ptsd Flood Gates Are Open!

[Michellee]

VA Simplifies Access to Health Care and Benefits for Veterans with PTSD

July 12, 2010

Printable Version

Need Viewer Software?

WASHINGTON – Secretary of Veterans Affairs Eric K. Shinseki announced a critical step forward in providing an easier process for Veterans seeking health care and disability compensation for Post-Traumatic Stress Disorder (PTSD), with the publication of a final regulation in the Federal Register.

“This nation has a solemn obligation to the men and women who have honorably served this country and suffer from the often devastating emotional wounds of war,” said Secretary of Veterans Affairs Eric K. Shinseki. “This final regulation goes a long way to ensure that Veterans receive the benefits and services they need.”

By publishing a final regulation in the Federal Register to simplify the process for a Veteran to claim service connection for PTSD, VA reduces the evidence needed if the trauma claimed by a Veteran is related to fear of hostile military or terrorist activity and is consistent with the places, types, and circumstances of the Veteran’s service.

This science-based regulation relies on evidence that concluded that a Veteran’s deployment to a war zone is linked to an increased risk of PTSD.

Under the new rule, VA would not require corroboration of a stressor related to fear of hostile military or terrorist activity if a VA doctor confirms that the stressful experience recalled by a Veteran adequately supports a diagnosis of PTSD and the Veteran's symptoms are related to the claimed stressor.

Previously, claims adjudicators were required to corroborate that a non-combat Veteran actually experienced a stressor related to hostile military activity. This final rule simplifies the development that is required for these cases.

VA expects this rulemaking to decrease the time it takes VA to decide access to care and claims falling under the revised criteria. More than 400,000 Veterans currently receiving compensation benefits are service connected for PTSD. Combined with VA’s shorter claims form, VA’s new streamlined, science-based regulation allows for faster and more accurate decisions that also expedite access to medical care and other benefits for Veterans.

PTSD is a medically recognized anxiety disorder that can develop from seeing or experiencing an event that involves actual or threatened death or serious injury to which a person responds with intense fear, helplessness or horror, and is not uncommon among war Veterans.

Disability compensation is a tax-free benefit paid to a Veteran for disabilities that are a result of -- or made worse by -- injuries or diseases associated with active service.

For additional information, go to www.va.gov or call VA’s toll free benefits number at 1-800-827-1000.

Wow if I am understanding this right seeing that I am under the influence of multiple medications to include narcotics for pain I have to always read and reread and still careful with my interpretation. But as I read this it sounds like it is saying that to make it easier for veterans that they no longer have to prove a stressor for PTSD just have VA Doc confirm the stress experience by the veteran and have a diagnoses by the DOC. Woweeeeeeeee!

[Tbird]

I may be wrong but the way I read it, I think it will be good for veterans.

For example, if you were in Fallujah Iraq, you will not have to prove that you were in such and such firefight on this day at this time. Just being in Fallujah, Iraq during the battle period would be enough. Now to my mind that is a good thing.

This makes showing your stressor easier, you still have to be diagnosed with PTSD and do the VA Hokey Pokey. I could be wrong, but I do think it will turn out to be a good thing for veterans. Getting a diagnosis of PTSD is not that easy, you have to meet the criteria in the DSM IV.

Just my two cents.

[Vync]

PTSD does not discriminate, it can hit any vet - combat or not.

A vet is a vet and PTSD is PTSD, no matter how you get it.

Bump!

[Vync]

The proposed rule that some of us commented on as well as the comments themselves is here:

http://www.regulatio...900006480a10bea

The proposed reg did not seem to eliminate any veteran at all but I dont know how this would apply to MST PTSD claims.

I am a civilian but I would think the military itself can be a hostile and fearful environment in some circumstances.

Final version:

http://edocket.access.gpo.gov/2010/2010-16885.htm

[Tbird]

http://edocket.access.gpo.gov/2010/2010-16885.htm

[Federal Register: July 13, 2010 (Volume 75, Number 133)]

[Rules and Regulations]

[Page 39843-39852]

From the Federal Register Online via GPO Access [wais.access.gpo.gov]

[DOCID:fr13jy10-13]

=======================================================================

-----------------------------------------------------------------------

DEPARTMENT OF VETERANS AFFAIRS

38 CFR Part 3

RIN 2900-AN32

Stressor Determinations for Posttraumatic Stress Disorder

AGENCY: Department of Veterans Affairs.

ACTION: Final rule.

-----------------------------------------------------------------------

SUMMARY: The Department of Veterans Affairs (VA) is amending its

adjudication regulations governing service connection for posttraumatic

stress disorder (PTSD) by liberalizing in some cases the evidentiary

standard for establishing the required in-service stressor. This

amendment eliminates the requirement for corroborating that the claimed

in-service stressor occurred if a stressor claimed by a veteran is

related to the veteran's fear of hostile military or terrorist activity

and a VA psychiatrist or psychologist, or a psychiatrist or

psychologist with whom VA has contracted, confirms that the claimed

stressor is adequate to support a diagnosis of PTSD and that the

veteran's symptoms are related to the claimed stressor, provided that

the claimed stressor is consistent with the places, types, and

circumstances of the veteran's service.

This amendment takes into consideration the current scientific

research studies relating PTSD to exposure to hostile military and

terrorist actions. The amendment acknowledges the inherently stressful

nature of the places, types, and circumstances of service in which fear

of hostile military or terrorist activities is ongoing. With this

amendment, the evidentiary standard of establishing an in-service

stressor will be reduced in these cases. The amendment will facilitate

the timely processing of PTSD claims by simplifying the development and

research procedures that apply to these claims.

DATES: Effective Date: This final rule is effective July 12, 2010.

