veteran or his

wife has “self-diagnosed” her with Bipolar Disorder

or Depression...given this state of affairs I cannot

state that “his wife’s mental health illness” led to his

eventual discharge during service.

In contrast, it is very clear both by the veteran’s

report and the military medical documentation that

shortly after he married his wife she attempted to

coerce him to leave the military by making threats of

suicide if he did not. The stress of their conflict

caused him to perform poorly in training and he

began repeatedly failing required training tests.

Given his wife’s opposition to his staying in the

military and her manipulative attempts to coerce

him to leave, it ultimately led to his Hardship

Discharge...

*************************************************

/es/ DAVID C. WEBSTER, Ph.D.

CHIEF OF PSYCHOLOGY

Signed: 06/17/2015 11:46

JA29

LOCAL TITLE: COMPENSATION & PENSION

STANDARD TITLE: C & P EXAMINATION NOTE

DATE OF NOTE: JUL 08, 2015@14:00

ENTRY DATE: JUL 08, 2015@15:05:30

AUTHOR: SARFF,PHILIP

EXP COSIGNER:

URGENCY:

STATUS: COMPLETED

COMPENSATION AND PENSION EXAMINATION

REPORT (FREE TEXT)

========================================

Review Post Traumatic Stress Disorder (PTSD)

Disability Benefits Questionnaire

Name of patient/Veteran: Norman Thornton

(T0097)

SECTION I:

----------------1. Diagnostic Summary

--------------------------------Does the Veteran now have or has he/she ever

been diagnosed with PTSD?

[X] Yes [ ] No

ICD Code:

Vet was last seen for a C&P Post-traumatic stress

disorder (Review) exam by Dr. Goldberg on 7/5/11.

Diagnostic impressions included Post-traumatic

stress disorder and GAF was 59.

2. Current Diagnoses

JA30

-----------------------------a. Mental Disorder Diagnosis #1: Post-traumatic

stress disorder, with depressive features

ICD Code:

Comments,

if

any

(including

causation/exacerbation): This is the condition for

which the vet is SC. His treating provider, Dr.

Kumar, had designated his PTSD as a “dissociative

type.” However, medical records (including a

neurology consult in 2012) note periods of confusion

and memory lapses that do not appear to be traumabased. He has been described during these events as

not being overly upset or “acting out” a trauma and

he says behaves as if he normally would. This would

be anything BUT a trauma-based dissociative

episode. As a rule, people with PTSD do not

dissociate unless they are in the middle of a

flashback. He does report having a few traditional

dissociative periods that could be connected to

PTSD, such as waking up from a nightmare choking

his wife or waking up outside as if he were on guard

duty.

b. Medical

diagnoses

relevant

to

the

understanding or management of the Mental

Health Disorder (to include TBI): See medical

records

ICD code:

Comments, if any:

3. Differentiation of symptoms

------------------------------------------a. Does the Veteran have more than one mental

disorder diagnosed?

[ ] Yes [X] No

JA31

b. Is it possible to differentiate what symptom(s)

is/are attributable to each diagnosis?

[ ] Yes [ ] No [X] Not applicable (N/A)

If no, provide reason that it is not possible to

differentiate what portion of each symptom is

attributable to each diagnosis:

If yes, list which symptoms are attributable to

each diagnosis:

c. Does the Veteran have a diagnosed traumatic

brain injury (TBI)?

[ ] Yes [ ] No [X] Not shown in records

reviewed

Comments, if any:

d. Is it possible to differentiate what symptom(s)

is/are attributable to each diagnosis?

[ ] Yes [ ] No [X] Not applicable (N/A)

If no, provide reason that it is not possible to

differentiate what portion of each symptom is

attributable to each diagnosis:

If yes, list which symptoms are attributable to

each diagnosis:

4. Occupational and social impairment

------------------------------------------------------a. Which of the following best summarizes the

Veteran’s level of occupational and social

JA32

impairment with regards

diagnoses? (Check only one)

to

all

mental

[ ] No mental disorder diagnosis

[ ] A mental condition has been formally

diagnosed, but symptoms are not severe

enough

either

to

interfere

with

occupational and social functioning or to

require continuous medication

[ ] Occupational and social impairment due to

mild or transient symptoms which

decrease work efficiency and ability to

perform occupational tasks only during

periods of significant stress, or; symptoms

controlled by medication

[ ] Occupational and social impairment with

occasional decrease in work efficiency and

intermittent periods of inability to perform

occupational tasks, although generally

functioning satisfactorily, with normal

routine

behavior,

self-care

and

conversation

[X] Occupational and social impairment with

reduced reliability and productivity

[ ] Occupational and social impairment with

deficiencies in most areas, such as work,

school,

family

relations,

judgment,

thinking and/or mood

[ ] Total occupational and social impairment

b. For the indicated level of occupational and

social impairment, is it possible to

differentiate what portion of the occupational

JA33

and social impairment indicated above is

caused by each mental disorder?

[ ] Yes [ ] No [X] No other mental

disorder has been

diagnosed

If no, provide reason that it is not possible

to differentiate what portion of the

indicated level of occupational and social

impairment is attributable to each

diagnosis:

If yes, list which portion of the indicated

level of occupational and social impairment

is attributable to each diagnosis:

c. If a diagnosis of TBI exists, is it possible to

differentiate what portion of the occupational

and social impairment indicated above is

caused by the TBI ?

[ ] Yes [ ] No [X] No diagnosis of TBI

If no, provide reason that it is not possible

to differentiate what portion of the

indicated level of occupational and social

impairment is attributable to each

diagnosis:

If yes, list which portion of the indicated

level of occupational and social impairment

is attributable to each diagnosis:

SECTION II:

------------------

JA34

Clinical Findings:

-----------------------1. Evidence review

--------------------------In order to provide an accurate medical opinion,

the Veteran’s claims folder must be reviewed.

a. Medical record review:

-----------------------------------Was the Veteran’s VA e-folder (VBMS or Virtual

VA) reviewed?

[X] Yes [ ] No

Was the Veteran’s VA claims file reviewed?

