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  1. All, few days ago I was awarded 90% being paid at 100% TDIU. Ebenefits says not P & T. I have 3 questions if someone could help me. My DAV rep was let go and now I have nobody to ask question about my claim. When I applied for TDIU she wrote increase for rating for my Lumbar DDD and PTSD which was 40 & 70% respectively. I have another 30% with both knees and tinnitus. Total rating of 90%. left and right knee is bilateral and radiculopathy is bilateral of left and right leg (not sure how those 4 ratings of 10% each are calculated)? Additionally, I was just diagnosed with moderate to severe sleep apnea and now using CPAP. I have a scar I never sought claim for which is in my medical records. I have high BP... rashes etc... never claimed that happened right after returning from Iraq. Unfortunately, I did not file or seek documentation. Question 1: My TDIU C & P was specific to determine employability which was stated in her notes. She also stated I had a separate and Comorbid diagnosis of MDD. Does that separate diagnosis effect my rating? Can MDD also be filed secondary to low back pain? is there anything I should do as far as claims for 100% SC based of this diagnosis? Question 2: Sleep apnea as 2nd to PTSD or aggrevated as a nexus for claiming sleep apnea even though I have been out 10 years. I have had it last five years before leaving army but never even heard of sleep apnea until recently. Yes, I have gained weight but PTSD dr in c & p stated my weight gain was because of my PTSD/MDD (I posted symptoms below). My question is: Should I file a claim Sleep apnea secondary to PTSD? I see some people said nexus should state PTSD and Sleep Apnea aggravated each other ???? I do not know what to do on this. any help would appreciated... question 3. I do not know how to add up the ratings. If I filed for Sleep apnea secondary to PTSD would that 50% rating take me over 100% sc threshold? I have scar for 10% that I could file that I never did. I know that is petty.... but they did cut out about 7 inches of meat out of my upper back.... left huge crater and scar. Question 4: Do I qualify for 100% SC P & T ? I was told the reason I did not receive 100% sc P & T when I filed for TdIU is because I did not state that in my claim. That I should have stated request for increase and 100% SC P & T rating instead of just TDIU. Really sorry for the long book.. I just do not know where to go and get answers to these questions. Everyone on here seems so knowedgable!!!!! I need your help!!! thanks you Current Diagnoses ------------------------------ If the Veteran currently has one or more mental disorders that conform to DSM-5 criteria, provide all diagnoses: a. Mental Disorder Diagnosis #1: Posttraumatic Stress Disorder ICD Code: F43.10 Mental Disorder Diagnosis #2: Major Depressive Disorder ICD Code: F33.9 b. Medical problems relevant to the understanding or management of the mental health disorder(s): Physical health problems that he described as affecting his day-to-day functioning or requiring the use of daily medication or medical devices include back pain and sleep apnea. Just got a CPAP yesterday. Please see his medical records for additional information about his physical health conditions. 3. Differentiation of Symptoms ------------------------------ a. Does the Veteran have more than one mental disorder diagnosed? [X] Yes [ ] No b. Is it possible to differentiate what symptom(s) is/are attributable to each diagnosis? [ ] Yes [X] No [ ] Not applicable (N/A) If no, provide reason that it is not possible to differentiate what portion of each symptom is attributable to each diagnosis and discuss whether there is any clinical association between these diagnoses: These conditions can co-occur, and there is some overlap in their symptoms and associated features, which precludes attribution of certain specific difficulties to one condition or another without resorting to speculation. Consequently, these conditions cannot be fully differentiated from each other. 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 [X] No [ ] Not applicable (N/A) 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: As these conditions cannot be fully differentiated from each other, their associated functional impairments cannot be differentiated without resorting to speculation. He has a service connection for PTSD, with a current rating of 70%. This examination was focused on his functioning since the previous examination on 4/xx/2017, although information regarding prior history was reviewed and obtained where relevant to the issues in question. Please see the report of the previous examination for relevant prior history. The present examination was based on a face-to-face interview with the Veteran and review of records as indicated above. Except where otherwise indicated, historical information presented above is taken from the interview. Results of the examination indicate that the Veteran's difficulties are consistent with current diagnostic criteria for PTSD. They also indicate that he experiences symptoms supporting a diagnosis of Major Depressive Disorder (MDD) at this time. These are considered to be separate, comorbid conditions which share some symptoms and a common etiology. Due to the overlap in symptoms and associated features of these disorders, it can at times be difficult to determine--and clinicians may reasonably differ regarding--whether the clinical picture might be better accounted for by a single diagnosis or by multiple diagnoses. Results of the examination indicate that as a result of his mental health conditions, he is experiencing significant impairments in a number of domains, including