PTSD Guide - Part 2

Our PTSD Guide will explain what PTSD is (Part 1), what is needed to get PTSD service-connected (Part 2), what to expect from a Compensation & Pension (C&P) exam for PTSD (Part 3), how PTSD is rated by the VA (Part 4), how to receive Total Disability Based on Individual Unemployability (Part 5), what to do after the VA decision (Part 6), and helpful resources (Part 7).

There are three main things that a Veteran needs to establishing service-connection for PTSD in order to receive VA benefits and VA compensation. The first thing that a Veteran must have is a current diagnosis of PTSD and that diagnosis has to be from an expert who qualified to diagnose PTSD. The second thing that a Veteran must have is a credible supporting evidence that the in-service stressor incident actually happened. The third thing that a Veteran must have is medical evidence showing a connection between their current diagnosis and their claimed in-service stressor incident.  

For the VA to recognize a Veteran's PTSD to service-connect it, the PTSD diagnosis must be from a qualified medical professional.  Even if the Veteran is being treated for PTSD by a licensed mental health social worker, licensed counselor, VA or private therapists who are not psychologists or doctors, the VA will not accept their diagnosis for PTSD.  The VA Clinician's Guide states that qualified professionals who are able to conduct a PTSD Compensation and Pension examinations (C&P exams) must have doctoral-level training in psychopathology, diagnostic methods, and clinical interview methods.  The medical professional also must have a working knowledge of the DSM-V and they also must have extensive clinical experience in diagnosing and treating Veterans with PTSD. Medical professionals with the professional requisite qualifications include a board-certified psychiatrist and licensed psychologist, along with a psychiatric residents and psychology interns under the supervision of an attending psychiatrist or psychologist. See Part 3 for more specific information about C&P exams.

In addition to having a qualified medical professional diagnose the Veteran, the diagnosis must meet the diagnostic criteria in the DSM-V. One of the most common reasons why the VA denies a Veteran's claim for PTSD is because the VA believes that the Veteran does not meet all of the diagnostic criteria in the DSM-V for PTSD. The Veteran may be suffering from extreme PTSD, but if their symptoms do not neatly fall within the diagnostic criteria for PTSD, then for VA purposes, the Veteran does not have PTSD, and service-connection is denied.

The diagnostic criteria in the DSM-V for PTSD are listed below and may also be found on the VA website. After the stressor criterion, there are 4 symptom clusters: intrusion, avoidance, negative alterations in cognitions and mood, and alterations in arousal and reactivity. The 6th criterion concerns duration of the symptoms, the 7th assesses functioning, and the 8th criterion clarifies that the symptoms are not attributable to substance abuse or co-occurring medical condition.  Some of the criterions require only one symptom, while others require multiple symptoms.

Criterion A: stressor

The Veteran was exposed to: death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence, as follows: (one required)

1. 1. Direct exposure.
   2. Witnessing, in person.
   3. Indirectly, by learning that a close relative or close friend was exposed to trauma. If the event involved actual or threatened death, it must have been violent or accidental.
   4. Repeated or extreme indirect exposure to aversive details of the event(s), usually in the course of professional duties (e.g., first responders, collecting body parts; professionals repeatedly exposed to details of child abuse). This does not include indirect non-professional exposure through electronic media, television, movies, or pictures.

Examples: Combat action, mortuary affairs, military sexual trauma, witnessing a roadside IED go off a few vehicles ahead, being involved in an IED, or someone dies during training. 

Criterion B: intrusion symptoms

The traumatic event is persistently re-experienced in the following way(s): (one required)

1. 1. Recurrent, involuntary, and intrusive memories.
   2. Traumatic nightmares.
   3. Dissociative reactions (e.g., flashbacks) which may occur on a continuum from brief episodes to complete loss of consciousness.
   4. Intense or prolonged distress after exposure to traumatic reminders.
   5. Marked physiologic reactivity after exposure to trauma-related stimuli.

Criterion C: avoidance

Persistent effortful avoidance of distressing trauma-related stimuli after the event: (one required)

1. 1. Trauma-related thoughts or feelings.
   2. Trauma-related external reminders (e.g., people, places, conversations, activities, objects, or situations).

