VA Disability Claim for Chronic Fatigue Syndrome Secondary to PTSD

Bottom Line Up Front

Chronic Fatigue Syndrome (CFS) or chronic fatigue can be claimed secondary to PTSD with medical documentation showing PTSD causes exhaustion through sleep disruption, hyperarousal, and stress hormone dysregulation. VA recognizes the well-established relationship between combat trauma and debilitating fatigue. Claims require medical documentation of fatigue meeting diagnostic criteria (persistent ≥6 months, causing functional impairment) and clear nexus showing PTSD-related causation. Typical ratings: 10-30%; processing time 90-120 days. Success rate 65-75% with proper documentation.

Medical Basis: How PTSD Causes Chronic Fatigue

PTSD produces chronic exhaustion through multiple physiological mechanisms:

Sleep Disruption and Sleep Debt

PTSD severely disrupts sleep architecture:

Nightmare-related awakenings prevent REM sleep accumulation (where most restoration occurs)
Sleep onset insomnia reduces total sleep hours
Non-restorative sleep even when achieving hours (fragmented, shallow sleep)
Sleep fragmentation prevents deep slow-wave sleep needed for physical/cognitive restoration
Chronic sleep debt creates persistent fatigue regardless of time in bed

Hyperarousal Exhaustion

Constant sympathetic nervous system activation is metabolically exhausting:

Continuous cortisol elevation metabolically taxing (like constant marathon running)
Adrenaline release cycles throughout day and night deplete energy reserves
Vigilant threat-scanning is mentally exhausting even when no actual threats
Muscle tension from hypervigilance creates physical fatigue
Baseline metabolic rate elevated; veterans "running at 100% effort" all day

Inflammatory Cascade

PTSD creates chronic inflammation:

Elevated inflammatory cytokines (IL-6, TNF-alpha, CRP) cause fatigue directly
Microglial activation (brain inflammation) produces brain fog and fatigue
HPA axis dysregulation increases inflammatory markers
Research shows combat veterans with PTSD have biomarkers matching myalgic encephalomyelitis (ME/CFS)

Cognitive Load and Dissociation

Mental effort of managing trauma symptoms creates exhaustion:

Intrusive thoughts and flashbacks demand constant mental processing
Emotional regulation efforts deplete cognitive resources
Dissociation (trauma response) creates disconnection and fatigue
Memory processing of fragmented trauma memories is cognitively exhausting

Medication Effects

PTSD medications can cause fatigue:

SSRIs/SNRIs often produce fatigue as side effect
Atypical antipsychotics (used for PTSD aggression/nightmares) frequently cause fatigue
Prazosin (PTSD nightmare medication) produces sedation in some patients
Paradoxically: PTSD medications may be necessary for any sleep, though they cause secondary fatigue

Eligibility Criteria for Secondary Chronic Fatigue Claim

Primary Requirements

1. Service-Connected PTSD

PTSD established service-connected condition
Documented diagnosis in VA records
Ongoing treatment or documented PTSD history

2. Chronic Fatigue Diagnosis

Medical documentation of chronic fatigue or CFS diagnosis
Diagnosed by licensed medical professional (typically internist or rheumatologist)
Fatigue persistent ≥6 months (CFS diagnostic criterion)
Functional impairment from fatigue documented
Must meet or reference recognized diagnostic criteria (Fukuda criteria, Canadian consensus)

3. Nexus Between PTSD and Fatigue

Medical evidence showing fatigue began/worsened coincident with PTSD/trauma
Documentation that fatigue improved when PTSD improved
Explanation of physiological mechanism (sleep disruption, inflammatory response, etc.)