Applicability Date: This final rule applies to an application for

service connection for PTSD that:

Is received by VA on or after July 12, 2010;

Was received by VA before July 12, 2010 but has not been

decided by a VA regional office as of that date;

Is appealed to the Board of Veterans' Appeals (Board) on

or after July 12, 2010;

Was appealed to the Board before July 12, 2010 but has not

been decided by the Board as of that date; or

Is pending before VA on or after July 12, 2010 because the

Court of Appeals for Veterans Claims (Veterans Court) vacated a Board

decision on the application and remanded it for readjudication.

FOR FURTHER INFORMATION CONTACT: Thomas J. Kniffen, Chief, Regulations

Staff (211D), Compensation and Pension Service, Veterans Benefits

Administration, Department of Veterans Affairs, 810 Vermont Avenue,

NW., Washington, DC 20420, (202) 461-9725. (This is not a toll-free

number.)

SUPPLEMENTARY INFORMATION: On August 24, 2009, VA published in the

Federal Register (74 FR 42617) a proposal to modify the evidentiary

standards for establishing an in-service stressor when a veteran files

a claim for service connection for PTSD. We proposed to add a new

paragraph (3) to 38 CFR 3.304(f) to state that, if a stressor claimed

by a veteran is related to the veteran's fear of hostile military or

terrorist activity and a VA psychiatrist or psychologist or contract

equivalent confirms that the claimed stressor is adequate to support a

diagnosis of PTSD and that the veteran's symptoms are related to the

claimed stressor, in the absence of clear and convincing evidence to

the contrary, and provided the claimed stressor is consistent with the

places, types, and circumstances of the veteran's service, the

veteran's lay testimony alone may establish the occurrence of the

claimed in-service stressor. This evidentiary liberalization is

consistent with the American Psychiatric Association's (APA) Diagnostic

and Statistical Manual of Mental Disorders, Fourth Edition (1994) (DSM-

IV) criteria for a PTSD diagnosis, as explained in the notice of

proposed rulemaking. The rule further re-designates former paragraph

(f)(3) as (f)(4), governing PTSD claims from former prisoners of war,

and re-designates paragraph (f)(4) as (f)(5), governing PTSD claims

based on in-service personal assault or military sexual trauma (MST).

Interested persons were invited to submit written comments on or

before October 23, 2009. We received 126 comments on the proposed rule.

VA received comments from veterans service organizations, including The

American Legion, National Organization of Veterans' Advocates, Disabled

American Veterans, Veterans for Common Sense, Paralyzed Veterans of

America, and The Wounded Warrior Project; from public interest groups,

including the Los Angeles Inner City Law Center and National Research

Center for Women and Families; from government agencies, such as the

New York City Department of Health and Mental Hygiene and the State of

New York Division of Veterans Affairs; and from individuals. VA also

received comments from members of the Subcommittee on Disability

Assistance and Memorial Affairs of the House of Representatives

Committee on Veterans' Affairs and other persons who participated in a

roundtable discussion of the proposed rule, as well as from members of

Congress.

We also received numerous comments from veterans and surviving

spouses regarding their individual claims for veterans benefits. We do

not respond to these comments in this notice as they are beyond the

scope of this rulemaking.

Presumption of Service Connection Based on Receipt of Certain Pay

Some commenters suggested that VA revise the rule to create a

presumption of service connection for PTSD based upon receipt of

imminent-danger or hostile-fire pay. We make no change based on these

comments because they are beyond the scope of the rule, which is

limited to providing a reduced evidentiary standard for establishing

occurrence of the stressor based upon a particular type of stressor.

Fear of Hostile Military or Terrorist Activity

Some commenters suggested that the rule should be revised to reduce

the evidentiary standard for veterans who had certain Military

Occupational Specialties (MOS). A MOS may be considered as evidence of

exposure to a stressor, including hostile military or terrorist

activity. See Veterans Benefits Administration (VBA) Adjudication

Procedures Manual Rewrite M21-1MR (Manual M21-1MR), Part IV, subpart

ii, ch. 1, sec. D, para. 13.k. However, a particular MOS does not

necessarily establish such an exposure. See Dizoglio v. Brown, 9 Vet.

App. 163, 166 (1996). Therefore, we make no changes based on these

comments.

Some commenters interpreted the proposed rule as limited to fear of

hostile or terrorist activity while serving in a combat zone, and

others suggested that the rule should be revised to provide a reduced

evidentiary standard on the basis of service in a combat zone. One

commenter asked whether the rule applies to veterans who served on a

submarine. The rule has no geographic requirement and is not limited to

service in a combat zone or on land. Rather, it applies to all persons

who served in active military, naval, or air service, as defined in 38

U.S.C. 101(24), and were discharged or released from

such service under conditions other than dishonorable.

One commenter stated the term ``stressor'' is ambiguous and may

lead one to believe that the rule applies only if a veteran can

identify a single specific event instead of hostile military or

terrorist activity generally. One commenter suggested that the rule

should apply as well to a series of events or the totality of

circumstances of deployment to a combat zone. Another commenter

questioned the meaning of the phrase ``consistent with the . . .

circumstances of service'' and doubted whether an examiner would ever

find that a traumatic event experienced by a veteran who had an MOS of

cook is consistent with the circumstances of the veteran's service.

Another commenter inquired about whether the examiner would be

responsible for determining whether the stressor is consistent with the

veteran's service.

VA believes that the language in the proposed rule is not

ambiguous. As stated in the rule, `` `fear of hostile military or

terrorist activity' means that a veteran experienced, witnessed, or was

confronted with an event or circumstance.'' (Emphasis added). The term

``circumstance'' means ``a condition, fact, or event accompanying,

conditioning, or determining another: an essential or inevitable

concomitant.'' Webster's Ninth New Collegiate Dictionary, 242 (1990).

