VVA's GUIDE on PTSD
The purpose of this guide is to assist you, the veteran or survivor, in presenting your claim based on the veteran's exposure to unusually stressful events that led to posttraumatic stress disorder (PTSD). The best way to present your claim to the U.S. Department of Veterans Affairs (VA) is to work with a trained veterans advocate.
This guide describes the VA's current programs for compensating veterans with PTSD or their survivors. Under current VA rules, you can be paid compensation for PTSD if you have a clear diagnosis of the condition, evidence that an in -service stressful event occurred and medical evidence that the "stressor" is linked to the PTSD. Once the VA agrees that your PTSD is service connected, it will then decide how seriously the condition impairs your ability to work.
This guide does not address treatment techniques but does give you suggestions for getting medical care. Additional resources are available to help you understand whether other VA programs may be available to you. (See last page.)
PTSD is not a new problem. It is simply a new name for an old disorder that has been around for thousands of years. The new name has been in use since 1980 when the American Psychiatric Association began to use it in its manual of mental disorders. Although it is often associated with Vietnam veterans, it is being increasingly reported in WWII veterans, perhaps as a consequence of publicity surrounding the 50th anniversaries of WWII events.
There have been many changes in the VA's rules involving PTSD since 1980 and some addi tional changes are expected soon as a result of new understanding about PTSD. Recent decisions by the U.S. Court of Veterans Appeals have also forced changes in how the VA processes these claims. Keep in touch with your representative for additional changes that occur after the publication of this guide.
We include in this guide a short description of what to do if the VA denies your claim or sets only a low percentage for the disability. For more information on how to appeal a denial,VVA has prepared a guide on VA Claims and Appeals.
WHAT IS PTSD?
The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (1994) states:
The essential feature of Posttraumatic Stress Disorder is the development of characteristic syptoms following exposure to an extreme traumatic stressor involving direct personal experience of an event that involves actual or threatened death or serious injury, or other threat to one's physical integrity; or witnessing an event that involves death, injury, or a threat to the physical integrity of another person, or learning about unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or other close associate (Criterion A1). The person's response to the event must involve intense fear, helplessness, or horror (or in children, the response must involve disorganized or agitated behavior) (Criterion A2). The characteristic symptoms resulting from the exposure to the extreme trauma include persistent re-experiencing of the traumatic event (Criterion B), persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (Criterion C), and persistent symptoms of increased arousal (Criterion D). The full sympton picture must be present for more than 1 month (Criterion E), and the disturbance must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (Criterion F).
Traumatic events that are experienced directly include, but are not limited to, military combat, violent personal assault (sexual assault, physical attack, robbery, mugging), being kidnapped, being taken hostage, terrorist attack, torture, incarceration as a prisioner of war or in a concentration camp, natural or manmade disasters, sever automobile accidents, or being diagnosed with a life-threatening illness. For children, sexually traumatic events may include developmentally inappropriate sexual experiences without threatened or actual violence or injury. Witnessed events include, but are not limited to, observing the serious injury or unnatural death of another person due to violent assault, accident, war, or disaster or unexpectedly witnessing a dead body or body parts. Events experienced by others that are learned about include, but are not limited to, violent personal assault, serious accident, or serious injury experienced by a family member or a close friend; learning that one's child has a life-threatening desease. The disorder may be especially severe or long lasting when the stressor is of human design (e.g., torture, rape). The likelihood of developing this disorder may increase as the intensity of and physical proximity to the stressor increase.
The traumatic event can be reexperienced in various ways. Commonly the person has recurrent and intrusive recollections of the event (Criterion B1) or recurrent distressing dreams during which the event is replayed (Criterion B2). In rare instances, the person experiences dissociative states that last from few seconds to several hours, or even days, during which components of the event are relived and the person behaves as though experiencing the event at that moment (Criterion B3). Intense psychological distress (Criterion B4) or physiological reactivity (Criterion B5) often occurs when the peron is exposed to triggering events that resemble or symbolize an aspect of the traumatic event (e.g., anniversaries of the traumatic event; cold snowy weather or uniformed guards for survivors of death camps in cold climates; hot, humid weather for combat veterans of the South Pacific; entering any elevator for a woman who was raped in an elevator).
