ptsd How Does The Va Rate On Ptsd Disability?

[RAKMEDIC3/187]

Good afternoon,

I have just received my medical from my C&P, and looking over I am worried that I am going to drop my 50% rate that I am currently at. From other posts, I seem to have gathered that most of the decision of the rating party rely on the Occupational ability of the Veteran. Do they look into other parts of this as well (Personal life, sleep, depression). Or do they solely base judgment on that small paragraph by the psych?

I will post my results later when I get home if I can figure it out.

[RAKMEDIC3/187]

Below is a copy of what was in the evaluation. Any ideas as to how this will be rated?

SECTION I:

----------

1. Diagnostic Summary

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

Does the Veteran now have or has he/she ever been diagnosed with PTSD?

[X] Yes[ ] No

ICD Code: 309.81

2. Current Diagnoses

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

a. Mental Disorder Diagnosis #1: PTSD, Chronic

ICD Code: 309.81

Mental Disorder Diagnosis #2: Unspecified Depressive Disorder

ICD Code: 311

Comments, if any: secondary to ptsd

CONFIDENTIAL Page 4 of 26

b. Medical diagnoses relevant to the understanding or management of the

Mental Health Disorder (to include TBI): IBS; DM; DJD; LBP;

HYPOTHYROIDISM

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:

Symptoms of PTSD/Depression overlap in areas of sleep disruption,

irritability, isolation/withdrawal, avoidance, poor concentration

&

memory and cannot be further separated without speculation.

c. Does the Veteran have a diagnosed traumatic brain injury (TBI)?

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

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 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

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[ ] 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: Symptoms of PTSD/Depression

overlap

in areas of sleep disruption, irritability, isolation/withdrawal,

avoidance, poor concentration & memory and cannot be further

separated

without speculation.

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

CONFIDENTIAL Page 5 of 26

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.

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 C-file) reviewed?

[ ] Yes[ ] No

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

[ ] 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

[ ] Other:

b. Was pertinent information from collateral sources reviewed?

[ ] Yes[ ] No

2. Recent History (since prior exam)

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

a. Relevant Social/Marital/Family history:

Veteran is now 50% SC for PTSD. He is aged __________, married and

resides in _________. He has two children ages _______________.

Veteran

described current family relationships as fairly close, however,

CONFIDENTIAL Page 6 of 26

described moderate impairments in role functioning related to anger,

irritability, limited stress/frustration tolerance, isolative and

avoidant behavior, depression, demotivation, and sleep disruption.

Veteran described current social functioning as "all I do is go to

work

and come home. I dont have any friends, now. I dont go out anywhere or

do anything, so I guess, I have no interest in talking to people. I

deal with enough in 8 hours at work. I just dont see the point in

it."

Veteran also described his usual recreational pursuits as "I just

sit

at home, I have dogs and pretty much all I do is sit with them..."

b. Relevant Occupational and Educational history:

Veteran is employed for ______________. He

described it as a "desk job" and is employed there full time.

He

related how it is "an easy job, all I do is print out reports and

I get

to work from home alot, so its real easy. All I do is check dates on

papers and make sure its on the computer. Not much too it."

c. Relevant Mental Health history, to include prescribed medications and

family mental health:

Review of CPRS today shows veteran has rx for Wellbutrin 5mg; Lamictal

150mg, and has continued in psychiatric care at __________since

2011. His most recent visit was recorded on 14 MAY 2015, as follows by

___________ staff psychiatrist: "Pertinent symptoms: Patient

seen in

__________clinic today. He is working "just sit at a desk and

answer a phone, do a lot of paperwork". He does not like his work.

Mood

"same as always". Sleep "not very good". Energy

level "depends on the

day". Appetite "fine"...He stated that he is compliant

with

lamictal...He said that he has job-related stress, and would like to

start a medication for stress/anxiety...Substance use: alcohol use

"been drinking alot, helps me relax after work". Use 4-5 big

beers 3-4

times a week, no alcohol use x 3 weeks

while on vacation, recommended

limits of alcohol use discussed..."

Veteran was today asked to describe any current symptoms or concerns

related to his claim for SC of PTSD, and described the following:

CONFIDENTIAL Page 7 of 26

CRITERION B-RELIVING/INTRUSION: Reliving traumatic events via periodic

nightmares of factual traumatic events 3-4x weekly, typically with

insomnia afterward and awakens with autonomic arousal/agitation.

Veteran also experiences intense physiological and psychological

distress in presence of cues associated with traumatic events, such as

sudden loud noises, frustration in heavy traffic, (does not like cars

being too close around him)

CRITERION C-AVOIDANCE: Veteran described avoiding crowds, loud noises,

war related movies or TV programs, heavy traffic.

