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Mental Disorders - M21-1mr

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This is from M21-1MR

Section H. Mental Disorders

PRIVATE INFOTYPE="OTHER" Overview

In this Section

This section contains the following topics:

Topic

Topic Name

See Page

27

General Information on Mental Disorders

4-H-2

28

General Information on Posttraumatic Stress Disorder (PTSD)

4-H-5

29

Evaluating Evidence of an In-Service Stressor

4-H-7

30

Evaluating Evidence in Claims Based on Personal Trauma

4-H-15

31

Handling Examinations in Claims for Service Connection for PTSD

4-H-18

32

Deciding a Claim for Service Connection for PTSD

4-H-21

27. General Information on Mental Disorders

PRIVATE INFOTYPE="OTHER"

Introduction

This topic contains general information about rating mental disorders, including

considering a change in the diagnosis of a psychiatric disorder

making reductions in evaluations of psychiatric disorders

considering attempted suicide

a definition of psychosis

handling a veteran’s discharge from service for a mental disorder due to traumatic stress, and

considering a Global Assessment of Functioning (GAF) score.

Change Date

August 3, 2009

a. Considering a Change in the Diagnosis of a Psychiatric Disorder If the diagnosis of a psychiatric condition is changed, return the examination and any appropriate records to the examiner to determine whether the new diagnosis represents

progression of the prior disorder

correction of an error in the prior diagnosis, or

development of a new and separate condition.

Reference: For more information on the diagnosis of mental disorders, see HYPERLINK "http://www.warms.vba.va.gov/regs/38CFR/BOOKC/PART4/S4_125.DOC"38'>http://www.warms.vba.va.gov/regs/38CFR/BOOKC/PART4/S4_125.DOC"38 CFR 4.125.

b. Making Reductions in Evaluations of Psychiatric DisordersDo not make drastic reductions in evaluations in ratings for psychiatric disorders

if a reduction to an intermediate rate is more in agreement with the degree of disability.

Observe the general policy of gradually reducing the evaluation to afford the veteran all possible opportunities for adjustment.

Reference: For more information on the stabilization of disability evaluations, see HYPERLINK "http://www.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_344.DOC"38 CFR 3.344.

STYLEREF "Map Title" 27. General Information on Mental Disorders, Continued

c. Considering Attempted SuicideIn the absence of any underlying psychiatric disability subject to service connection, a finding of mental unsoundness under the provisions of HYPERLINK "http://www.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_302.DOC" 38 CFR 3.302 does not, in itself, constitute a disability subject to service connection.

d. Definition: PsychosisFor the purpose of presumptive service connection under HYPERLINK "http://www.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_309.DOC" 38 CFR 3.309(a), a psychosis is any of the following disorders:

Brief Psychotic Disorder

Delusional Disorder

Psychotic Disorder Due to General Medical Condition

Psychotic Disorder Not Otherwise Specified

Schizoaffective Disorder

Schizophrenia

Schizophreniform Disorder

Shared Psychotic Disorder, and

Substance-Induced Psychotic Disorder.

Note: The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, of the American Psychiatric Association (DSM–IV–TR), has designated the disorders listed above as psychotic disorders.

Reference: For the regulation governing the definition of psychosis, see HYPERLINK "http://www.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_384.DOC" 38 CFR 3.384.

e. Handling a Veteran’s Discharge From Service for a Mental Disorder Due to Traumatic StressUnder HYPERLINK "http://www.warms.vba.va.gov/regs/38CFR/BOOKC/PART4/S4_127.DOC"38 CFR 4.129,

when a mental disorder that develops in service

from a highly stressful event is severe enough to result in the veteran’s discharge from active military service

assign a service-connected (SC) evaluation of at least 50 percent, and

schedule an examination within six months of the veteran’s discharge to determine whether a change in the evaluation is warranted.

STYLEREF "Map Title" 27. General Information on Mental Disorders, Continued

f. Considering a GAF Score

A Global Assessment of Functioning (GAF) score is an assessment of an individual’s overall level of psychological, social, and

occupational functioning on a scale of zero to 100.

When considering a GAF score

evaluate the score in light of all the evidence in the case, including symptomatology and manifestations shown at the mental status examination and in treatment records, and do not base the disability evaluation solely or primarily on the score.

Note: The GAF score is shown on Axis V of a psychiatric diagnosis.

Reference: For more information on the GAF score, see the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV).

28. General Information on Posttraumatic Stress Disorder (PTSD)

PRIVATE INFOTYPE="OTHER"

Introduction

This topic contains general information about rating posttraumatic stress disorder (PTSD), including

the responsibility of the Rating Veterans Service Representative (RVSR)

the requirements for establishing service connection for PTSD

considering the relationship between stressor and symptoms, and

handling an in-service diagnosis of PTSD.