Therefore, the rule provides that a veteran's ``fear'' need not emanate

from a single event or be consistent with the veteran's MOS but rather

the fear may result from conditions to which the veteran was exposed

during service. The requirement that a claimed stressor be consistent

with the places, types, and circumstances of the veteran's service

originates in the statute that authorizes this regulation, 38 U.S.C.

1154(a), which requires VA to duly consider the places, types and

circumstances of the veteran's service. In addition, consistent with

section 1154(a), VA regulations provide that consistency with the

places, types, and circumstances of service is shown by the veteran's

service records, the official history of each organization in which the

veteran served, medical records, and all pertinent medical and lay

evidence. 38 CFR 3.303(a). Finally, VA adjudicators, not examining

psychiatrists and psychologists, will decide whether the claimed

stressor is consistent with the veteran's service.

One commenter stated that the term ``confronted with an event or

events that involved actual or threatened death or serious injury, or a

threat to the physical integrity of self or others'' implies that a

veteran must experience an event that is close and highly lethal. As

stated above, there is no geographic requirement for the regulation.

However, the stressor must be consistent with the places, types, and

circumstances of the veteran's service. 38 U.S.C. 1154. In addition, an

event does not have to be lethal. As provided in the rule, the

traumatic event can involve actual or threatened serious injury, as

well as death, or a threat to the physical integrity of the veteran or

others.

One commenter stated that the list of examples in the definition of

``fear of hostile military or terrorist activity'' is incomplete and

would ``likely result in [VA] rejecting as adequate stressors such

events as injuring or killing of civilians.'' Another commenter

suggested adding language to clarify that an event or circumstance does

not have to include one of the situations listed in the definition,

e.g., ``an actual or potential improvised explosive device; * * *

incoming artillery, rocket, or mortar fire; grenade.'' A list of

examples cannot reasonably include every conceivable event or

circumstance that would qualify as hostile military or terrorist

activity under the rule. Nevertheless, we disagree that this

``incompleteness'' would likely result in VA rejecting events such as

the injuring or killing of civilians. The definition of ``fear of

hostile military or terrorist activity'' is not limited to any

particular class of individuals. Involvement of ``actual or threatened

death or serious injury, or a threat to the physical integrity of the

veteran or others,'' which is not limited to military personnel, is all

that is required to qualify as ``an event or circumstance'' within the

meaning of the rule. Therefore, if a veteran experienced, witnessed, or

was confronted with an event involving actual or threatened death,

serious injury, or a threat to the physical integrity of civilians, the

event would qualify as a stressor. Also, by using the modifying phrase

``such as,'' VA intends to present a list of examples to illustrate

what qualifies as an event or circumstance, not a defining restriction.

See Donovan v. Anheuser-Busch, Inc., 666 F.2d 315, 327 (8th Cir. 1981).

A commenter suggested that the definition of ``fear of hostile

military or terrorist activity'' be extended to include domestic as

well as foreign activity. The regulation is not limited to events or

circumstances perpetrated by a foreign enemy. Therefore, VA makes no

change based on the comment.

Some commenters said that VA should define when a stressor would be

considered consistent with the places, types, and circumstances of the

veteran's service. One commenter asked whether a veteran's claimed fear

of hostile military activity during service in South Korea after the

Korean Conflict ended or in the continental United States after

September 11, 2001, would be consistent with the places, types, and

circumstances of such service. Another commenter suggested that the

rule should explain the types of evidence needed to establish

consistency with the places, types, and circumstances of service.

The question of consistency is a matter involving application of 38

U.S.C. 1154(a) and 38 CFR 3.303(a) to the myriad of facts presented by

individual claims. We note, however, that inclusion of the conjunction

``and'' in the statute and regulation means that a stressor must be

consistent with all three of the enumerated criteria. Watson v. Dep't

of the Navy, 262 F.3d 1292, 1299 (Fed. Cir. 2001). Finally, the statute

and regulation indicate that VA is to consider the places, types, and

circumstances of service as shown by service records, the official

history of each organization in which the veteran served, the veteran's

medical records, and all pertinent medical and lay evidence. Some

commenters suggested that the rule be broadened to provide a reduced

evidentiary standard based solely on deployment to a war zone or fear

of such deployment, rather than on fear of hostile military or

terrorist activity. One commenter suggested that such a rule is

supported by the Institute of Medicine (IOM), Gulf War & Health, Vol.

6: Physiologic, Psychologic, and Psychosocial Effects of Deployment-

Related Stress, 319 (2008) (IOM Report), which states:

The epidemiologic literature on deployed vs[.] nondeployed

veterans yielded sufficient evidence of an association between

deployment to a war zone and psychiatric disorders, including

[PTSD], other anxiety disorders, and depression; alcohol abuse;

accidental death and suicide in the first few years after return

from deployment; and marital and family conflict, including

interpersonal violence.

We do not adopt this suggestion because many of the hardships related

to deployment, such as uncertainty about the length of a tour of duty

and lack of companionship or family contact, do not satisfy the DSM-IV

requirements for a PTSD diagnosis, i.e., experiencing, witnessing, or

confronting an event involving actual or threatened death or serious

injury or threat to the physical integrity of self or others. IOM

Report at 35-38; DSM-IV at 427. We have instead focused the rule on

factors associated with deployment that comport with the DSM-IV

definition of PTSD.