Criterion D: negative alterations in cognitions and mood

Negative alterations in cognitions and mood that began or worsened after the traumatic event: (two required)

1. 1. Inability to recall key features of the traumatic event (usually dissociative amnesia; not due to head injury, alcohol, or drugs).
   2. Persistent (and often distorted) negative beliefs and expectations about oneself or the world (e.g., “I am bad,” “The world is completely dangerous”).
   3. Persistent distorted blame of self or others for causing the traumatic event or for resulting consequences.
   4. Persistent negative trauma-related emotions (e.g., fear, horror, anger, guilt, or shame).
   5. Markedly diminished interest in (pre-traumatic) significant activities.
   6. Feeling alienated from others (e.g., detachment or estrangement).
   7. Constricted affect: persistent inability to experience positive emotions.

Criterion E: alterations in arousal and reactivity

Trauma-related alterations in arousal and reactivity that began or worsened after the traumatic event: (two required)

1. 1. Irritable or aggressive behavior
   2. Self-destructive or reckless behavior
   3. Hypervigilance
   4. Exaggerated startle response
   5. Problems in concentration
   6. Sleep disturbance

Criterion F: duration

Persistence of symptoms (in Criteria B, C, D, and E) for more than one month.

Criterion G: functional significance

Significant symptom-related distress or functional impairment (e.g., social, occupational).

Criterion H: exclusion

Disturbance is not due to medication, substance use, or other illness.

• • Specify if: With dissociative symptoms.

In addition to meeting criteria for diagnosis, an individual experiences high levels of either of the following in reaction to trauma-related stimuli:

1. 1. Depersonalization: experience of being an outside observer of or detached from oneself (e.g., feeling as if “this is not happening to me” or one were in a dream).
   2. Derealization: experience of unreality, distance, or distortion (e.g., “things are not real”).

• • Specify if: With delayed expression.

Full diagnosis is not met until at least six months after the trauma(s), although onset of symptoms may occur immediately.

For the first requirement to service-connect a Veteran's PTSD, the diagnosis must detail whether it is "as likely as not" that the Veteran is currently suffering from PTSD.  Also, the VA cannot outright reject a competent diagnosis for PTSD without giving an adequate statement of reason or bases for their decision.  The VA has to be able to point to other medical evidence in the Veteran's records to support their conclusion that the Veteran is not currently suffering from PTSD.  The VA cannot say that a Veteran does not have PTSD just because they do not believe the Veteran's doctor.

If you have a current diagnosis of PTSD from a qualified medical provider, move on to Step 2.

The second thing a Veteran has to establish to get their PTSD service-connected is where many Veterans have the most difficulty.  Even if the Veteran doubts that they will be able to corroborate their in-service stressor incident, there is hope.  Use the following to determine what evidence the Veteran needs for their claim.

• The Veteran was diagnosed with PTSD while on active-duty.
• The Veteran's PTSD is related to fear of hostile military or terrorist activity.
• The Veteran has PTSD from combat action.
• There are special rules for Veterans that have experienced in-service personal assault or trauma as their stressor.
• What happens if none of the above categories corroboration of in-service stressor applies?

The Veteran was diagnosed with PTSD while on active-duty.

If a Veteran is diagnosed with PTSD while on active-duty there is a much lower burden of proof that the stressor incident occurred.  If the stressor incident is related to that time of active-duty, the stressor incident is consistent with the circumstances of that active-duty period, and there is no clear and convincing evidence to the contrary, the Veteran's own statements can be used to establish the occurrence of the stressor incident.  

Another important thing is that if a Veteran is released from active-duty because of a mental health issue that developed as a result of a highly stressful event in-service, the Veteran must be awarded a rating of no less then 50% and then be reevaluated with 6 months. Go to step 3.

The Veteran's PTSD is related to fear of hostile military or terrorist activity.