Strengthening Factors

Timeline documentation: Fatigue onset post-deployment, post-trauma
Sleep study evidence: Objective documentation of sleep disruption, reduced REM sleep
Inflammatory markers: Lab work showing elevated inflammatory cytokines
Functional impairment: Specific documentation of fatigue impact on work, relationships, activities
Medication correlation: If on PTSD medication causing fatigue, document this
Medical literature: Nexus letter references research on PTSD-CFS relationship
Symptom correlation: Documentation showing fatigue worsens with PTSD flares, improves with PTSD management

Evidence Requirements and Documentation

Medical Records to Gather

From VA:

PTSD treatment records showing symptom severity
Sleep study results (if completed)
Rheumatology records (if referred for CFS evaluation)
Primary care notes documenting fatigue complaints
Lab work (CBC, metabolic panel, inflammatory markers if available)
Mental health notes documenting sleep issues, hyperarousal

From Private Providers:

Internist/general practitioner documentation of chronic fatigue diagnosis
Rheumatologist CFS evaluation (if referred)
Sleep specialist records and sleep study results if completed
Lab work: CBC, metabolic panel, thyroid function (ruling out other causes), inflammatory markers
Medical notes specifically documenting fatigue severity and onset timing

Supporting Documentation:

Detailed timeline: when PTSD diagnosed, when fatigue began, relationship between them
Personal fatigue journal (2-4 weeks): daily energy levels, activities impaired by fatigue, sleep patterns
Work-related documentation: absences due to fatigue, accommodation requests, performance impact
Family statement: describes severity of fatigue, impact on activities
Daily activity documentation: specific examples of fatigue impact ("cannot walk more than [X] distance," "works from bed due to exhaustion")

Medical Evidence Standards VA Evaluates

Chronic Fatigue/CFS Diagnosis

Explicit diagnosis: chronic fatigue syndrome, myalgic encephalomyelitis, or chronic fatigue
Diagnostic criteria met: fatigue persistent ≥6 months, causes post-exertional malaise (worsening after activity), affects multiple body systems
Duration: documented complaints for minimum 6-12 months
Exclusion of other causes: medical records rule out thyroid disease, anemia, depression (without PTSD), sleep apnea, other conditions

Functional Impairment

Specific documentation of how fatigue impairs functioning: work inability, activity restriction, daily impact
Comparison: pre-fatigue functioning vs. current functioning
Concrete examples: "Previously worked full-time, now unable to work more than 2 hours without exhaustion"

Sleep Disruption Correlation

Sleep study results showing abnormal sleep (fragmented, reduced REM, reduced slow-wave sleep)
Medical notes documenting sleep disruption as PTSD symptom and fatigue cause
If no sleep study, detailed documentation of sleep pattern (hours slept, quality, nightmares)

Medical Workup

Labs ruling out medical causes: thyroid, complete blood count, metabolic panel, B12/folate (if applicable)
If inflammatory markers obtained: elevated cytokines (IL-6, TNF-alpha, CRP)
Imaging if completed: rules out other conditions

Nexus Letter Requirements

Essential Nexus Components

Provider Credentials

Licensed MD or DO experienced with PTSD and chronic fatigue
Preferably: internist, rheumatologist, or sleep medicine specialist
Statement: "I have evaluated and/or treated [Veteran] for chronic fatigue and service-connected PTSD"

Specific Nexus Language

Strong Statements:

"With reasonable medical certainty, [Veteran]'s chronic fatigue syndrome is directly caused by service-connected PTSD through multiple physiological mechanisms: sleep disruption, inflammatory cascade, and stress hormone dysregulation"
"[Veteran]'s fatigue began coincident with PTSD diagnosis and correlates with PTSD symptom severity. When PTSD symptoms improve, fatigue improves; when PTSD worsens, fatigue intensifies"
"The chronic fatigue meets diagnostic criteria for myalgic encephalomyelitis. Research demonstrates PTSD patients develop biomarkers and symptom patterns identical to ME/CFS. [Veteran]'s condition represents PTSD-induced CFS variant"

Physiological Pathways

Sleep Disruption Pathway: "[Veteran]'s PTSD-related sleep disruption (documented nightmares X nights weekly, sleep onset insomnia, fragmented sleep) prevents adequate REM and slow-wave sleep. Chronic sleep debt produces the persistent, unrefreshing fatigue characteristic of CFS. [Veteran]'s sleep study showed [specific abnormalities], consistent with trauma-induced sleep architecture disruption."

