ptsd Enough Evidence?

[thisangel]

In jun 2006 i was sexually assaulted, by nov 2006 I was medically discharged from the Air Force for major depression among other things. In 2007 I filed my disability claim. I received 20% for chronic back pain and ankle problems. My claim for PTSD was denied because I didn't submit any evidence(too traumatic). Needless to say it has really physically taking a toll on me. If I submit the following evidence do you think my personal statement about the event can be less in depth? I really really don't want to write it at all.

Rape treatment center notes, OSI (air force investigator) notes, and current PTSD diagnosis.

While on active duty I was treated for major depression because of the assault I guess it hadn't progressed to PTSD until a little later or I did an okay job of hiding it.

Also, I have been going to school since Nov 08. I informed the school of this medical condition with supporting documentation and they have been working with me. But a few weeks ago I received a letter from my school stating they are aware of my medical condition but I am missing too much school and not progressing. They told me i had to take a leave of absence or they would kick me out. Is this something I should also submit with my claim?

I also had another incident in jan-feb 05. A guy was stalking me and threating mine/and my daughters' lives. I had my reporting date to my new assignment moved from jun to Mar and my daughter stayed with her dad for a mo until until we left. The local PD did nothing but the base Judge Advocate banned him from the base for 5yrs. Is this something I could include in my claim?

I've been trying to walk around like everything is okay and I just can't do it anymore. I'm tired, my body is tired. I need help

[carlie]

30. Evaluating Evidence in Claims Based on Personal Trauma

From M21-1MR

http://www.warms.vba.va.gov/M21_1MR.html

Scroll down to:

SubptIV - General Rating Process

Chapter 4 - Rating Specific Disabilities, Updated 12/13/05

Click on:

Section H - Mental Disorders, Updated 8/3/09

30. Evaluating Evidence in Claims Based on Personal Trauma

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.

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.

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 Evidence In 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 Patton v. West, 12 Vet. App. 272 (1999).

f. Obtaining Evidence For more information on obtaining service records, medical treatment records, and evidence of personal trauma, see M21-1MR, Part IV, Subpart ii, 1.D.

31. Handling Examinations in Claims for Service Connection for PTSD

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 Examination In 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 M21-1MR, Part III, Subpart iv, 3.A

· PTSD examinations, see the “Best Practice Manual” in the Rating Job Aids website, and

· requesting medical evidence, see M21-1MR, Part I, 1.C.