POST TRAUMATIC STRESS DISORDER (PTSD)

1. POST TRAUMATIC STRESS DISORDER (PTSD)

2. LEARNING OBJECTIVES • History of PTSD Diagnosis • Etiology and Symptoms of PTSD • Service Connection for PTSD Secondary to Personal Assault • Service Connection for PTSD Secondary Combat • Current Laws, Regulations and Court Precedents

3. HISTORY OF PTSD • Traumatic stress first identified in World War I as shell- shock, clinically diagnosed as traumatic neurosis. • In 1980 APA added PTSD to DSM-III • Conceptualized as a catastrophic stressor outside the range of usual human experience. • Stressors included war, torture, rape, atomic bombings, and man-made and natural disasters. • DSM-III diagnostic criteria revised 1994 in DSM-IV. • Effective 11/07/96, 38 CFR Part 4, Schedule for RatingDisabilities, revised to incorporate DSM-IV.

4. ETIOLOGY & SYMPTOMS OF PTSD • PTSD is a mental condition classified among the anxiety disorders. • Characterized by physiological and behavioral symptoms following exposure to or awareness of extreme traumatic stressful events involving actual or threatened death or serious injury, or other threat to one’s physical integrity.

5. Stressful Events • A stressful event or stressor (cause or condition capable of producing stress) stimulates the onset of feelings of intense fear, helplessness and/or horror. • Despite persistent efforts to avoid stressors associated with situations or conditions, re-experiencing of events occurs.

6. Traumatic Stressful Events Traumatic events experienced directly by an individual include: • military combat, • physical or sexual assault/harassment, • being kidnapped or taken hostage, • terrorist attack, • incarceration as a prisoner of war, • natural or man-made disasters, and • being diagnosed with a life-threatening illness.

7. Symptoms of Traumatic Events Include: • Nightmares or flashbacks, insomnia • Difficulties in experiencing emotion and impaired mood-control ability, • Irritability, outbursts of anger, • Self-destructive and impulsive behaviors, • Abnormal thought processes, • Physiological complaints, • Feelings of being threatened or injured, • Hostility and social withdrawal, and • Impaired relationships

8. GENERAL COURSE OF PTSD • Severity, duration and proximity of an individual's exposure to a traumatic event are the most important factors related to the development of the condition. • Reactions occurring shortly after the trauma are called acute distress disorder. If the reaction is delayed or recurrent, the term used is PTSD.

9. SERVICE CONNECTION FOR PTSD REQUIRES • Credible supporting evidence that the claimed in-service stressor actually occurred, • Medical evidence establishing a clear diagnosis in accordance with 38 CFR 4.125(a), and • A nexus or link established by medical evidence, between symptomatology and the in-service stressor. • 38 CFR 3.304(f)

10. DEVELOPMENT FOR PTSD SECONDARY TO COMBAT & PERSONAL ASSAULT • PTSD secondary to combat and personal assault & physical trauma are special issues. • Each requires specific development and special consideration when VA weighs evidence and adjudicates the claim.

11. PTSD SECONDARY TO SEXUAL/PERSONAL TRAUMA • Both males and females may have experienced sexual or physical trauma while serving on active military duty. • Some veterans seek counseling and treatment for the after-effects of the trauma; many have never discussed the incident or their medical or psychological condition with anyone. • Victims are uncomfortable talking about the incident and know that they have "not felt the same" since the trauma occurred.

12. THE VA EXAMINATION • Unless medical evidence adequate for rating purposes is already of record, a VA examination must be ordered. • The claims folder should be sent to the VA medical facility of jurisdiction. • The Request for Physical Examination should be annotated "Claims folder to be made available to examiner prior to exam."

13. AN IMPORTANT NOTE If the veteran wants a gender-specific physician, ensure this request is sent to VA so they can convey the veteran’s request to the examining facility.

14. REQUIREMENT FOR NEXUS BETWEEN TRAUMA AND CURRENT SYMPTOMATOLOGY • A relationship must be drawn, by the examining physician, between the trauma and the current diagnosis.

15. CLINICAL INTERPRETATIONS • In Personal Assault claims, secondary evidence of behavior changes may be the only evidence of record to support a stressful event occurred. • A request to VA to obtain service personnel records should be a part of the claim which is filed. • Evidence that documents such behavior changes may require clinical interpretation in relationship to the medical diagnosis by a neuropsychiatric physician.

16. REMINDER When there is evidence of record documenting behavior changes AND There is not evidence which would concede a stressor, request clinical interpretation of the behavior changes when filing the claim.

17. DEVELOPING THE CASE • To service-connect PTSD as secondary to personal assault, there must be credible evidence to support the veteran's assertion that the stressful event occurred. • This does not mean that the evidence actually proves that the incident occurred, rather that there be at least an approximate balance of positive and negative evidence that it occurred. • Assualt is quite often NOT reported.