CRITERION D-NEGATIVE ALTERATIONS IN COGNITIONS AND MOOD: Veteran c/o

frequent anxiety, worrying in excess, being easily overwhelmed,

relaxing, feels tense most of the time, ongoing irritability with

limited stress-frustration tolerance, frequent anger outbursts,

confrontational behavior with without altercations, occasional panic

attacks with SOB, sweating, agitation, urge to leave (fight or

flight),

sense of dread or impending doom, without avoiding going out due to

fear of onset, lasting usually 15-30 minutes occuring about 1-2x

weekly, and c/o frequent depression hallmarked by sadness, periods of

hopelessness, without crying, guilt feelings about traumatic events,

(says he thinks about what could have, should have or would have been

if he could do it over) or SI/HI, but with fatigue, "some days I

feel

better, but usually I have to force myself to do anything..."

with

frequent periods of withdrawal, "My wife is always on my butt

about

everything, especially not wanting to do anything." He also c/o

loss of

interest in usual activities, "I used to be pretty outgoing, did

all

kinds of stuff, like I was big into going to the gym, riding my

motorcycle alot, going to church, I had friends, now I just dont want

to do anything..." He also c/o decreased libido, fluctuating

appetite,

and decreased motivation and apathy.

CRITERION E-ALTERATIONS IN AROUSAL/REACTIVITY: Veteran also described

how he feels like he has to watch everyone in public, poor sleep

defined as a usual 1-2 hour variable latency, then wakes up "off

and

on" throughout the night, awakens at the slightest sound, and

feels he

has to get up and check his doors or windows at least 1x each night,

and rarely gets more than 4-5 hours of sleep.

CONFIDENTIAL Page 8 of 26

d. Relevant Legal and Behavioral history:

Denied

e. Relevant Substance abuse history:

Denied using illegal substances. Veteran stated he uses smokeless

tobacco every two days. Veteran stated he drinks beer, usually three

to

four 24 ounce cans an evening, two to three times per week, but has

not

had any in about a month.

f. Other, if any:

No response provided.

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 (DSM-5). 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 other things should be noted under #6 - "Other

symptoms".

Criterion A: Exposure to actual or threatened a) death, b) serious

injury,

c) sexual violation, in one or more of the following ways:

[X] Directly experiencing the traumatic event(s)

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

occurred to others

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 distressing dreams in which the content and/or

affect of the dream are related to 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).

CONFIDENTIAL Page 9 of 26

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 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, 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.

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] Exaggerated startle response.

[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.

Criterion G:

[X] The PTSD 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

CONFIDENTIAL Page 10 of 26

effects of a substance (e.g., medication, alcohol) or

another medical condition.

4. Symptoms

-----------

For VA rating purposes, check all symptoms that actively apply to the

Veteran's diagnoses:

[X] Depressed mood

[X] Anxiety

[X] Panic attacks more than once a week

[X] Chronic sleep impairment

[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

[X] Impaired impulse control, such as unprovoked irritability with

periods

of violence

5. Behavioral Observations:

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

Upon interview today, the veteran was observed to be in adequate hygiene,

and seasonally and casually dressed. The veteran reported that he drove

himself to the appointment. During the interview, the veteran was alert

and well oriented to person, place time and circumstance. The veteran

made

good eye contact and was cooperative. The veteran was ambulatory without

devices and there was no atypical psychomotor movement observed.

Speech pace, intensity and amplitude were WNL. There was no evidence of

expressive or receptive articulation dysfluencies noted. Stream of

thought

was linear and persistent. Content of thought was logical and goal

directed. The veteran denied acute suicidal and homicidal ideation in

active or passive forms. This individual understands the consequences of

their own behavior. The veteran can interpret simple proverbs adequately.

The veteran denied experiencing acute mania, hypomanic, hallucinations

(visual, auditory, tactile, olfactory, and gustatory). Affect was mildly

dysphoric today. Attention-concentration and general memory appeared

grossly intact.

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

7. Competency

CONFIDENTIAL Page 11 of 26

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

Is the Veteran capable of managing his or her financial affairs?

[X] Yes[ ] No

8. Remarks, (including any testing results) if any:

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

Discussed purpose of the evaluation with the Veteran and limits of

confidentiality and veteran was given the opportunity to ask questions

and

indicated understanding of these limits prior to beginning this exam

today.