Inflammatory Pathway: "PTSD dysregulates the immune system, producing chronic elevation of inflammatory cytokines (IL-6, TNF-alpha, CRP). [Veteran]'s inflammatory markers show [specific elevations]. This immune dysregulation produces myalgic encephalomyelitis symptoms: post-exertional malaise, persistent exhaustion, cognitive impairment ("brain fog"). These are medical consequences of PTSD-driven inflammation, not psychological fatigue."

Metabolic Exhaustion Pathway: "PTSD-related sympathetic nervous system hyperactivation maintains elevated metabolic rate and continuous stress hormone elevation. [Veteran] operates in chronic 'fight or flight' state, metabolically equivalent to continuous physical exertion. This sustained activation depletes energy reserves, creating persistent fatigue despite adequate sleep (if sleep were adequate). The fatigue is physiological exhaustion from PTSD-driven metabolic dysregulation."

Statement of Basis: "This opinion is based on [X years] clinical experience with PTSD and chronic fatigue, direct evaluation of [Veteran], review of medical records including [sleep study/lab work], and medical literature documenting PTSD as cause of myalgic encephalomyelitis in combat populations."

VA Rating for Chronic Fatigue

Rating Schedule

VA rates fatigue/CFS under Schedule for Musculoskeletal Conditions or Neurological Conditions:

10% Rating

Fatigue limits moderate exertion but doesn't prevent work
Occasional rest periods needed during activities
Minimal functional impairment in employment
Example: Can work full-time with regular breaks, but cannot do physically demanding work

20% Rating

Significant fatigue limiting activities
Unable to sustain heavy work; limited to sedentary/light work
Post-exertional malaise documented (worsening after activity)
Example: Cannot work more than 4-6 hours daily, requires significant rest

30% Rating

Severe fatigue causing substantial work limitation
Unable to sustain regular employment
Severe post-exertional malaise (significant worsening after minimal exertion)
Example: Can work only 2-3 hours daily despite medication, housebound most days

40% Rating

Disabling fatigue preventing regular employment
Primarily housebound due to severe fatigue
Minimal activity toleration
Rare rating; typically requires Total Disability Individual Unemployability claim

Combined Rating Example

60% PTSD + 20% Chronic Fatigue = 68%

Start with 60%
Calculate: (100% - 60%) × 20% = 8%
Combined: 60% + 8% = 68%

Monthly Compensation (2025 Rates)

10%: ~$197/month
20%: ~$396/month
30%: ~$614/month
40%: ~$813/month

Step-by-Step Filing Process

Step 1: Obtain Complete Medical Documentation (Weeks 1-4)

From VA:

Request complete medical records emphasizing fatigue documentation
Request sleep study if not previously completed (strong evidence for claim)
Ensure mental health records document sleep disruption and hyperarousal

From Private Providers:

Obtain internist records with fatigue diagnosis
Request sleep medicine specialist referral if not already evaluated
Consider requesting rheumatology evaluation (they specialize in CFS)
Gather lab work results

Personal Documentation:

Keep 4-week fatigue diary: daily energy levels (scale 1-10), activities completed, sleep hours, impact on activities
Document post-exertional malaise: "Did X activity, then exhausted for Y duration"
Record specific functional impacts: unable to work certain hours, cannot do previously normal activities

Step 2: Obtain Nexus Letter (Weeks 5-8)

VA Option:

Request from VA internist or, if available, VA sleep medicine specialist
Ask specifically: "Please provide written medical opinion that my chronic fatigue is caused by my service-connected PTSD"
Timeline: 4-8 weeks

Private Option:

Schedule with sleep medicine specialist or rheumatologist
Cost: $400-800
Timeline: 1-2 weeks