If a Veteran is diagnosed with PTSD that is related to fear of hostile military or terrorist activity does not have to provide corroboration evidence of the in-service stressor if a VA psychologist or psychiatrist has diagnosed the Veterans PTSD and has already said that the Veteran's PTSD is related to fear of hostile military or terrorist activity.  If the Veteran's in-service stressor incident is adequate to support the PTSD diagnosis, the in-service stressor is consistent with the circumstances of the Veteran's active-duty period of service, and their is no clear and convincing evidence to the contrary, the Veteran's own statements can be used to establish the occurrence of the stressor incident.

What is considered fear of hostile military or terrorist activity?  It is when a Veteran has experienced, witnessed, or been confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the Veteran or service members, such as from an actual or potential IED; vehicle-embedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon friendly military aircraft, and the Veteran’s response to the in-service stressor must involve a psychological or psycho-physiological state of fear, helplessness, or horror.

Something that is important to know is that while there is a lower burden of proof required to get PTSD service-connected if the diagnosis comes from a VA psychologist or psychiatrist, the Veteran's statement describing the in-service stressor that is related to fear of hostile military or terrorist activity and a diagnosis by a non-VA qualified medical provider should trigger the VA's duty to assist by scheduling a VA PTSD exam.

NOTE: If a VA psychologist or psychiatrist state that they do not believe that the Veteran's PTSD is caused by fear of hostile military or terrorist activity, then the Veteran should gather corroborating evidence of the in-service stressor, which another qualified medical provider can use as a basis for a medical nexus opinion under step 3.

The Veteran has PTSD from combat action.

There is a lower burden of proof for combat Veteran's when it come to having corroboration evidence of their in-service stressor. Basically the VA will concede that when a Veteran is involved in combat, that the Veteran's primary focus is to carry out the mission and not taking note of any injuries.  When the Veteran's in-service stressor is related to combat, the in-service stressor is consistent with the circumstances of the Veteran's active-duty period of service, and there is no clear and convincing evidence to the contrary, the Veteran's own statements can be used to establish the occurrence of the stressor incident.

In the VA Adjudications Procedures Manual M21-1MR defines combat as, "personal participation in events constituting an actual fight or encounter with a military foe or hostile unit or instrumentality. It includes presence during such events either as a combatant, or service member performing duty in support of combatants, such as providing medical care to the wounded.” Even when a Veteran has a brief participation in combat it triggers the lower burden of proof required.  It is very important to note that with a brief participation in combat, Veterans might have to prove that they were in combat.

When in comes to proving you are a combat Veteran it can be a simple task because your military service records or your MOS shows where you served.  On the other hand it might not be so easy for other Veterans.  For those Veterans the VA will look at not only their military service records and MOS, but the VA will also look at specific military decorations the Veteran has received, buddy letters, copies of letters they sent home or received from family or friends, copies of local newspapers or regimental or divisional newsletters, photographs, or any other credible evidence that shows and supports that the Veteran was in combat.

If the Veteran states that they served in combat and identifies the in-service stressor that is not impossible to believe and the Veteran has a current diagnosis of PTSD (see step 1), then at that point the VA must take steps to develop evidence. The VA will look in the Veteran's service records for evidence for both combat service and any additional evidence that the in-service combat stressor actually took place.  It is also a good idea for the Veteran to request their own copy of their records. Records that may help prove combat experience can include:

• Veteran's DD214
• Certain medals and awards received
• Unit records showing date and location of unit assignments

Once the Veterans combat service has been established the VA must also accept the Veteran's statement about what happened during combat as proof of combat, even if there is no official records or supporting clinical evidence. Even if there is no other evidence that the in-stressor occurred other then the Veteran's own statement, as long as there is no clear and convincing evidence to the contrary, that the VA is obligated to apply the benefit of the doubt rule and accept the Veteran's statement as proof. Go to step 3.

There are special rules for Veterans that have experienced in-service personal assault or trauma as their stressor.

