Depression Secondary To Tinnitus
Posted 16 March 2009 - 11:54 AM
I have a CNP Exam on thursday for Depression and adjustmant disorder secondary to tinnitus on the 3/19/09
I just would like someone to give me their opinion
Citation Nr: 0306065 Decision Date: 03/31/03 Archive Date: 04/08/03DOCKET NO. 97-10 201 ) DATE ) )On appeal from theDepartment of Veterans Affairs (VA) Regional Office (RO) in Jackson, MississippiTHE ISSUEEntitlement to an initial evaluation in excess of 30 percent for adjustment disorder with mixed anxiety and depressed mood. REPRESENTATIONAppellant represented by: Disabled American VeteransWITNESS AT HEARING ON APPEALAppellantATTORNEY FOR THE BOARDM. Cooper, CounselINTRODUCTIONThe veteran served on active duty from August 1974 to August 1978 and from July 1980 to July 1982. This matter comes before the Board of Veterans' Appeals (Board) on appeal from adverse actions by the VA RO. Historically it is noted that in December 1998, the issue of service connection for a psychiatric disability, characterized as adjustment disorder with mixed anxiety and depressive mood was remanded to the RO for further development. Service connection for the veteran's psychiatric disability was granted in a March 1999 RO decision with a 30 percent evaluation. The veteran expressed disagreement with the assigned rating and a timely appeal to the Board was ultimately perfected by the veteran. The Board again remanded the case to the RO in November 1999 for further development. In a November 2000 decision, the Board determined that entitlement to an evaluation in excess of 30 percent for adjustment disorder with mixed anxiety and depressive mood was not warranted. Thereafter, the veteran appealed the Board's decision to the United States Court of Appeals for Veterans Claims (formerly the United States Court of Veterans Appeals) (the Veterans Claims Court). In March 2001, the VA filed a Motion to Remand and To Stay Further Proceedings. By Order dated in May 2001, the Veterans Claims Court vacated the Board's November 2000 decision, and remanded the case pursuant to 38 U.S.C.A. § 7252(a). In April 2002, the Board undertook additional development of the issue currently on appeal. The additional development has been completed and the claim is now ready for appellate consideration. In January 2003, the Board wrote the veteran and informed him of the additional evidence received in regard to his claim and provided copies of the evidence for his review. The veteran was informed that he had 60 days to submit additional evidence or argument in response to the new evidence. In January 2003, the veteran's representative submitted a supplemental brief containing additional argument pertaining to the issue on appeal. FINDINGS OF FACT1. All relevant available evidence necessary for an equitable disposition of the appropriate claims addressed by this decision has been obtained by the RO. 2. The veteran's service-connected psychiatric disorder is manifested by depression, anxiety, decreased concentration and difficulty sleeping, all secondary to his service-connected tinnitus. There is no evidence of flattened affect; circumstantial, circulatory, or stereotyped speech, panic attacks, difficulty in understanding complex commands, impairment of short and long-term memory, and impaired judgment and/or abstract thinking. CONCLUSION OF LAWThe criteria for the assignment of an initial evaluation in excess of 30 percent for the veteran's service-connected psychiatric disorder have not been met. 38 U.S.C.A. §§ 1155, 38 U.S.C.A. §§ 1155, 5100, et. seq. (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326, 4.1, 4.2, 4.3, 4.7, 4.130, Diagnostic Code 9440 (2002). REASONS AND BASES FOR FINDINGS AND CONCLUSIONInitially, the Board notes that the Veterans Claims Assistance Act (VCAA) of 2000 became effective during the pendency of this appeal. 38 U.S.C.A. § 5100 et. seq. (West 2002). There have also been final regulations promulgated to implement the new law. See 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326 (2002). The Board has therefore reviewed this case with the provisions of those laws in mind, and finds that VA's duty to assist the appellant in developing the evidence pertinent to the claims has been met. In this regard, the Board notes that the veteran has undergone several VA examinations and pertinent medical treatment records were requested. The veteran has been informed of the information and evidence necessary to substantiate his claim through rating decisions and statements of the case, and was specifically advised of the notice and duty to assist provisions of the VCAA in correspondence dated in August 2002. In this regard, the Board notes that the August 2002 correspondence made specific reference to evidence that would be obtained by the Board and records that the veteran was asked to submit in support of his appeal. He has not identified any additional, relevant evidence that has not been requested or obtained.. As it appears that all pertinent evidence has been obtained, the Board finds that the claims are ready to be reviewed on the merits. See VCAA; Quartuccio v. Principi, 16 Vet. App. 183 (2002). Further, letters to the veteran have informed him as to evidence he should submit, and informed him of what the VA would obtain. As there is no showing that there is additional evidence that could be obtained, the Board may proceed.Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1 (2002). Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2002). However, the Board will consider only those factors contained wholly in the rating criteria. See Massey v. Brown, 7 Vet. App. 204, 208 (1994). Where there is a question as to which of two evaluations shall be applied, the higher evaluations will be assigned if the disability more closely approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2002). When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the veteran. 38 C.F.R. § 4.3 (2002). The veteran's service-connected psychiatric disability is rated as 30 percent disabling under 38 C.F.R. § 4.30, Diagnostic Code 9440. A 30 percent evaluation is warranted when psychiatric symptoms are productive of occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as depressed mood, anxiety, suspiciousness, panic attacks on no more than a weekly basis, chronic sleep impairment, and mild memory loss (such as forgetting names, directions, and recent events). A 50 percent evaluation is warranted when the disorder causes occupational and social impairment, with reduced reliability and productivity, due to such symptoms as flattened affect; circumstantial, circulatory, or stereotyped speech; panic attacks more frequently than once per 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; and difficulty in establishing and maintaining effective work and social relationships.A 70 evaluation is warranted for 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); and an inability to establish and maintain effective relationships. A 100 percent evaluation is warranted for 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; and memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, Diagnostic Code 9440. As noted above, service connection for adjustment disorder with mixed anxiety and depressive mood secondary to tinnitus was granted in a March 1999 RO decision with a 30 percent evaluation. In light of the fact that the veteran has appealed the initial disability rating, the decision that follows will include consideration of whether there is any basis for "staged" ratings. See Fenderson v. West, 12 Vet. App. 119 (1999). Private medical records dated from January 1992 to June 1995 essentially reflect treatment for a variety of psychiatric symptoms. Diagnoses included major depression, panic disorder with agoraphobia, adjustment disorder with depressed mood, and alcohol and benzodiazepine abuse. A January 1995 private medical statement indicated that the veteran was diagnosed with major depression. He was treated with anti-depressant medications and individual psychotherapy. VA medical correspondence dated in November 1996 showed that the veteran received VA outpatient psychiatric treatment. His diagnoses included mood disorder due to medical condition; tinnitus and essential hypertension were also noted. A November 1996 VA hospital discharge summary reflects diagnoses of malingering and adjustment disorder with depressed mood. His Global Assessment of Functioning (GAF) score was 75. On VA examination in October 1997, the veteran complained that his tinnitus made it difficult for him to sleep and was distracting. At that time, it was noted that the veteran was employed in a manufacturing plant. The examiner noted that there was no direct method of ascertaining that the veteran's depressed mood was secondary to his tinnitus but that he gave a plausible report concerning the connection. The diagnoses included adjustment disorder with depressed mood secondary to tinnitus. His GAF score was 55 reflecting moderate symptoms and moderate difficulty in social and occupational functioning. On VA examination in December 1997, the veteran reported that he had lost his job at the manufacturing plant due to difficulty in thinking, crying spells and "quality problems" on the his shift. It was noted that the veteran had numerous jobs since his service discharge and generally left them due to difficulty concentrating. On examination, it was noted that he was alert, fully oriented and cooperative. His mood was both anxious and moderately depressed. Diagnostic testing verified that the veteran was in some emotional distress and that he was having some bizarre sensory experiences. The examiner indicated that it was possible that his excessive use of alcohol could be contributing to his mood disorder. The diagnoses included adjustment disorder, probably due to tinnitus and alcohol and drug abuse. His GAF score was 55. During the October 1997 RO hearing, the veteran testified that his tinnitus severely limited his ability to sleep and that this resulted in depression and a reduction in the ability to think. The veteran related that he had been employed at ten different jobs, but that he had not been employed since June 1998. He claimed that he was fired from his most recent job as a night shift supervisor at a manufacturing plant due to "confusion" caused by his tinnitus. On VA examination in February 1999, the