~OST·TRAU MATle

STRESS
DISORDER
(PTSD)

Michael A. Herma
M. Levi Wrig

July 20, 2006

 What is P SO?

• PTSD = Post-traumatic Stres · order

• A mental illness classified amon
Anxiety Disorders.
• A term for certain psychological
consequences (symptoms) of exposu
to, or confrontation with stressful
experiences that the person experienc
as highly traumatic (stressor).

July 20, 2006

 Some sympt ms of PTSD

• Nightmares
• Flashbacks
• Emotional detachment or num
feelings
• Insomnia
• Avoidance of reminders and extre
distress when exposed to the remind
("triggers")
• Irritability
• Hypervigilance
• Memory loss
• Excessive startle response

July 20, 2006

 Factors com ~ning to result
in PTSD

• Suddenness & unexpec

stressful incident
• Active combat & terrorist
• Prolonged & chronic stress
exposure to inhumane treatm
• A victim's psychologic &
constitutional strengths &
weaknesses
• A victim's concurrent bodily
• •
InjUry
• Nature & availability of social
supports

July 20, 2006

 Historic ~ Evolution -
Diagnostic C~sification of
PTSD
• U.8. Civil War - "soIdler

• WWI - "shell shock" or "tra

neurosis"

• WWII & Korea - "combat fatig

• Post-Vietnam - "post-traumatic
stress disorder"
-APA added PTSD to its Diagnostic &
Statistical Manual of Mental Disorders
Third Edition (DSM-III) in 1980 and wa
added to the Rating Schedule in April
1980 (DC 9411)

July 20, 2006

 Service onnection for
pTso:
38 CFR §3:a04(f)
1. A diagnosis supported by exam (or
equivalent)
Must be in accordance WI
CFR §4.125a - Diagnostic
of DSM-IV
2. Reasollably credible evidence of st
event
Regulatory & admillistrative
criteria satisfied?
Claims folder llave evidence of
stressor?
Stressor verified?
3. Nexus/link, established by medical
evidence, between the in-service
stressor and the current PTSD
diagnosis

July 20, 2006

 Establishi 9 a diagnosis of
PTS'O -
Diagnostic crit'Enia of DSM-
IV
In order for a stressor to suC ·ently
support a diagnosis of PTSD, son
must have been ex osed to a tra tic
event in which the person ex erie
witnessed, or was confronted with
event that involved actual or threat
death or serious injury, or a threat t
the pllysical integrity of self or others
and the person's response involved
illtense fear, helplessness, or horror.

July 20, 2006

 Evolutions, hanges, and
things to r~ember

• DSM-III versus DSM-IV - · gnostic

criteria for a PTSD stressor
sufficiency of the stressor) cha
being based on individualized
experiences and responses to "ot
well as self.
• DSM-IValso shifted to a more
subjective standard in determining
whether a stressor was sufficient to
trigger PTSD (no longer "evoke in
almost everyone"), which the Court t
notice of in Cohen v. Brown, 10 Vet.
App. 128 (1997).
• Effective March 7, 1997, the
requirement of a "clear diagnosis" of
PTSD under 38 C.F.R. § 3.304(f) was
replaced by requiring that the veteran
submit "medical evidence diagnosing the
condition."
July 20, 2006
 Evolutions, hanges, and
things to ~ember

• If the preponderance of t evidence

shows that the veteran does
PTSD, the development of a
"downstream issue" is require
verifying stressor). See Gilpin v
West, 155 F.3d 1353 (Fed.eir. 19
• An in-service diagnosis of PTSD (
even psychiatric problems) is not
necessary.

July 20, 2006

 Zarycki v. Bra ~ 6 Vet. App. 91,
98 (1993)

• Mere service in combat ne not

enough to support a diag is of
PTSD
• Must make a factual
determination: Was veteran
engaged in combat with the
enemy?
- Once conlbat is determined, furth
evidentiary development unnecessa
- Then: Do claimed stressors support
diagnosis of PTSD (medical opinion)
and
- Is currently diagnosed PTSD causall
related to those stressors?

July 20, 2006

Cohen v. Brown, '0 Vet. App. 128
(1997)

Held that the Board must gen

make specific filldings of fact, s
by an adequate statement of reas
bases as to whether or not tile vete
was engaged in combat with the en
and, if so, whether the claimed stres
was related to such combat.

