Sample Letter
Date
VA File #:
Veteran’s SSN:
To Whom It May Concern,
Introduction
My name is ______________ List Credentials___________( State # __________). I hold a bachelor’s degree in and (higher level degree(s)_______________. (Describe your activity relevant to conditions) Example: I serve as a national continuing education provider, speaker, and published author, with a specialization in the identification, treatment, and recovery from concurrent psychological and metabolic health disorders. I have an active clinical partnership or current membership with the (List relevant associations (AMA, APA, ACA etc.,) you are a member of or participate with).
I am writing in support of ____________ ____________’s appeal for Total Disability based on Individual Unemployability, in this case, an adjustment from 70% to 100% based on the worsening of his / her service-connected disability conditions, associated health issues that have surfaced, and the ongoing risk of further his /her deterioration.
Since his / her medical separation in 2014, ____________’s mental health and well-being continue to be severely impacted during times of marked stress when the frequency, duration, and intensity of his / her symptoms escalate to a debilitating level. Therefore, his / her total disability rating should be based on concurrent major depressive disorder recurrent without psychotic features, (F32.2), general anxiety disorder (F41.1), bulimia nervosa (F50.2), attention deficit disorder (F90.9), and a GAF score of 47.
Clinical Overview of Eating Disorders and Co-Occurring Mental Health Disorders
Eating disorders (ED) are serious mental illnesses characterized by disturbances in behaviors, thoughts and feelings towards body weight and shape, and/or food and eating, that have a substantial impact on the well-being and quality of life of the person experiencing the eating disorder [1]. The effects of malnutrition, binge eating, and purging can affect every organ system in the body [2]. Importantly, the lifetime burdens and psychosocial impairments associated with an ED can be substantial because these illnesses can persist for decades [3, 4]. Most people suffering from bulimia nervosa (BN) and anxiety or depression experience symptoms of the psychological condition prior to onset of the ED. It is well established that this / here are greater functional impairments and mortality rates for those with comorbid mental and physical health illnesses [4] and that ED’s frequently co-occur with other psychiatric disorders, particularly depression, anxiety, attention deficit disorder, post-traumatic stress disorder, and more [4].
A comparison of the three most prevalent DSM-5 ED diagnoses, indicates that the long-term effects are significantly worse for individuals diagnosed with bulimia nervosa [3]. Data from the National Comorbidity Survey Replication exploring the lifetime co-morbidity of EDs with other core disorders among US Adults, reported that of the three prevalent eating disorders, BN has the highest comorbidity with depression, anxiety, mood, impulse (ADHD) and other disorders [3].
Over 40% percent of individuals diagnosed with BN experience severe impairment, 33% percent report attempting suicide. The prognosis of BN is considered to be poor. Only 50% of individuals diagnosed with it will go on to recover. 30% will have cycles of partial recovery and relapse, 20 % of individuals diagnosed with bulimia nervosa will suffer with a life-long diagnosis that never meets criteria for remission. For individuals concurrently suffering with major depressive disorder and bulimia nervosa, this / here is a 14.39 increased adjusted risk factor for suicide attempts compared with those suffering with BN alone (5.0) [6].
Members of the U.S. military experience eating disorders at comparable rates to civilians [7]. According to the National Eating Disorders Association, a survey of 3,000 women in the military found that over 60% of respondents had an eating disorder. Within the Veteran population, research indicates that EDs are prevalent and affect as many as 19% of female veterans [8]. Female soldiers are six times more likely to be diagnosed with bulimia nervosa than women in the general population. Similarly when other trauma or other psychological factors present, such as MDD, 33% of overweight/obese veterans report engaging in “making weight” disordered eating behaviors during active military service [9].
Discussion - Appeal to Increase Benefits to 100%
In 2021, ____________ was referred to me for mental health counseling by (Base Hospital, Location by his / her physician) ___________ who was extremely concerned for his / her mental and physical well-being and the possibility for an increased risk for self-harm.
Over the (duration of treatment) _____________ weekly counseling with ____________, I personally reviewed his / her medical and mental health history, including (unsuccessful) inpatient treatment for bulimia nervosa at (List Treatment Center) ________________________.
The Navy’s medical service records indicate that while on active duty, ____________ was diagnosed with the above-referenced psychiatric disorders when he / she returned to his / her home base (Enter Base and Location)______ after his / her deployed attachments to (Fill in Deployment Base / Location Information ).
I was afforded numerous opportunities to discuss in-service events, polices, and stressors which ultimately led his / her to begin binge-purge behaviors of eating to “make weight.” As this feeding pattern was taking hold, he / she also experienced increased anxiety and panic attacks directly related to the pervasive and demeaning workplace culture and stigma (at the time) associated with maintaining weight, image, and fitness. Ultimately as attempts to lose weight became frantic and extreme, ____________ met all the diagnostic criteria for a diagnosis of bulimia nervosa (BN) in addition to depression and anxiety disorders.
