Good afternoon and welcome to CCK live. My name is Jenna Zellmer and joining me today are Alyse Galoski and Nick Briggs We all work on Veterans Benefits appeals here at CCK And today we're gonna be talking about anxiety. Now before we get into it I just wanted to remind you all that if you have any questions or comments during our conversation You can go ahead and leave them in the comment box below You will also be posting links to blogs and more information on our website at CCK-LAW.com So let's get into it. So Nick, why don't you start us off? We're gonna be talking about both service connection and increased rating for anxiety today Let's start with talking about service connection So Nick what are some common anxiety disorders that veterans can claim service connection for? Sure So one of the more common types that we see are generalized anxiety disorders But there are also other specific types of anxiety disorders like social anxiety, Panic disorders, and then specific phobias like agoraphobia.

Okay. And Alyse, what are some common symptoms that characterize these anxiety disorders? Sure So there's some of those like invisible symptoms like excessive worry or difficulty concentrating but then there's also symptoms that physically manifest so you can Feel jumpy or you might be dizzy, have difficulty sleeping have mental have muscle tension feel nauseous or even lightheaded. So these are all manifestations of an underlying anxiety condition and I think that it's really important. I think a lot of times veterans Think that they can only give service-connected for PTSD because I think that you know often PTSD is goes in hand-in-hand with a lot of experiences the veterans experience in service but Even though anxiety disorders are a little bit different if you go to your doctor, and they don't diagnose you with PTSD But they do diagnose you with any of these symptoms or any of the anxiety disorders that Nick mentioned And you can still claim service-connection for that specific condition. So What do veterans need in order to show service connection for this condition? So the first and most important thing that you want to be able to demonstrate is in service incurrence And that can take a number of different forms either the veterans specifically treats for and is diagnosed with an anxiety disorder in service They might just check that they were experiencing depression or excessive worry on their discharge Examination or there might have been some specific incident that they remember that caused their anxiety, and it's continued to persist since then You don't need to be diagnosed with anxiety.

Sure. Okay, you just have to have some sort of notation. Alyse, what else? What after an in-service occurrence, what else do you need? First thing that you need is a Nexus so, that's what's gonna Connect both your in service condition to what's going on with you now Typically that's gonna require some type of medical opinion because lay persons are not competent typically to make that connection so It's a medical opinion Usually that's gonna draw that nexus. And we have a Facebook live All about what you need to show all three elements of service connection, so we'll link that In our notes, and if you want more information just on general service connection. You can check us out there So Alyse you had mentioned that you need a nexus and that generally requires an examination or medical determination so, how do C&P exams which is what we also call them which stands for compensation and pension exam How do those work in relation to anxiety conditions? What would happen in a service connection for anxiety claim? Sure So typically with a C&P exam you're going to be meeting with a VA physician Who it's gonna be somebody that you've never met before most likely they will ask you about your experiences during service They'll also ask you about experiences that you have now.

They may also ask you about Any medical history any family medical history It's gonna be a lot of questions that are all gonna be what they're gonna use to Support an opinion on as to whether what's what you have now is related to service or not So it's gonna be a lot of those background questions family medical questions And they'll also ask you about what your current symptoms are. Mm-hmm And I think we also have a Facebook live all about C&P examinations Which has a lot of great information kind of explaining what's gonna happen in these exams and what you should and shouldn't you do. I think the biggest thing is you have to always show up for your examinations and then if you get an unfavorable opinion Nick, what are some remedies that the veteran can pursue? Sure Well oftentimes a veteran won't necessarily know that the opinion was negative until they get the next decision from VA denying their claim so first and foremost They need to make sure that they're requesting a copy of their VA examination which they're entitled to do And then once they have the exam they should go through it at length making sure to identify any specific problems that they noticed or things that they think Conflict with other evidence they've submitted before one of the things that VA examiner's are supposed to do is review the claims file and make sure that they're looking at Everything the veterans submitted including lay evidence and then considering all of those things in light of the examination itself Great.

