PTSD & MDD seperate comorbid

[smith22]

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.

 

[Tyr]

Question 1) It doesn't matter really.  You will get one mental health grant.  Other diagnoses may be added to that grant, but you're not going to get one 50% eval for PTSD and then another 50% eval for MDD.  It can matter if they say they can differentiate symptoms of PTSD and MDD, and determine that your PTSD is due to service, but your MDD is not.  Then they won't count the symptoms for your evaluation that are not related to service.  Thats rare though, usually they say they can't split them out.  In your case, no, you filing a claim for MDD really just wastes time for everyone.  

 

Question 2) A grant of OSA secondary to PTSD is very, very, very rare.  Your best bet to get a grant is to get a positive opinion with a sound rationale from a private provider and then submit that with a claim for it.  If you just file a claim for it, I'd be shocked if it was granted.  From what I can gather, the two are correlated, but there isn't really much that shows that PTSD actually causes OSA.  The grants that I've seen have had a good rationale from a qualified provider.  

 

Question 3) I don't know.  I want to see every single thing you are service connected for, at what percentage.  What knee, what %.  What radiculopathy, what %.  etc etc.  You say you have knees and back for another 30%.  Well, you probably don't actually.  You may have 3 separate 10% grants, but in VA math that doesn't add up to 30%.  Those things alone, sure.  But if you have PTSD at 50, then those three don't add up to give you a combined of 80.  The gist of VA math is that they use the whole man concept.

 

You start at 100% healthy.  Then you have PTSD at 50% disabling.  That leaves you 50% healthy, 50% disabled.  The next highest disability is factored from your healthy part.  So if you have a back at 40%, its 40% of the 50% thats left.  So 40 percent of the 50 that remains from your PTSD is 20.  That adds to your first 50 to combine to 70% disabled.  Which leaves 30% healthy.  If you have tinnitus at 10%, thats 10 percent of the 30 thats left.  So thats really only considered to be 3% disabling.  Which adds to your 70 to become 73.  So the higher your percentage is, the harder it is to get to that next level.  Its really hard to get to 100 sometimes.  But enough 10s can do it.  Especially if you have a 50 a 40 and a 20 or 2.  

 

Question 4) IDK what your overall % should be, because you haven't listed them.  If you are PT, then it (DEA) should be granted automatically.  It is absolutely NOT a thing that won't get granted until you claim it.  If entitlement is there, it should be granted.  Of course, mistakes happen and sometimes people get stupid.  That said, the program that raters use will bring up a prompt to show that you should grant DEA if it calculates that the veteran is at 100% and there are no routine future exams scheduled.  So people have to try to ignore it a couple times.  So the odds are pretty good that you are not PT.

 

Good luck to you.

 

lol damn, I just saw this was from a long time ago.  Oh well, hopefully someone else can learn from it.