Change Date

August 3, 2009

a. Responsibility of the RVSR

Deciding the issue of service connection for posttraumatic stress disorder (PTSD) is the sole responsibility of the appropriate decision maker

at the local level, generally a Rating Veterans Service Representative (RVSR) or a Decision Review Officer (DRO).

Note: Central Office opinion or guidance may be requested on complex cases.

STYLEREF "Map Title" 28. General Information on Posttraumatic Stress Disorder (PTSD), Continued

b. Requirements for Establishing Service Connection for PTSDPer HYPERLINK "http://www.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_304.DOC" 38 CFR

3.304(f), a finding of service connection for PTSD requires credible supporting evidence that the claimed in-service stressor actually occurred

medical evidence diagnosing the condition in accordance with HYPERLINK "http://www.warms.vba.va.gov/regs/38CFR/BOOKC/PART4/S4_125.DOC" 38 CFR 4.125, and

a link, established by medical evidence, between current symptomatology and the claimed in-service stressor.

Note: The lay testimony of a combat veteran alone may establish an in-service stressor for the purposes of establishing service connection for PTSD.

Reference: For more information on establishing service connection for PTSD, see

HYPERLINK "http://10.220.1.4/bl/21/M21-1MR/index.asp?id=pt04_sp02_ch01_secD.xml" \l "IV.ii.1.D"M21-1MR, Part IV, Subpart ii, 1.D

HYPERLINK "http://www.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_304.DOC"38 CFR 3.304(f), and

HYPERLINK "http://straylight.law.cornell.edu/uscode/html/uscode38/usc_sec_38_00001154----000-.html"38 U.S.C. 1154(b).

c. Considering the Relationship Between Stressor and Symptoms

To establish service connection for PTSD the relationship between stressor and symptoms must be specifically addressed in the Department of Veterans Affairs (VA) examination report, and supported by documentation.

d. Handling an In-Service Diagnosis of PTSD When PTSD is properly diagnosed in service, the veteran’s testimony alone may establish

that the claimed stressor occurred, as long as the claimed stressor is related to the veteran’s service, and

consistent with the circumstances, conditions, or hardships of that service.

Reference: For more information, see HYPERLINK "http://www.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_304.DOC"38 CFR 3.304(f)(1).

29. Evaluating Evidence of an In-Service Stressor

PRIVATE INFOTYPE="OTHER"

Introduction

This topic contains information about evaluating evidence of an in-service stressor, including

the significance of combat and POW service

the definition of engaging in combat

individual decorations as evidence of combat participation

action to take if a veteran received a combat decoration but does not state the nature of the stressor

what constitutes credible supporting evidence

the degree of stressor corroboration required

non-combat-related stressors

primary evidence to corroborate a claimed in-service stressor

secondary sources of evidence which may corroborate a claimed in-service stressor

considering testimony in PTSD claims

considering buddy statements, and

obtaining evidence related to claimed stressors.

Change Date

August 3, 2009

Continued on next page

STYLEREF "Map Title" 29. Evaluating Evidence of an In-Service Stressor, Continued

a. Significance of Combat and POW ServiceThe veteran’s testimony alone establishes the occurrence of the claimed in-service stressor if

the evidence of record confirms the veteran

engaged in combat, or

was a POW as defined by HYPERLINK "http://www.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_1.DOC"38 CFR 3.1(y)

the claimed stressor is related to that episode of combat or POW experience

there is no clear and convincing evidence to the contrary, and

the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran’s service.

References: For more information on

claims for service connection for PTSD, see

HYPERLINK "http://www.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_304.DOC"38 CFR 3.304(f), and

HYPERLINK "http://straylight.law.cornell.edu/uscode/html/uscode38/usc_sec_38_00001154----000-.html"38 U.S.C. 1154(b), and

accepting lay evidence of combat-related disability, see HYPERLINK "http://www.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_304.DOC" 38 CFR 3.304(d), and

evidence that may be used to support a determination that a veteran engaged in combat with the enemy, see HYPERLINK "http://vbaw.vba.va.gov/bl/21/Advisory/PRECOP/99op/Prc12_99.doc"VAOPGCPREC Opinion 12-99.

b. Definition: Engaging in Combat

Engaging in combat with the enemy means personal participation in events constituting an actual fight or encounter with a military foe or hostile unit or instrumentality. It includes presence during such events either as a combatant, or service member performing duty in support of combatants,

such as providing medical care to the wounded.