Stimuli associated with the trauma are persistently avoided. The person commonly makes deliberate efforts to avoid thoughts, feeling, or conversations about the traumatic event (Criterion C1) and to avoid activities, situations, or people who arouse recollections of it (Criterion C2). This avoidance of reminders may include amnesia for an important aspect of the traumatic event (Criterion C3). Diminished responsiveness to the external world, referred to as "psychic numbing" or "emotional anesthesia," usually begins soon after the traumatic event. The individual may complain of having markedly diminished interest or participation in previously enjoyed activities (Criterion C4), of feeling detached or estranged from other people (Criterion C5), or of having markedly reduced ability to feel emotions (especially those associated with intimacy, tenderness, and sexuality) (Criterion C6). The individual may have a sense of foreshortened future (e.g., not expecting to have a career, marriage, children, or a normal life span) (Criterion C7).
The individual has persistent symptoms of anxiety or increased arousal that were not present before the trauma. These symptoms may include difficulty falling or staying asleep that may be due to recurrent nightmares during which the traumatic event is relived (Criterion D1), hyper-vigilance (Criterion D4), and exaggerated startle response (Criterion D5). Some individuals report irritability or outbursts or anger (Criterion D2) or difficulty concentrating or completing tasks (Criterion D3).
TIPS ON WORKING WITH YOUR SERVICE REPRESENTATIVE
Keep in touch: You should talk to your representative at least once per month while your claim is pending. Whenever you get mail from the VA, call your representative to make sure s/he has gotten it and that you both understand it.
Ask questions: If you do not understand something about your case, ask about it. Don't worry about asking a stupid questionyour representative works for you and part of his or her job is making sure that you understand everything.
Be insistent: If something needs to be done, insist that it happen. Do not be talked out of anything unless you understand what is going on. Insist that your representative:
STEP 1: GET HELP
It is a good idea to get a representative to help you present your claim to the VA. VA rules and procedures are very complicated. It can be frustrat ing and hazardous to go it alone.
Many veterans service organizations and state and county veterans service agencies offer free assistance. No matter who you select to represent you, it is important that you be personally involved in your case and make certain that everything that should be done, is done.
Although it can be a difficult task, shop around for the best advocate. Talk to the prospective rep resentative; ask if there are any limits on his ser vice; get a feel for the person who will be working for you before you sign a power of attorney appointing the person as yo ur representative.
STEP 2: APPLY
STEP 3: GET DIAGNOSIS
You cannot get benefits from the VA for PTSD if you do not have a clear diagnosis of PTSD. That diagnosis should come from a mental health professional (psychiatrist, psychologist, social worker or therapist). You, your mother and your lawyer may know you have PTSD but the VA will not pay you unless a medical professional can firmly diagnose you as suffering from PTSD and can link the PTSD to a stressful event during your military service.
If at all possible, work with a private mental health professional who has had experience with PTSD patients and understands the requirements for a clear diagnosis and who is willing to write a detailed report for you that explains exactly the reasons he or she concludes you have PTSD.
Frequently, veterans with PTSD may have other diagnoses: for example, personality disorder or substance abuse. It is very important that your doctor explain how your current diagnosis of PTSD relates to these other disorders. If alcohol or drug abuse was "self-medication" to lessen the symp toms of PTSD, that should be stated.
You can expect the VA to contact you for evidence or for permission to write to your doctor for your medical records. Your response to any VA request for evidence should be made only after consulting with your representative.
The VA ordinarily schedules you for an examination by one of its doctor at a VA hospital or clinic. This "C&P exam" is intended to confirm a diagno sis of PTSD. If you bring a copy of your doctor's report with you, it will be easier for the VA doctor to complete the exam.
If you do not already have a private doctor's report, you should expect the VA doctor to ask many questions about what symptoms you have, when you began to have them, how often and how long you have had them. Some of the hardest questions will be about the stressful experience you had. You will need to be able to describe in detail (and sometimes painful detail) exactly what you experienced. You might also be asked to take a written, standardized test.
The VA doctor prepares a written report that is sent to the VARO in about a month.
STEP 4: GET EVIDENCE OF STRESSOR
To win a PTSD-based claim, you need (1) a diagnosis of PTSD and (2) evidence of a stressful event during your military service. Even if you convince 10 VA and 10 private psychiatrists that you have PTSD, the VARO can still deny your claim if it does not accept your evidence about the stressful event that caused the PTSD.
