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Disability Benefits Questionnaires


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I'm in the process of utilizing one of these DBQs with my Orthopedic surgeon for a IME, and the only crucial item that has us stumped, is how does this form work it's way in when writing out the IME. I understand the format of the letter is going to change somewhat, but exactly how?

In my case, we're using it to rebut some of the items/opinions my C&P examiner noted in his DBQ for a current claim being adjudicated. Does my Dr just argue the differences of opinions pointed out in their exams only? Or does it changed anything at all, and just use the DBQ as a supplement. I realize this is something just coming out, and I probably won't get a correct answer, but I'm open to anyone's opinions.

Coot

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Cooter, I'm not sure I understand your situation fully, but to answer re the letters: There are now DBQs for almost every condition, mental & physical. The new letter format is called SNL (simplified notification letter). Basically you will not be getting the huge ponderous ratings with all the explanations as to how we determined your claim. Instead, the ratings will be short & sweet, with only grants or confirm&continue ratings listed. The actual notification letter you get will explain the decisions, but not in depth like it used to be. (ie: if you claim hypertension & none was found in either your service or treatment records, the denial will simply read along the lines of "denied because there is no diagnosed condition."). The DBQ format of the exams allows the rater to more accurately input the evaluation, and lessens the chance that a doctor will miss discussing a key element (such as range of motion for a joint or if thee's arthritis) because they are all bulleted and must be answered in the same order by the doctor as we input them into our ratings.

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  • HadIt.com Elder

Back about 45 year ago it was the same way. You got two pages of reasons why you should be satisfied with 10% for being unable to work, and by the way don't bother us any more.

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John>..The way I understand, these DBQs has already been utilized 6 other times during the past years. Maybe they used one of these DBQs with you..lol

Veldrina>..Thanks for explaining that part of it. I noticed after reading my copy of the C&P exam I had recently, the Questionnaire didn't have anything written about medications and their effects. Is this something they left out on purpose, cause I thought I was reading somewhere that it was suppose to be added to it.

Coot

Edited by cooter (see edit history)
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each DBQ is different & closely follows the rating schedule. i think the most they touch upon re medication is of you are on continuous medication for control of a condition or not. For diabetes it's whether u are on oral hypoglycemics or insulin for control.

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As I'm in total agreement with this, wouldn't VA think opiates be considered as continuous medication for a chronic pain condition as well? If it's not, then the only reason I can think of is, chronic pain is considered a temporary condition, but at the same time it could also last years and years. Some medications has side effects that's worse than the disability itself. I find it hard to think the VA would even consider pain medicine as not part of an exam where pain is involved.

Coot

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If it's a condition whose evaluation is based on "continuous medication for control" then opiates could be considered such. Again each condition is different, and sometimes they concentrate more on physical manifestations for a higher evaluation rather than pain or pain control.

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So it would make since for anyone in this situation where chronic pain is essential to be considered is to have a Dr state, his/her chronic opiates is needed for "continuous medication for control".

Coot

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Hopefully this does not sound off topic. I have four Rated Conditions and another ten that are secondary and or, residual that have not been rated. With the DBQ process, do I submit the other ten as soon as I get them completed all at once, or do I submit them gradually? My overall total physical and mental condition has deteriorated so rapidly in the past three years, I can barely keep up with it myself.

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That's a very good question and no doubt will probably lure in a few different opinions here.

Just so you will get more eyes on your question, you'll need to start your own thread in the (Veterans claims Research) Forem. This thread has already started and probably been read by other members that won't come back. That's the reason I say you need to start your own. That's all you gotta do to get going on the right track.

Coot

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As I'm in total agreement with this, wouldn't VA think opiates be considered as continuous medication for a chronic pain condition as well? If it's not, then the only reason I can think of is, chronic pain is considered a temporary condition, but at the same time it could also last years and years. Some medications has side effects that's worse than the disability itself. I find it hard to think the VA would even consider pain medicine as not part of an exam where pain is involved.

