Adjustment Disorder with Anxiety VA Disability Ratings

Video Transcription

Maura Black: Hi, everyone. Thank you so much for tuning in for today’s CCK Live discussion. My name is Maura Black. I’m joined today by Kevin Medeiros and Rachel Foster.

Today we’re going to be discussing VA Ratings for Adjustment Disorder and Anxiety.  So, we’ve got some information about what these two conditions are, and then later, we’ll get into how VA rates these conditions if they are service-connected, or if VA recognizes that these two disabilities, either alone or together, are related to a claimant’s military service.

Rachel, can you start us off by explaining what adjustment disorder is? Just for the people who may not know some of the specifics.

Rachel Foster: Adjustment disorder is characterized as a short-term condition that occurs when a person has great difficulty coping with or adjusting to a stressful event, but one that’s still within the normal everyday range of human experience.  It’s sometimes referred to as situational depression because it’s generally based on the current circumstances going on in someone’s life.  Some examples of what these stressors can be that trigger adjustment disorder could be the ending of a relationship or a marriage, losing or changing a job, the death of a loved one, developing a serious illness, being the victim of a crime or living through trauma, having a serious accident, or just undergoing a major life change, such as a new baby or starting retirement.

Well, a lot of the characteristics are shared.  Unlike major depressive disorder, adjustment disorder does not involve as many of the full range of physical and emotional symptoms of clinical depression.  So, we’re not seeing significant changes in sleep, appetite, or energy.  It also doesn’t tend to involve the more intense levels of severity, for example, suicidal ideation that we would see in major depressive disorder.

Adjustment disorder is also different than post-traumatic stress disorder in that PTSD occurs as a reaction at least one month after a life-threatening event, and its symptoms tend to last longer.

Maura: That’s all really helpful because one of the things that I think is particularly difficult to understand about adjustment disorder is how it might differ from other psychiatric conditions.  I don’t think it’s one of the more commonly diagnosed.  I don’t know for sure but I think we hear things like depression and anxiety, generally, and have a decent sense of what those conditions entail.  But that’s all good information about how adjustment disorder specifically is diagnosed.

Another hallmark feature of an adjustment disorder is that the symptoms that come along with it include emotional and behavioral symptoms.  They are usually experienced between three and six months following the stressful event.  So that’s another descriptor or differentiation from another psychiatric condition is that you can expect to see symptoms in response to the stressful event at issue between three to six months following the event itself.  We know that it can take a long time for symptoms to manifest when people have other psychiatric diagnoses or are exposed to trauma such as with PTSD.

Another thing that’s different about adjustment disorder is that it involves a response to a stressful event that’s sort of beyond what would be expected for a person to experience in terms of stress and difficulties adapting to the situation.  So that’s another consideration that comes into play when thinking about how this condition is diagnosed.  It’s usually that the response is out of the norm or excessive in terms of psychiatric symptoms in dealing with the stressful event.

I think that takes care of adjustment disorder.  Now, Kevin, can you talk to us a little bit about what anxiety is?  I think this is something that people might think they understand a little bit more.  It’s maybe discussed a little bit more, but can you take us through what that disability entails?

Kevin Medeiros: Yeah. Anxiety is defined as the mind and body’s reaction to a stressful, dangerous, or unfamiliar situation and it typically manifests by intense, excessive, or persistent worry or fear about everyday situations.  Common symptoms include feeling restless, jumpy, or on edge, excessive worrying, difficulty concentrating, rapid heartbeat, trembling or twitching, muscle tension, shortness of breath, difficulty breathing, and difficulty sleeping.

There are several types of anxiety disorders.  I’m sure most people watching this video have experienced anxiety at one point or another in their life, but some that manifest to clinical diagnosable levels include generalized anxiety disorder, panic disorder, and phobia-related disorders.

Maura: Great.  And then there is often sometimes a connection between the two. I just realized I said often sometimes–that doesn’t make a whole lot of sense.  But you do, sometimes, see a connection between adjustment disorder or anxiety.  In other words, they can manifest alongside each other.  And when both conditions are present, you can expect to see such symptoms as fear, separation anxiety, jitters, memory loss, suspiciousness, sometimes even suicidal ideation, irritability, difficulty sleeping, things like that you tend to see if a person is suffering from both adjustment disorder and Anxiety.  And we know from our experience and we also know from the Diagnostic and Statistical Manual of Mental Disorders, or the DSM, that adjustment disorder and anxiety are very common conditions among veterans.  So, I think that takes care of the basics.

Again, what does each diagnosis entail?  Rachel, can you talk to us a little bit about how, generally speaking, a person might go about obtaining service connection for either of these conditions?  I know we have a lot of information on our website, cck-law.com, about how to obtain service connections in different ways.  But just generally, with respect to these two conditions, what are some things that people should be mindful of?