Some commenters inquired whether the rule would cover a service

member who experienced fear of hostile military or terrorist activity

after learning about the experiences of others with such activity but

before being deployed to a war zone. It is not our intention that the

new evidentiary standard apply in such a situation, and we do not

interpret the rule to cover that situation. Such a claim would be

adjudicated under the generally applicable standard set forth in the

introductory text of 38 CFR 3.304(f). The IOM Committee ``defin[ed]

deployment-related stress as deployment to a war zone'' and

``considered that military personnel deployed to a war zone, even if

direct combat was not experienced, have the potential for exposure to

deployment-related stressors that might elicit a stress response.'' IOM

Report at 13. Consistent with these findings, the rule is intended to

apply only when the veteran's service is proximate in time and place to

the traumatic event to which the veteran has responded with intense

fear, helplessness, or horror. This is consistent with current

provisions of 38 CFR 3.304(f) that do not require corroborating

evidence of occurrence of a stressor if a veteran was diagnosed with

PTSD in service, engaged in combat with the enemy, or was a prisoner of

war, i.e., circumstances of service in which it is undisputed that the

veteran was personally exposed to a stress-inducing event, making it

unnecessary to obtain supporting documentation. See Proposed Rule, 57

FR 34536 (Aug. 5, 1992) (not requiring corroborating evidence that a

stressor occurred if evidence establishes that the veteran engaged in

combat or is a former prisoner of war). A non-deployed veteran who

learns that others were subject to a hostile military or terrorist

activity in a war zone cannot be said to have ``experienced, witnessed,

or [been] confronted with an event or circumstance'' within the

contemplation of the new regulation. In such cases, the claimed

stressor (the hostile military or terrorist activity) would not be

consistent with the places, types, and circumstances of the veteran's

service when the activity occurred or the veteran learned that others

were subjected to such activity.

Coverage of Other Stressors

VA also received comments suggesting that the rule should cover

stressors such as MST, abuse by military personnel of subordinate

military personnel, harassment, suicide of a fellow service member,

witnessing a military vehicle accident in the United States, a fellow

soldier's or sailor's post-service suicide, and social, political, and

economic discrimination. One commenter suggested that VA should

promulgate a similar rule to assist those with physical injuries due to

hostile military or terrorist activity. These comments are outside the

scope of this rule. Therefore, we make no change based on them.

However, regarding MST, we note as well that 38 CFR 3.304(f)(5) (before

this rulemaking codified at 38 CFR 3.304(f)(4)) permits evidence other

than a veteran's service records to corroborate the occurrence of an

in-service personal assault and prohibits VA from denying a claim for

service connection for PTSD based on in-service personal assault

without first advising the claimant that evidence from sources other

than a veteran's service records may prove the stressor occurred.

Post-Combat Stress Disorder

A number of commenters suggested that use of the term PTSD is

socially stigmatizing, is embarrassing to combat veterans, and may

cause veterans to forego needed professional treatment. One commenter

suggested that VA re-categorize PTSD rated as 70 percent or more

disabling as post-combat stress disorder to diminish the stigma

associated with a diagnosis of PTSD, encourage veterans to seek

treatment, and prevent possible suicide. As explained in 38 CFR 4.130,

the nomenclature in the VA schedule of ratings for mental disorders is

based upon the DSM-IV, and 38 CFR 4.125 requires that a diagnosis of a

mental disorder conform to the DSM-IV in order to substantiate a claim.

Because the DSM-IV does not include post-combat stress disorder as a

diagnosis, we make no change based on these comments.

Opposition to Liberalizing Evidentiary Standard

VA received written comments objecting to the liberalizing

evidentiary standard for PTSD claims based on fear of hostile military

or terrorist activity. Several commenters alleged that the rule implies

that all a veteran must do to be granted service connection is

communicate that he or she experienced ``fear'' to corroborate a

stressor, will invite frivolous or fraudulent claims against the

Federal Government, is offensive to heroic combat veterans of current

and past wartime periods, and will delay adjudication of their claims.

One commenter suggested that VA should re-evaluate veterans diagnosed

with PTSD.

The reduced evidentiary standard provided by the rule is not

applicable solely because a veteran reports that he or she experienced

fear. Under the rule, VA will not rely on a veteran's lay testimony

alone to establish occurrence of the stressor unless the following

requirements are satisfied. First, the veteran must have experienced,

witnessed, or have been confronted by an event or circumstance that

involved actual or threatened death or serious injury, or a threat to

the physical integrity of the veteran or others, and the veteran's

response to the event or circumstance must have involved a

psychological or psycho-physiological state of fear, helplessness, or

horror. Second, a VA psychiatrist or psychologist, or a psychiatrist or

psychologist with whom VA has contracted, must confirm that the claimed

stressor is adequate to support a diagnosis of PTSD and that the

veteran's symptoms are related to the claimed stressor. Third, there

must be in the record no clear and convincing evidence to the contrary,

and fourth, the claimed stressor must be consistent with the places,

types, and circumstances of the veteran's service. Because all of these

requirements must be met for the veteran's lay testimony alone to

establish the occurrence of the claimed stressor, we believe the

likelihood of fraud to be minimal. Finally, 38 CFR 3.327(a) requires a

reexamination whenever VA determines there is a need to verify either

the continued existence or the current severity of a disability.

This rule is not intended to discount the heroic efforts of combat

veterans, but rather is VA's response to scientific studies related to

PTSD and military troop deployment. As noted in the proposed rule:

Combat is one of the most potent stressors that a person can

experience, but as military conflicts have evolved to include more

guerilla warfare and insurgent activities, restricting the

definition of deployment-related stressors to combat may fail to

acknowledge other potent stressors experienced by military personnel

in a war zone or in the aftermath of combat. Those stressors include

constant vigilance against unexpected attack, the absence of a

defined front line, the difficulty of distinguishing enemy

combatants from civilians, the ubiquity of improvised explosive

devices, caring for the badly injured or dying, duty on the graves

registration service, and being responsible for the treatment of

prisoners of war.

