Increased Rating Claims — PTSD & Major Depressive Disorder
Your symptoms aren't just what you say in a 30-minute exam. They're what the condition has done to your life.
If you are already service connected for PTSD or depression and the rating no longer matches how you live, the missing evidence is usually not a new diagnosis. It is the behavior you have never told anyone about.
What often goes unsaid in the exam room
- “I gamble when I feel numb.”
- “I'm up all night because I can't sleep.”
- “I avoid my spouse.”
- “I lie about money.”
- “I can't stop, even though it's hurting my marriage.”
Dr. Jessica Allen — licensed psychiatrist and former VA Compensation & Pension examiner. Medical opinions documenting severity and functional impairment for veterans seeking an increased mental health rating.
What is a PTSD or depression increase nexus letter?
A PTSD increase nexus letter or depression increase nexus letter is a physician's medical opinion documenting how severe an already service-connected condition has become. Because service connection is settled, the letter addresses current severity and functional impairment rather than the link to service, describing occupational and social impairment in the terms used by the VA rating schedule at 38 C.F.R. § 4.130.
Key points
- Increase claims turn on occupational and social impairment, not on the diagnosis.
- Behaviors veterans hide — gambling, rage, overspending, neglected hygiene — map directly onto the 50% and 70% criteria.
- Passive thoughts of death are suicidal ideation, a 70% criterion, under Bankhead v. Shulkin.
- Symptoms missing from your VA chart are not evidence that they are absent, under Buczynski v. Shinseki.
- An increase may be paid up to a year retroactively under 38 C.F.R. § 3.400(o)(2).
An increase PTSD or depression claim is not about proving your condition is connected to service. That is already settled. It is about proving how severe it has become — and severity is measured in function, not in diagnosis.
That distinction decides most of these claims. The VA rates mental health conditions on occupational and social impairment: what the condition has taken from your work, your marriage, your friendships, your ability to manage an ordinary day. A veteran can carry the same diagnosis for a decade while the impairment underneath it deepens every year.
The behaviors most veterans are least willing to describe — gambling, drinking, compulsive pornography use, rage, overspending, withdrawal, letting hygiene go — are often the clearest available evidence of exactly that impairment. Left out of the record, the rating reflects a version of you that shows up showered and composed for thirty minutes twice a decade.
How the VA actually decides
How does the VA decide a PTSD or depression increase claim?
The rating turns on function, not on the diagnosis.
Mental health conditions are evaluated under the General Rating Formula for Mental Disorders at 38 C.F.R. § 4.130, at 0, 10, 30, 50, 70, and 100 percent. Two principles matter more than veterans are usually told.
The symptom lists are examples, not a checklist. Under Mauerhan v. Principi, 16 Vet. App. 436 (2002), you do not need to exhibit the specific symptoms named at a given level. They illustrate the kind and degree of impairment contemplated.
Symptoms and impairment are both required. Under Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013), a rating requires symptoms of the kind described and the corresponding level of occupational and social impairment.
50 percent
Occupational and social impairment with reduced reliability and productivity — including flattened affect, panic attacks more than once a week, impairment of short- and long-term memory, impaired judgment, disturbances of motivation and mood, and difficulty establishing and maintaining effective work and social relationships.
70 percent
Occupational and social impairment with deficiencies in most areas — work, school, family relations, judgment, thinking, or mood — including suicidal ideation; obsessional rituals which interfere with routine activities; near-continuous panic or depression; impaired impulse control, such as unprovoked irritability with periods of violence; neglect of personal appearance and hygiene; difficulty adapting to stressful circumstances, including a work or worklike setting; and inability to establish and maintain effective relationships.
Read that 70 percent list again with your own week in mind. Impaired impulse control. Neglect of hygiene. Difficulty adapting to stress at work. Inability to maintain relationships. For many veterans, the evidence is already there — it has simply never been written down.
The reframe
Which behaviors support a higher PTSD or depression rating?
The purpose of raising a behavior like this is not to confess to it. It is to show which rating criterion it satisfies.