Coot

Coot,

If I am understanding your issue correctly, I'd like to add my thoughts by a

hypothetical example.

Vet is SC'd for condition X

Vet files claim for secondary disability of pain due to SC'd condition - gets 10 %

Vet files claim for secondary disability of hemorrhoids (as a residual side effect of constipation)

due to medications taken for pain to treat the primary SC'd disability.

Does this example work ?

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Actually carlie what I was getting at is when I had my last C&P exam, the Dr stated I was only to do sedentary work. Ok, now the meds (opiates) I'm taking has me running ever which way but loose. ha..Since the side effects are really disabling, I was curious of the reason why it wasn't part of the DBQ questions. I also thought I read somewhere that it was suppose to be included in the exam. But nothing was mentioned about any meds the Vet is taking.

Coot

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Actually carlie what I was getting at is when I had my last C&P exam, the Dr stated I was only to do sedentary work. Ok, now the meds (opiates) I'm taking has me running ever which way but loose. ha..Since the side effects are really disabling, I was curious of the reason why it wasn't part of the DBQ questions. I also thought I read somewhere that it was suppose to be included in the exam. But nothing was mentioned about any meds the Vet is taking.

Coot

Coot,

Your SC'd for disability X.

You are RX's meds to treat disability X.

Your doctor writes an opinion that you now have a diagnosis of condition of Y

and this is a residual condition due to treatment of SC'd disability X.

You file a claim for disability Y and submit the doctors opinion.

Also,look over the criteria for DC's 7232,7233, 7234 and see if it applies.

JMHO

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remember, "pain" is not a compensable disability under VA regulations. But yes Coot, it would help if doc said that.

Race, if u have 10 other issues, u could put them all in, but again i will stress that the more issues u bombard the V with, the less chance of getting it resolved quickly. Also, sometimes folks put in for things that are actually the same issue, such as insomnia, memory loss, depression, anxiety and PTSD. While it sounds like 5 issues, in reality all mental conditions are one, & all those conditions are symptoms of most mental conditions (ie anxiety can appear under both depression & PTSD, insomnia can occur under anxiety, depression or PTSD, etc.). By claiming it as "a mental (or psychiatric) condition to include: PTSD, depression, sleep problems, memory problems," etc, or something like that, you can condense the issues into one.

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Cooter, I'm not sure I understand your situation fully, but to answer re the letters: There are now DBQs for almost every condition, mental & physical. The new letter format is called SNL (simplified notification letter). Basically you will not be getting the huge ponderous ratings with all the explanations as to how we determined your claim. Instead, the ratings will be short & sweet, with only grants or confirm&continue ratings listed. The actual notification letter you get will explain the decisions, but not in depth like it used to be. (ie: if you claim hypertension & none was found in either your service or treatment records, the denial will simply read along the lines of "denied because there is no diagnosed condition."). The DBQ format of the exams allows the rater to more accurately input the evaluation, and lessens the chance that a doctor will miss discussing a key element (such as range of motion for a joint or if thee's arthritis) because they are all bulleted and must be answered in the same order by the doctor as we input them into our ratings.

I just went to a C&P yesterday which was very good I do like these new forms they fill on the computer very detailed and it covered everything. So I guess a lot less of they forgot to put in a certain ROM etc and sending it back to the VAMC for more info or clarification. But my question I don't see anywhere for them to make the service connection statement like in the past i.e. most likely, least likely, is caused by military service etc. Unless they can put that in the remarks section XVII. Are they now leaving it up to the raters on review of all the evidence to make that determination?

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Actually Veldrina your wrong!

You stated "Also, sometimes folks put in for things that are actually the same issue, such as insomnia, memory loss, depression, anxiety and PTSD. While it sounds like 5 issues, in reality all mental conditions are one, & all those conditions are symptoms of most mental conditions (ie anxiety can appear under both depression & PTSD, insomnia can occur under anxiety, depression or PTSD, etc.). By claiming it as "a mental (or psychiatric) condition to include: PTSD, depression, sleep problems, memory problems," etc, or something like that, you can condense the issues into one."