Proposed Rule, 74 FR at 42618 (quoting IOM Report at 2). Finally, we

believe that this rule will improve the timeliness of the adjudication

of claims of all veterans by eliminating the need to search for

corroborating evidence in certain cases. For these reasons, we

make no change based on these comments.

DSM-IV Definition of PTSD

Some commenters stated that the proposed rule is inconsistent with

DSM-IV, which does not require ``a psychological or psycho-

physiological state of fear, helplessness, or horror'' to a traumatic

event. Another commenter stated that VA is prohibited from using terms

in the regulation that do not appear in DSM-IV.

The commenters are incorrect. In order to satisfy the DSM-IV

diagnostic criteria for PTSD, a person's response to a traumatic event

must involve ``intense fear, helplessness, or horror.'' DSM-IV at 428.

In addition, the traumatic event must be persistently reexperienced in

one or more of several ways, including ``intense psychological distress

at exposure to internal or external cues that symbolize or resemble an

aspect of the traumatic event'' and ``physiologic reactivity on

exposure to internal or external cues that symbolize or resemble an

aspect of the traumatic event,'' all of which involve intense

psychological stress or psycho-physiological response. Id. In any

event, nothing prohibits VA from using in this regulation a term that

does not appear in the DSM-IV. As indicated above, the nomenclature

employed by VA in the schedule for rating mental disorders ``is based

upon the [DSM-IV].'' 38 CFR 4.130. This rule, however, does not concern

the evaluation of mental disorders. It liberalizes the evidentiary

standard for corroboration of a stressor in certain cases. Using a term

that does not appear in the DSM-IV is well within VA's authority to

prescribe exactly which cases may benefit from the liberalized

evidentiary standard.

A commenter expressed concern that the rule is limited to ``fear of

hostile or terrorist activity'' and asked whether a veteran would be

entitled to the reduced evidentiary standard if the veteran manifested

flashbacks and nightmares long after service. Both this rule and

flashbacks and nightmares are related to the diagnostic criteria for

PTSD, but they relate to distinct criteria. The rule relates to the

criterion of a person's exposure to a traumatic event and the person's

response to that event. See DSM-IV at 427-428. Flashbacks and

nightmares relate to the criterion of the person's re-experiencing of

the traumatic event. DSM-IV at 428.

Another commenter asserted that the requirement in the rule that

the stressor must be consistent with the places, types, and

circumstances of a veteran's service renders the rule narrower than the

DSM-IV definition of PTSD and that the requirement that the stressor

relate to a veteran's fear of hostile military or terrorist activity

narrows the DSM-IV definition of PTSD.

As indicated above, in replying to a comment about the meaning of

the phrase ``consistent with the * * * circumstances of service,''

under 38 U.S.C. 1154(a), VA must duly consider the places, types, and

circumstances of a veteran's service as shown by the veteran's service

record, the official history of each organization in which such veteran

served, the veteran's medical records, and all pertinent medical and

lay evidence. Such consideration is a general requirement that applies

to any service connection claim, not just claims for service connection

of PTSD. Because section 1154 is the authority for this rule, we

incorporate the statutory requirement into the rule.

Because the requirement that a claimed stressor relate to a

veteran's fear of hostile military or terrorist activity has no effect

on the diagnostic criteria for PTSD, the requirement does not narrow

the DSM-IV definition of PTSD. The effect of the rule is to relax the

evidentiary standard for establishing the occurrence of an in-service

stressor for certain veterans, and the rule is limited to cases in

which the claimed stressor is related to the veteran's fear of hostile

military or terrorist activity for the reasons given in the notice of

proposed rulemaking. Proposed Rule, 74 FR at 42618 (explaining that the

rule is consistent with scientific studies related to PTSD and military

troop deployment). The rule focuses on the procedure for establishing

service connection for PTSD, not the criteria for establishing a

legitimate diagnosis. Therefore, there is no inconsistency with the

medical community at large, and we make no change based on the comment.

In addition, the rule defines ``fear of hostile military or terrorist

activity'' as ``involv[ing] a psychological or psycho-physiological

state of fear, helplessness, or horror.''

One commenter stated that fear of hostile military or terrorist

activity may not be sufficient to give rise to a diagnosis of PTSD in

accordance with DSM-IV absent occurrence of an actual event. We agree

that the occurrence of an actual event or circumstance is necessary. In

fact, as the commenter noted, the first DSM-IV diagnostic criterion for

PTSD is exposure to a traumatic event. DSM-IV at 427. The rule does not

permit diagnosis of PTSD in the absence of exposure to a traumatic

event or circumstance. The rule lists several examples of events or

circumstances that could give rise to the requisite fear. The rule

eliminates the need for corroborating evidence of the event if the

requirements of the rule are met.

Another commenter asserted that the Global Assessment of

Functioning (GAF) score has limited use and should be replaced. Axis V

of the DSM-IV multiaxial diagnosis system measures the overall severity

of psychiatric disturbance based on the GAF Scale, which rates an

individual's social, occupational, and psychological functioning. VA

regulations do not require a GAF score for purposes of determining

whether PTSD is service connected, although the score may be required

or requested by the Veterans Court, the Board, or a rating specialist

for purposes of assessing the extent of disability after service

connection has been established. This comment is therefore beyond the

scope of this rulemaking.

Psychiatrist or Psychologist Employed by VA or With Whom VA Has

Contracted

The majority of comments that VA received expressed disagreement

with the requirement that the evidentiary standard for establishing

occurrence of the stressor will be liberalized only if ``a VA

psychiatrist or psychologist, or a psychiatrist or psychologist with

whom VA has contracted, confirms that the claimed stressor is adequate

to support a diagnosis of [PTSD] and that the veteran's symptoms are

related to the claimed stressor.'' We have grouped these comments

together by subject matter and address them below.