veteran complained of depression and anxious feelings related to his service-connected tinnitus. He said that he was unable to concentrate in work situations and lost several jobs as a result. On mental status examination, the veteran was fully oriented and able to maintain attention and concentration throughout the interview. His mood was depressed and anxious. The veteran's memory was adequate. Thought process was logical and coherent, with goal-directed content. The veteran denied suicidal or homicidal ideation and no delusional material was elicited. Abstract ability was judged adequate. Psychological testing revealed a pattern of over-reporting of psychopathology, but indicated that the veteran was under situational stress which tended to reduce his ability to function. The diagnostic assessments included adjustment disorder with mixed anxiety and depressed mood, secondary to tinnitus; alcohol abuse; personality disorder, not otherwise specified, with avoidant and dependent traits. His GAF score was 50. On VA examination in December 1999, the veteran reported sleep difficulty, depressed mood and feelings of hopelessness due to his tinnitus. On mental status examination, the veteran was alert and oriented, times four. His mood was described as hopeless. His affect was constricted and appropriate to the content of the interview. He denied any hallucinations and did not appear to be responding to internal stimuli. He denied suicidal or homicidal ideations, paranoia or delusions. Memory was intact for two out of three objects in five minutes. Speech was regular rate and rhythm, goal directed and without looseness of associations or flight of ideas. Insight and judgment both appeared to be good. The diagnostic impressions included adjustment disorder with depressed mood, chronic, secondary to tinnitus; and personality disorder, not otherwise specified, by history. His GAF score was 60. In a February 2000 addendum to the December 1999 VA examination report, the examiner related that the veteran reported distractibility, decreased concentration, and decreased sleep which appeared to be related to diagnosed adjustment disorder with depressed mood, secondary to tinnitus. The examiner noted that the overall disability picture was complicated by current alcohol use. In addition, his diagnosed personality disorder added further difficulties to his functioning both socially and occupationally. The examiner stated that the veteran appeared to have moderate to severe impairment in social and occupational functioning and that such findings were unchanged from his level of functioning as assessed during the February 1999 VA examination. On VA examination in September 2002, the veteran reported feelings of depression and hopelessness. He indicated sleep difficulties, decreased concentration, decreased energy and decreased interest in activities. On mental status examination, the veteran was alert and fully oriented. His speech was delivered in a moderate tone and pace. The content of his speech was logical and goal-directed. No delusional material was elicited. His memory appeared to be grossly intact within the interview setting. Mood was sad and affect was constricted but appropriate to the content of the interview. He showed no evidence of in the interview to suggest that he was responding to internal stimuli. He did not describe any obsessions, compulsions or panic symptoms. The examiner noted that the veteran's functioning over the years was impacted by his depressive disorder as well as by his physical disorders. Additional complicating factors included his history of alcohol use and a personality disorder. By the veteran's report, he last worked in December 2001 and had not resumed work presumably due to his depressive disorder, tinnitus, medications and non-service-connected medical problems, including cervical spondylosis for which he required surgery. Regarding his social functioning, it was noted that the veteran continued to maintain involvement with his family and to some extent within his community. The examiner, related that his current level of functioning did not appear to be appreciably changed from that described in the December 1999 VA examination report. The diagnostic impressions included major depressive disorder, recurrent; dysthymic disorder and personality disorder, by history. General medical conditions were noted as tinnitus, cervical spondylosis, chronic pain, hyperlipidemia, sleep apnea, and hypertension. His GAF score was 55. Based upon the current evidentiary record as summarized above, the Board is unable to conclude that an evaluation in excess of 30 percent is warranted for the veteran's service-connected psychiatric disorder under the relevant schedular criteria. The veteran's psychiatric disorder is currently manifested by symptoms productive of moderate social and industrial impairment (as indicated by the reported GAF score of 55), according to the most recent VA examination in September 2002. It has been noted that additional complicating factors included a history of alcohol abuse and a personality disorder. In addition, earlier examinations conducted in 2000, 1999, and 1997 reflect similar findings. There is no