[john999]

I don't think they will try and reduce your rating of 50%. You are able to work 8 hours a day so that puts the kabash on a higher rating I think. However, from what I read you are like many of us in that your quality of life sucks. This is a big issue to me, but not to the VA. If you were to lose your job and not be able to find another one due to your PTSD you would be in line for 70%-100% because the fact you can still work means you are bumping up against the 50% ceiling. Stay in therapy because the day you find it impossible to continue to work you want all your ducks in a row. Being able to work is really the dividing line for higher ratings for MH issues. A guy loses an arm, eye, or leg and he gets a set rating even if he becomes a millionaire. If you have a mental health issue it mostly all revolves around your ability to work. That is my experience over 40 years of dealing with the VA. Why did you get the C&P exam?

John

[RAKMEDIC3/187]

Thanks John,

I applied for what i had thought to be a new claim for insomnia and alcohol. Turned out to be an increase... I was aggrevated with the psychiatrist that i see saying i would no longer get ambien. I guess i should have just asked for a new one instead. I also filed a new claim for IBS, that one is pretty sure to be a SC. The dr said so during exam however i do not know what the percentage will be. I dont really care as long as they finally address the issue instead of putting it off as a poor diet.

The only percentage that i care about is my PTSD, like you said quality of life really sucks!!! I use to be really active and into everything but now not so much... The best I've felt in years was on a beach in the middle of nowhere with nobody around but that only lasted two weeks.

[Navy04]

You should continue at 50% bud, but you really never know. As stated based on the fact that you can work a full time job, you could be decreased to 30%. Just try to be calm and let us know when your claim is complete. Good luck and God Bless!!!

[cmhunt68]

Im new to the forum and RAKMEDIC3/187s report could be a mirror image of what I'm experiencing.  Thanks to all who commented as with this knowledge, I hope comes power - power to understand my situation and deal with it.   Best of luck to RAKMEDIC3/187!

[bluevet]

The VA is required to look at the total disability picture to assign a disability rating. The Dr. has chosen a level of impairment which matches a 30% rating, however under "Symptoms for rating purposes", there are some symptoms that fall in the 38 CFR ratings criteria for 30%, some that fall under 50% and some that fall under 70%. It's hard to say what a rater will do, but if I had to guess it would be a continued 50% rating. This is because in order to reduce your rating, the VA must show, by a preponderance of the evidence, that a reduction is warranted. They must consider the entire record and not just your latest C&P exam in reaching this conclusion. If the VA proposes a reduction, you have 60 days to get any evidence against the proposed reduction into the record for consideration. If they do propose a reduction to 30%, you should get an IME from a private doctor done right away. Here is the  38 CFR rating criteria for you to review:

1.The general rating formula for mental disorders assigns a 10

percent rating on the basis of 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 continuous medication.

 

2. A 30 percent rating is assigned on the basis of occupational

and social impairment with occasional decrease in work

efficiency and intermittent periods of inability to perform

occupational tasks (although generally functioning

satisfactorily, with routine behavior, self-care, and

conversation normal), due to such symptoms as:  depressed

mood, anxiety, suspiciousness, panic attacks (weekly or less

often), chronic sleep impairment, mild memory loss (such as

forgetting names, directions, recent events).

 

3. A 50 percent rating is assigned on the basis of occupational

and social impairment with reduced reliability and

productivity due to such symptoms as:  flattened affect;

circumstantial, circumlocutory, or stereotyped speech; panic

attacks more than once a week; difficulty in understanding

complex commands; impairment of short- and long-term memory

(e.g., retention of only highly learned material, forgetting

to complete tasks); impaired judgment; impaired abstract

thinking; disturbances of motivation and mood; difficulty in

establishing and maintaining effective work and social

relationships.

 

4. A 70 percent rating is assigned on the basis of occupational

and social impairment, with deficiencies in most areas, such

as work, school, family relations, judgment, thinking, or

mood, due to such symptoms as:  suicidal ideation;

obsessional rituals which interfere with routine activities;

speech intermittently illogical, obscure, or irrelevant;

near-continuous panic or depression affecting the ability to

function independently, appropriately and effectively;

impaired impulse control (such as unprovoked irritability

with periods of violence); spatial disorientation; neglect of

personal appearance and hygiene; difficulty in adapting to

stressful circumstances (including work or a worklike

setting); inability to establish and maintain effective

relationships.

 

5. A 100  percent rating is assigned on the basis of total

occupational and social impairment, due to such symptoms as: 

gross impairment in thought processes or communication;

persistent delusions or hallucinations; grossly inappropriate

behavior; persistent danger of hurting self or others;

intermittent inability to perform activities of daily living

(including maintenance of minimal personal hygiene);

disorientation to time or place; memory loss for names of

close relatives, own occupation, or own name.  38 C.F.R. § 4.130.

 

Edited September 2, 2015 by bluevet