| Behavior | What it shows clinically | Criterion it speaks to |
|---|---|---|
| Gambling | Impaired impulse control, escape behavior, depression-related avoidance — sometimes a diagnosable gambling disorder | 70% impaired impulse control · 50% impaired judgment |
| Anger outbursts, altercations | PTSD hyperarousal, irritability, loss of behavioral control | 70% impaired impulse control, such as unprovoked irritability with periods of violence |
| Skipping showers, letting grooming go | Anhedonia, psychomotor slowing, collapse of motivation | 70% neglect of personal appearance and hygiene |
| Passive thoughts of death | Suicidal ideation — passive ideation is still ideation | 70% suicidal ideation |
| Withdrawal, lost friendships, marital breakdown | Avoidance, emotional numbing, anhedonia | 70% inability to establish and maintain effective relationships · 50% difficulty doing so |
| Compulsive pornography use | Intimacy avoidance, emotional numbing, a shame cycle, coping with insomnia | 70% obsessional rituals interfering with routine activities · 50% disturbances of motivation and mood |
| Calling out, missing deadlines, dodging calls | Avoidance under pressure, collapse of work tolerance | 70% difficulty adapting to stressful circumstances, including a work or worklike setting |
| Rechecking, rereading, needing lists for everything | Memory impairment and compensatory ritual | 50% impairment of short- and long-term memory · 70% obsessional rituals |
| Excessive spending | Impulsivity, poor judgment, mood instability, self-soothing | 70% impaired impulse control · 50% impaired judgment |
| Alcohol misuse | PTSD coping, depression self-medication, or alcohol use disorder | Evidence of severity; may also support a separate diagnosis |
| Excessive gaming or screen use | Avoidance, isolation, escape, sleep disruption | 50% disturbances of motivation and mood |
Gambling
Clinically: Impaired impulse control, escape behavior, depression-related avoidance — sometimes a diagnosable gambling disorder
Criterion: 70% impaired impulse control · 50% impaired judgment
Anger outbursts, altercations
Clinically: PTSD hyperarousal, irritability, loss of behavioral control
Criterion: 70% impaired impulse control, such as unprovoked irritability with periods of violence
Skipping showers, letting grooming go
Clinically: Anhedonia, psychomotor slowing, collapse of motivation
Criterion: 70% neglect of personal appearance and hygiene
Passive thoughts of death
Clinically: Suicidal ideation — passive ideation is still ideation
Criterion: 70% suicidal ideation
Withdrawal, lost friendships, marital breakdown
Clinically: Avoidance, emotional numbing, anhedonia
Criterion: 70% inability to establish and maintain effective relationships · 50% difficulty doing so
Compulsive pornography use
Clinically: Intimacy avoidance, emotional numbing, a shame cycle, coping with insomnia
Criterion: 70% obsessional rituals interfering with routine activities · 50% disturbances of motivation and mood
Calling out, missing deadlines, dodging calls
Clinically: Avoidance under pressure, collapse of work tolerance
Criterion: 70% difficulty adapting to stressful circumstances, including a work or worklike setting
Rechecking, rereading, needing lists for everything
Clinically: Memory impairment and compensatory ritual
Criterion: 50% impairment of short- and long-term memory · 70% obsessional rituals
Excessive spending
Clinically: Impulsivity, poor judgment, mood instability, self-soothing
Criterion: 70% impaired impulse control · 50% impaired judgment
Alcohol misuse
Clinically: PTSD coping, depression self-medication, or alcohol use disorder
Criterion: Evidence of severity; may also support a separate diagnosis
Excessive gaming or screen use
Clinically: Avoidance, isolation, escape, sleep disruption
Criterion: 50% disturbances of motivation and mood
A closer look
What behaviors do veterans most often hide from the VA?
Gambling after PTSD, depression, or anxiety
For some veterans gambling starts as entertainment and becomes compulsive — something they turn to when depressed, anxious, lonely, angry, ashamed, or unable to sleep. It may bring financial loss, secrecy, lying to a spouse, debt, marital conflict, missed work, and worsening depression after losses.
The key is not simply that a veteran gambles. It is whether the gambling reflects worsening impairment — impaired judgment, poor impulse control, mood dysregulation, avoidance — and whether that impairment flows from the service-connected condition.
Compulsive pornography use after PTSD or depression
This topic deserves care. Veterans rarely raise it, and when they do it is usually with considerable shame. But the clinical picture is often straightforward: a way to avoid intimacy that feels unsafe, to interrupt emotional flatness, or to fill hours when sleep will not come.
What matters for a rating is not moral judgment about the behavior. It is whether it reflects avoidance, numbing, or impaired control tied to the service-connected condition, and what it has cost in a marriage, a sleep schedule, or a working day.
What it can look like
Three brief examples
PTSD & gambling
Gambling to escape at night
A veteran with service-connected PTSD gambles at night because he can't sleep and wants to escape intrusive memories. He loses money, hides it from his spouse, and grows irritable when confronted.
May show: Impaired impulse control, distress intolerance, sleep disruption, marital strain, worsening mood.
Depression & pornography use
Numbness and disconnection
A veteran with service-connected depression spends hours watching pornography because he feels numb, lonely, and disconnected from his spouse. It worsens his insomnia and fuels relationship conflict.