[ ] Yes [X] No

If yes, list any records that were reviewed but

were not included in the Veteran’s VA claims

file:

If no, check all records reviewed:

[ ] Military service treatment records

[ ] Military service personnel records

[ ] Military enlistment examination

[ ] Military separation examination

[ ] Military post-deployment questionnaire

[ ] Department of Defense Form 214

Separation Documents

[X] Veterans Health Administration medical

records (VA treatment records)

Vet has been followed by Dr. Kumar for psychiatric

care since about 2003. Working diagnosis is Post-

JA35

traumatic stress disorder, with “dissociative type”. It

was noted on 1/22/15 that he will have episodes of

losing time for up to two days.

Vet was seen for a neuropsychological screening

consult in 2012 using the RBANS. Problems were

noted with concentration, but not memory.

[ ] Civilian medical records

[ ] Interviews with collateral witnesses

(family and others who have known the

Veteran before and after military service)

[ ] No records were reviewed

[ ] Other:

b. Was pertinent information from collateral

sources reviewed?

[ ] Yes [ ] No

If yes, describe:

2. Recent History (since 7/5/11)

-------------------------------------------a. Relevant Social/Marital/Family history:

Vet is married, but has been separated for two years;

they were separated because of a “combination of

things”, including his “disabilities”; she also was

online talking with an old boyfriend, and he gave

him an ultimately. He has no children with her, but

she had a daughter from a previous marriage.

His two children are 24 (son) and 22 (daughter); he

reports having good relationships with his two kids.

JA36

“They think the world of me.” He talks to one or both

almost daily.

Vet has a younger brother, and they are not real

close; he also has half-sister who is a lot younger

than he. He also had a brother who died as a child.

His parents are divorced, since he was about 13. He

says his relationship with his mother is great, but he

is less close with his father. He says that his father

had cheated on his mother, and he still has some

resentment about that and other issues from

childhood.

Vet lives in a mobile home alone.

Vet reports having friends, including several 4-5

close friends that he sees on a regular basis. He does

medieval re-enactments through a world-wide club

of 180,000 people. He goes to 2-3 events per year;

there are meetings and practice sessions in between

events. He has done chain mail jewelry and some

costume work.

b. Relevant

history:

Occupational

and

Educational

Vet has been doing mostly “side jobs” over the past

4-5 years. He last worked over the Christmas

holiday for greeting card company. He also worked

at a motel doing handyman and maintenance jobs,

but he was told that he showed up to work one day

without being asked to come. He was accused of

being unreliable. “I lose days. I lose time.” He finds

JA37

more work during the summer months, including

mowing grass.

His income comes from SC pension and his side

Vet had worked as a contract carpenter for several

years; he and his brother closed the business to free

up personal time and because of financial issues. He

believes he did well with that, and they specialized

in remodeling and special projects.

Vet says his main barrier to work, now, he believes,

is sudden intense fatigue that comes out of nowhere.

“Part of it is memory”, i.e., he has forgotten to go

places.

c. Relevant Mental Health history, to include

prescribed medications and family mental

health:

Vet has been followed by Dr. Kumar for psychiatric

care for several years. He does not recall the name of

his medication, but recognizes “paroxetine”. He

believes the medication helps, in the sense that he

knows when he misses doses.

Vet has had no therapy, other than with Dr. Kumar.

d. Relevant Legal and Behavioral history:

None

e. Relevant Substance abuse history:

JA38

Vet drinks “here and there” and will “very rarely”

will drink too much. He denies use of illicit drug use.

f. Relevant Medical (Non-Mental Health)

history, to include prescribed medications.

Vet has migraines, for which he takes medication; he

has migraines at various frequency. This month has

been good, last month was “hell.” He has found they

are triggered by beer or hard cheese.

He has chronic fatigue syndrome, for which he take

no medication.

Vet has had memory lapses, or episodes, where he

does things and does not remember what he was

doing. He states that he is “doing whatever I

normally do”.

He has these incidents at various frequencies, as

well. He does not recall seeing neurology, but CPRS

has notes from 2012.

g. Other, if any: None

3. PTSD Diagnostic Criteria

---------------------------------------Please check criteria used for establishing the

current PTSD diagnosis. The diagnostic criteria

for PTSD, are from the Diagnostic and Statistical

Manual of Mental Disorders, 5th edition (DSM5). The stressful event can be due to combat,

personal trauma, other life threatening situations

(non-combat related stressors.) Do NOT mark

symptoms below that are clearly not attributable

to the criteria A stressor/PTSD. Instead,

overlapping symptoms clearly attributable to

JA39

other things should be noted under #5 - “Other

symptoms”.

Criterion A: Exposure to actual or threatened

a) death, b) serious injury, c)

sexual violation, in on or more of

the following ways:

[X] Directly experiencing the traumatic event(s)

[presumed due to SC status]

[X] Witnessing, in person, the

traumatic event(s) as they

occurred to others [presumed due

to SC status]

[ ] Learning that the traumatic

event(s) occurred to a close

family member or close friend;

cases of actual or threatened

death must have been violent or

accidental;

or,

experiencing

repeated or extreme exposure to

aversive details of the traumatic

events(s) (e.g., first responders

collecting human remains; police

officers repeatedly exposed to

details of child abuse); this does

not apply to exposure through

electronic

media,

television,

movies, or pictures, unless this

exposure is work related.

Criterion B: Presence of (one or more) of the

following intrusion symptoms

associated with the traumatic

JA40

event(s), beginning after

traumatic event(s) occurred:

the

[X] Recurrent,

involuntary,

and

intrusive distressing memories of the traumatic

event(s) [these might happen 2-3 times per week,

often with a guilt overtone)

[X] Recurrent distressing dreams in

which the content and/or affect of the dream are

related to the traumatic event(s)[he has been told he

has awakened in the middle of the night doing

various things, like choking his wife)

[ ] Dissociative

reactions

(e.g.,

flashbacks)

in

which

the

individual feels or acts as if the

traumatic

event(s)

were

recurring. (Such reactions may

occur on a continuum, with the

most extreme expression being a

complete loss of awareness of

present surroundings)

[X] Intense

or

prolonged

psychological distress at exposure to internal or

external cues that symbolize or resemble an aspect

of the traumatic event(s) [he was extremely vague;

he talked about a recent incident when a man had

some kind of episode at an re-enactment event; his

response to that episode was to sob for an hour

because he believes the man did not get treated

properly in the process; he reacts to jack hammers

and the sound of helicopters, as well]

[ ] Marked physiological reactions to

internal or external cues that

JA41

symbolize or resemble an aspect

of the traumatic event(s).