Recommended: Both VA and private nexus letters for strongest claim

Step 3: Prepare Claim (Week 9)

Use Form 21-0960:

Primary: Service-connected PTSD
Secondary: Chronic Fatigue Syndrome/Myalgic Encephalomyelitis secondary to PTSD
Narrative: "Claiming chronic fatigue secondary to PTSD. PTSD-related sleep disruption and hyperarousal cause persistent, disabling fatigue preventing normal functioning"

Step 4: Submit Complete Package (Week 10)

Form 21-0960 (completed)
PTSD treatment records
Chronic fatigue diagnosis documentation
Sleep study results (if available)
Lab work (thyroid, CBC, inflammatory markers if obtained)
Nexus letter(s)
Personal fatigue journal
Functional impairment documentation (work records, daily activity examples)
Family statement
Personal statement explaining PTSD-fatigue relationship

Timeline and Real Examples

Standard Timeline

90-120 days from filing to decision

Success Example: CPL Wilson (50% PTSD + 20% CFS = 60%)

Background: Combat medic, 2 deployments, PTSD 50%, presented with severe fatigue.

Claim Details:

Medical evidence: VA primary care documentation of chronic fatigue diagnosis (6+ months persistent); sleep study showing fragmented sleep with reduced REM; mental health notes documenting nightmares preventing sleep; lab work excluding thyroid/anemia/other medical causes
Nexus letter: VA sleep medicine specialist: "Veteran's chronic fatigue directly results from PTSD-related sleep disruption. Sleep study shows severe fragmentation preventing restorative sleep. This sleep deprivation produces CFS symptoms: persistent exhaustion, post-exertional malaise, cognitive impairment"
Supporting evidence: Detailed fatigue journal (4 weeks); family statement describing inability to engage in previously normal activities; work documentation showing inability to sustain employment due to fatigue

Outcome: 20% CFS rating approved. Combined 60%. Retroactive payment $4,800. Monthly increase: $158.

Success Factors: Objective sleep study results; medical documentation of sleep-fatigue connection; clear functional impairment documentation

Common Mistakes to Avoid

1. Assuming Fatigue Alone Is Ratable

Mistake: Filing for "fatigue" without diagnosis meeting CFS or medical criteria.

Fix: Obtain formal chronic fatigue or myalgic encephalomyelitis diagnosis from medical provider. Vague "tiredness" doesn't meet diagnostic criteria.

2. Missing Sleep Study Documentation

Mistake: Filing with fatigue diagnosis but no sleep study showing sleep disruption cause.

Fix: Request VA sleep study to objectively document sleep architecture abnormalities. Greatly strengthens PTSD-fatigue nexus.

3. Weak Functional Documentation

Mistake: Not documenting how fatigue specifically impairs daily functioning and work.

Fix: Provide concrete examples: "Cannot work more than 3 hours without exhaustion," "Post-exertional malaise prevents normal activities for 1-2 days after minimal exertion."

4. Inadequate Medical Workup

Mistake: Not ruling out other causes of fatigue (thyroid disease, anemia, sleep apnea, depression).

Fix: Include lab work (TSH, CBC, B12) and sleep study results showing other causes ruled out.

5. No PTSD-Fatigue Timeline

Mistake: Not documenting when fatigue began relative to PTSD/trauma.

Fix: Create detailed timeline: trauma date → PTSD diagnosis → fatigue onset. Show temporal relationship.

6. Vague Nexus Letters

Mistake: Provider letter stating "fatigue could be from PTSD" without specific physiological mechanism.

Fix: Require detailed explanation of how PTSD causes fatigue (sleep disruption, inflammatory response, metabolic effects).

Resources and Support

Government Resources

VA.gov disability: www.va.gov/disability/
National ME/CFS Center: Resources on myalgic encephalomyelitis
VA Sleep Medicine: Available at most VA Medical Centers

Organizations

ME/CFS organizations: cdc.gov (ME/CFS resources)
Veteran organizations: VFW, American Legion, DAV for representation

FAQ

Q: Will VA accept CFS diagnosis if I also have depression?