Um, I think you know the one important thing that I heard you saying that is lay evidence So, you know, we've talked about medical evidence and why we need that usually for a nexus But can you talk a little bit about what other kind of evidence including lay evidence You might need to support a claim for anxiety? Sure lay evidence is often one of the things we go to most often if only because a lot of the time veterans don't feel comfortable seeking treatment for their condition during service or even afterward because it's something that you know, It's kind of stigmatized and people don't necessarily like to talk about it so it could be many years before they actually go get to the point where they feel they need to seek treatment and Lay evidence from the veteran him or herself and all their family members can help fill in some of those gaps But whenever possible it's also a good idea to submit treatment information from either your VA doctors or any private psychologists that you see.

So Let's kind of take a step back and talk about The Appeals Modernization Act. So we have a whole Facebook live on the AMA as we call it essentially back in February VA totally revamped their appeal system and so now There are several different Avenues that a veteran can pursue after they receive a unfavorable rating decision. So if A veteran, you know wants to file an appeal. What should they kind of know about the AMA? After they receive a rating decision from VA? Sure So the most important thing is that if their claim was previously denied and they're filing a supplemental claim Which is one of the new options under the appeals modernization system. They need to make sure that they're submitting new and relevant evidence That's meant to be a relatively relaxed evidentiary standard So it could be something as simple as providing a lay statement talking about how their symptoms are related to service Um, it could be submitting medical evidence establishing that they have a current diagnosis.

But whatever it is, it needs to be something that is relevant to their claim And then they can also pursue taking their case to the board with or without submitting additional evidence if they really do think That it's a situation where the regional office is just getting it wrong. But all of those options are still available to them They just need to be conscious of the 1-year time frames. Great. Yeah, I think You know, the AMA is a pretty new system and it's pretty complicated Although it is supposed to provide veterans with more choices, and it's supposed to clarify a lot of things I think it's still unclear kind of how it's going to work for veterans so we would really encourage you if you're seeking to initiate an appeal under the AMA to Consult your veteran service organization or an attorney. Someone who has some expertise in this area of law And as I mentioned, we'll link some more information to the AMA in the case notes or in the in the comments below so we're talking about service connection and we mentioned in-service incurrence a Nexus and a current, you know disability What if a veteran doesn't have an in-service occurrence can the veteran get service connection another way Alyse? Yes.

So an alternative way to get service connection is called secondary service connection This happens when you have an already service-connected disability, that is either causing or aggravating Your anxiety or a second condition So say that you have just for example you have a knee condition and your knee condition causes you a lot of pain and It makes you anxious to to get out of bed. It makes you anxious to walk down the street or to walk to work You could potentially show that you have secondary service connection for your anxiety because your knee conditions already service-connected whether it's either causing or Aggravating an already, you know existing anxiety condition Yeah, I think that anxiety is something that a lot of veterans probably have secondary to their service connected disabilities, especially physical disabilities I think In your example for example If the veteran had a lot of instability in their knee and they were never sure whether or not they were gonna fall You know I can imagine that causing a lot of anxiety And so just the same way that you would need a nexus opinion for direct service connection You would still want to get a doctor to make an opinion about whether or not that knee causes or aggravates anxiety.

Really good So let's assume that a veteran has received service connection, you know, they've met that first threshold Either secondary or direct. Let's talk about how VA rates anxiety. So Let's take a step back a little bit and talk about kind of how VA rates things in general and I think that we do Have some information on that in our past Facebook lives Alyse you want to talk a little bit about what Diagnostic codes are? And what the diagnostic code for anxiety is? Sure So if you think about the diagnostic code the best way think of it is it's this rubric Where they where the VA has established certain Disabilities and under those disabilities are certain rubrics.