STYLEREF "Map Title" 29. Evaluating Evidence of an In-Service Stressor, Continued

c. Individual Decorations as Evidence of Combat ParticipationConsider the receipt of any of the following individual decorations as evidence of personal participation in combat:

Air Force Achievement Medal with “V” Device

Air Force Combat Action Medal

Air Force Commendation Medal with “V” Device

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 (Note: Prior to February 1969, the Navy Achievement Medal with “V” Device was awarded.)

Combat Aircrew Insignia

Combat Infantry/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, and/or

Silver Star.

Important:

Receipt of one of the decorations cited above is not the only acceptable evidence of engagement in combat.

If a veteran received a Global War on Terrorism Expeditionary Medal, Global War on Terrorism Service Medal, Afghanistan Campaign Medal, or Iraq Campaign Medal, but not one of the combat decorations cited above, develop for the claimed stressor as shown in HYPERLINK "pt04_sp02_ch04_secH.xml" \l "IV.ii.1.D.14" M21-1MR, Part IV, Subpart ii, 1.D.14. Receipt of these campaign medals alone does not generally indicate engagement in combat.

Continued on next page

STYLEREF "Map Title" 29. Evaluating Evidence of an In-Service Stressor, Continued

d. Action to Take if Veteran Received Combat Decoration but Does Not State Nature of StressorIf a veteran received one of the combat decorations cited in HYPERLINK "pt03_sp04_ch04_secH" \l "III.iv.4.H.29.c"M21-1MR, Part III, Subpart iv, 4.H.29.c but does not expressly state the nature of the stressor

assume the stressor is combat related

order an examination, if necessary to decide the claim, and

in the examination request

state that VA has verified the veteran’s combat service, and

specify any details regarding the combat stressor contained in the record.

e. What Constitutes Credible Supporting EvidenceCredible supporting evidence that an in-service stressor actually occurred includes not only evidence that specifically documents the veteran’s personal participation in the event, but evidence that

indicates the veteran served in the immediate area and at the particular time in which the stressful event is alleged to have occurred, and

supports the description of the event.

Notes:

Evaluate the evidence as a whole to determine whether a stressor is sufficiently corroborated. (See HYPERLINK "http://vbaw.vba.va.gov/bl/21/Advisory/CAVCDAD.htm" \l "bmm"Moran v. Principi, 17 Vet. App. 149 (2003).)

Corroborating evidence of a stressor is not restricted to service records, but may be obtained from other sources. (See HYPERLINK "http://vbaw.vba.va.gov/bl/21/Advisory/CAVCDAD.htm" \l "bmd"Doran v. Brown, 6 Vet. App. 283 (1994).)

The credible supporting evidence requirement does not necessarily demand the submission of official documentary evidence.

STYLEREF "Map Title" 29. Evaluating Evidence of an In-Service Stressor, Continued

f. The Degree of Stressor Corroboration RequiredCorroboration of every detail, including the claimant’s personal participation in the claimed stressful event,

is not required. The evidence may be sufficient if it implies a veteran’s personal exposure to the event.

Examples:

When considered as a whole, evidence consisting of a morning report, radio log, and nomination for a Bronze Star may be sufficient to corroborate

a veteran’s account of an event, even if it does not specifically include mention of the veteran’s name.

(See HYPERLINK "http://vbaw.vba.va.gov/bl/21/Advisory/CAVCDAD.htm" \l "bms"Suozzi v. Brown, 10 Vet. App. 307 (1997).)

Unit records documenting the veteran’s presence with a specific unit at the time mortar attacks occurred may be sufficient to corroborate

a veteran’s statement that she/he experienced such attacks personally. (See HYPERLINK "http://vbaw.vba.va.gov/bl/21/Advisory/CAVCDAD.htm" \l "bmp"Pentecost v. Principi, 16 Vet. App. 124 (2002).)

g. Non-Combat-Related Stressors

Potential non-combat-related stressors include, but are not limited to

plane crash

ship sinking

explosion

rape or assault

duty

on a burn ward

in graves registration unit, or

involving liberation of internment camps

witnessing the death, injury, or threat to the physical being of another person not caused by the enemy

actual or threatened death or serious injury, or other threat to one’s physical being, not caused by the enemy.

STYLEREF

"Map Title" 29. Evaluating Evidence of an In-Service Stressor, Continued

h. Primary Evidence to Corroborate a Claimed In-Service Stressor

Primary evidence is generally considered the most reliable source for corroborating in-service stressors.

It is typically obtained from the U.S. Army and Joint Services Records Research Center (JSRRC) (formerly the U.S. Armed Services Center for Unit Records Research (CURR)), the National Archives and Records Administration (NARA), or the Marine Corps University Archives (MCUA)

and should be carefully reviewed for information confirming participation in combat or to otherwise corroborate a claimed in-service stressor.