Criterion C: Persistent avoidance of stimuli

associated with the traumatic

event(s), beginning after the

traumatic events(s) occurred, as

evidenced by one or both of the

following:

[X] Avoidance of or efforts to avoid

distressing memories, thoughts,

or feelings about or closely

associated with the traumatic

event(s).

[X] Avoidance of or efforts to avoid

external

reminders

(people,

places, conversations, activities,

objects, situations) that arouse

distressing memories, thoughts,

or feelings about or closely

associated with the traumatic

event(s) [he avoids branding

because of the smell; he avoids

shooting his gun]

Criterion D: Negative

alterations

in

cognitions and mood associated

with the traumatic event(s),

beginning or worsening after the

traumatic event(s) occurred, as

evidenced by two (or more) of the

following:

JA42

[ ] Inability

to

remember

an

important

aspect

of

the

traumatic event(s) (typically due

to dissociative amnesia and not

to other factors such as head

injury, alcohol, or drugs).

[X] Persistent

and

exaggerated

negative beliefs or expectations

about oneself, others, or the

world (e.g., “I am bad,: “No one

can be trusted,: “The world is

completely

dangerous,:

“My

whole

nervous

system

is

permanently ruined”).

[ ] Persistent, distorted cognitions

about the cause or consequences

of the traumatic event(s) that

lead to the individual to blame

himself/herself or others.

[ ] Persistent negative emotional

state (e.g., fear, horror, anger,

guilt, or shame).

[ ] Markedly diminished interest or

participation

in

significant

activities.

[ ] Feelings of detachment or

estrangement from others.

[ ] Persistent inability to experience

positive emotions (e.g., inability

to

experience

happiness,

satisfaction, or loving feelings.)

Criterion E: Marked alterations in arousal

and reactivity associated with

JA43

the traumatic event(s), beginning

or worsening after the traumatic

event(s) occurred, as evidenced

by two (or more) of the following:

[X] Irritable behavior and angry

outbursts (with little or no

provocation) typically expressed

as verbal or physical aggression

toward people or objects.

[ ] Reckless

or

self-destructive

behavior.

[X] Hypervigilance.

[ ] Exaggerated startle response.

[X] Problems with concentration.

[X] Sleep disturbance (e.g., difficulty

falling or staying asleep or

restless sleep).

Criterion F:

[X] The duration of the symptoms

described above in Criteria B, C,

and D are more than 1 month.

[ ] Veteran does not meet full

criteria for PTSD

Criterion G:

[X] The PTSD symptoms described

above cause clinically significant

distress or impairment in social,

occupational, or other important

areas of functioning.

[ ] The PTSD symptoms described

above do NOT cause clinically

JA44

significant

distress

or

impairment

in

social,

occupational, or other important

areas of functioning.

[ ] Veteran does not meet full

criteria for PTSD

Criterion H:

[X] The

disturbance

is

not

attributable to the physiological

effects of a substance (e.g.,

medication, alcohol) or another

medical condition.

4. Symptoms

------------------For VA rating purposes, check all symptoms that

apply to the Veterans diagnoses:

[X] Depressed mood (when he feels down, it

can last for a day or two)

[X] Anxiety (he says he feels anxious often, and it can

be “about anything”; he sometimes is puzzled why he

feels that way, and it simply comes over him;

irritability also can happen like this; he is more

likely to feel anxious around “civilians” vs. people

who had been in the military)

[ ] Suspiciousness

[ ] Panic attacks that occur weekly or less

often

[ ] Panic attacks more than once a week

[ ] Near-continuous panic or depression

affecting

the

ability

to

function

JA45

independently,

appropriately

and

effectively

[X] Chronic sleep impairment (vet has trouble

getting to sleep and staying asleep; he is not sure

how long it takes to get to sleep; it might take an

hour, and has not been to sleep at all for a couple

days; he reports that he has nightmares at various

frequencies, depending on what is going on in his

life; he is more likely to have then when he talks to a

military friend; he has sleep apnea, but cannot

tolerate the mask; he feels tired most of the time)

[X] Mild memory loss, such as forgetting

names, directions or recent events

[ ] Impairment of short- and long-term

memory, for example, retention of only

highly learned material, while forgetting to

complete tasks

[ ] Memory loss for names of close relatives,

own occupation, or own name

[ ] Flattened affect

[ ] Circumstantial,

circumlocutory

or

stereotyped speech

[ ] Speech intermittently illogical, obscure, or

irrelevant

[ ] Difficulty in understanding complex

commands

[ ] Impaired judgment

[ ] Impaired abstract thinking

[ ] Gross impairment in thought processes or

communication

[ ] Disturbances of motivation and mood

[ ] Difficulty in establishing and maintaining

effective work and relationships

JA46

[X] Difficulty in adapting to stressful

circumstances, including work or a worklike setting

(“it depends on my day”; he has more trouble with

his own stress, vs. his kids’)

[ ] Inability to establish and maintain

effective relationships

[ ] Suicidal ideation

[ ] Obsessional rituals which interfere with

routine activities

[ ] Impaired impulse control, such as

unprovoked irritability with periods of

violence

[ ] Spatial disorientation

[ ] Persistent delusions or hallucinations

[ ] Grossly inappropriate behavior

[ ] Persistent danger of hurting self or others

[ ] Neglect of personal appearance and

hygiene

[ ] Intermittent inability to perform activities

of daily living, including maintenance of

minimal personal hygiene

[ ] Disorientation to time or place

5. Mental Status and Behavioral Observations:

----------------------------------------------------------------Veteran presented for the evaluation as alert and

oriented to person, place, and time. He interacted in

a logical, coherent, and very cooperative fashion.