You only have one brain so PTSD and Depression though rated as one can actually be helpful to each other. If you were to be 30% for PTSD and the rater feels worse than 30% for Depression you will be rated Depression w/PTSD at 50%. If they didn't do that, they are not doing their job. The benefit of the doubt rule should be applying. Also all the mental healh issues can come with sleep issues but they sleep issues can be rated seperately. People do get sleep studies and have been found to have restless leg syndrome and/or sleep apnea. Sleep Apnea can be linked to PTSD.

You can do a NEXUS letter to link Sleep Apnea to PTSD and Depression. Get your doctor or doctors to write the nexus letter (see attached) so you can get linked to your sleep issue. 50% for PTSD and 50% for Sleep Apnea is an 80% rating.

Am J Geriatr Psychiatry. 2010 Jun 10. [Epub ahead of print]

Sleep-Disordered Breathing in Vietnam Veterans with Posttraumatic Stress Disorder.

Yesavage JA, Kinoshita LM, Kimball T, Zeitzer J, Friedman L, Noda A, David R, Hernandez B, Lee T, Cheng J, O'Hara R.

From the Department of Veterans Affairs Health Care System (JAY, LMK, TK, JZ, TL, JC, ROH), Palo Alto, CA; Department of Psychiatry and Behavioral Sciences (JAY, LMK, TK, JZ, LF, AN, BH, TL, JC, ROH), Stanford University School of Medicine, Palo Alto, CA; and Memory Center (RD), CMRR - CHU, University of Nice Sophia, Antipolis, France.

Abstract

OBJECTIVE: To study the prevalence of sleep-disordered breathing (SDB) in Vietnam-era veterans.

METHODS: This was an observational study of Vietnam-era veterans using unattended, overnight polysomnography, cognitive testing, and genetic measures.

RESULTS: A sample of 105 Vietnam-era veterans with posttraumatic stress disorder: 69% had an Apnea Hypopnea Index >10. Their mean body mass index was 31, "obese" by Centers for Disease Control and Prevention criteria, and body mass index was significantly associated with Apnea Hypopnea Index (Spearman r = 0.41, N = 97, p < 0.0001). No significant effects of sleep-disordered breathing or apolipoprotein status were found on an extensive battery of cognitive tests.

CONCLUSION: There is a relatively high prevalence of SDB in these patients which raises the question of to what degree excess cognitive loss in older PTSD patients may be due to a high prevalence of SDB.

PMID: 20808112 [PubMed - as supplied by publisher]

Prim Care Companion J Clin Psychiatry. 2010;12(2). pii: PCC.07m00563.

Correlates of daytime sleepiness in patients with posttraumatic stress disorder and sleep disturbance.

Westermeyer J, Khawaja I, Freerks M, Sutherland RJ, Engle K, Johnson D, Thuras P, Rossom R, Hurwitz T.

Mental Health Service, Minneapolis VA Medical Center, Minneapolis, Minnesota ; Department of Psychiatry, University of Minnesota, Minneapolis ; and Department of Psychology, University of Texas, Houston.

Abstract

OBJECTIVE: To assess the correlates of daytime sleepiness in patients with a lifetime diagnosis of posttraumatic stress disorder (PTSD) and ongoing sleep disturbance not due to sleep apnea or other diagnosed sleep disorders.

METHOD: The sample consisted of 26 veterans receiving mental health care at the Minneapolis VA Medical Center, Minneapolis, Minnesota. The Epworth Sleepiness Scale was the primary outcome measure. Other sleep-related instruments consisted of the Pittsburgh Sleep Quality Scale, a daily sleep log, and daily sleep actigraphy. In addition, data included 3 symptom ratings (Posttraumatic Stress Disorder Checklist, Clinician Administered PTSD Scale [CAPS], and Beck Depression Inventory). Data were collected from 2003 to 2005. Current and lifetime PTSD diagnoses were based on DSM-IV criteria and were obtained by experienced psychiatrists using the CAPS interview.