Primary evidence includes

unit and organizational histories

daily staff journals

operational reports-lessons learned

after action reports

radio logs

deck logs and ship histories

muster rolls

command chronology

war diaries

monthly summary, and

morning reports.

STYLEREF

"Map Title" 29. Evaluating Evidence of an In-Service Stressor, Continued

i. Secondary Sources of Evidence That May Corroborate a Claimed In-Service Stressor Review the following alternative sources of evidence critically and carefully for information confirming participation in combat or to otherwise corroborate a claimed in-service stressor:

military occupational specialty (MOS) evidence (Note: A veteran’s MOS may be specified on his/her DD Form 214, Certificate of Release or Discharge from Active Duty, or in the personnel folder.)

hazard pay records (Note: This information may be requested from the Department of Defense Finance and Accounting Service (DFAS).)

personnel folder (Note: This information may be requested via PIES.)

service treatment records

performance reports (Note: This information may be requested via PIES.)

verification that the veteran received Combat/Imminent Danger/Hostile Fire Pay

(Note: This information may be requested through the Veterans Information Solution (VIS).)

buddy statements

contemporaneous letters and diaries

newspaper archives, and

information from Veterans Benefits Administration (VBA)-sanctioned websites, which may be accessed through the HYPERLINK "http://vbaw.vba.va.gov/bl/21/rating/rat06.htm"PTSD Rating Job Aid website.

Reference: For more information on Combat/Imminent Danger/Hostile Fire Pay, see the

HYPERLINK "http://vbaw.vba.va.gov/bl/21/rating/rat06.htm"PTSD Rating Job Aid website, and

HYPERLINK "http://vbaw.vba.va.gov/bl/21/Calendar/Agenda/FY06/Agenda0306.htm"VSCM Conference Call, March 16, 2006.

Important:

All sources of evidence obtained for purposes of stressor verification must be fully documented in the file.

While confirmation of receipt of Combat/Imminent Danger/Hostile Fire Pay through the VIS alone does not constitute verification of a combat-related stressor, it may, in combination with other evidence, "tip the scales" in favor of the veteran's assertion of his/her involvement in combat.

Continued on next page

STYLEREF "Map Title" 29. Evaluating Evidence of an In-Service Stressor, Continued

j. Considering Testimony in PTSD ClaimsA combat veteran’s lay testimony alone may establish an in-service stressor for purposes of establishing service connection for PTSD.

Evidence that does not qualify as credible supporting evidence of the occurrence of an in-service stressor as required by HYPERLINK "http://www.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_304.DOC" 38 CFR 3.304(f) includes

a non-combat veteran’s testimony alone (except as provided in HYPERLINK "http://www.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_304.DOC"38 CFR 3.304(f)(1) when PTSD is diagnosed in service) and

after-the-fact psychiatric analyses that infer the occurrence of a traumatic event.

References: For more information on

using lay evidence to establish service connection for PTSD, see HYPERLINK "http://vbaw.vba.va.gov/bl/21/Advisory/CAVCDAD.htm" \l "bmc"Cohen v. Brown, 10 Vet. App. 128 (1997), and

a non-combat veteran’s testimony and after-the-fact psychiatric analyses as examples of evidence that does not qualify as credible supporting evidence, see HYPERLINK "http://vbaw.vba.va.gov/bl/21/Advisory/CAVCDAD.htm" \l "bmm"Moreau v. Brown, 9 Vet. App. 389 (1996).

k. Considering Buddy Statements

Accept a buddy statement as corroboration of a claimed in-service stressor, so long as the statement is consistent with the time, place, and circumstances of the service of both the veteran and the buddy.

If the evidence available calls into question the qualifications of the buddy to make the statement, ask the person to submit his/her DD Form 214 or other evidence of service with the claimant.

Note: Upon receipt of a DD Form 214 (or other document containing personally identifiable information) from a fellow veteran

place the document in a separate envelope in the claims folder, and

annotate on the envelope that the contents must not be

reproduced, or

reviewed by the veteran to whom the claims folder pertains or his/her representative.

l. Obtaining Evidence Related to Claimed StressorsFor more information on obtaining service records, medical treatment records, and evidence of stressors,

see HYPERLINK "pt04_sp02_ch01_secD.xml" \l "IV.ii.1.D"M21-1MR, Part IV, Subpart ii, 1.D.

30. Evaluating Evidence in Claims Based on Personal Trauma

PRIVATE INFOTYPE="OTHER"

Introduction

This topic contains information about evaluating evidence in claims based on personal trauma, including

evidence of personal trauma

alternative evidence of in-service personal trauma

evaluating the available evidence

development requirements for secondary evidence

interpretation of secondary evidence, and

obtaining evidence.