Observed affect was even-keeled, and he appeared to

be in no acute distress. He notes that his mood tends

to vary. He says he does get depressed sometimes

and may wake up “absolutely pissed off”, but is not

sure why. Speech was normal for rate and volume,

JA47

and he was frank. No signs of thought disorder,

hallucinations, or delusions.

General Appearance and Observed

Casually dressed; plainly groomed

hygiene:

Psychomotor: Gait was not observed via telehealth.

Insight: Fair

Concentration: Vet notes that his focus is pretty good

“most of the time.”

6. Other symptoms

--------------------------Does the Veteran have any other symptoms

attributable to PTSD (and other mental

disorders) that are not listed above?

[ ] Yes [X] No

If yes, describe:

7. Competency

--------------------Is the Veteran capable of managing his or her

financial affairs?

[X] Yes [ ] No

If no, explain:

8. Remarks, (including any testing results) if

any:

--------------------------------------------------------------------None

JA48

9. Reliability and credibility of self-report:

----------------------------------------------------------Average

10. The purpose of the evaluation and limits of

confidentiality were discussed and the veteran gave

informed consent. Yes [X] No [ ]

TELEHEALTH: The veteran gave informed consent

to conduct this examination via

telehealth: Yes [X] No [ ]

11. Veteran was told that the examiner would be

typing their information into a computerized record

during the interview and [ ] did [X] did not raise

objects to that. If veteran objected, please describe

their objection and the examiner’s reaction to it:

12. Time spent in evaluation:

Clinical interview: 50 minutes

Record review: 10 minutes

Additional report preparation (after interview): 10

minutes

/es/ Philip L Sarff, Ph.D, LP

Psychologist

Signed: 07/08/2015 15:05

JA49

DEPARTMENT OF VETERANS AFFAIRS

UNITED STATES OF AMERICA

Initial Post-Traumatic Stress Disorder (PTSD)

– DSM V

Disability Benefits Questionnaire

LAST NAME, FIRST

NAME, MIDDLE

NAME (SUFFIX):

JOSHUA BUFKIN E

HOME ADDRESS:

[REDACTED]

FOUNTAIN, CO 80817

HOME TELEPHONE:

[REDACTED]

SOCIAL

TODAY’S

SECURITY

DATE

NUMBER:

04/19/2018

[REDACTED]

EXAMINING

LOCATION AND

ADDRESS:

VES

CONTRACTOR: VES NUMBER:

VES

[REDACTED]

VA CLAIM

NUMBER:

IMPORTANT—THE

DEPARTMENT

OF

VETERANS AFFAIRS (VA) WILL NOT PAY OR

REIMBURSE

ANY

EXPENSES

OR

COST

INCURRED IN THE PROCESS OF COMPLETING

AND/OR SUBMITTING THIS FORM. PLEASE

READ THE PRIVACY ACT AND RESPONDENT

BURDEN

INFORMATION

BEFORE

COMPLETING THIS FORM.

NOTE TO PSYCHIATRIST/PSYCHOLOGIST—

Your patient is applying to the U. S. Department of

Veterans Affairs (VA) for disability benefits. VA will

JA50

consider the information you provide on this

questionnaire as part of their evaluation in

processing the veteran’s claim. Please note that this

questionnaire is for disability evaluation, not for

treatment purposes. This evaluation should be based

on DSM-5 diagnostic criteria.

NOTE: If the Veteran experiences a mental health

emergency during the interview, please terminate

the interview and obtain help, using local resources

as appropriate. You may also contact the Veterans

Crisis Line at 1-800-273-TALK (8255). Stay on the

Crisis Line until help can link the Veteran to

emergency care.

Mental Health professionals with the following

credentials are qualified to perform initial C&P

examinations for mental disorders. They are: a

Board Certified psychiatrist; psychiatrist who have

successfully completed an accredited psychiatry

residency and who are appropriately credentialed

and privileged; licensed doctorate-level psychologist;

non-licensed doctorate level psychologists working

toward licensure under close supervision by a board

certified or board eligible psychiatrist or licensed

doctoral level psychologist; psychiatry resident

under close supervision by a board-certified or board

eligible psychiatrist or licensed doctoral level

psychologist; psychology residents under close

supervision of a board eligible psychiatrist or

licensed doctoral level psychologist.

NOTE: Close supervision means that the

supervising psychiatrist or psychologist met with the

JA51

Veteran and conferred with the examining mental

health professional in providing the diagnosis and

the final assessment. The supervising psychiatrist or

psychologist co-signs the examination report.

SECTION I – DIAGNOSTIC SUMMARY

1. DIAGNOSTIC SUMMARY

This section should be completed based on the

current examination and clinical findings.

Does the Veteran have a diagnosis of PTSD that

conforms to DSM-5 criteria based on today’s

evaluation?

[] Yes [X] No

ICD Code:

If no diagnosis of PTSD, check all that apply:

[X] Veteran’s symptoms do not meet the

diagnostic criteria for PTSD under DSM-5

criteria

[] Veteran does not have a mental disorder that

conforms with DSM-5 criteria

[X] Veteran has another Mental Disorder

diagnosis.

Continue

to

complete

this

Questionnaire and/or the Eating Disorder

Questionnaire.

2. CURRENT DIAGNOSES

2A. Mental Disorder Diagnosis #1:

Intermittent Explosive Disorder

ICD Code: F63.81

JA52

Comments, if any:

The veteran’s main complaint is his frequent

outbursts of anger that seem to be unprovoked.

He endorses having outbursts where he becomes

physically aggressive to himself or inanimate

objects or verbally aggressive to his family

members. He has been reprimanded at work for

being verbally aggressive as well. This aggression

is grossly disproportionate to the magnitude of

the psychosocial stressors.

Mental Disorder Diagnosis #2:

Chronic Adjustment Disorder with mixed

disturbance of emotion and conduct, persistent

form

ICD Code: F43.25

Comments, if any:

The veteran does not meet criteria for PTSD due

to the fact that he did not endorse any stressors

that meet criteria for Criterion A.