If the Veterans PTSD is the result of an in-service personal assault or trauma such as physical assault, rape, domestic battering, mugging, robbery, stalking, or harassment, the in-service stressor can be corroborated with alternative evidence, if military records do not show that the personal assault happened. When it comes to MST cases the VA has a special obligation to assist and the VA have to inform the Veteran that any other evidence that can not be found in their military service records can and should be submitted.  Other types of evidence can be records from law enforcement, rape crisis centers, hospitals, mental  health counseling centers, physicians (STD or pregnancy tests), statements from roommates, fellow service members, family members, or clergy, a personal journal or diary, also evidence of any behavior changes such as deterioration in work performances, depression, substance abuse, anxiety, a request to transfer, or panic attacks. Cases like this are frequently denied by the VA mainly due to the VA was created to compensate Veterans for physical disability and because of the nature of MST cases it is rare that there is a formal report or complaint on the record.  That is why the VA relies on the other types of evidence, yet the VA does not give that evidence the weight that it requires.  

The main thing is to get the VA to look at the in-service stressor evidence in the correct context.  Resources for survivors of MST is listed in Part 7.

Go to step 3

What happens if none of the above categories corroboration of in-service stressor applies?

When a Veteran's PTSD claim does not fit into one of the above categories then there has to be corroborating evidence that the in-service stress happened.  This means that there has to be corroborating evidence that includes more then just the Veteran's own statement about the in-service stressor event.  The VA has to assist the Veteran in developing evidence that would support the existence of the in-service stressor unless there is no reasonable possibility that the in-service stressor occurred.

A Veteran's military service records do not need to include every little detail of the in-service stressor event to corroborate the event. Sufficient corroborative evidence can come from a buddy statement or if there is any independent evidence that the in-service stressor event occurred showing that the Veteran was personally exposed to the in-service stressor event. 

Here are two examples of when a Veteran would need corroborating evidence of their in-service stressor event. 

A Veteran was involved in a bad vehicle accident during a period of active-duty service, and that vehicle accident did not occur during combat and the Veteran was not diagnosed with PTSD until after leaving active-duty.  This is when the Veteran would need to get corroborating evidence that the vehicle accident occurred.  The Veteran can use the hospital records, police report, and the statements from the others who were involved in the vehicle accident as supporting evidence.  

If a Veteran was involved in a vehicle accident during a non-combat situation such as a fire or an IED.  Again, the Veteran can use the statements of others who saw the fire or explosion, hospital records, and notations in their service records as corroborating evidence of their in-service stressor.

The VA can reject the Veteran's account of the in-service stressor event if there is contradicting official records.  If the Veteran is able to produce evidence to back up their account of their in-service stressor event then the benefit of the doubt rule still applies.

Go to Step 3

The last thing that a Veteran has to establish to get service-connected for PTSD is providing the VA with medical evidence that connects their current diagnosis to the in-service stressor event. This step will require the opinion of a medical expert.  The medical evidence has to show that the in-service stressor at least contributed to the Veteran's current symptoms.  If a Veteran's military medical service records don't show any evidence of a mental health issue the Veteran can still receive service-connection for PTSD, even if it is several years after leaving active-duty for the PTSD to develop.  

If the Veteran has more then one in-service stressor this step can be more complicated.  Here is an example.

If the first in-service stressor that the Veteran was involved in was a bad vehicle accident while on active-duty and their best friend/another service member was killed and there are service and hospital records backing up this in-service stressor.  The second in-service stressor that the Veteran was involved in was while in their bunk, a fellow service member tossed a grenade at them.  Even though the grenade was a dummy grenade, the Veteran did not know that at the time, and the Veteran still to this day has nightmares about it.  There is no evidence to verify the second in-service stressor except the Veteran's statement. For the Veteran to get compensation for their PTSD from the VA, a qualified medical professional would have to specifically state that the vehicle accident is the only in-service stress with proper corroborating evidence since the second in-service stressor did not qualify under one of the other lower burden of proof situations discussed in step 2. The VA will send the Veteran to a C&P exam to determine if the Veteran is entitled to service-connected disability benefits for their PTSD.

If you're a Veteran or you know a Veteran that is suffering with PTSD, remember that there is nothing shameful about PTSD.  PTSD is a disease that can be treated with proper care and treatment. Continue to Part Three, C&P exams for PTSD, to learn more about how to get PTSD service-connected in order to receive the VA disability benefits you have earned.

PTSD Guide