If you meet certain criteria under the rubric then you're granted You should be granted or certain rating specifically anxiety is rated under the general formula for medical or mental rather disorders So that's gonna also include other Mental disorders which could be schizophrenia. It could also be PTSD the very many different types of anxiety there are and probably any other type of Mental condition that you can think of are all rated under the same Diagnostic code that's going to be diagnostic 4.130 That diagnostic code goes up to 100% It starts at a non-compensable rating of 0% And it lists specific symptoms and overall functional impairment that you would have to meet to Get a specific rating So Nick, Alyse mentioned that kind of several different Psychiatric conditions are all rated under this one general formula. So what Happens if the veteran has for example, both anxiety and PTSD or anxiety and depression? Does that affect your rating at all? Sure, so like Alyse mentioned, you know, even though individual psychiatric conditions do have their own diagnostic codes they're all rated under this general formula and Because of that and because they're all rated based off of the same criteria of factoring it in the same symptoms You're not going to receive separate ratings for each individual mental health condition.

They're going to figure out which symptoms are imposed by each of those conditions and then give you one overall rating using the general formula. Good and I think it's important to kind of keep that in mind when you're looking at your rating code sheet, you know, every rating decision comes with the code sheet that lists out all of your disabilities and over the course of your life and your different appeals your rating for your psych condition can change and the Characterization of your psych condition can change based on what VA determines– kind of what the diagnosis you have so for example you know veterans who were service-connected a long time ago for psychiatric conditions might be originally rated under something called like a nervous condition and then as you know medical information has kind of evolved that could get re-characterized as PTSD or anxiety and then sometimes You know a veteran could be service connected for one thing and then later on claim service connection for another psychiatric condition As Nick said you're not gonna get a separate rating for that second condition But they might recharacterize what it's called on your code sheet and so that's important to keep in mind and just to make sure that you know, if There are symptoms that weren't originally Compensated under your original characterization, but you feel are now Encompassed in that in that characterization you might want to make a claim for an increase rating.

So, you know Alyse you mentioned the different possible rating levels and you mentioned that The diagnostic code and the rating formula provides different symptoms and different criteria that you need to meet in order to get to a higher rating so Do veterans have to meet every single criteria in that rating in order to get to the higher rating? No. So technically you don't even have to meet a single one of the criteria What you have to do is show that your functional loss is similar and what's called severity frequency and duration To the type of symptoms and functional loss listed in this diagnostic code.

So if you receive a board decision that says, "The veteran is not entitled to a higher rating because he does because although he has certain symptoms in the seventy Criteria, he does not have them all that would be error" You don't have to meet all of their criteria What you have to do is show that your functional loss is overall similar in severity duration and frequency To these types of symptoms that they're listing it's a list.

It's a non exhaustive list and it's really just supposed to be examples And there are two cases that kind of go to that point about this, Claudio and Mauer. Yes, so For those of you who kind of want to take a little deeper into the case law The court has made clear that these symptoms are not required. So Nick what happens if a veteran's condition is so severe that they actually have to get hospitalized? Sure so periods of Hospitalization are considered to be totally disabling So in a situation where a veteran's hospitalized due to their mental health disability for more than 21 days They're entitled to a 100% rating for the period of the hospitalization But if the veteran is hospitalized for an extended stay of more than six months They're not only assigned the 100% rating for the entire length of the hospitalization But as well as six additional months after the date of their discharge I think that makes sense.