Mental Disorder Diagnosis #3:

ICD Code:

Comments, if any:

Mental Disorder Diagnosis #4:

ICD Code:

JA53

Comments, if any:

If additional diagnoses, describe using above

format:

2B. Medical diagnoses relevant to the understanding

or management of the Mental Health Disorder (to

include TBI):

The veteran notes that he has severe GERD,

which makes him vomit at times.

ICD code: K21

Comments, if any:

3. DIFFERENTIATION OF SYMPTOMS

3A. Does the Veteran have more than one mental

disorder diagnosed?

[X] Yes [] No

If “Yes,” complete Item 3B.

3B. Is it possible to differentiate what

symptom(s) is/are attributable to each diagnosis?

[X] Yes [] No [] Not applicable

If “No,” provide reason that it is not possible to

differentiate what portion of each symptom is

attributable to each diagnosis and discuss

JA54

whether there is any clinical association between

these diagnoses:

If “Yes,” list which symptoms are attributable to

each diagnosis and discuss whether there is any

clinical association between these diagnoses:

Intermittent Explosive Disorder: angry outbursts,

verbal and physical aggression

Adjustment disorder: depression, anger

All other symptoms overlap

There is a clinical association. When the veteran

experiences stress, he experiences an inability to

adjust to it, lashing out in anger instead.

3C. Does the Veteran have a diagnosed traumatic

brain injury (TBI)?

[] Yes [] No [X] Not shown in records reviewed

(If “Yes,” complete Item 3D)

Comments, if any:

3D. Is it possible to differentiate what

symptom(s) is/are attributable to each diagnosis?

[] Yes [] No [X] Not applicable

If “No,” provide reason that it is not possible to

differentiate what portion of each symptom is

attributable to each diagnosis:

JA55

If “Yes,” list which symptoms are attributable to

each diagnosis:

4. OCCUPATIONAL

IMPAIRMENT

AND

SOCIAL

4A. Which of the following best summarizes the

Veteran’s level of occupational and social

impairment with regards to all mental diagnoses?

(Check only one)

[] No mental disorder diagnosis

[] A mental condition has been formally diagnosed,

but symptoms are not severe enough either to

interfere with occupational and social functioning

or to require continuous medication

[] Occupational and social impairment due to mild or

transient symptoms which decrease work

efficiency and ability to perform occupational

tasks only during periods of significant stress, or

symptoms controlled by medication

[X] Occupational and social impairment with

occasional decrease in work efficiency and

intermittent periods of inability to perform

occupational

tasks,

although

generally

functioning satisfactorily, with normal routine

behavior, self-care and conversation

[] Occupational and social impairment with reduced

reliability and productivity

[] Occupational and social impairment with

deficiencies in most areas, such as work, school,

family relations, judgment, thinking and/or mood

[] Total occupational and social impairment

JA56

4B. For the indicated level of occupational and social

impairment, is it possible to differentiate what

portion of the occupational and social impairment

indicated above is caused by each mental disorder?

[] Yes [X] No [] No other mental disorder has been

diagnosed

If “No,” provide reason that it is not possible to

differentiate what portion of the indicated level of

occupational

and

social

impairment

is

attributable to each diagnosis:

The veteran struggles with both disorders

concurrently, so it is not possible to determine

what portion of the impairment is attributable to

each diagnosis.

If “Yes,” list which portion of the indicated level

of occupational and social impairment is

attributable to each diagnosis:

4C. If a diagnosis of TBI exists, is it possible to

differentiate what portion of the occupational and

social impairment indicated above is caused by the

TBI?

[] Yes [] No [X] No diagnosis of TBI

If “No,” provide reason that it is not possible to

differentiate what portion of the indicated level of

occupational

and

social

impairment

is

attributable to each diagnosis:

JA57

If “Yes,” list which portion of the indicated level

of occupational and social impairment is

attributable to each diagnosis:

SECTION II – CLINICAL FINDINGS

1. EVIDENCE REVIEW

In order to provide an accurate medical

opinion, the Veteran’s claims folder must be

reviewed.

Evidence reviewed (check all that apply):

[] Not Requested

[] No records were reviewed

[] VA claims file (hard copy paper C-file)

[X] VA e-folder (VBMS or Virtual VA)

[] CPRS

[] Other (please identify other evidence reviewed):

Evidence Comments:

Veteran brought in a list of his current mental

health medications.

2. HISTORY

2A. Relevant social/marital/family history (premilitary, military, and post-military):

JA58

Pre-military

The veteran was born in Clarksville, TN. His

father was in the Army, so he was raised in

Texas, Louisiana and Colorado. He was raised by

his mother “a majority of the time.” His parents

were married until he was around 20 years old.

His father was in and out due to deployments. He

has one brother and one sister. He gets along

with his mother well. His father does not talk to

him or his siblings. He does get along with his

brother and sister.

He denies any significant childhood trauma.

Military

The veteran joined the military in 2005. He

joined the Air Force. He was in the service for six

months. His highest rank was E-3. He was not

deployed. His discharge was “a hardship

discharge.”

Post-military

The veteran is currently married and has been

since 2005. This is his first marriage. He does not

have any children. He notes that he and his wife

have been getting along well lately, but that

there have been issues in the past.

He does not have any friends he spends time

with. For fun, the veteran likes to watch TV and

play video games.

JA59

2B. Relevant occupational and educational history

(pre-military, military, and post-military):

Pre-military

The veteran graduated from high school in May

2001. The veteran went to college at Pikes Peak

Community College where he studied Computer

Science. He obtained credits but no degree from

this. He did “modeling” after he graduated from

high school. “Truthfully, I did everything but

porn.”

Military

The veteran was in security forces while he was

in the service. He notes that this is not what he

wanted to do.

Post-military

The veteran “bounced around” after he

discharged from the service. He applied for a

police department job. “I got all the way to the

end and then they asked me if I would have a

problem putting down a suspect. I told her no,

and they said that I failed the psychological part.