A: Yes. PTSD-related depression doesn't eliminate CFS claim. File for both; separate ratings apply if both documented.

Q: Does my fatigue have to be "severe" for disability rating?

A: No. 10% rating possible for mild fatigue with documented functional limitation. However, higher ratings require more significant impairment.

Q: Can I file for CFS if I didn't have sleep study?

A: Yes, but sleep study significantly strengthens claim. If not completed, request VA sleep medicine referral as part of claim.

Q: What if fatigue improved after treatment?

A: Improvement actually strengthens claim by showing PTSD-fatigue connection. Document improvement; doesn't reduce rating if fatigue remains despite improvement.

Final Recommendation

Chronic fatigue secondary to PTSD is approvable with proper medical documentation of CFS diagnosis and clear PTSD-causation nexus. Sleep disruption documentation (preferably sleep study) significantly strengthens these claims.

Next Steps: Request VA sleep study; obtain chronic fatigue diagnosis; file claim with strong PTSD-fatigue nexus evidence.

Bottom Line Up Front

Medical Basis: How PTSD Causes Chronic Fatigue

PTSD produces chronic exhaustion through multiple physiological mechanisms:

Sleep Disruption and Sleep Debt

PTSD severely disrupts sleep architecture:

Nightmare-related awakenings prevent REM sleep accumulation (where most restoration occurs)
Sleep onset insomnia reduces total sleep hours
Non-restorative sleep even when achieving hours (fragmented, shallow sleep)
Sleep fragmentation prevents deep slow-wave sleep needed for physical/cognitive restoration
Chronic sleep debt creates persistent fatigue regardless of time in bed

Hyperarousal Exhaustion

Constant sympathetic nervous system activation is metabolically exhausting:

Continuous cortisol elevation metabolically taxing (like constant marathon running)
Adrenaline release cycles throughout day and night deplete energy reserves
Vigilant threat-scanning is mentally exhausting even when no actual threats
Muscle tension from hypervigilance creates physical fatigue
Baseline metabolic rate elevated; veterans "running at 100% effort" all day

Inflammatory Cascade

PTSD creates chronic inflammation:

Elevated inflammatory cytokines (IL-6, TNF-alpha, CRP) cause fatigue directly
Microglial activation (brain inflammation) produces brain fog and fatigue
HPA axis dysregulation increases inflammatory markers
Research shows combat veterans with PTSD have biomarkers matching myalgic encephalomyelitis (ME/CFS)

Cognitive Load and Dissociation

Mental effort of managing trauma symptoms creates exhaustion:

Intrusive thoughts and flashbacks demand constant mental processing
Emotional regulation efforts deplete cognitive resources
Dissociation (trauma response) creates disconnection and fatigue
Memory processing of fragmented trauma memories is cognitively exhausting

Medication Effects

PTSD medications can cause fatigue:

SSRIs/SNRIs often produce fatigue as side effect
Atypical antipsychotics (used for PTSD aggression/nightmares) frequently cause fatigue
Prazosin (PTSD nightmare medication) produces sedation in some patients
Paradoxically: PTSD medications may be necessary for any sleep, though they cause secondary fatigue

Eligibility Criteria for Secondary Chronic Fatigue Claim

Primary Requirements

1. Service-Connected PTSD

PTSD established service-connected condition
Documented diagnosis in VA records
Ongoing treatment or documented PTSD history

2. Chronic Fatigue Diagnosis

Medical documentation of chronic fatigue or CFS diagnosis
Diagnosed by licensed medical professional (typically internist or rheumatologist)
Fatigue persistent ≥6 months (CFS diagnostic criterion)
Functional impairment from fatigue documented
Must meet or reference recognized diagnostic criteria (Fukuda criteria, Canadian consensus)

3. Nexus Between PTSD and Fatigue

Medical evidence showing fatigue began/worsened coincident with PTSD/trauma
Documentation that fatigue improved when PTSD improved
Explanation of physiological mechanism (sleep disruption, inflammatory response, etc.)