competent medical evidence indicating circumstantial, circumlocutory, or stereotyped speech, impairment of short- or long-term memory, panic attacks more than once per week, difficulty in understanding complex commands, and impaired judgment, such as are contemplated by the next higher rating of 50 percent. The veteran is shown to be depressed and anxious with difficulty sleeping and decreased concentration. However, the veteran is usually described as well oriented with normal speech patterns, fair judgment and insight, without verified psychotic manifestations. Moreover, the veteran has continued to maintain contact with his family and in his community which provides at least a minimum of social exposure. The Board has concluded that the veteran's reported symptoms are consistent with and contemplated by the present 30 percent schedular disability rating. His psychiatric symptoms do not more nearly approximate the criteria for a 50 percent rating. 38 C.F.R. § 4.7. The Board has also reviewed the claim for a rating in excess of 30 percent mindful of the guidance of Fenderson, supra. With consideration of all pertinent evidence, the Board finds that the assignment of the 30 percent evaluation since the grant of service connection is proper. The assignment of a rating in excess of 30 percent is not warranted for any portion of the time period in question. Finally, there is nothing in the record to suggest such an unusual disability picture so as to render application of the regular provisions impractical. It has not been contended or otherwise indicated that the veteran's psychiatric disability alone results in hospitalization or other marked interference with employment beyond that contemplated by the provisions of the schedule. It is not shown that there is actual employment interference. As such, further consideration of the provisions of 38 C.F.R. § 3.321 is not indicated. ORDERAn initial rating in excess of 30 percent for the veteran's service-connected psychiatric disability is denied for the entire period at issue. MICHAEL D. LYON Member, Board of Veterans' AppealsIMPORTANT NOTICE: We have attached a VA Form 4597 that tells you what steps you can take if you disagree with our decision. We are in the process of updating the form to reflect changes in the law effective on December 27, 2001. See the Veterans Education and Benefits Expansion Act of 2001, Pub. L. No. 107-103, 115 Stat. 976 (2001). In the meanwhile, please note these important corrections to the advice in the form:? These changes apply to the section entitled "Appeal to the United States Court of Appeals for Veterans Claims." (1) A "Notice of Disagreement filed on or after November 18, 1988" is no longer required to appeal to the Court. (2) You are no longer required to file a copy of your Notice of Appeal with VA's General Counsel.? In the section entitled "Representation before VA," filing a "Notice of Disagreement with respect to the claim on or after November 18, 1988" is no longer a condition for an attorney-at-law or a VA accredited agent to charge you a fee for representing you.
Posted 16 March 2009 - 12:08 PM
Edited by simple fly, 16 March 2009 - 12:10 PM.
Posted 16 March 2009 - 07:31 PM
1. In the case you cited, the Veteran had a medical diagnosis of depression secondary to tinnitus. If your C and P doc also offers a similar opinion, then you should see a similar result. That being said, RO results are very inconsistent across the board. According to a recent AG report, The RO understates their error rate by 10%...rembering that these numbers consider only "decided" cases. If you also consider that the VA never decides a lot of cases..the Veteran either abandons his claim or dies..this error rate is considerably worse than even the AG reports, as shredded claims, unopened claims, secretly denied claims, abandoned claims, and deceased Veterans with pending claims would all increase the VARO error rates. Also, in at least one RO (New YOrk) the RO was faking dates..and had been doing so for years. So, if they faked dates to make their numbers look better, why would they not fake error rates as well?
In a nutshell, theory suggests that if you have similar circumstances, you can expect a similar result. However, in actuallity, the RO error rate, considering all the above, is about 50% (my number..not the AG's). The bottom line is that you have about a fifty percent chance of your decision being wrong, even if you have a good diagnosis. However, before you have any chance of winning your claim, you first have to win the diagnosis. I am unaware of in the entire history of the world a Veteran ever being awarded benefits without a medical diagnosis. It would appear the error rate would go both ways..both in favor of the Veteran and not favoring the Veteran..however, it never works that way. The favor the Veteran rule is about like the "no sex before marriage rule"..it almost never happens nowadays.
Posted 16 March 2009 - 08:53 PM
Posted 16 March 2009 - 09:09 PM
Posted 17 March 2009 - 07:31 AM
Posted 17 March 2009 - 01:26 PM
"I have read of other people trying to claim depression etc secondary to tinnitus and them being ridiculed on hadit."
Do you have a link to support this ?