18. DEVELOPING THE CASE (con’t) Evidence to support a claim may be extremelydifficult to obtain. Development may require alternative evidence or what is referred to as markers.

19. DEFINITION OF A MARKER • Markers are isolated events which, by themselves have no specific relationship to the traumatic event, but take on meaning when viewed in the context of other facts and circumstances contemporary to the trauma/ harassment. • Markers are identified by changes in behavior.

20. BEHAVIOR CHANGES INDICATIVE OF A MARKER • Treatment without specific diagnosis • Treatment for physical injuries around the time of trauma • Sudden request for change in occupation or duty assignment • Abuse of leave without an apparent reason such as family obligations or family illness • Changes in performance evaluations • Increased or decreased use of prescription medications • Evidence of substance abuse such as alcohol or drugs • Increased disregard for military or civilian authority

21. BEHAVIOR CHANGES INDICATIVE OF A MARKER (con’t) • Pregnancy tests around the time of the incident • HIV testing or testing for sexually transmitted diseases • Breakup of a primary relationship • Unexplained economic or social behavior changes • Lay statements describing episodes of depression, panic attacks or anxiety but no identifiable reasons for the episodes

22. REMINDER Service personnel records can be extremely important as they may contain the essential markers required to concede or prove a stressor.

23. Sources of Evidence • A rape crisis center or center for domestic abuse, • A counseling facility or health clinic, • Family members or roommates, • A faculty member, • Civilian or military police reports, • Medical reports from military or civilian • physicians or hospital reports, • A chaplain or clergy, • Fellow service-persons, or • Personal diaries or journals.

24. REMINDER A claim for PTSD as secondary to personal assault should not be denied without VA first advising the claimant that evidence from sources other than the veteran's service records or evidence of behavior changes may constitute credible supporting evidence of the stressor.

25. Patten v. West (March 1999) • Requirement for clinical interpretation of behavioral changes, • resolving reasonable doubt when evidence is in equipoise and not a preponderance of, • duty to assist veteran in fully developing claim.

26. REMINDER • Do not ignore additional mental disorders diagnosed in someone with PTSD. • Request VA ask the examiner to discuss other diagnosis(ses) in relationship to PTSD.

27. PTSD SECONDARY TO COMBAT If claimed stressor is related to combat, in the absence of information to the contrary, receipt of any of the following individual decorations will be considered evidence of participation in a stressful event: • Air Force Cross • Air Medal with "V" Device • Army Commendation Medal with "V" Device • Bronze Star Medal with "V" Device • Combat Action Badge • Combat Action Ribbon

28. EVIDENCE OF PARTICIPATION IN A STRESSFUL EVENT (con’t) • Combat Aircrew Insignia • Combat Infantryman Badge • Combat Medical Badge • Distinguished Flying Cross • Distinguished Service Cross • Joint Service Commendation Medal with "V" Device • Medal of Honor • Navy Commendation Medal with "V" Device • Navy Cross • Purple Heart • Silver Star

29. REMINDER • Medals that specify a “V” (Valor) Device are not acceptable as a verified stressor if they do not include the “V” Device. • Medals by the same name but without the “V” may be authorized for any outstanding accomplishment, not just valor; thus do not represent a verified stressor. • Only when awarded with “V” Device do they signify the veteran was in combat.

30. EVIDENCE OF PARTICIPATION IN A STRESSFUL EVENT (con’t) See FL 05-11 for information on four additional medals that have recently been established. They are: • Global War on Terrorism Expeditionary Medal • Global War on Terrorism Service Medal • Afghanistan Campaign Medal • Iraq Campaign Medal

31. LAY TESTIMONY • If evidence establishes veteran engaged in combat with enemy and claimed stressor is related to that combat, and • in absence of clear and convincing evidence to contrary and provided claimed stressor is consistent with the circumstances of service, then • veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. (Authority: 38 USC 1154(b))

32. REMINDER • A non-combat veteran's testimony alone does not qualify as "credible supporting evidence" of the occurrence of an in-service stressor as required by 38 CFR 3.304(f). • After-the-fact psychiatric analyses which infer a traumatic event are likewise insufficient in this regard.

33. Specific Requests to VA for Combat Development • Request development for service Department (personnel) records (M21-1 MR, IV.ii.1.D.14) • Request a VA exam when filing the claim

34. HOW TO SUBMIT A QUALITY STRESSOR STATEMENT • A two-month specific date range when stressful event occurred; • Veteran's unit of assignment at the time of the stressful event; and • Geographic location where the stressful event took place; and • Medals or citations received by veteran; and • Account(s) of stressful events witnessed by veteran (names of other soldiers or sailors involved, dates, units of assignment, and their geographic location is essential).

35. QUESTION AND ANSWER PERIOD