Consistency With 38 U.S.C. 5125

Some commenters asserted that the rule is contrary to 38 U.S.C.

5125, which one commenter contended means that VA must accept the

opinion of a private physician if the opinion is adequate for rating

purposes. In support of this contention, the commenter relied upon the

heading of section 5125, ``Acceptance of reports of private physician

examinations.''

Section 5125 provides that, ``[f]or purposes of establishing any

claim for benefits under chapter 11 or 15 of [title 38], a report of a

medical examination administered by a private physician that is

provided by a claimant in support of a claim for benefits * * * may be

accepted without a requirement for confirmation by an examination by a

physician employed by the Veterans Health Administration [(VHA)] if the

report is sufficiently complete to be adequate for the purpose of

adjudicating such claim.'' (Emphasis added). Generally, use of the word

``may'' suggests that a provision is permissive, not mandatory. Jama v.

Immigration & Customs Enforcement, 543 U.S. 335, 346 (2005). See 60 FR

27409 (May 24, 1995) (final rule amending 38 CFR 3.326 to reflect

section 5125's authorization of private physician's examination reports

if adequate for rating purposes). The meaning of section 5125 is plain,

and therefore, the heading of the section cannot be used to limit its

meaning. Bhd. of R.R. Trainmen v. Baltimore & O.R. Co., 331 U.S. 519,

528-29 (1947). Thus, VA is not required to accept the report of a

private physician as sufficient for rating a claim in all

circumstances.

Alternative Qualifications for Psychiatrists and Psychologists

Commenters wrote that VA should accept the opinion of any

psychiatrist or psychologist who evaluates the claimed condition based

on the DSM-IV protocol or VA's protocol for PTSD examinations or who is

certified by the APA. Several commenters asserted that private

physicians provide more comprehensive and/or better examinations. Other

commenters alleged that VA examiners refuse to diagnose PTSD and that

their examinations are inconsistent and do not comply with DSM-IV.

Also, one commenter contended that no confirmatory evidence from a VA

psychiatrist or psychologist should be required because these examiners

are often biased against claimants and likely to diagnose a mental

disorder other than PTSD.

We decline to expand the rule to include the opinion of any

psychiatrist or psychologist whose diagnosis conforms to DSM-IV or VA's

protocol or who is certified by the APA because we believe that VA or

contract examiners are uniquely qualified for the following reasons.

VA Examiners Are Trained To Provide Forensic Opinions Necessary To

Decide PTSD Claims

By making 38 U.S.C. 5125 discretionary rather than mandatory,

Congress clearly recognized that there may be circumstances in which VA

would require a confirmatory medical opinion. The situation described

in this rule is such a circumstance because it eliminates the

requirement of credible supporting evidence of the occurrence of an

alleged non-combat stressor under 38 CFR 3.304(f) in the situation

described. Because the rule permits the proof of an in-service stressor

based on the claimant's lay statement alone, VA believes that it is

reasonable to limit this liberalization to medical opinions from

practitioners who it knows are well-skilled and well-equipped to

provide such forensic evidence, rather than broaden the rule to include

opinions from private physicians.

VA's need for such forensic evidence is particularly important in

the case of a claim for service connection for a mental disorder.

When the DSM-IV categories, criteria, and textual descriptions

are employed for forensic purposes, there are significant risks that

diagnostic information will be misused or misunderstood. These

dangers arise because of the imperfect fit between the questions of

ultimate concern to the law and the information contained in a

clinical diagnosis. * * *

Nonclinical decision makers should also be cautioned that a

diagnosis does not carry any necessary implications regarding the

causes of the individual's mental disorder or its associated

impairments.

DSM-IV at xxiii; see VHA Directive 2008-005 (Jan. 29, 2008).

Consistent with the DSM-IV, VA has limited the mental health

professionals who are qualified to perform initial Compensation and

Pension (C&P) examinations for mental disorders to highly trained

professionals. See VBA Fast Letter 06-03 (Mar. 15, 2006).

A C&P examination for PTSD is particularly complex because an

examiner must:

(1) Make complex judgments about potential malingering

in the context of an administrative evaluation that will have obvious

financial implications for a veteran;

(2) Comprehensively diagnose all comorbid mental disorders and

apportion disability to various disorders in veterans who increasingly

have co-occurring mental disorders; and

(3) Render an informed opinion about the effects of PTSD on social

and occupational functioning, requiring a careful and often time-

consuming review of a veteran's history. Department of Veterans

Affairs, Best Practice Manual for Posttraumatic Stress Disorder (PTSD)

Compensation and Pension Examinations (Best Practice Manual) 21-22,

http://www.avapl.org...0final%206.pdf.

VA Examiners Are Well-Trained in How To Perform PTSD Examinations

VA provides extensive guidance to VHA examiners about how to

perform C&P examinations and gives specific guidance about PTSD

examinations. Id. at 13-22; C&P Service Clinician's Guide (Clinician's

Guide), ch. 14 (Mar. 2002), http://www.warms.vba.../21guides.html.

VA Certifies VA Examiners and Reviews the Quality of Examinations by VA

and Contract Examiners

In addition, all PTSD C&P evaluations are performed by qualified

examiners who utilize evidence-based instruments, as recommended in the

Fiscal Year 2007 report of the VA Special Committee on PTSD. The Under

Secretary for Health's Post-Traumatic Stress Disorder Special

Committee: FY 2006 Annual Report, 9 (Jun. 5, 2007). In response to the

Special Committee's recommendation, the Compensation and Pension Exam

Program (CPEP), in conjunction with the Employee Education System and

VHA/DoD Program Coordination Office, established a program requiring

training and certification of all VHA clinicians who conduct C&P

examinations, including Fee-for-Service Providers, which program

includes special modules and tests for initial examinations for PTSD.