Rachel: Sure.  So, when establishing service connection, veterans must first establish the in-service incurrence or event, the current diagnosis, and a medical nexus linking the two.  When developing for service connection, VA may request evidence related to each element of service connection, such as requesting that the veteran attended compensation and pension examination, requesting lay evidence, maybe discussing the details of the in-service events or current symptomatology.  Service medical or personal records or opinions from medical providers. VA will use this evidence to evaluate each element of service connection.

And as Maura mentioned, we have a lot of information on our website.  So, if you’re looking for more information about attending compensation and pension examinations and the type of evidence VA will gather during the claims process, please check out our blogs at cck-law.com, which will give you more in-depth information about what these processes entail.

When it comes to establishing service connection there are a few different avenues or theories.  So, the first is that classic direct service connection, and it really is just all of the elements of the current diagnosis.  So, you have to have a current diagnosis of adjustment disorder with anxiety, in this case, evidence of an in-service event, injury, or illness.  So, the symptoms first started in service or there’s an event that happened in service that as a result of, you now have the adjustment disorder with anxiety.  And lastly, the medical nexus linking the in-service incurrence to the current diagnosed adjustment disorder with anxiety.  So, if all of those elements are met and the relationship is established during the veteran’s active period of service, that is direct service connection.

Now, another way to establish service connection is on a secondary basis.  So, a veteran can show that an already service-connected condition either caused or aggravated their adjustment disorder with anxiety.

So, just as an example, if during service a veteran sustained a traumatic brain injury that they are now service-connected for, and years later the symptoms of their TBI exacerbate their ability to handle life stressors and as a result, they’ve now developed a diagnosis of adjustment disorder with anxiety.  Because this new condition is due to a service-connected disability, even though it didn’t directly happen or manifest in service, you can still get a service connection on a secondary basis.  And the same way, if it’s not causally related but there is an increase of symptoms, you can get it on a secondary basis through aggravation.

Lastly, the type of service connection we’ll talk about is based on aggravation through active military service.  So, where a veteran upon entry, if adjustment disorder or anxiety is noted on the entrance examination, or if it’s not on the entrance exam and VA discovers that there’s clear and unmistakable evidence that they have condition existed prior to entry.  If there is an increase of those symptoms beyond the natural progression of the disease and they’re shown in service, then service connection can be awarded based on aggravation.

Here, I do just want to note that aggravation can often be a very complex legal theory.  So if this is an avenue of service connection that you’re seeking, you may want to consider obtaining help from a veteran service organization or an accredited claims agent or attorney.

Maura: That’s great information, Rachel.  Thank you.  Especially, since sometimes we are talking about conditions during these presentations where direct service connection versus secondary service connection, one of the two avenues tends to be more… that we see it more often or it tends to be more viable.  But with respect to psychiatric conditions, especially adjustment disorder and anxiety, or both really, both have ways to be related to military service, both are on the direct side of things—so they may manifest in service, they may be due to an in-service event, or they may be secondary to an already service-connected condition.  They may arise due to a stressful event that occurs due to a service-connected disability.  Rachel was talking about the TBI example, I think that’s a really helpful one.

And as Rachel mentioned, I totally agree that if aggravation of a pre-existing injury is the pathway to service connection that you’re interested in, it’s definitely important to read the rules about aggravation.  There is sort of two types of aggravation.  We don’t need to get too much into the details.  I think what Rachel said is perfect and suffices for this conversation, but that’s where it definitely tends to get more complex.

Something that’s a little bit more straightforward at least in my opinion, is how VA rates psychiatric conditions.  Kevin, can you explain, if a veteran is already service-connected for adjustment disorder or anxiety or both, what can they expect in terms of the evaluation or rating process, and what kinds of things is VA going to be looking at in determining what disability rating the person should receive?

Kevin: The veteran will receive a rating under the diagnostic criteria that contemplates psychiatric conditions.  The regulation is 38 CFR § 4.130, and that provides ratings for veterans starting at 0 and going up by increments of 10 and then 30 percent, and then 50 percent, 70 percent, and ultimately a 100 percent if the veteran is totally disabled from the psychiatric condition.

Each rating contemplates first what symptoms the veteran has and then second, the level of social and occupational impairment that those symptoms cause.  So, each rating will list a variety of symptoms and an ultimate social and occupational impairment that’s being contemplated.  But one thing to know is that the symptoms listed for each rating don’t necessarily need to align exactly with what the veteran has.  They’re listed as examples and the rater has to take into account the frequency, severity, and duration of the symptoms, and the ultimate social and occupational impairment that’s caused.