Change Date

August 3, 2009

a. Evidence of Personal Trauma

Personal trauma is an event of human design that threatens or inflicts harm, such as

rape

physical assault and domestic battering

robbery and mugging

stalking, and

harassment.

b. Alternative Evidence of In-Service Personal Trauma

If the military record contains no documentation that personal trauma, including in-service sexual assault, occurred, alternative evidence

might still establish an in-service stressful incident.

Sources of such evidence include

a rape crisis center or center for domestic abuse

a counseling facility or health clinic

family members or roommates

a faculty member

civilian police reports

medical reports from civilian physicians or caregivers who treated the veteran immediately or sometime later

a chaplain or clergy

fellow service persons, and

personal diaries or journals.

STYLEREF

"Map Title" 30. Evaluating Evidence in Claims Based on Personal Trauma, Continued

c. Evaluating the Available Evidence

Rating Veterans Service Representatives (RVSRs) must carefully evaluate all of the available evidence.

If the military records contain no documentation that personal trauma occurred, consider secondary evidence, such as

lay statements indicating increased use or abuse of leave without an apparent reason, such as family obligations or family illness, or

describing episodes of depression, panic attacks, or anxiety, but no identifiable reasons for the episodes, and

evidence of behavioral changes that occurred around the time of the incident, including

visits to a medical or counseling clinic or dispensary without a specific diagnosis or specific ailment

use of pregnancy tests or tests for sexually-transmitted diseases around the time of the incident

sudden requests that the veteran’s military occupational series or duty assignment be changed without other justification

changes in performance and performance evaluations

increased or decreased use of prescription medications

increased use of over-the-counter medications

evidence of substance abuse, such as alcohol or drugs

increased disregard for military or civilian authority

obsessive behavior such as overeating or undereating

increased interest in tests for HIV or sexually transmitted diseases

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, and/or

the breakup of a primary relationship.

Notes:

Secondary evidence may need interpretation by a clinician in personal trauma claims, especially if the claim involves behavior changes.

Evidence that documents behavior changes may require interpretation in relation to the medical diagnosis by a neuropsychiatric physician.

Important: When preparing letters of notification or rating decisions in personal trauma cases, use a tone that conveys sensitivity and compassion,

regardless of whether the claim is granted or denied.

STYLEREF "Map Title" 30. Evaluating Evidence in Claims Based on Personal Trauma, Continued

d. Development Requirements for Secondary Evidence

Do not deny a PTSD claim that is based on in-service personal trauma without first advising the claimant that evidence from sources other than service treatment records (STRs), such as evidence of behavioral changes, may constitute credible supporting evidence of the stressor.

Allow the veteran the opportunity to furnish this type of evidence or indicate its potential sources.

e. Interpretation of Secondary EvidenceIn personal trauma claims, interpretation of secondary evidence by a clinician may be required, especially if the claim involves behavioral changes.

Evidence that supports such behavioral changes may require

interpretation in relationship to the medical diagnosis, or

an opinion by an appropriate medical or mental health professional as to whether it indicates that personal trauma occurred.

Reference: For more information on VA’s responsibility to obtain secondary evidence needed to corroborate a personal trauma claim, see HYPERLINK "http://vbaw.vba.va.gov/bl/21/Advisory/CAVCDAD.htm" \l "bmp"Patton v. West, 12 Vet. App. 272 (1999).

f. Obtaining EvidenceFor more information on obtaining service records, medical treatment records, and evidence of personal trauma, see HYPERLINK "pt04_sp02_ch01_secD.xml" \l "IV.ii.1.D" M21-1MR, Part IV, Subpart ii, 1.D.

31. Handling Examinations in Claims for Service Connection for PTSD

PRIVATE INFOTYPE="OTHER"

Introduction

This topic contains information about handling examinations in claims for service connection for PTSD, including

when to proceed with an examination

requesting initial PTSD examinations, and

handling inadequate examination reports.

Change Date

August 3, 2009

a. When to Proceed With an ExaminationIn PTSD claims alleging personal trauma, if development fails to identify credible supporting evidence that

the claimed stressor actually occurred, or fails to show in-service behavioral changes, deny the claim.

Otherwise, request an examination if it is necessary to decide the claim.

In PTSD claims alleging a stressor other than personal trauma, if development fails to identify credible supporting evidence that the claimed

stressor actually occurred, then deny the claim.

Request an immediate examination if evidence or records confirm the stressor occurred

evidence (to include lay statements) indicates the veteran currently suffers from symptoms consistent with a diagnosis of PTSD, and

medical evidence adequate for rating purposes is not already of record.