If you think about how VA rates disabilities and that the ratings are supposed to be based on Impairment in earning capacity. So obviously if a veteran is hospitalized they can't be working and so, you know It's really important if you do get hospitalized you want to make sure that you Tell VA and make sure the VA is appropriately compensating you so that's really important to keep that in mind and then you know I think that a lot of times when the veterans are going to seek treatment or they're seeking a VA examination They get something called GAF scores GAF So Alyse, do you want to talk about a little bit about GAF scores and whether or not they're even still relevant or what? What's going on with GAFscores? Sure so a GAF score is a somewhat or outdated way that Practitioners used to measure how severe a person's psychiatric disorder was it is from a previous version of the DSM a VA has since come out with a court decision called golden which says that those GAF scores are No longer in the dsm-5 and therefore they're they're outdated and they shouldn't be used by the board So in some circumstances, you might still see them mentioned your board decisions But the board really shouldn't be relying on them to deny you a higher rating Yeah, and if you see the board talk about gaps scores in relation to what rating you should be receiving That should be a red flag and and you can talk to you know An attorney or a VSO about potentially appealing that decision to the board Or to the court, excuse me, And Alyse mentioned the DSM.

So the DSM stands for Diagnostic Statistical Manual it's the manual that all Mental health professionals use in diagnosing mental health conditions. So we have a question from Stephen can you explain the difference between occupational and social impairment with reduced reliability and productivity and occupational and social impairment with deficiencies in most areas So these are the criteria for the 50 and the 70% ratings and this is actually an excellent question so. I'm smiling stephen Because it is a very good question and it's one that the board has not yet answered for us Yeah the court or the court, rather.

So They haven't provided exact definitions of what those things mean But if you look to the diagnostic code, you can try and get a sense of what types of symptoms fall under each of those But unfortunately they don't have like, a You know a straight answer for you because the court and the board– VA have not defined it further than what we already see In the code, you can look at some of the symptoms for example in the 50% What is contemplated by occupational and social impairment with reduced reliability and productivity include flattened effect Panic attacks more than once a week impaired judgment impaired abstract thinking difficulty in establishing and maintaining social Relationships in the step higher you're seeing it involve more areas of your life Other than just the occupation and some of your relationships.

You're also seeing suicidal ideation obsessive rituals Near-continuous panic rather than panic attacks once a week. You're seeing an inability to establish and maintain Effective relationships now what we were saying before you do not need to show all of these symptoms It's just meant to be a list of examples to give you an idea of what that level of functional loss is. Precisely Become the different ratings are so vague. Right. What is the difference between reduce reduced reliability and Deficiencies in most areas? And so you use the symptoms in order to kind of parse that out but as Alyse said, you know, the court hasn't really given us a lot of guidance on this and that results in a lot of wildly, inconsistent board decisions And that's –sorry Nope, go ahead. That's what makes the board's Requirement to provide adequate reasons and bases so important because they don't have a strict definition of what these things mean They're really supposed to be properly explaining to you As the veteran why you're not entitled to a higher rating With what we call adequate reasons and basis.

Yeah and it's especially important in the Context of anxiety disorders because often times it's the type of mental health illness that might only really manifest itself in two or three specific Symptoms where it's the overwhelming anxiety and frequent panic attacks that are causing you to be unable to function in these areas But because VA tends to rely on the number of symptoms that you have rather than how severe they are It can get complicated especially when they're not really Defining the concepts that they're using. Right, sure that goes back to what Alyse was saying about It's really focusing on the frequency severity and duration of these symptoms And so if you see VA kind of using this rating criteria as a checklist that should you know You know raise a red flag that it's probably not a very good decision and that you could potentially appeal it yeah, I think that's a really good point Nick, especially because we are talking about anxiety, which is not a condition that Typically actually manifests itself into a lot of the symptoms that you see in the highest 100% rating like hallucination But if you for example have such severe agoraphobia that you can't leave your house or can't leave your room Then you might have total occupational social impairment.

So even though a Agoraphobia isn't a symptom listed under the 100% the overall functional loss might be enough to get you there. Mm-hmm so it's a really great question and I think it's just it really highlights why this area of law is so Unclear and why it's important to You know consult with your VSO or consult with an attorney because they can kind of navigate this and figure out what the best solution or argument to make in your case is. Great so We talked about GAF scores And the DSM, so I think the next thing that we want to talk about is what happens if a mental health condition Overlaps a non psychiatric condition Nick. Do you want to talk about that? I mean It's a concept we talk about a lot called pyramiding and I think we have our own Facebook live sessions on that topic So, please refer to that if you have any more detailed questions but the basic idea is that VA is only going to compensate each symptom that a veteran experiences once so if the veteran Experiences or suffers from an orthopedic disability that causes sleep impairment and then a psychiatric disability that causes sleep impairment They're gonna generally rate that symptom under one of those diagnostic codes one of those conditions and then not rate it under the other one just to make sure that they're not overcompensating the veteran for the symptom.