July 20, 2006

 Result of Co en v. Brown

• 38 CFR §3.304(f) revised effec

03/07/1997:
- If a veteran engaged in comba
- If the claimed stressor is related
combat,
- Occurrence of the claimed stressor
be established by the veteran's lay
testimony alone
.In the absence of clear & convincing
evidence to the contrary (38 C.F.R.
§3.304(f)(1)), and
.Pro vided that the claimed stressor is
consistent with the circumstances,
conditions, or hardships of the veteran's
•
service.

July 20, 2006

Evolution of 3 CFR §3.304(f)

• Revised again effective

- includes language regardin
resulting front personal assa
- cannot deny such claims base
service personal assault withou
advising claimants that evidence
from sources other than service
records may help prove such stres
occurred.
See 38 C.F.R. §3.304(f)(3).

July 20, 2006

 Other suppa ~ve evidence

• VAOPGCPREC 12-99 Id:

- The meaning of "engaged ombat
with the enemy" requires t e
veteran have taken part in a or
encounter with a military foe
hostile unit or instrumentality
mine).
- Satisfactory proof of engagemen
depends upon the facts of each ca
- No statutory of regulatory limit on
types of evidence.
- Statements in SRs depends upon th
case.
- Benefit-of-the-doubt rule may apply.

July 20, 2006

 Gaines v. Wes , 11 Vet. App. 113
(199 )

Every decision involvin

of service connection for
alleged to have occurred as
result of combat must inclu
factual determination as to
whether or not the veteran
engaged in combat, including t
reasons or bases for that finding.

July 20, 2006

 Some rem·~ers about
streSSQrs

• PTSD need not have onset

combat.
• Stressor need not be limited to
episode.
• PTSD can be caused by events be
during or after service.
• PTSD can occur hours, months or y
after military stressor.
• Evidence must support assertion that
veteran served in area wllere stressful
event occurred.
• Evaluate on an individual case basis
following analysis of all evidence of
record, particularly veteran's
description of events.

July 20, 2006

 Evidence 0 ~-service combat
stres ors:

Chapter 4. Secti H.29.c

Consider the receipt of any of t following

individual decorations as e ce of
exposure to combat- related s
• Air Force Cross
• Air Medal with "V" Device
• ArnlY Commendation Medal with "V" De
• Bronze Star Medal with "V" Device
• Conlbat Action Badge

July 20, 2006

 Evidence of in service combat
stres~rs:

• Combat Action Ribbon

• Combat Aircrew Insignia

• Combat Infantryman Badg~

• Combat Medical Badge

• Distinguished Flying Cross

• Distinguished Service Cross

• Joint Service Conlmendation Medal with "V"

Device

July 20, 2006

 Evidence of in service combat
stres~rs:

• Joint Service Conlmendation Me

Device

• Medal of Honor

• Navy Commendation Medal with "V"

• Navy Cross

• Purple Heart

• Silver Star

July 20, 2006

 Documentati of awards

• DD Form 214 or equiv

• Copies of citations
• Personnel records

July 20, 2006

 Final t to remember
·~s
When
PTSD is clairn~d as 2° to
combat

• Testimony of a veteran
engaged in combat with t
is acceptable proof of serVI
related stressor,

• No further proof necessary.

Cohen v. Brown, 10 Vet. App. r
(1997).

unless ....

• Clear & convincing evidence to

contrary.

July 20, 2006

 Pentecost ~rincipi, 17 Vet.
App. 257 (2003)

• Held that the veteran's unit cords

constituted independent desc tions of
rocket attacks that were exper ed by
the veteran's unit when he was ned
in Vietnam, which, when viewed
light most favorable to the veteran
objectively corroborated his claim
having experienced rocket attacks.

• Corroboration of every detail of a

stressor under such circumstances, suc
as the claimant's own personal
involvement, is not necessary.

July 20, 2006

 SC for PTSD 0 Non-combat
Reas6ns

• VA can grant 2° nonco at

stressors, including sexua
personal assault.
• 38 CFR §3.304(f) states legal
requirements.
• Non-combat veteran's testimon
alone does not qualify as "credi
supporting evidence" of the
incurrence of an in-service
stressor.
• After-the-fact psychiatric analyses
which infer a traumatic event are
insufficient.
July 20, 2006
 Typical non-co bat stressors

• Includes, but is not limi to,

evidence that the veteran
involved in:
- plane crash,
- ship sinking,
- explosion,
- rape or assault,
- POW status,
- duty on burn ward or graves
registration unit.