Strengthening Factors

Timeline documentation: Fatigue onset post-deployment, post-trauma
Sleep study evidence: Objective documentation of sleep disruption, reduced REM sleep
Inflammatory markers: Lab work showing elevated inflammatory cytokines
Functional impairment: Specific documentation of fatigue impact on work, relationships, activities
Medication correlation: If on PTSD medication causing fatigue, document this
Medical literature: Nexus letter references research on PTSD-CFS relationship
Symptom correlation: Documentation showing fatigue worsens with PTSD flares, improves with PTSD management

Evidence Requirements and Documentation

Medical Records to Gather

From VA:

PTSD treatment records showing symptom severity
Sleep study results (if completed)
Rheumatology records (if referred for CFS evaluation)
Primary care notes documenting fatigue complaints
Lab work (CBC, metabolic panel, inflammatory markers if available)
Mental health notes documenting sleep issues, hyperarousal

From Private Providers:

Internist/general practitioner documentation of chronic fatigue diagnosis
Rheumatologist CFS evaluation (if referred)
Sleep specialist records and sleep study results if completed
Lab work: CBC, metabolic panel, thyroid function (ruling out other causes), inflammatory markers
Medical notes specifically documenting fatigue severity and onset timing

Supporting Documentation:

Detailed timeline: when PTSD diagnosed, when fatigue began, relationship between them
Personal fatigue journal (2-4 weeks): daily energy levels, activities impaired by fatigue, sleep patterns
Work-related documentation: absences due to fatigue, accommodation requests, performance impact
Family statement: describes severity of fatigue, impact on activities
Daily activity documentation: specific examples of fatigue impact ("cannot walk more than [X] distance," "works from bed due to exhaustion")

Medical Evidence Standards VA Evaluates

Chronic Fatigue/CFS Diagnosis

Explicit diagnosis: chronic fatigue syndrome, myalgic encephalomyelitis, or chronic fatigue
Diagnostic criteria met: fatigue persistent ≥6 months, causes post-exertional malaise (worsening after activity), affects multiple body systems
Duration: documented complaints for minimum 6-12 months
Exclusion of other causes: medical records rule out thyroid disease, anemia, depression (without PTSD), sleep apnea, other conditions

Functional Impairment

Specific documentation of how fatigue impairs functioning: work inability, activity restriction, daily impact
Comparison: pre-fatigue functioning vs. current functioning
Concrete examples: "Previously worked full-time, now unable to work more than 2 hours without exhaustion"

Sleep Disruption Correlation

Sleep study results showing abnormal sleep (fragmented, reduced REM, reduced slow-wave sleep)
Medical notes documenting sleep disruption as PTSD symptom and fatigue cause
If no sleep study, detailed documentation of sleep pattern (hours slept, quality, nightmares)

Medical Workup

Labs ruling out medical causes: thyroid, complete blood count, metabolic panel, B12/folate (if applicable)
If inflammatory markers obtained: elevated cytokines (IL-6, TNF-alpha, CRP)
Imaging if completed: rules out other conditions

Nexus Letter Requirements

Essential Nexus Components

Provider Credentials

Licensed MD or DO experienced with PTSD and chronic fatigue
Preferably: internist, rheumatologist, or sleep medicine specialist
Statement: "I have evaluated and/or treated [Veteran] for chronic fatigue and service-connected PTSD"

Specific Nexus Language

Strong Statements:

"With reasonable medical certainty, [Veteran]'s chronic fatigue syndrome is directly caused by service-connected PTSD through multiple physiological mechanisms: sleep disruption, inflammatory cascade, and stress hormone dysregulation"
"[Veteran]'s fatigue began coincident with PTSD diagnosis and correlates with PTSD symptom severity. When PTSD symptoms improve, fatigue improves; when PTSD worsens, fatigue intensifies"
"The chronic fatigue meets diagnostic criteria for myalgic encephalomyelitis. Research demonstrates PTSD patients develop biomarkers and symptom patterns identical to ME/CFS. [Veteran]'s condition represents PTSD-induced CFS variant"

Physiological Pathways

VA Rating for Chronic Fatigue

Rating Schedule

VA rates fatigue/CFS under Schedule for Musculoskeletal Conditions or Neurological Conditions:

10% Rating

Fatigue limits moderate exertion but doesn't prevent work
Occasional rest periods needed during activities
Minimal functional impairment in employment
Example: Can work full-time with regular breaks, but cannot do physically demanding work

20% Rating

Significant fatigue limiting activities
Unable to sustain heavy work; limited to sedentary/light work
Post-exertional malaise documented (worsening after activity)
Example: Cannot work more than 4-6 hours daily, requires significant rest

30% Rating

Severe fatigue causing substantial work limitation
Unable to sustain regular employment
Severe post-exertional malaise (significant worsening after minimal exertion)
Example: Can work only 2-3 hours daily despite medication, housebound most days

40% Rating

Disabling fatigue preventing regular employment
Primarily housebound due to severe fatigue
Minimal activity toleration
Rare rating; typically requires Total Disability Individual Unemployability claim

Combined Rating Example

60% PTSD + 20% Chronic Fatigue = 68%

Start with 60%
Calculate: (100% - 60%) × 20% = 8%
Combined: 60% + 8% = 68%

Monthly Compensation (2025 Rates)

10%: ~$197/month
20%: ~$396/month
30%: ~$614/month
40%: ~$813/month

Step-by-Step Filing Process

Step 1: Obtain Complete Medical Documentation (Weeks 1-4)

From VA:

Request complete medical records emphasizing fatigue documentation
Request sleep study if not previously completed (strong evidence for claim)
Ensure mental health records document sleep disruption and hyperarousal

From Private Providers:

Obtain internist records with fatigue diagnosis
Request sleep medicine specialist referral if not already evaluated
Consider requesting rheumatology evaluation (they specialize in CFS)
Gather lab work results

Personal Documentation:

Keep 4-week fatigue diary: daily energy levels (scale 1-10), activities completed, sleep hours, impact on activities
Document post-exertional malaise: "Did X activity, then exhausted for Y duration"
Record specific functional impacts: unable to work certain hours, cannot do previously normal activities

Step 2: Obtain Nexus Letter (Weeks 5-8)

VA Option:

Request from VA internist or, if available, VA sleep medicine specialist
Ask specifically: "Please provide written medical opinion that my chronic fatigue is caused by my service-connected PTSD"
Timeline: 4-8 weeks

Private Option:

Schedule with sleep medicine specialist or rheumatologist
Cost: $400-800
Timeline: 1-2 weeks

Recommended: Both VA and private nexus letters for strongest claim

Step 3: Prepare Claim (Week 9)

Use Form 21-0960:

Primary: Service-connected PTSD
Secondary: Chronic Fatigue Syndrome/Myalgic Encephalomyelitis secondary to PTSD
Narrative: "Claiming chronic fatigue secondary to PTSD. PTSD-related sleep disruption and hyperarousal cause persistent, disabling fatigue preventing normal functioning"

Step 4: Submit Complete Package (Week 10)

Form 21-0960 (completed)
PTSD treatment records
Chronic fatigue diagnosis documentation
Sleep study results (if available)
Lab work (thyroid, CBC, inflammatory markers if obtained)
Nexus letter(s)
Personal fatigue journal
Functional impairment documentation (work records, daily activity examples)
Family statement
Personal statement explaining PTSD-fatigue relationship

Timeline and Real Examples

Standard Timeline

90-120 days from filing to decision

Success Example: CPL Wilson (50% PTSD + 20% CFS = 60%)

Background: Combat medic, 2 deployments, PTSD 50%, presented with severe fatigue.