Then I think that the kind of reverse of that is what Alyse was mentioning earlier as if your psychiatric condition results in non psychiatric symptoms then you can potentially get It's like the opposite of pyramiding it's when pyramiding isn't a problem is when there are distinct manifestations of Your condition and you can get separate ratings for that. So, um, we talked a little bit about this in terms of total occupational and social impairment But what happens if a veteran's anxiety prevents them from working? Sure, so there is an avenue to receive a 100% rating called tdiu this is what you may be entitled for if your Disabilities could be your anxiety alone or your anxiety combined with all of your other service-connected disabilities prevent you from obtaining securing what's called substantial gainful employment So this is actually a lower standard than total occupational impairment substantially gainful employment is another one of those terms that we're working on having, you know, getting a really good definition for But basically it is something that is more than just a marginal employment something that is more than what we call protected work environment and If somebody if somebody's anxiety or somebody's anxiety combined with their other disabilities prevent them from really obtaining Secure employment then they might be entitled to to TDIU we have Absolutely have a lot of information on their website about tdiu.

That is a very large area of veterans law But it so if you have any questions about that Absolutely advise you to look at our website as well as well our other– I'm sure there's a Facebook you're live on that as well. Definitely So what other kinds of evidence? Should veterans be kind of collecting and submitting in order to support their increased rating claims, Nick? we've mentioned it a few times in the context of service connection, but it applies equally well to Increased ratings and that's lay evidence Obviously the veteran will only see their treating provider or a VA doctor every so often There are going to be months or even years where they don't seek treatment But the people who know them who live with them who experience their symptoms on the day to day basis are often in the best Position to provide a description of you know, what those symptoms are and how they affect them I'm so getting statements from yourself getting statements from family members can go a long way And I think you know one of the most common mistakes I see in that situation is at the board or VA Provides or assigned more value to those treatment records as opposed to the lay statements and as Nick said I think it's really important to kind of highlight that they are both equally valuable and that they are probably complementary in most situations so even though a veteran You know might go to treatment and might not be super-severe on that one day he goes to treatment if he has all these lay statements filling in the gaps between treatment you can kind of get a bigger picture so That's kind of one of the more common mistakes that I see VA making Just to kind of wrap things up Do you guys have any other? thoughts on common mistakes VA makes in adjudicating anxiety claims or things that you think letter and should remember when they're making these claims? One thing actually it's along the lines of lay statements if you are submitting lay statements and this is kind of a new one Make sure that what you're submitting is legible because you'll want to make it easy for VA to agree with you So if they can't really read your handwriting then it's very difficult for them to understand what symptoms or what your story is.

So I just suggest whether you're typing it or in very neat handwriting lay statements should be Legible easy to understand make it easy for them to want to give you an increased rating. That's really good advice It's better for us too Another common example we see in the case of service connection is VA improperly requiring a verified stressor Which is something that's only really in place for post-traumatic stress disorder So most veterans are probably most familiar with PTSD.

So that tends to be the condition that they claim But VA is supposed to construe that Claim broadly and liberally so the veteran might end up being diagnosed with a different mental health disability But because they claimed PTSD initially VA will often get stuck on trying to adjudicate the claim at way But at the end of the day like we talked about before it's really just all about establishing Anxiety in service or reports of anxiety and then symptoms afterward. That's really good Great. Um Thank you for joining us today.

We will be back next week and we hope that you check out all the information we provided.

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