occupational functioning. As he is no longer working, his occupational functioning is inferred from his past work history, from his current social functioning, and from the nature and severity of his current symptomatology. He has not held paid employment since February 2016, when he lost his job due to irritability and angry outbursts. He indicated a previous history of work-related difficulties due to anxiety and panic. Taken together with fatigue, problems with attention and concentration, forgetfulness, intrusive thoughts, hypervigilance, discomfort in interpersonal interactions, and a propensity for social withdrawal and avoidance as a means of coping with stress, these difficulties would significantly limit his ability to secure and maintain gainful employment. He would likely experience challenges in adjusting successfully to a work environment due to difficulty establishing and maintaining effective work relationships, as well as to reduced reliability, productivity, efficiency, accuracy, and timeliness in attending work and fulfilling job responsibilities. --------------------------- Symptoms --------------------------- For VA rating purposes, check all symptoms that actively apply to the Veteran's diagnoses: [X] Depressed mood [X] Anxiety [X] Suspiciousness [X] Panic attacks more than once a week [X] Chronic sleep impairment [X] Mild memory loss, such as forgetting names, directions or recent events [X] Impairment of short- and long-term memory, for example, retention of only highly learned material, while forgetting to complete tasks [X] Flattened affect [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 Other Symptoms --------------------------- Does the Veteran have any other symptoms attributable to PTSD and other mental disorders that are not listed above? [X] Yes [ ] No If yes, describe: [X] Irritable or angry mood [X] Loss of interest or pleasure in activities [X] Appetite disturbance [X] Weight disturbance [X] Fatigue or loss of energy [X] Difficulty thinking, concentrating, or making decisions [X] Feelings of worthlessness or guilt [X] Emotional numbing and detachment [X] Witnessing, in person, the traumatic event(s) as they occurred to others [X] 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 event(s), beginning after the traumatic event(s) occurred: [X] Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). [X] Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s). [X] Marked physiological reactions to internal or external cues that 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). 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: [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"). [X] Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead 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. 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] Hypervigilance. [X] Problems with concentration. [X] Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep). Criterion F: [X] Duration of the symptoms described above in Criteria B, C, D, and E is more than 1 month. Criterion G: [X] The symptoms described above cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Criterion H: [X] The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition.
  2. I'm seeing a LOT of veterans recently having their PTSD ratings re-evaluated and moved into another mental issue such as Major Depressive Disorder, Adjustment Disorder, etc. The ramifications of this to the veteran is not clear, but it looks like it is a bid to remove them from a service-connected rating. PTSD is the only mental rating that I know that can be diagnosed more than a year out of service. There are many PTSD claims that are getting denied because they fail to get Criterion F - "symptoms more than one month in duration." That seems like utter horse hockey because it takes more than one month to get into the system for a C&P exam. It's a 2-3 yr wait for most of us to get to the diagnostic exam phase. If you don't have something in every Criterion in the VA's PTSD and DSM-5 guidelines, it's not PTSD it's something else. I've talked to one woman who requested a female examiner and got a male examiner that got negative marks on Criterion C - Avoidance. So, she's coming in for PTSD due to MST and the VA rattles her with a male examiner instead of the female she requested. And somehow that very fact does not get marked as Avoidance? It's the very definition of Avoidance!! I'm putting the text from the VA web page on PTSD Criterion here, because they may make that page unavailable if the VA thinks veterans are actually reading it. ------ PTSD and DSM-5 In 2013, the American Psychiatric Association revised the PTSD diagnostic criteria in the fifth edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM-5; 1). PTSD is included in a new category in DSM-5, Trauma- and Stressor-Related Disorders. All of the conditions included in this classification require exposure to a traumatic or stressful event as a diagnostic criterion. For a review of the DSM-5 changes to the criteria for PTSD, see the American Psychiatric Association website on Posttraumatic Stress Disorder. DSM-5 Criteria for PTSD Full copyrighted criteria are available from the American Psychiatric Association (1). All of the criteria are required for the diagnosis of PTSD. The following text summarizes the diagnostic criteria: Criterion A (one required): The person was exposed to: death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence, in the following way(s): Direct exposure Witnessing the trauma Learning that a relative or close friend was exposed to a trauma Indirect exposure to aversive details of the trauma, usually in the course of professional duties (e.g., first responders, medics) Criterion