July 20, 2006

Developing non-combat
stre~ r
• Veteran must be given opportunl to provide
sufficient details for a search. At a nimunl:
e

- Full names,
- Dates (at least month & year),
- Places,
- Units of assignment (battalion or co
level).
• VA must then ask U.S. Army & Joint Servi
Records Research Center (JSRRC), former
the U.S. Armed Services Center for Unit
Records Research (CURR), and before that
Research of Unit Records, Environmental
Support Group (ESG), or
• VA may use other any other authorized means
to verify the claimed stressor.

July 20, 2006

 Developin non-combat
stre~or
• M21-1MR, Part IV.ii.l.D. .d - VA
is not obligated to verify st
that are too vague. The clai
must provide, at a mininlum,
stressor that can be documente
location of where the incident
occurred, the approximate date
within 2 nlonths, and the unit of
assignment.
• M21-1MR, Part IV.ii.l.D.15.a-
when corroboration/verification is
not feasible, then a referral to the
JSRRC is not warranted.

July 20, 2006

 PTSD claims b sed on personal
ass~Jt

• Unique problems documen · g clainls

• An event of human design th hreatens
or inflicts harm
• Rape, physical assault, domestic
battering, robbery, mugging, stal
• Sexual harassment may be less ob
more difficult to corroborate, but
- should not be ruled out as a stres
- repeated instances may be conside
a stressor
• Male veterans also victims

July 20, 2006

 PTSD claims b sed on personal
ass~Jt

• Extremely personal & sensi

• Many incidents not reported
• Difficulty producing evidence 0
• Problems with development of th
claims
- Shame, social stignla
• Alternative evidence must be sought

July 20, 2006

 PTSD claims b sed on personal
assciliJt

• Must have credible evidenc 0 support

an assertion that a stressful e
occurred.
• Evidence does not have to prov
event occurred
• Must have at least an approximat
balance of positive & negative evid
• Review claim & all attached docunt
• Develop for SMRs and personnel
records iltformation as needed

July 20, 2006

 PTSD claims ased on personal
assault - AdditT<;~1 information
sources

• Rape crisis • CiVI n police

center repor
• Center for • Civilia
domestic abuse medical
reports
• Counseling
• Chaplain 0
facility clergy
• Family • Fellow servi
members or persons
roommates • Personal
• Faculty diaries or
member journal

July 20, 2006

 PTSD claims b sed on personal
ass~Jt

• Carefully evaluate all avail e evidence

• Some types of behavioral cha
following the incident which m
to the claimed in-service stresso
- Visits to medical or counseling clinic
dispensary without specific diagnosis
specific ailment
- Sudden request for change of MOS or
assignment
- Lay statements indicating increased use 0
abuse of leave without apparent reason
- Changes in performance & perfornlance
evaluations
- Lay statements describing episodes of
depression, panic attacks or anxiety but no
identifiable reasons

July 20, 2006

 PTSD claims b sed on personal
assciliJt

- Increased or decreased use 0

medicines
- Increased use of over-the-counte
medications
- Evidence of substance abuse - alcoh
drugs
- Increased disregard for military or civ
authority
- Obsessive behavior - over- or undereatin
- Pregnancy tests around time of incident
- Increased interest in tests for HIV or STD
- Unexplained economic or social behavior
changes
- Treatment for physical injuries around the
time of the claimed trauma but not reported
as a result of the trauma
- Breakup of a primary relationship
July 20, 2006
 PTSD claims b sed on personal
ass~Jt

• Secondary evidence rna equire

interpretation by a clinici
especially if involving beha
changes.
• Evidence that documents suc
behavior changes may require
interpretation in relationship to
the medical diagnosis by a
neuropsychiatric physician.

July 20, 2006

 eXU5-
Link Bet~n In-Service
Stre~'Or

& Diagno\~s

• VA or other exam must provl elevant

specific information about the ed
stressor.
• Examiner should comment on pr
or absence of other traumatic even
their relevance to current symptom
• PTSD diagnosis must be supported Jj
history & description.
• Examination must link current
symptoms to in-service stressful
event(s).

July 20, 2006

 Questions?

July 20, 2006