May show: Avoidance, impaired intimacy, social impairment, sleep disruption, worsening depression.
Anxiety & spending
Late-night relief that costs more
A veteran with anxiety and PTSD shops online late at night for temporary relief from distress. The spending leads to debt, marital conflict, and worsening anxiety.
May show: Impaired judgment, poor impulse control, difficulty adapting to stress.
Illustrative composites for educational purposes. Individual circumstances and outcomes vary.
The most overlooked criterion
Do passive thoughts of death count as suicidal ideation for a 70% rating?
Yes — thoughts alone can meet the criterion.
Many veterans will say they would never act on anything, and therefore say nothing at all. But suicidal ideation appears in the 70 percent criteria, and the Court has been explicit about what it means.
In Bankhead v. Shulkin, 29 Vet. App. 10 (2017), the Court held that passive and active suicidal ideation both consist of thoughts — passive ideation being thoughts such as wishing you were dead — and that the presence of suicidal ideation alone may produce occupational and social impairment with deficiencies in most areas. The Board erred by demanding more than thoughts, and erred again by treating the absence of hospitalization as a reason to deny the 70 percent level. As the Court put it, the VA “is not at liberty to create evaluation criteria out of thin air” and then rely on their absence from a veteran's records.
Risk of actual self-harm belongs to the 100 percent criteria. Thoughts belong to the 70 percent criteria. A veteran who has never made an attempt, never been hospitalized, and never told a clinician may still meet this criterion — but only if someone documents it.
A common denial reason
What if my VA treatment records don't mention any of this?
A silent chart is not a healthy veteran.
Increase claims are frequently denied on the reasoning that the treatment records do not document the symptoms claimed. That reasoning has limits. Under Buczynski v. Shinseki, 24 Vet. App. 221 (2011), the absence of a notation in a medical record cannot be treated as substantive negative evidence unless the matter is one that would ordinarily have been recorded.
Nobody's VA chart says patient lost eleven thousand dollars on sports betting this year or patient has not showered since Tuesday. Those things do not appear in a chart because they are not asked about, and because veterans do not volunteer them. Their absence proves nothing.
This is precisely the gap a detailed independent evaluation is built to close.
What the opinion does
What does a PTSD or depression increase nexus letter include?
A medical opinion supporting an increased rating does not simply record that a behavior occurred. It establishes what the behavior demonstrates about severity, and states it in the language the rating schedule uses:
- The service-connected condition and its documented course since the last evaluation
- The behavior that developed or worsened, when it began, and what triggers it
- The functional consequences at work, at home, and in relationships
- Whether it reflects impaired judgment, impaired impulse control, avoidance, or numbing
- Whether a separate diagnosis, such as gambling disorder or alcohol use disorder, is present
- Which criteria under 38 C.F.R. § 4.130 the documented impairment corresponds to
- Whether the impairment supports individual unemployability under 38 C.F.R. § 4.16
On effective dates
Under 38 C.F.R. § 3.400(o)(2), if a claim for increase is received within one year of the date it became factually ascertainable that the disability worsened, the increase may be effective from that earlier date. Documenting when the deterioration began — not merely that it exists — can be worth a year of benefits.
Get started
Need a PTSD or depression increase nexus letter?
If you are service connected for PTSD or major depressive disorder and the evaluation no longer reflects how you actually function, the evidence that closes the gap is usually the part of your life nobody has asked about.
Your symptoms are not just what you say in a 30-minute exam. They are what your condition has done to your life.
At Brightview Psychiatry Solutions, Dr. Jessica Allen provides psychiatric medical opinions for veterans with complex mental health claims. Documentation supports a claim; it does not guarantee a particular VA rating. Dr. Allen is not an accredited representative and does not file or prosecute claims.
Common questions
Frequently asked questions
Related
More on mental health rating increases
- PTSD Increase Nexus Letter
- Conditions Claimed Secondary to PTSD
- How to Write a Strong Personal Statement
- Emotional Eating vs. Binge Eating: What Veterans Need to Know for Nexus Letters
- Substance Use Secondary to PTSD: What Veterans Need to Know
Educational information only. This article is provided for general educational purposes and does not constitute medical advice, legal advice, or a treatment relationship. Reading it does not establish a physician–patient relationship with Dr. Allen or Brightview Psychiatry Solutions PLLC. No outcome in any VA claim is promised or implied; the VA determines service connection and assigns all disability evaluations. Veterans should consult their own treating providers regarding medical care and an accredited representative, agent, or attorney regarding claims. If you are in crisis, the Veterans Crisis Line is available 24/7: dial 988 and press 1, or text 838255.