B (one required): The traumatic event is persistently re-experienced, in the following way(s): Intrusive thoughts Nightmares Flashbacks Emotional distress after exposure to traumatic reminders Physical reactivity after exposure to traumatic reminders Criterion C (one required): Avoidance of trauma-related stimuli after the trauma, in the following way(s): Trauma-related thoughts or feelings Trauma-related reminders Criterion D (two required): Negative thoughts or feelings that began or worsened after the trauma, in the following way(s): Inability to recall key features of the trauma Overly negative thoughts and assumptions about oneself or the world Exaggerated blame of self or others for causing the trauma Negative affect Decreased interest in activities Feeling isolated Difficulty experiencing positive affect Criterion E (two required): Trauma-related arousal and reactivity that began or worsened after the trauma, in the following way(s): Irritability or aggression Risky or destructive behavior Hypervigilance Heightened startle reaction Difficulty concentrating Difficulty sleeping Criterion F (required): Symptoms last for more than 1 month. Criterion G (required): Symptoms create distress or functional impairment (e.g., social, occupational). Criterion H (required): Symptoms are not due to medication, substance use, or other illness. Two specifications: Dissociative Specification. In addition to meeting criteria for diagnosis, an individual experiences high levels of either of the following in reaction to trauma-related stimuli: Depersonalization. Experience of being an outside observer of or detached from oneself (e.g., feeling as if "this is not happening to me" or one were in a dream). Derealization. Experience of unreality, distance, or distortion (e.g., "things are not real"). Delayed Specification. Full diagnostic criteria are not met until at least six months after the trauma(s), although onset of symptoms may occur immediately. Note: DSM-5 introduced a preschool subtype of PTSD for children ages six years and younger. How Do the DSM-5 PTSD Symptoms Compare to DSM-IV Symptoms? Overall, the symptoms of PTSD are generally comparable between DSM-5 and DSM-IV. A few key alterations include: The revision of Criterion A1 in DSM-5 narrowed qualifying traumatic events such that the unexpected death of family or a close friend due to natural causes is no longer included. Criterion A2, requiring that the response to a traumatic event involved intense fear, hopelessness, or horror, was removed from DSM-5. Research suggests that Criterion A2 did not improve diagnostic accuracy (2). The avoidance and numbing cluster (Criterion C) in DSM-IV was separated into two criteria in DSM-5: Criterion C (avoidance) and Criterion D (negative alterations in cognitions and mood). This results in a requirement that a PTSD diagnosis includes at least one avoidance symptom. Three new symptoms were added: Criterion D (Negative thoughts or feelings that began or worsened after the trauma): Overly negative thoughts and assumptions about oneself or the world; and, negative affect Criterion E (Trauma-related arousal and reactivity that began or worsened after the trauma): Reckless or destructive behavior What Are the Implications of the DSM-5 Revisions on PTSD Prevalence? Changes in the diagnostic criteria have minimal impact on prevalence. National estimates of PTSD prevalence suggest that DSM-5 rates were only slightly lower (typically about 1%) than DSM-IV for both lifetime and past-12 month (3). When cases met criteria for DSM-IV, but not DSM-5, this was primarily due the revision excluding sudden unexpected death of a loved one from Criterion A in the DSM-5. The other reason was a failure to have one avoidance symptom. When cases met criteria for DSM-5, but not DSM-IV, this was primarily due to not meeting DSM-IV avoidance/numbing and/or arousal criteria (3). Research also suggests that similarly to DSM-IV, prevalence of PTSD for DSM-5 was higher among women than men, and increased with multiple traumatic event exposure (3).
  3. It is not possible to record the C&P exam with an audio recorder. While state law does allow for recordings in some states with one-party consent, there are many states that require consent of all parties to the recording. In Maryland law, as long as both parties are aware of the recording and consent to it, it is legal. If one is unaware it is illegal in most cases. DC is completely different. In Washington, DC, you can record whatever because it's one-party consent. But this is Federal law, not state. There's a statute that forbids recordings or attorneys present because the exam is investigative in nature, not judicial. One thing, though, can you have someone present in your exam? To give morale support and take notes of the proceeding? Or at least bear witness? I've seen several cases now of women with PTSD from MST where they have requested a female examiner, been promised a female examiner, and on the day of the exam it's a male ready to review them. In one case, the female examiner that she was scheduled with was free that hour and when the veteran put up a fuss, they brought the female examiner into the room to sit by her while the male examiner conducted the exam. Then, after asking the questions in the C&P, the male examiner asked her to take a series of exams to uncover other mental issues and malingering: MMPI-2, MENT, TOMM. The TOMM exam is inexplicable because it is used to uncover malingering for Alzheimer's or other memory diseases. Why would that be used in a PTSD exam? MMPI-2 appears to be used to declare her PTSD as another personality disorder to deny the claim.
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