VHA Directive 2008-005. In a May 2009 report to Congress, the Special

Committee advised that the recommendation had been ``met.''

The CPEP office also reviews the quality of examinations of

claimants conducted by VHA clinicians, including PTSD examinations, and

when CPEP identifies problems in the quality of examinations, steps are

taken to improve the quality via CPEP-sponsored conferences and

training.

VBA provides contract examiners with information regarding the

requirements of C&P examinations, and the quality of examinations

provided by VA contractors is reviewed quarterly by a physician and

nurse employed by VBA.

VA and Contract Examiners Are Often Better Informed About the Veteran.

In addition, VA psychiatrists and psychologists and contract

examiners are often better informed about a veteran being examined than

private practitioners are. When VBA requests a mental-disorder

examination, including an examination for PTSD, it sends the claims

folder to the examiner for the examiner's review. Manual M21-1 MR, Part

III, subpart iv, ch. 3, sec. A, para. 1.e. The C&P examination

worksheet for an initial evaluation for PTSD requires review of the

veteran's claims file. The worksheet states, ``A diagnosis of PTSD

cannot be adequately documented or ruled out without obtaining a

detailed military history and reviewing the claims folder.''

Clinician's Guide at 207. A private psychiatrist or psychologist would

not have access to such documentation before opining about whether a

claimed stressor is adequate to support a PTSD diagnosis and whether the veteran's symptoms are

related to the claimed stressor.

VA Examiners Perform More Examinations, Thereby Ensuring Consistency in

Evaluations.

Finally, VA believes that the requirement in the rule for a

confirmatory opinion from a VA psychiatrist or psychologist, or a

psychiatrist or psychologist with whom VA has contracted, will ``ensure

standardization and consistency of mental health evaluations and

reporting of these evaluations.'' Proposed Rule, 74 FR at 42618. VHA

performs over 700,000 C&P examinations annually, VHA Directive 2008-

005, at 1, and contract physicians provide approximately 120,000 C&P

examinations annually. As explained above, CPEP reviews VHA examination

reports, and VBA reviews the reports of contract examiners. The review

of these reports helps to guarantee the quality and consistency of PTSD

examinations. However, VA has no control over the quality of

examinations performed by private healthcare providers. Because VA is

willing to liberalize the evidentiary standard for proving a stressor

only in cases on which it can depend on the quality of the medical

opinion, we decline to accept the opinion of any psychiatrist or

psychologist as suggested.

With regard to the assertion that private physicians provide more

comprehensive and/or better examinations, we believe that the protocol

for initial VA examinations for PTSD, to which all VA and contract

examiners must adhere, ensures comprehensive examinations addressing

all aspects of a veteran's medical, social, and psychological history

and the veteran's current mental status. Clinician's Guide at 206-12.

We therefore make no change based on this comment.

We are unaware of VA examiners who refuse to diagnose PTSD, are

biased against claimants, or are likely to diagnose a mental disorder

other than PTSD, as other commenters alleged. In fact, a VBA review

revealed that, when C&P examinations were conducted, PTSD was diagnosed

in 77% of initial claims. Best Practice Manual at 1, 5, 57. We believe

that the CPEP and VBA reviews of VA and contract examinations ensure

consistency in examinations, and if CPEP assessments identify problems,

steps are taken to improve quality and consistency, such as CPEP-

sponsored training or recommendations to revise examination templates

and/or worksheets. Also, if a VA examination does not comply with DSM-

IV, as the commenter alleges, the examination is returned to the

examiner for substantiation, as required by 38 CFR 4.125(a). We

therefore make no changes to the regulation based on these comments.

VA Social Workers, Counselors, and Former Clinicians

Some commenters urged VA to accept confirmatory opinions from VA

social workers, counselors, therapists, and former psychiatrists and

psychologists. One commenter contended that consistency in examinations

by such providers is guaranteed by VHA Handbook 1160.01, Uniform Mental

Health Services in VA Medical Centers and Clinics, http://www1.va.gov/

emshg/docs/VHA_CEMP_Uniform_Mental_Health_Services_Hndb_1160_

01_61108.pdf, and VA Handbook 5005/23, Part II, Appendix G39,

providing the requirements for appointment as a VHA social worker. As

explained above, a C&P examination is forensic evidence for purposes of

determining whether a veteran is entitled to disability compensation

for PTSD and, if so, how much. This rule requires the medical opinion

of a VA psychiatrist or psychologist, or a contract psychiatrist or

psychologist, because VA can rely on the consistency and quality of

examinations conducted by such individuals. These handbooks, on the

other hand, pertain to care of VA patients, not C&P examinations, and

to the appointment of personnel. They do not ensure the degree of

training, information, and experience necessary to ensure quality and

consistency in examinations.

With regard to former VA psychiatrists and psychologists, some

former clinicians may not have been CPEP-certified depending upon when

they were employed by VA. In addition, their examinations would not be

subject to ongoing CPEP review, nor would they have access to a

veteran's claims file to conduct the review required by the PTSD

examination protocol. Therefore, VA would be unable to ensure

standardization, consistency, and quality of their examinations. For

that reason, we decline to permit their medical opinions to qualify for

the evidentiary liberalization provided by this rule.

Potential Conflict for VA Examiners

Two commenters stated that the rule might present a conflict for a

VA examiner who is required to act in the best interests of his or her

patient. VBA Fast Letter 06-03 acknowledges that, ``[t]o maintain the

integrity of the patient-provider relationship, it is preferable that a

veteran's treating health care provider not perform the C&P

examination,'' and advises that, when an adjudicator requests a mental-

disorder examination or opinion, the adjudicator ``specify that the

veteran's treating health care provider should not perform the

examination if possible.'' This should avert any conflict.