Notes:

Do not request an examination until

all development actions are complete, and

all medical evidence requested has been received (or the specified time limit for submitting the evidence has expired).

Forward the claims folder to the examining facility and request its review as part of the examination process anytime the issue is service connection for PTSD.

References: For more information on

requesting examinations, see HYPERLINK "pt03_sp04_ch03_secA.xml" \l "III.iv.3.A" M21-1MR, Part III, Subpart iv, 3.A

PTSD examinations, see the “Best Practice Manual” in the HYPERLINK "http://vbaw.vba.va.gov/bl/21/Rating/rat01.htm"Rating Job Aids website, and

requesting medical evidence, see HYPERLINK "pt01_ch01_secC.xml" \l "I.1.C" M21-1MR, Part I, 1.C.

Continued on next page

STYLEREF "Map Title" 31. Handling Examinations in Claims for Service Connection for PTSD, Continued

b. Requesting Initial PTSD Examinations When evidence of exposure to combat-related stressors is established by a veteran’s individual decoration(s),

include a statement to that effect in the Remarks section of the examination request.

This evidence allows VA (including the examiner) to accept the veteran’s own description of the specific events without further corroboration.

Important: Evidence of exposure to combat, in itself, does not satisfy the diagnostic criteria for PTSD stated in the Diagnostic and Statistical Manual

of Mental Disorders, Fourth Edition (DSM-IV). The examiner is still required to elicit details of a specific traumatic event or events described

by the veteran to determine whether the event is persistently reexperienced. This information is needed to support a diagnosis of PTSD,

if found, in accordance with the DSM-IV diagnostic criteria.

Note: When requesting a PTSD examination, specify that if possible, the veteran’s treating mental health professional should not perform the examination.

Reference: For more information on evidence of combat-related stressors, see

HYPERLINK "http://10.220.1.4/bl/21/M21-1MR/index.asp?id=pt03_sp04_ch04_secH.xml" \l "III.iv.4.H.29"M21-1MR, Part III, Subpart iv, 4.H.29, and

HYPERLINK "http://10.220.1.4/bl/21/M21-1MR/index.asp?id=pt04_sp02_ch01_secD.xml" \l "IV.ii.1.D"M21-1MR, Part IV, Subpart ii, 1.D.

Continued on next page

STYLEREF "Map Title" 31. Handling Examinations in Claims for Service Connection for PTSD, Continued

c. Handling Inadequate Examination Reports

If an examination report is received with a diagnosis of PTSD that does not contain essential information

return the examination report as inadequate for rating purposes note the deficiencies of the examination, and

request a reexamination.

Examples:

An unacceptable examination report

fails to sufficiently describe symptomatology

fails to identify or to adequately describe the stressor

fails to acknowledge and consider prior reports demonstrating a mental disorder that do not support a diagnosis of PTSD, or

fails to conform to DSM-IV.

Notes:

The diagnosis of PTSD must be made by a competent (properly qualified) medical professional and should be unequivocal.

The examining psychiatrist or psychologist should comment on whether the veteran has experienced other traumatic events and,

if so, indicate the relevance of these events to the current symptoms.

32. Deciding a Claim for Service Connection for PTSD

PRIVATE INFOTYPE="OTHER"

Introduction

This topic contains information about deciding a claim for service connection for PTSD, including

considering stressors when making the decision

determining combat service

considering

secondary evidence, and

participation in operations or campaigns

the requirement for credible supporting evidence

identifying credible supporting evidence of a non-combat stressor

reviewing evidence for corroboration of a stressor

examples of credible supporting evidence to corroborate a claimed in-service stressor

determining link between in-service stressor and diagnosis

making a decision, and

denying a claim because of an unconfirmed stressor.

Change Date

August 3, 2009

STYLEREF

"Map Title" 32. Deciding a Claim for Service Connection for PTSD, Continued

a. Considering Stressors When Making the Decision

When determining the occurrence of stressors to establish service connection for PTSD, consider the following:

PTSD does not need to have its onset as a result of combat (for example, vehicular or airplane crashes, large fires, floods, earthquakes, and other disasters evoke significant distress in most involved persons)

the trauma may be experienced alone, such as in cases of rape or assault, or in the company of groups of people, such as in military combat

do not limit a stressor to just one single episode; a group of experiences also may affect an individual, leading to the development of PTSD

PTSD can be caused by events that occur before, during, or after service, and

PTSD can develop hours, months, or years after a stressor.

Notes:

The relationship between stressors during military service and current problems/symptoms will govern the question of service connection.

Despite the possibly long latent period, PTSD may be recognizable by a relevant association between the stressor and the current presentation of symptoms.