She told me I was too gung ho.” He worked in

security, then started work at Ft. Carson as a

general services contractor. He has been in this

position for 8 years. He currently works full time

in this position. He does not like the job, but he

does like the paycheck. He is taking classes for a

JA60

BS in Homeland Security. It’s a field in Criminal

Justice with an emphasis on homeland security.

2C. Relevant mental health history, to include

prescribed medications and family mental health

(pre-military, military, and post-military):

Pre-military

The veteran denies any personal or family mental

health history prior to his time in the service.

Military

In the military, the veteran and his wife had

problems. “It was being apart problems. She

would miss me, so we spent a lot of my paychecks

getting her to come to see me. We would be

having sex and she would tell me I was hurting

her. She would lay there and cry. She started to

see a doctor who diagnosed her with

endometriosis. They checked and there was

nothing wrong with her. We started to see a

marriage counselor. The counselor said it was my

fault because of the way I approached her. This

went on for 10 years. There was times that I’ve

had women that approached me. I have done bad

things with women that I’m sorry for, but it was

because I felt my marriage was going down the

toilet. I wanted someone to want me instead of

feeling like I was hurting them.

The veteran notes that he was discharged about

six months after going in. “I would talk to her

JA61

every day and she would cry. She had a mental

episode where she went to the mental health

hospital. She was having a hard time with me

gone, so I called the mental health providers

about it. They told me I could divorce my wife

and stay in the military, or I could go home and

never come back.

Post-military

The veteran first started to notice himself having

mental health difficulties within a year of his

discharge. He notes that his mood would “go up

and down. My temper would flare up and I would

hit things, never my wife, but just things.” He

remembers that he would cry a lot, but he does

not know why. “Then it started with my wife.”

After he started to have problems with his wife,

he noticed extreme anger. “I would get so angry I

would punch myself in the face. I finally started

seeing Dr. Goos and he gave me lots of different

kinds of medication. Things have gotten better

with my wife, she still doesn’t trust me.” He

describes a time when his wife jumped out and

scared him. “I don’t remember, so I don’t know if

I blacked out. As soon as I realized it, I let her go,

but it made me feel like a criminal.” He notes

that he wakes in the middle of the night with

weapons in his hands. “So my wife made me take

away my weapons.” He notes that he has

difficulties with his mother, “like she’ll say

something that makes me mad and I’ll hit myself

instead of hitting her. We are not speaking right

now because she’s scared of me.” He shares that

JA62

he has a lot of hypervigilance. “Not only do I

watch what everyone does, but I was so ready to

hurt someone if they looked at me wrong. I have

gotten into verbal stuff with people but I’ve never

hit anyone. People tell me I look pissed off all the

time. I stay away from people. I don’t have

friends. I have had thoughts of killing people, and

I plan it out. It’s not just a thought. But I’ve

never acted on it. I’m not thinking any of those

things today. I have thoughts about suicide. The

only reason I haven’t is because I believe in God

and I don’t want to go to hell.” He is not having

any suicidal thoughts today. “I will be honest, I

hate life. My doctor told me I see things black and

white. It’s either one way or the other way,

nothing in between. I don’t get much pleasure out

of stuff. Since I’ve been married to my wife, I’ve

gone through 34 cars. I’m never satisfied. I

should be grateful about the amount of money I

make. I really wanted to be a career military, but

it didn’t work out.”

The veteran is currently taking: Lamotrigine

200mg, Escitalopram (Lexapro) 20mg, Zolpidem

tartrate 5mg, Lorazepam 1ml.

The veteran notes that he is “really tired a lot. If

I lay on the couch, I can sleep. But if I go to the

bed, I can’t sleep unless I take my medicine.” He

does not feel rested when he wakes. He notes that

he does have nightmares when he does not take

his medicines. He notes that his nightmares

include “me killing people.” He is a restless

sleeper when he does not take his medicines.

JA63

The veteran notes that his appetite is “okay.” He

has not thrown up due to GERD for a while.

His memory is impaired. “It’s not good.” He has

trouble remembering things his wife has said or

asked him to do. “I’ll ask her a question and then

ask her the same question a few minutes later.”

He can’t remember what he’s eaten. “The other

thing that kinda sucks right now is I’m going

back to school. I can’t remember or take notes on

what he’s saying, so I take a little recorder.” He

notes that his wife creates his calendar for him,

so he does not miss appointments. “I can’t get

words out. I pause for a minute and I can’t get it

out.” Recently, the veteran is having trouble with

concentration. “I get bored easily. I bounce from

activity to activity but I can’t keep attention.”

The veteran’s mood has “sucked” recently. “There

was a time a few weeks ago when I just started

crying, and then I was happy. I get somber and

then the other day I threw a tool and broke a

ladder after I got mad. I get pissed and tell her to

not say anything. It’s all over the place, it’s like a

roller coaster.”

The veteran notes that he struggles with anxiety

when he drives. “It’s a feeling of scared.” He also

notes that he gets nervous every time he goes to

class. “When I get in the classroom, I get ok.” He

also notes that he doesn’t look people in the eyes

anymore.

JA64

The veteran notes that his libido has dropped

significantly lately.

2D. Relevant legal and behavioral history (premilitary, military, and post-military):

Pre-military

No relevant history based on current exam and

review of any available medical records.

Military

No relevant history based on current exam and

review of any available medical records.

Post-military

The veteran notes that he was working at a clinic

in Pueblo two years ago, and the police came to

his workplace because they were told he was

exhibiting threatening behavior. He was assessed

by a psychologist, who “let him go.” He now works

from home and cannot return to his workplace.

2E. Relevant substance abuse history (pre-military,

military, and post-military):

Pre-military

No relevant history based on current exam and

review of any available medical records.

Military

JA65

No relevant history based on current exam and

review of any available medical records.

Post-military

No relevant history based on current exam and

review of any available medical records

2F. Other, (if any):

None.

3. STRESSORS

The stressful event can be due to combat, personal

trauma, other life threatening situations (noncombat related stressors).