While some recover from mental health disorders ____________ has not. His / her concurrent diagnoses have persisted without remission for more than a decade and his / her GAF score is 47. Name____________ has suffered significantly. His / her mental health disorders and conditions have been unrelenting and continue to detrimentally affect his / her psychological and physical ability to function in critical life-sustaining areas: the workplace, social settings, and activities outside of his / her home.
Due to a history and ongoing experiences with workplace and social discrimination, the best way to describe ____________’s life might be nearly non-functional agoraphobia that has significantly worsened over the time I have known him / her. Well before his / her medical separation from the US Navy, due to the combination of MDD and BN, ____________ had begun withdrawing from his / her friends and family. He / She began avoiding any occasions where food or discussions of his / her appearance, health or wellness might arise.
In (Year) ____, desperate for change and hoping to escape from unrelenting social and workplace hostility due to his / her weight, (Name)____________ moved from _______to be closer to his / her roots in _______. Despite his / her hopes, ____________ has been unable to overcome stigma and challenges of his / her depression, anxiety, and bulimia nervosa, and failed to reconnect social connections.
The move from (Name State)_______ forced ____________ to re-establish his / her medical and psychiatric care in Kansas City. My summary of these visits to establish care. The hostile experiences ____________ has related from disinterested or dismissive providers have been demeaning, traumatic, and exacerbated every preexisting condition, resulting in the escalation of his / her depression and increased frequency and severity of bulimia symptoms and behaviors.
Summary and Recommendation
It is my professional opinion that it is more likely than not that ____________’s diagnosis of bulimia nervosa and his / her inability to work is a direct result of his / her active duty military service time while in the United States Navy.
Therefore, his / her total disability rating should be based on concurrent major depressive disorder recurrent without psychotic features, (F32.2), general anxiety disorder (F41.1), bulimia nervosa (F50.2), attention deficit disorder (F90.9), and a GAF score of 47.
Sincerely,
Your Name and Credentials
Address:
State License #
Office:
Confidential Fax
Clinical References
1. American Psychiatric Association (2013) Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
2. National Eating Disorders Association (2023). Common Health Consequences of Eating Disorders. Retrieved from: https://www.nationaleatingdisorders.org/health-consequences
3. Crone, C., Fochtmann, L. J., Attia, E., Boland, R., Escobar, J., Fornari, V., ... & Medicus, J. (2023). The American Psychiatric Association practice guideline for the treatment of patients with eating disorders. American Journal of Psychiatry, 180(2), 167-171.
4. Udo T, Grilo CM. (2018). Prevalence and Correlates of DSM-5-Defined Eating Disorders in a
Nationally Representative Sample of U.S. Adults. Biol Psychiatry. 2018 Sep 1;84(5):345-354. doi: 10.1016/j.biopsych.2018.03.014. Epub 2018 Apr 17. PMID: 29859631; PMCID: PMC6097933.
5. Kessler, R. C., Berglund, P., Chiu, W. T., Demler, O., Heeringa, S., Hiripi, E., Jin, R., Pennell, B. E., Walters, E. E., Zaslavsky, A., & Zheng, H. (2004). The US National Comorbidity Survey Replication (NCS-R): design and field procedures. International journal of methods in psychiatric research, 13(2), 69–92. https://doi.org/10.1002/mpr.167
6. Udo, T., Bitley, S. & Grilo, C.M. Suicide attempts in US adults with lifetime DSM-5 eating disorders. BMC Med 17, 120 (2019). https://doi.org/10.1186/s12916-019-1352-3
7. Bartlett, B. A., & Mitchell, K. S. (2015). Eating disorders in military and veteran men and women: A systematic review. The International journal of eating disorders, 48(8), 1057–1069. https://doi.org/10.1002/eat.22454
8. Hardin, S., Vogt, D., Smith, B. N., Kehle-Forbes, S., Masheb, R., Iverson, K. M., & Mitchell, K. (2022). Male and Female Veterans' Preferences for Eating Disorders Screening. Journal of general internal medicine, 37(Suppl 3), 819–822. https://doi.org/10.1007/s11606-022-07571-
9. Breland, J. Y., Donalson, R., Li, Y., Hebenstreit, C. L., Goldstein, L. A., & Maguen, S. (2018). Military sexual trauma is associated with eating disorders, while combat exposure is not. Psychological Trauma: Theory, Research, Practice, and Policy, 10(3), 276.
Tables
1. Clinical Impairment in Psychosocial Functioning Associated with Disordered Eating (% by DSM-5 Eating Criteria) [3].
Lifetime
AN BN BED
Interfere with normal daily activities 23.5 (3.34) 49.5 (7.23) a 52.5 (3.88) a
Serious problems getting along with othis / hers 21.2 (3.04) 32.9 (6.57) 20.9 (3.10)
Serious problems fulfilling responsibilities 17.5 (2.81) 25.1 (4.63) 28.2 (3.55)
Any Form
30.7 (3.49)
61.4 (7.54) a
53.7 (3.99) a
2. [4]. Lifetime Co-morbidity of Eating Disorders with Other Core Disorders Among U.S. Adults.