Important: Symptoms must have a clear relationship to the military stressor as described in the medical reports.

STYLEREF

"Map Title" 32. Deciding a Claim for Service Connection for PTSD, Continued

b. Determining Combat ServiceEvery decision involving the issue of service connection for PTSD that allegedly developed as a result of combat must include a factual determination as to whether or not the veteran was engaged in combat, including the reasons or bases for that finding.

Important: In order to conclude that a veteran “engaged in combat with the enemy,” the evidence must establish that the veteran was present during an encounter with a military foe either as a combatant or as a service member performing duty in support of combatants.

Notes:

There are no limitations as to the type of evidence may be accepted to confirm engagement in combat.

Any evidence that is probative of (serves to establish the fact at issue) combat participation may be used to support a determination that a veteran

engaged in combat.

Determining whether evidence proves a veteran developed PTSD as a result of combat-related stressors requires an evaluation of all evidence in the case, including an assessment of the credibility of the evidence, and

whether the evidence can establish that the stressful event occurred.

Apply the benefit-of-the-doubt standard if the evidence is in equipoise.

References:

For more information on

the need to determine combat involvement in PTSD claims, see HYPERLINK "http://vbaw.vba.va.gov/bl/21/Advisory/CAVCDAD.htm" \l "bmg"Gaines v. West, 11 Vet. App. 113 (1998), and

what evidence may be used to support a determination that a veteran engaged in combat, see HYPERLINK "http://vbaw.vba.va.gov/bl/21/Advisory/PRECOP/99op/Prc12_99.doc"VAOPGCPREC 12-99.

c. Considering Secondary EvidenceAlthough secondary evidence may be used to confirm engagement in combat, it must be critically and

carefully reviewed for sufficiency.

Note: In many instances, secondary evidence does not constitute competent evidence to support such a determination.

Reference: For more information on secondary sources of evidence, see HYPERLINK "pt03_sp04_ch04_secH" \l "III.iv.4.H.29.h"M21-1MR, Part III, Subpart iv, 4.H.29.h.

Continued on next page

STYLEREF "Map Title" 32. Deciding a Claim for Service Connection for PTSD, Continued

d. Considering Participation in Operations or Campaigns

Generally, reference to a veteran’s participation in a particular “operation” or “campaign” will not, by itself, confirm engagement in combat.

However, there may be circumstances in which the language and context of the reference does reflect combat participation.

e. Requirement for Credible Supporting Evidence

The requirement for credible supporting evidence means that there must be some believable evidence that tends to support the veteran’s assertion.

In determining whether evidence is credible, consider its

plausibility

consistency with other evidence in the case, and

source.

Note: Credibility is only a minimum requirement. (Evidence that is not believable is not entitled to any weight.)

In addition to being credible, evidence must also be material or probative to the issue, and

have enough weight to persuade the decision-maker that the stressor is sufficiently verified with some degree of specificity.

f. Identifying Credible Supporting Evidence of a Non-Combat Stressor

If the claimed stressor is not combat-related, a claimant’s lay testimony regarding in-service stressors

is not sufficient, by itself, to establish the occurrence of the stressor, and must be corroborated by credible supporting evidence.

Credible supporting evidence of a non-combat stressor may include

service treatment or personnel records

private medical records

lay statements, or

newspaper accounts of the traumatic event.

Example:

STRs may contain record of the veteran’s medical treatment after an accident.

STYLEREF

"Map Title" 32. Deciding a Claim for Service Connection for PTSD, Continued

g. Reviewing Evidence for Corroboration of a Stressor

There is no requirement in VA statutes or regulations that corroboration must, and may only, be found in official documentary records.

In most cases, however, this type of evidence will serve as the most reliable source of stressor verification.

When reviewing evidence for corroboration of a claimed stressor(s),

carefully analyze the most reliable sources of evidence first, and if these sources do not contain the necessary information,

review secondary sources of evidence carefully and critically for their adequacy and reliability.

Note:

Generally, documents written or recorded by the lowest possible unit in the chain of the command are the most probative source of information to verify a claimed stressor, because they tend to include details of events with greater precision.

Examples:

A company commander’s narrative is likely of greater relevance and specificity than a battalion commander’s, and

a Navy ship’s deck log would likely yield more probative information than a fleet log.

h. Examples of Credible Supporting Evidence to Corroborate a Claimed In-Service Stressor

The following court cases include examples of evidence found to be sufficient to meet the requirement of credible supporting evidence

to corroborate a claimed in-service stressor:

In HYPERLINK "http://vbaw.vba.va.gov/bl/21/Advisory/CAVCDAD.htm" \l "bmp"Pentecost v. Principi, 16 Vet. App. 124 (2002), the veteran claimed as stressors the occurrence of rocket attacks while he was stationed in Da Nang in 1967 and 1968. Unit records obtained in support of the claim contained descriptions of rocket attacks occurring while the veteran was stationed at Da Nang in January 1968.