NOTE: For VA purposes, “fear of hostile military or

terrorist activity” means that a veteran experienced,

witnessed, or was

confronted with an event or circumstance that

involved actual or threatened death or serious

injury, or a threat to the physical integrity of the

Veteran or others, such as from an actual or

potential improvised explosive device; vehicleimbedded explosive device; incoming artillery,

rocket, or mortar fire; grenade; small arms fire,

including suspected sniper fire; or attack upon

friendly military aircraft.

Describe one or more specific stressor event(s) the

Veteran considers traumatic (may be pre-military,

military, or post-military):

JA66

3A. Stressor #1:

The veteran states that he was told to leave the

military because his wife was having mental

health problems.

Does this stressor meet Criterion A (i.e., is it

adequate to support the diagnosis of PTSD)?

[] Yes [X] No

Is the stressor related to the Veteran’s fear of

hostile military or terrorist activity?

[] Yes [X] No

If “No”, explain:

This was due to his wife’s medical problems.

Is the stressor related to in-service personal

assault, e.g. military sexual trauma?

[] Yes [X] No

If “Yes”, please describe the markers that may

substantiate the stressor:

3B. Stressor #2:

Does this stressor meet Criterion A (i.e., is it

adequate to support the diagnosis of PTSD)?

[] Yes [] No

Is the stressor related to the Veteran’s fear of

hostile military or terrorist activity?

[] Yes [] No

JA67

If “No”, explain:

Is the stressor related to in-service personal

assault, e.g. military sexual trauma?

[] Yes [] No

If “Yes”, please describe the markers that may

substantiate the stressor:

3C. Stressor #3:

Does this stressor meet Criterion A (i.e., is it

adequate to support the diagnosis of PTSD)?

[] Yes [] No

Is the stressor related to the Veteran’s fear of

hostile military or terrorist activity?

[] Yes [] No

If “No”, explain:

Is the stressor related to in-service personal

assault, e.g. military sexual trauma?

[] Yes [] No

If “Yes”, please describe the markers that may

substantiate the stressor:

JA68

3D. Additional stressors: If additional stressors,

describe (list using the above sequential format):

4. PTSD DIAGNOSTIC CRITERIA

NOTE: Please check criteria used for

establishing the current PTSD diagnosis. Do

NOT mark symptoms below that are clearly not

attributable to the criteria A stressor/PTSD. Instead,

overlapping symptoms clearly attributable to other

things should be noted under #7—Other symptoms.

The diagnostic criteria for PTSD, referred to as

Criteria A-H, are from the Diagnostic and Statistical

Manual of Mental Disorders, 5th edition (DSM-5).

Criterion A: Exposure to actual or threatened a)

death, b) serious injury, c) sexual violation, in one or

more of the following ways:

[] Directly experiencing the traumatic event(s)

[] Witnessing, in person, the traumatic event(s) as

they occurred to others

[] Learning that the traumatic event(s) occurred to

a close family member or close friend; cases of

actual or threatened death must have been

violent or accidental; or, experiencing repeated or

extreme exposure to aversive details of the

traumatic event(s) (e.g., first responders

collecting human remains; police officers

repeatedly exposed to details of child abuse); this

does not apply to exposure through electronic

media, television, movies, or pictures, unless this

exposure is work related

JA69

[X] No criterion in this section met.

Criterion B: Presence of (one or more) of the

following intrusion symptoms associated with the

traumatic event(s), beginning after the traumatic

event(s) occurred:

[] Recurrent, involuntary, and intrusive distressing

memories of the traumatic event(s).

[] Recurrent distressing dreams in which the

content and/or affect of the dream are related to

the traumatic event(s).

[] Dissociative reactions (e.g., flashbacks) in which

the individual feels or acts as if the traumatic

event(s) were recurring. (Such reactions may

occur on a continuum, with the most extreme

expression being a complete loss of awareness of

present surroundings.)

[] Intense or prolonged psychological distress at

exposure to internal or external cues that

symbolize or resemble an aspect of the traumatic

event(s).

[] Marked physiological reactions to internal or

external cues that symbolize or resemble an

aspect of the traumatic event(s).

[X] No criterion in this section met.

Criterion C: Persistent avoidance of stimuli

associated with the traumatic event(s), beginning

after the traumatic event(s) occurred, as evidenced

by one or both of the following:

[] Avoidance of or efforts to avoid distressing

memories, thoughts, or feelings about or closely

associated with the traumatic event(s).

JA70

[] Avoidance of or efforts to avoid external

reminders

(people,

places,

conversations,

activities, objects, situations) that arouse

distressing memories, thoughts, or feelings about

or closely associated with the traumatic event(s).

[X] No criterion in this section met.

Criterion D: Negative alterations in cognitions and

mood associated with the traumatic event(s),

beginning or worsening after the traumatic event(s)

occurred, as evidenced by two (or more) of the

following:

[] Inability to remember an important aspect of the

traumatic event(s) (typically due to dissociative

amnesia and not to other factors such as head

injury, alcohol, or drugs).

[] Persistent and exaggerated negative beliefs or

expectations about oneself, others, or the world

(e.g., “I am bad,” “No one can be trusted,” “The

world is completely dangerous,” “My whole

nervous system is permanently ruined”).

[] Persistent, distorted cognitions about the cause

or consequences of the traumatic event(s) that

lead to the individual to blame himself/herself or

others.

[X] Persistent negative emotional state (e.g., fear,

horror, anger, guilt, or shame).

[X] Markedly diminished interest or participation in

significant activities.

[X] Feelings of detachment or estrangement from

others.

[] Persistent inability to experience positive

emotions (e.g., inability to experience happiness,

satisfaction, or loving feelings.)

JA71

[] No criterion in this section met.

Criterion E: Marked alterations in arousal and

reactivity associated with the traumatic event(s),

beginning or worsening after the traumatic event(s)

occurred, as evidenced by two (or more) of the

following:

[X] Irritable behavior and angry outbursts (with

little or no provocation) typically expressed as

verbal or physical aggression toward people or

objects.

[X] Reckless or self-destructive behavior.

[X] Hypervigilance

[] Exaggerated startle response.

[X] Problems with concentration.

[X] Sleep disturbance (e.g., difficulty falling or

staying asleep or restless sleep).

