POST TRAUMATIC STRESS DISORDER PTSD

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POST TRAUMATIC STRESS DISORDER (PTSD)
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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

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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
  Rating Disabilities, revised to incorporate
  DSM-IV.

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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 ones physical integrity.

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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.

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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.

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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

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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.

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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)

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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.

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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.

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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."

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AN IMPORTANT NOTE

• If the veteran wants a gender-specific physician,
  ensure this request is sent to VA so they can
  convey the veterans request to the examining
  facility.

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REQUIREMENT FOR NEXUS BETWEEN TRAUMA AND CURRENT
SYMPTOMATOLOGY

• A relationship must be drawn, by the examining
  physician, between the trauma and the current
  diagnosis.

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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.

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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.

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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.

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DEVELOPING THE CASE (cont)

• Evidence to support a claim may be extremely
  difficult to obtain.
• Development may require alternative evidence or
  what is referred to as markers.

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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.

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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

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BEHAVIOR CHANGES INDICATIVE OF A
MARKER (cont)

• 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

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REMINDER

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

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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.

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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.

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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.
  

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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.

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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

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EVIDENCE OF PARTICIPATION IN A STRESSFUL EVENT
(cont)

• 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

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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.

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EVIDENCE OF PARTICIPATION IN A STRESSFUL EVENT
(cont)

• 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

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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))

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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.

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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

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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).

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QUESTION AND ANSWER PERIOD