RESULTS: Univariate analyses showed that daytime sleepiness on the Epworth Sleepiness Scale was associated with daytime dysfunction on the Pittsburgh Sleep Quality Index (P < .001), less use of sleeping medication (P = .02), and more self-rated posttraumatic symptoms (P = .05). Within posttraumatic symptom categories, hypervigilance symptoms were more correlated with daytime sleepiness (P = .03) than were reexperiencing and avoidance symptoms (P = .09 for both).

CONCLUSION: In this selected sample, daytime sleepiness was most strongly and independently associated with daytime dysfunction.

PMID: 20694134 [PubMed]PMCID: PMC2910986Free PMC Article

Chest. 2009 May;135(5):1370-9.

Update on sleep and psychiatric disorders.

Sateia MJ.

Section of Sleep Medicine, Dartmouth Medical School, Section of Sleep Medicine, Lebanon, NH 03756, USA. msateia@dartmouth.edu

Abstract

Current data demonstrate a high rate of comorbidity between sleep disorders and various psychiatric illnesses, especially mood and anxiety disorders. The disturbance of sleep quality and continuity that is associated with many sleep disorders predisposes to the development or exacerbation of psychological distress and mental illness. Likewise, the presence of psychiatric illness may complicate the diagnosis and treatment of sleep disorders. This focused review examines the literature concerning the interaction between major International Classification of Sleep Disorders, 2nd edition, diagnoses and psychiatric conditions with respect to sleep findings in various psychiatric conditions, psychiatric comorbidity in sleep disorders, and reciprocal interactions, including treatment effects. The data not only underscore the high frequency of psychopathology and psychological distress in sleep disorders, and vice versa, but also suggest that combined treatment of both the mental disorder and the sleep disorder should become the standard for effective therapy for all patients.

PMID: 19420207 [PubMed - indexed for MEDLINE]Free Article

Sleep Med Rev. 2008 Jun;12(3):169-84.

Disturbed sleep in post-traumatic stress disorder: secondary symptom or core feature?

Spoormaker VI, Montgomery P.

Centre for Evidence-Based Intervention, University of Oxford, 32 Wellington Square, Oxford, OX1 2ER, United Kingdom. spoormaker@sleephealth.eu

Abstract

Sleep disturbances are often viewed as a secondary symptom of post-traumatic stress disorder (PTSD), thought to resolve once PTSD has been treated. Specific screening, diagnosis and treatment of sleep disturbances is therefore not commonly conducted in trauma centres. However, recent evidence shows that this view and consequent practices are as much unhelpful as incorrect. Several sleep disorders-nightmares, insomnia, sleep apnoea and periodic limb movements-are highly prevalent in PTSD, and several studies found disturbed sleep to be a risk factor for the subsequent development of PTSD. Moreover, sleep disturbances are a frequent residual complaint after successful PTSD treatment: a finding that applies both to psychological and pharmacological treatment. In contrast, treatment focusing on sleep does alleviate both sleep disturbances and PTSD symptom severity. A growing body of evidence shows that disturbed sleep is more than a secondary symptom of PTSD-it seems to be a core feature. Sleep-focused treatment can be incorporated into any standard PTSD treatment, and PTSD research needs to start including validated sleep measurements in longitudinal epidemiologic and treatment outcome studies. Further clinical and research implications are discussed, and possible mechanisms for the role of disturbed (REM) sleep in PTSD are described.

J Clin Psychiatry. 2007 Aug;68(8):1257-70.

Sleep disturbance in adults with posttraumatic stress disorder: a review.

Lamarche LJ, De Koninck J.