In HYPERLINK "http://vbaw.vba.va.gov/bl/21/Advisory/CAVCDAD.htm" \l "bms"Suozzi v. Brown, 10 Vet. App. 307 (1997), the veteran claimed as his stressor the events of May 2, 1967, when his company came under attack, taking heavy casualties.

He and a lieutenant had to identify the bodies of those killed. The veteran recalled being sick for days after this, and STRs confirmed he received medical attention for several days thereafter.

The veteran later submitted a morning report and a radio log corroborating the events of that day.

The lieutenant who assisted in identifying the bodies signed the morning report, and the radio log confirmed that the veteran’s company

had come under big attack and had taken a lot of casualties.

The logs did not specifically name the veteran but included the names of his superiors, who later nominated the veteran for a Bronze Star.

STYLEREF

"Map Title" 32. Deciding a Claim for Service Connection for PTSD, Continued

i. Determining Link Between In-Service Stressor and Diagnosis

Establish service connection for PTSD only where the examination and supporting material indicate a link between current symptoms and

a verified in-service stressful event(s).

j. Making a Decision

Use the table below when making a decision regarding service connection for PTSD.

If …

Then …

the claimant has failed to provide a minimal description of the stressor, such as an indication of the time or place of a stressful eventrefer the claim to the JSRRC coordinator for the actions described in HYPERLINK "pt04_sp02_ch01_secD.xml" \l "IV.ii.1.D.16" M21-1MR, Part IV, Subpart ii, 1.D.16, and

deny the claim based on an unconfirmed stressor.

Note: The rating decision should note the previous request for information.

Reference: For more information on denying a claim because of an unconfirmed stressor, see HYPERLINK "pt03_sp04_ch04_secH" \l "III.iv.4.H.32.k"M21-1MR, Part III, Subpart iv, 4.H.32.k.

STYLEREF

"Map Title" 32. Deciding a Claim for Service Connection for PTSD, Continued

STYLEREF "Block Label"

j. Making a Decision (continued)

If …

Then …

the veteran has provided at least a minimum description of the stressor, such as approximate time, place, and unit, and

the records contain prima facie evidence of a PTSD diagnosis, such as

outpatient treatment reports showing treatment for PTSD or PTSD symptoms, or

the veteran’s description of symptoms indicative of PTSD.

request additional evidence from JSRRC, NARA, or the Marine Corps, as appropriate.

Important: Do not schedule a VA examination before receiving corroboration of the claimed stressor from JSRRC, NARA, or the Marine Corps.

Note: JSRRC researches Army, Navy, Air Force, and Coast Guard records only.

Reference: For more information on requesting evidence from JSRRC, NARA, or the Marine Corps see

HYPERLINK "pt04_sp02_ch01_secD.xml" \l "IV.ii.1.D.15"M21-1MR, Part IV, Subpart ii, 1.D.15.

a VA medical examination fails to establish a diagnosis of PTSD

deny the claim on that basis.

Note: If the existence of a stressor has not been determined, do not include a discussion of the alleged stressor in the rating decision.

Continued on next page

STYLEREF "Map Title" 32. Deciding a Claim for Service Connection for PTSD, Continued

k. Denying a Claim Because of an Unconfirmed Stressor A denial solely because of an unconfirmed stressor is improper unless JSRRC, NARA, or the Marine Corps, as appropriate, has confirmed that the claimed stressor cannot be corroborated, or

the veteran has failed to provide the basic information required to conduct research, and

the JSRRC coordinator has taken the actions described in HYPERLINK "pt04_sp02_ch01_secD.xml" \l "IV.ii.1.D.16" M21-1MR, Part IV, Subpart ii, 1.D.16.

If JSRRC, NARA, or the Marine Corps requests a more specific description of the stressor in question, immediately ask the veteran to provide the necessary information. If the veteran provides additional substantive information, forward it to the requesting agency. Failure of the veteran to respond substantively to the request for information will be grounds to deny the claim based on an unconfirmed stressor.

Reference: For more information, see HYPERLINK "pt04_sp02_ch01_secD.xml" \l "IV.ii.1.D.15"M21-1MR, Part IV, Subpart ii, 1.D.15.

M21-1MR, Part III, Subpart iv, Chapter 4, Section H

M21-1MR, Part III, Subpart iv, Chapter 4, Section H

4-H- PAGE 28

4-H- PAGE 25

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