The veteran doesn’t need to have—if they’re rated at 30 percent say and seek a higher rating—that they don’t have to have the exact symptoms listed in the higher rating criteria if the symptoms that they do have are severe enough to interfere sufficiently with their social and occupational impairment.

Maura: We all know, especially Kevin knows all too well, that that is a common error that VA makes when rating psychiatric conditions.  The rating criteria as Kevin explained that are in the diagnostic criteria or the rating schedule will contain a list of symptoms that might be expected to be seen with the different levels of evaluation.  So, each level—the 30 percent, 50 percent, 70 percent—has a descriptor of occupational and social impairment.  Reduced reliability and productivity are something that’s mentioned in the 50 percent criteria.  Milder, transient symptoms, I think is mentioned with 10 percent criteria, but it’s really that level of impairment that VA is supposed to be assessing as a whole based on the veterans’ whole disability picture, and then the symptoms that follow are meant to be examples of that level of impairment.

VA tends to do the opposite.  They skip right to the symptoms part.  They try to match the specific symptoms that the veteran or the claimant has to the symptoms that are listed in the rating schedule and then pick the evaluation that aligns with those specific symptoms.  The evaluation process isn’t supposed to work like that.  It’s supposed to be a holistic assessment of the veterans’ entire disability picture, and it’s a common error that we see from VA that they’re not doing that.  They’re just sort of linking what’s in the rating schedule to what is showing up in the veterans’ medical records.

So, it can be really helpful I think if you’re pursuing a claim for a higher rating for a psychiatric condition to include adjustment disorder and anxiety, but really, any other psychiatric condition that’s rated under 38 CFR § 4.130 to make sure that you are pointing out facts to VA that shows the occupational and social impairment level and not just the symptoms that are specifically listed in the rating schedule.

Throughout this conversation, we have spoken about psychiatric conditions in general, and although this discussion is focused on adjustment disorder and anxiety, it’s important to note that typically, if a person has multiple psychiatric conditions, multiple diagnoses even, that person shouldn’t expect to get separate ratings for all of those psychiatric illnesses.  That’s a common question that we get.  If I have depression and anxiety and PTSD, will I be getting a separate rating for each of those three conditions?  And therefore, compensation is three times for those conditions.  And the answer is usually no, there won’t be separate ratings for those three conditions.

The reason is that as Kevin mentioned, the criteria for psychiatric conditions are pretty broad and they typically encompass all of the different symptoms that might be manifesting with different illnesses.  So, the symptoms for depression, anxiety, adjustment disorder, PTSD—they all tend to speak to a person’s level of occupational and social impairment, which is exactly what the rating schedule contemplates.  So, VA will tend to rate them all as one underneath whatever evaluation level VA decides is appropriate through their application of the rating schedule.

So, it doesn’t mean that if you believe that your rating for your psychiatric conditions if they’re service-connected should be higher.  It doesn’t mean you can’t go for a higher rating by using your other diagnosis to show how severe your overall disability picture is, assuming that all of your diagnosis can be linked to service or a service-connected condition, but it is important to note that you shouldn’t expect to receive separate ratings for those different conditions.  That’s very, very rare that we see that.  And the origin of that is that VA has rules against pyramiding or in other words, getting duplicate ratings for duplicate symptoms.

Kevin and Rachel, do either of you have anything to add to anything that we may have discussed, whether it’s theories of service connection or rating issues that touch on these topics?

Kevin: I think that when, once a veteran is service-connected and seeking maybe a higher rating, it’s important or it’s helpful to submit lay statements describing your symptoms and how it affects you on a day-to-day basis.  A lot of times, VA will have a veteran go to be examined, the examiner will describe what they saw but it might not fully encompass what the veterans experiencing on a day-to-day basis.  So, submitting lay statements describing your symptoms can be very helpful in achieving a higher rating.

Rachel: The only other thing I will add is that it does get tricky sometimes when there are multiple diagnoses, some of which are service-connected and some which are non-service-connected.  Common sense tells us that there’s going to be of course a lot of overlap between those symptoms, and VA law states that even symptoms that are stemming from non-service-connected psychiatric conditions, the benefit of the doubt should apply and if those can’t be separated out, those symptoms should still go and be compensated and evaluated under their service-connected disability.

Maura: Thank you all for tuning in today.  We appreciate seeing you and we hope to see you again in the future.  Please don’t forget to subscribe to our YouTube channel and like this video.

If you’d like to see more veteran’s law content, we have a lot of it on our website, as we mention frequently, but subscribing here will also be helpful in getting access to the videos that we are routinely putting out there for all of you to use.  So we hope that this was helpful and again, we hope to see you all next time.  Take care.