School of Psychology, University of Ottawa, Ottawa, Ontario, Canada.

Abstract

OBJECTIVE: To present a critical review of the literature and research on sleep difficulties in adults with posttraumatic stress disorder (PTSD), more specifically the existing treatment options, and to formulate recommendations regarding future treatment approaches and research related to sleep and PTSD.

DATA SOURCES: The following databases were consulted: PsycInfo (1872-2006) and MEDLINE (1966-2006). The search was conducted using the following key terms: PTSD and sleep, PTSD and nightmares, PTSD and dreams, PTSD and insomnia, PTSD and periodic limb movement disorder, and PTSD and sleep disordered breathing. Only studies examining sleep disturbance among adults with PTSD were included, and only articles written in English were consulted.

STUDY SELECTION: Studies and reviews related to the prevalence, causes, and treatments of sleep disturbance among adults with PTSD, as well as those examining the relationship between sleep and PTSD, were selected.

CONCLUSIONS: Promising treatment options are available for treating sleep difficulties among adults with PTSD. In particular, cognitive-behavioral therapy including a component for nightmares (imagery rehearsal therapy) and insomnia has been found to significantly improve sleep disturbance among these individuals. It is proposed that with the inclusion of other components, such as a screening for other sleep disorders, relaxation exercises, positive self-talk, imagery rehearsal related to recurring images before bed, and a daytime nap, sleep-related symptoms may improve to a greater degree, which may then lead to a significant decrease in other PTSD symptoms and overall PTSD severity. The inclusion of sleep medicine specialists should also be considered for sleep medicine treatment of individuals with PTSD. Collaboration between mental health professionals and sleep medicine specialists is therefore recommended for treatment of sleep-related difficulties among individuals with PTSD.

PMID: 17854251 [PubMed - indexed for MEDLINE]

Tijdschr Psychiatr. 2007;49(9):629-38.

[sleep disturbances in post-traumatic stress disorder. An overview of the literature]

[Article in Dutch]

van Liempt S, Vermetten E, de Groen JH, Westenberg HG.

Onderzoekscentrum Militaire Geestelijke Gezondheidszorg Defensie, Centraal Miliair Hospitaal, Postbus 90.000, 3509 AA Utrecht, Netherlands. s.vanliempt@umcutrecht.nl

Abstract

BACKGROUND: Nightmares and insomnia are experienced by 70% of patients suffering from post-traumatic stress disorder (PTSD). These sleep problems are often resistant to treatment and exert a strong negative influence on the quality of life. In the last few decades several studies have reported on the characteristics of sleep disturbances in PTSD.

AIM: To provide an overview of objective features of sleep disturbances - as opposed to self-report methods - in patients with PTSD.

METHOD: Articles on this topic, published in peer-reviewed journals between 1980 and the present, were retrieved from Medline and Embase, using the search terms 'PTSD', 'sleep', 'nightmares', 'insomnia', 'polysomnography'.

RESULTS: Studies reported on changes in sleep efficiency, arousal regulation, motor activity during sleep, rem characteristics and delta sleep activity during sleep. Also, correlations were found between nightmares and sleep apnoea in ptsd. In some studies on sleep disturbance no objective sleep disturbances were found in PTSD patients. However, most studies on PTSD related sleep disturbances were conducted in small, heterogeneous groups, and results were therefore inconsistent. Even the results of larger and more homogeneous studies were sometimes contradictory.

CONCLUSION: There is a discrepancy between the clinical importance of sleep problems in PTSD and unambiguous objective sleep disorders. Future research should try to establish objective criteria for identifying the altered sleep patterns in PTSD. These criteria should help us to understand the neurobiological mechanisms of sleep disturbances in PTSD and develop new treatment strategies.

PMID: 17853372 [PubMed - indexed for MEDLINE]Free Article

case report sleep apnea PTSD.pdf

Nexus Letter.doc

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