The stressor you experienced needs to be documented. If your stressor was related to combat while engaged in action with the enemy, your testimony alone should convince the VA that you experienced the event. The VA should not even question your statement if you had a combat MOS or you received a Purple Heart or other award indicating combat service.
On the other hand, if you did not have a combat MOS and simply state that you were often under mortar and rocket attacks, the VA may simply say that your experience was not stressful enough to have caused PTSD since nearly everyone stationed in Vietnam came under such attacks. If, however, you were next to a buddy who was killed or injured, the fact of the death or injury is something that can be confirmed.
If you are a Vietnam vet and you provide the VA with enough details about stressful events in your service, the VA will contact the U.S. Army and Joint Services Environmental Support Group and ask it to review records of the Vietnam war to try to corroborate your experiences. Your representative should be able to show you the guide for the Preparation of PTSD Research Requests that the Support Group offers to reps to help them make a request that the Support Group can work with.
To understand what evidence the VA already has collected, get a free copy of your VA claims file from the VARO. If you need to document your service in Vietnam, get a free set of your complete military personnel records from the National Personnel Records Center in St. Louis using a Standard Form 180, Request Pertaining to Military Records. This form is available from your representative or any VA office.
HOW MUCH MONEY
STEP 5: PRESENT EVIDENCE
You do not help yourself if you simply dump a wad of loose records on the VA. Organize the records and explain their significance in a letter you and your representative prepare together.
You almost always want a hearing at the VA Regional Office if it denies your claim. The hearing will be before an official (the Hearing Officer) who was not involved in the earlier denial. Try to bring even more evidence with you to this hearing.
Read the VA's denial letter carefully to determine whether your claim is being rejected because the VA does not accept what you said about your stressful experience or whether the VA says you do not have a diagnosis of PTSD.
If the VA is rejecting your explanation of your stressful event go to the hearing and provide greater details about it. You also should bring additional evidence; for example, statements from buddies who were with you, newspaper accounts of the operations you were in.
IF YOU LOSE: APPEAL
If the VA Regional Office says your disability is not service-connected or if the percentage of disability is lower than what you think is fair, you have the right to appeal to the Board of Veterans' Appeals.
The first step in appealing is to send the VA Regional Office a "Notice of Disagreement." This Notice is a letter saying that you "disagree" with the denial. Be sure to include in your letter the date of the VA's denial letter and be sure to list the benefits you are still seeking.
Deadline: The Notice of Disagreement must be mailed to the VA Regional Office within one year of the denial of your claim or you cannot appeal. (You still can reopen your claim if you miss this deadline but you lose an earlier "effective date" for an award of back benefits.)
If you win, one issue which you should examine carefully with your representative is whether the VA has set the correct effective date for your award. If you think an earlier effective date is appropriate, you can file a Notice of Disagreement on that issue. More help is available in VVA's Guide on VA Claims and Appeals.
HOW VA SETS LEVEL OF DISABILITY
Once the VA agrees that your PTSD is service-connected, it must determine how im paired you are. The VA regulation that controls this determination is the VA Schedule for Rating Disabilities, 38 C.F.R. §4.130, Diagnostic Code 9411. Under this regulation, PTSD can be rated at 0, 10, 30, 50, 70 or 100%. The symptoms that the VA looks for to set a rating are listed below. Share this regulation with your therapist and ask him or her to write to the VA describing the severity of your condition. Also ask your therapist to use the Global Assessment of Functioning Scale listed in the Diagnostic and Statistical Manual of Mental Disorders.
Keep in mind that under another VA regulation (38 C.F.R. § 4.16), if you can't work be cause of your PTSD, the VA must set you at 100% even if you don't meet the criteria listed below for a 100% rating. If the VA evaluates your disability too low, you should appeal that.
38 C.F.R. 4.130 (excerpt),
Total occupational and social impairment, due to such symptoms
as: gross impairment in thought process or communication; persistent
delusions or hallucinations; grossly inappropriate behavior; persistent
danger of hurting self or others; intermittent inability to perform
activities of daily living (including maintenance of minimal personal
hygiene); disorientation to time or place; memory loss for names of
close relatives, own occupation, or own name