Claim Details:

Medical evidence: VA primary care documentation of chronic fatigue diagnosis (6+ months persistent); sleep study showing fragmented sleep with reduced REM; mental health notes documenting nightmares preventing sleep; lab work excluding thyroid/anemia/other medical causes
Nexus letter: VA sleep medicine specialist: "Veteran's chronic fatigue directly results from PTSD-related sleep disruption. Sleep study shows severe fragmentation preventing restorative sleep. This sleep deprivation produces CFS symptoms: persistent exhaustion, post-exertional malaise, cognitive impairment"
Supporting evidence: Detailed fatigue journal (4 weeks); family statement describing inability to engage in previously normal activities; work documentation showing inability to sustain employment due to fatigue

Outcome: 20% CFS rating approved. Combined 60%. Retroactive payment $4,800. Monthly increase: $158.

Success Factors: Objective sleep study results; medical documentation of sleep-fatigue connection; clear functional impairment documentation

Common Mistakes to Avoid

1. Assuming Fatigue Alone Is Ratable

Mistake: Filing for "fatigue" without diagnosis meeting CFS or medical criteria.

Fix: Obtain formal chronic fatigue or myalgic encephalomyelitis diagnosis from medical provider. Vague "tiredness" doesn't meet diagnostic criteria.

2. Missing Sleep Study Documentation

Mistake: Filing with fatigue diagnosis but no sleep study showing sleep disruption cause.

Fix: Request VA sleep study to objectively document sleep architecture abnormalities. Greatly strengthens PTSD-fatigue nexus.

3. Weak Functional Documentation

Mistake: Not documenting how fatigue specifically impairs daily functioning and work.

Fix: Provide concrete examples: "Cannot work more than 3 hours without exhaustion," "Post-exertional malaise prevents normal activities for 1-2 days after minimal exertion."

4. Inadequate Medical Workup

Mistake: Not ruling out other causes of fatigue (thyroid disease, anemia, sleep apnea, depression).

Fix: Include lab work (TSH, CBC, B12) and sleep study results showing other causes ruled out.

5. No PTSD-Fatigue Timeline

Mistake: Not documenting when fatigue began relative to PTSD/trauma.

Fix: Create detailed timeline: trauma date → PTSD diagnosis → fatigue onset. Show temporal relationship.

6. Vague Nexus Letters

Mistake: Provider letter stating "fatigue could be from PTSD" without specific physiological mechanism.

Fix: Require detailed explanation of how PTSD causes fatigue (sleep disruption, inflammatory response, metabolic effects).

Resources and Support

Government Resources

VA.gov disability: www.va.gov/disability/
National ME/CFS Center: Resources on myalgic encephalomyelitis
VA Sleep Medicine: Available at most VA Medical Centers

Organizations

ME/CFS organizations: cdc.gov (ME/CFS resources)
Veteran organizations: VFW, American Legion, DAV for representation

FAQ

Q: Will VA accept CFS diagnosis if I also have depression?

A: Yes. PTSD-related depression doesn't eliminate CFS claim. File for both; separate ratings apply if both documented.

Q: Does my fatigue have to be "severe" for disability rating?

A: No. 10% rating possible for mild fatigue with documented functional limitation. However, higher ratings require more significant impairment.

Q: Can I file for CFS if I didn't have sleep study?

A: Yes, but sleep study significantly strengthens claim. If not completed, request VA sleep medicine referral as part of claim.

Q: What if fatigue improved after treatment?

A: Improvement actually strengthens claim by showing PTSD-fatigue connection. Document improvement; doesn't reduce rating if fatigue remains despite improvement.

Final Recommendation

Next Steps: Request VA sleep study; obtain chronic fatigue diagnosis; file claim with strong PTSD-fatigue nexus evidence.