[] No criterion in this section met.

Criterion F:

[] Duration of the disturbance (Criteria B, C, D, and

E) is more than 1 month.

[X] No criterion in this section met.

Criterion G:

[] The disturbance causes clinically significant

distress or impairment in social, occupational, or

other important areas of functioning.

[X] No criterion in this section met.

Criterion H:

[] The disturbance is not attributable to the

physiological effects of a substance (e.g.,

medication, alcohol) or another medical condition.

JA72

[X] No criterion in this section met.

Criterion I: Which stressor(s) contributed to the

Veterans PTSD diagnosis?

[] Stressor #1

[] Stressor #2

[] Stressor #3

[] Other, please indicate stressor number (i.e.

stressor #4, #5, etc.) as indicated above:

[X] No criterion in this section met.

5. SYMPTOMS

For VA rating purposes, check all symptoms that

apply to the Veteran’s diagnoses:

[X] Depressed mood

[X] Anxiety

[X] Suspiciousness

[] Panic attacks that occur weekly or less often

[] Panic attacks more than once a week

[] Near-continuous panic or depression affecting the

ability to function independently, appropriately

and effectively

[X] Chronic sleep impairment

[X] Mild memory loss, such as forgetting names,

directions or recent events

[] Impairment of short- and long-term memory, for

example, retention of only highly learned

material, while forgetting to complete tasks

[] Memory loss for names of close relatives, own

occupation, or own name

[] Flattened affect

JA73

[] Circumstantial, circumlocutory or stereotyped

speech

[] Speech intermittently illogical, obscure, or

irrelevant

[] Difficulty in understanding complex commands

[X] Impaired judgment

[] Impaired abstract thinking

[] Gross impairment in thought processes or

communication

[X] Disturbances of motivation and mood

[X] Difficulty in establishing and maintaining

effective work and social relationships

[X] Difficulty in adapting to stressful circumstances,

including work or a work like setting

[] Inability to establish and maintain effective

relationships

[X] Suicidal ideation

[] Obsessional rituals which interfere with routine

activities

[] Impaired impulse control, such as unprovoked

irritability with periods of violence

[] Spatial disorientation

[] Persistent delusions or hallucinations

[] Grossly inappropriate behavior

[X] Persistent danger of hurting self or others

[] Neglect of personal appearance and hygiene

[] Intermittent inability to perform activities of

daily living, including maintenance of minimal

personal hygiene

[] Disorientation to time or place

6. BEHAVIORAL OBSERVATIONS

JA74

The veteran appeared for his appointment on

time. He was dressed in shorts and a t-shirt. He

sat on the edge of his chair and moved his head in

what appeared to be a motor tic movement

throughout the interview. He was very polite and

cooperative and appeared to answer the questions

to the best of his ability. His speech was WNL.

His thoughts were somewhat paranoid and

narcissistic in nature, as the veteran continually

talked about women asking him to engage with

them sexually. He used terms such as “throwing

themselves at me” to describe this behavior. He

was alert and oriented x4. He denied any current

SI or HI.

7. OTHER SYMPTOMS

Does the Veteran have any other symptoms

attributable to PTSD (and other mental disorders)

that are not listed above?

[] Yes [X] No

If “Yes,” describe:

8. COMPETENCY

Is the Veteran capable of managing his or her

financial affairs?

[X] Yes [] No

If “No,” explain:

JA75

9. REMARKS (INCLUDING ANY TESTING

RESULTS), IF ANY:

The veteran notes that he feels suicidal often, but

that he does not hurt himself because of his

religion.

I believe this Veteran/Service Member should be

considered an INCREASED but not current

imminent risk.

The veteran was equipped with the VA Crisis line

number.

SECTION

III

PSYCHOLOGIST

SIGNATURE

–

PSYCHIATRIST/

CERTIFICATION

AND

CERTIFICATION – To the best of my knowledge,

the information contained herein is accurate,

complete and current.

10A. PSYCHIATRIST/

PSYCHOLOGIST

SIGNATURE AND TITLE:

10B. PSYCHIATRIST/

PSYCHOLOGIST

PRINTED NAME:

10C. DATE SIGNED

10D. PSYCHIATRIST/

PSYCHOLOGIST PHONE

AND FAX NUMBERS:

10E. PSYCHIATRIST/

PSYCHOLOGIST

NATIONAL PROVIDER

IDENTIFIER (NPI)

/s/ Rebecca Richey,

Phys.D, LCSW

REBECCA M.

RICHEY, PsyD

04/19/2018

1-877-637-8387

Fax: 1-800-320-3908

1033230990 /

PSY.0004113 CO

JA76

NUMBER AND MEDICAL

LICENSE NUMBER AND

STATE:

VA-DENVER

CO

B&M VADCO 14142

DENVER

WEST

PARKWAY

10F. PSYCHIATRIST/ BLDG 51 – SUITE

PSYCHOLOGIST 285, LAKEWOOD, CO

ADDRESS: 80401

10G. PSYCHIATRIST’S

SPECIALTY: Psychologist

NOTE: VA may request additional medical

information, including additional examinations, if

necessary to complete VA’s review of the Veteran’s

application.

JA77

DEPARTMENT OF VETERANS AFFAIRS

EASTERN COLORADO

HEALTH CARE SYSTEM

1055 Clermont Street

Denver, Colorado 80220

303-399-8020

To: Joshua Bufkin

12/23/2019

Joshua suffers from chronic PTSD due to a number

of issues, but the primary issue is that he was

essentially forced out of the military due to intense

family problems that put him in a very difficult

psychological situation. He had to choose between

his goal of making a career in the military or keep

his marriage intact. There was no good solution. He

decided to save his marriage, and is still happily

married, but the sense of loss of losing his military

career has been very difficult for him. He has tried to

find another career that is as satisfying, but has not

been able to so far. Some examiners do not consider

this to be PTSD, but it was clearly traumatic for

Joshua. At a minimum, he has developed a severe

anxiety disorder.

/s/

Charles Mellon, MD

Psychiatrist

Pueblo VA