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Why is it so hard to get benefits for PTSD?

PTSD is a psychiatric condition where a traumatic event occurs (called a “stressor”), and later (sometimes many years later), the veteran experiences symptoms related to that event. These symptoms can include nightmares, flashbacks, guilty feelings, an increased startle response, social isolation, and difficulty with authority figures, to name a few.

Normally, when a veteran seeks service connection for a condition, the claim can be granted if there is a current diagnosis and a doctor gives an opinion that the current condition is related to service. When a veteran is trying to get service connection for PTSD, it’s not so easy, because VA regulations provide an extra hurdle for veterans to get over before being service-connected for PTSD.

To be granted service connection for PTSD, the veteran must have a current diagnosis of PTSD. In addition, the psychologist, counselor or psychiatrist who provides the diagnosis must attribute the PTSD to a stressor that happened while the veteran was on active duty.

Now, here’s the twist. If the stressor is something that happened to the veteran when in the military, but not in combat, there must be evidence that the stressor actually occurred. The proof that the stressor happened cannot come from the veteran’s own memory of the event. Instead, there needs to be independent confirmation. This can come from service records or official military histories, a statement from a buddy who witnessed the event, or a newspaper article about the event. There is one exception to this rule that makes it a little bit easier for a veteran who was assaulted to prove that the assault happened. A bit more about that later in this post.

If the stressor occurred during combat (which includes coming under enemy fire or shelling), it’s a little easier to prove the case, because the stressor does not need to be independently confirmed. However, the veteran will still need to prove he or she was in combat. A veteran can show he or she was in combat through his or her own testimony, as well as through official records.

Here are a few examples to illustrate how a PTSD claim works.

Let’s say that our friend Joe Veteran was in Vietnam in 1968. Although Joe’s military occupational specialty (MOS) was supply clerk, that didn’t stop him from being assigned to various other jobs, including guard duty and driving soldiers back and forth between his station and another twenty miles away. One day in May 1968, Joe was assigned to drive two other soldiers to another station. Along the way, there was a small village where children were playing beside the road. As he was driving by the children, one of them ran out in front of the Jeep, and before he realized what was happening, Joe hit the child. The villagers took the child back to care for him, and although Joe told his superiors about the accident, he isn’t sure if it was officially reported or not. Now, 40 years later, when Joe is driving and sees a Jeep, memories of the accident come rushing back. He has bad dreams about hitting the child, and hasn’t been able to hold a job for more than six months before—he always seems to get into an argument with his boss, and quits or gets fired. After talking with his buddy Steve, who is receiving a 100-percent disability for PTSD, Joe agrees to go to the VA to be seen at the PTSD clinic. His doctor says there’s no doubt, he has PTSD from the stressor of the in-service accident. In this case, because the event didn’t happen during combat, Joe has to show that the accident actually happened. His word by itself, isn’t enough to prove the case. Joe can confirm the stressor in several ways. He can see if he can locate one of the soldiers who was with him in the Jeep on the day of the accident. If either one of them can provide a statement about the accident, that should be enough to confirm the stressor. Joe could also ask for VA’s help to see if there was an official report made about the accident. If so, that report would also be enough to confirm that the stressor occurred. If Joe can’t find any independent confirmation of the stressor, however, he is out of luck, and cannot be service-connected for PTSD.

Let’s change the facts now. Instead of having an accident on the way, this time, while on the road, Joe and his fellow soldiers are suddenly surprised to find that enemy shells are exploding around them. They manage to get away, but years later, Joe finds himself ducking down every time he hears a car backfire or another loud noise. He has nightmares about getting killed by one of the shells, and Joe’s doctor says his PTSD is caused by the shelling incident. Since Joe came under enemy fire, he is considered to have been in combat. Therefore, Joe doesn’t have to prove that the shelling incident actually occurred, and it will be easier for him to be granted service connection. Under an old set of rules, VA sometimes will say that without a medal documenting combat, or a combat MOS, that there’s no evidence of combat. However, VA is not allowed to simply ignore a veteran’s report of having been in combat. This alone can be enough to prove combat.

A third situation is one where a veteran is assaulted in service. Let’s get back to Joe. This time, Joe and his sergeant don’t get along. One day, after a heated argument, Joe’s sergeant sneaks up behind him and hits him over the head with a large piece of wood. No one else is there to witness the event. Joe doesn’t want to get in more trouble with his sergeant, so he doesn’t report the incident. However, he does ask to be transferred to another company, making up an excuse as to why. Now, years later, when he sees someone who looks like his sergeant, Joe has flashbacks about the attack. He’s been diagnosed with PTSD as a result of the attack, and applies for service connection. Since the attack didn’t happen in combat, Joe has to prove that the attack actually occurred. VA recognizes that veterans are often unwilling to talk about or report such attacks, and the rules make it a bit easier for a veteran to prove that the stressor occurred. He can prove it happened through showing things such as behavior changes, requests for transfer or though statements from family members. Here, for example, although Joe gave an excuse for asking for his transfer to another company, he can use that event to prove that the attack occurred.

Here is the text of some relevant VA regulations:

38 C.F.R. § 3.304(f) Post-traumatic stress disorder. Service connection for post-traumatic stress disorder requires medical evidence diagnosing the condition in accordance with 4.125(a) of this chapter; a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. Although service connection may be established based on other in-service stressors, the following provisions apply for specified in-service stressors as set forth below:

(1) If the evidence establishes that the veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran’s service, the veteran’s lay testimony alone may establish the occurrence of the claimed in-service stressor.

(2) If the evidence establishes that the veteran was a prisoner-of-war under the provisions of 3.1(y) of this part and the claimed stressor is related to that prisoner-of-war experience, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran’s service, the veteran’s lay testimony alone may establish the occurrence of the claimed in-service stressor.

(3) If a post-traumatic stress disorder claim is based on in-service personal assault, evidence from sources other than the veteran’s service records may corroborate the veteran’s account of the stressor incident. Examples of such evidence include, but are not limited to: records from law enforcement authorities, rape crisis centers, mental health counseling centers, hospitals, or physicians; pregnancy tests or tests for sexually transmitted diseases; and statements from family members, roommates, fellow service members, or clergy. Evidence of behavior changes following the claimed assault is one type of relevant evidence that may be found in these sources. Examples of behavior changes that may constitute credible evidence of the stressor include, but are not limited to: a request for a transfer to another military duty assignment; deterioration in work performance; substance abuse; episodes of depression, panic attacks, or anxiety without an identifiable cause; or unexplained economic or social behavior changes. VA will not deny a post-traumatic stress disorder claim that is based on in-service personal assault without 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 and allowing him or her the opportunity to furnish this type of evidence or advise VA of potential sources of such evidence. VA may submit any evidence that it receives to an appropriate medical or mental health professional for an opinion as to whether it indicates that a personal assault occurred.

38 C.F.R. § 4.125(a) If the diagnosis of a mental disorder does not conform to DSM-IV or is not supported by the findings on the examination report, the rating agency shall return the report to the examiner to substantiate the diagnosis.