Training and Availability of VA Psychiatrists and Psychologists

A commenter expressed concern about the training and education of

psychiatrists or psychologists employed by VA or with whom VA has

contracted and stated that it may be necessary for these examiners to

receive training in military history. Another commenter said that the

rule would require veterans to visit doctors who may be unfamiliar with

their medical and treatment histories and could unnecessarily cause

veterans to relive past stressors in order to establish service

connection for a disability for which they have already been diagnosed.

The commenter also said that the rule would impose on veterans who live

in rural states an unreasonable burden to travel long distances to

obtain the requisite examination by a VA psychiatrist or psychologist

or an examiner with whom VA has contracted.

VA examiners are well-trained in how to interact with veterans

during a C&P examination. As explained above, the PTSD examination

protocol requires examiners to review the veteran's claims file so that

the examiner will be familiar with the veteran's medical and military

history. See Best Practice Manual at 22. In addition, it is estimated

that examiners should spend 20 minutes orienting the veteran to the

interview, reviewing the veteran's military history, and conducting a

trauma assessment. Id. The Best Practice Manual states at page 14 that

it is important to explain to the claimant that it is necessary

to obtain a detailed description of one or more traumatic events

related to military service, in order to complete the examination.

Further, it is helpful to alert him or her to the fact that trauma

assessment, though brief (about 15-20 minutes), may cause some

distress. The veteran should be advised that trauma assessment is a

mutual and collaborative process, and that he or she is not required

to provide unnecessarily detailed answers to all questions, if it is

too distressing to do so.

Assessment of a personally relevant trauma proceeds only ``after

sufficient rapport has developed and some cursory details regarding the

context of the trauma situation(s) have been gathered.'' Id.

VA recognizes that an accurate diagnosis of PTSD requires extended

discussion of experiences that may have been extremely traumatic and

that repression, denial, and general haziness of memories are often

hurdles in obtaining an adequate military history. Clinician's Guide at

196-97. Examiners are therefore advised that ``it is crucial that the

examiner place emphasis on avoiding an authoritarian role, avoiding

judgmental interventions, and establishing rapport through an initial

focus on current life experiences or other discussion which encourages

comfort in the interview.'' Id. at 197. Based upon the training

provided to these examiners, which we have explained above, we believe

that they are well-prepared to examine veterans while minimizing the

risk of causing veterans undue distress through reliving of their

traumatic experiences.

As for the availability of examiners to provide the opinions

required by the rule, VA intends to carefully monitor the need for

examiners in various regions of the country and to make examiners

available in response to demand. In fact, one reason for using contract

examiners is to provide qualified examiners in places far from the

closest VA medical facility.

Private Practitioners Other Than Psychiatrists and Psychologists

Some commenters suggested that VA expand the rule to include the

opinion of a private licensed therapist, counselor, or social worker

who has treated the claimant. To ensure that examiners are competent to

provide findings and opinions that are valid and necessary for rating

purposes, VBA determined that individuals who conduct C&P mental

disorder examinations must have specific qualifications. VBA Fast

Letter 06-03.

Only mental health professionals with the following

credentials are qualified to perform initial C&P mental disorder

examinations:

(1) Board-certified psychiatrists or board-``eligible''

psychiatrists;

(2) licensed doctorate-level psychologists;

(3) doctorate-level mental health providers under the close supervision of

a board-certified or board-eligible psychiatrist or licensed doctorate-

level psychologist;

(4) psychiatry residents under the close

supervision of a board-certified or board-eligible psychiatrist or

licensed doctorate-level psychologist; and (5) clinical or counseling

psychologists completing a one-year internship or residency (for

purposes of a doctorate-level degree) under the close supervision of a

board-certified or board-eligible psychiatrist or licensed doctorate-

level psychologist. Because VA has no guarantee that a private licensed

therapist, counselor, or social worker who has treated a veteran has

the qualifications required for a C&P mental disorder examination, we

decline to adopt the commenters' suggestion.

Consideration of Veteran's Evidence

Some commenters asserted that the requirement for a confirmatory

opinion from a VA practitioner or contract examiner discriminates

against veterans with PTSD or veterans whose claims are based on a

particular type of stressor and potentially violates their right to

equal protection under the law. Another commenter asserted that the

rule violates due process by denying a claimant the ability to submit

competent medical evidence from private mental health professionals to

rebut the VA opinion. One commenter suggested that the rule should

specifically provide for rebuttal of the VA examiner's opinion with

non-VA evidence. Also, commenters asserted that the rule would not

permit a veteran to submit evidence from a private physician or

psychologist or would require VA to reject such an opinion, thereby

conflicting with VA's obligation to consider all evidence of record,

and would violate the benefit of the doubt rule. Another commenter

asserted that, absent the opinion of a VA psychiatrist or psychologist

confirming that the claimed stressor is adequate to support a PTSD

diagnosis and that the veteran's symptoms are related to the claimed

stressor, VA adjudicators would not weigh or analyze the evidence.

Other commenters asserted that the rule would violate 38 CFR 3.303(a)

and 38 U.S.C. 5107(b).

These concerns are unfounded. Nothing in the rule precludes a

claimant from submitting private medical evidence, permits VA to ignore

any evidence that is submitted, or requires VA to reject an opinion

from a private physician or psychologist. Statute and regulation

require VA to consider all information and lay and medical evidence of

record when deciding a claim for veterans benefits. 38 U.S.C. 5107(b);

38 CFR 3.303(a). Service connection for PTSD requires medical evidence

diagnosing the disability, medical evidence establishing a link between

the veteran's current symptoms and an in-service stressor, and credible

evidence corroborating occurrence of the stressor. 38 CFR 3.304. If a

stressor claimed by a veteran is related to the veteran's fear of

hostile military or terrorist activity, the evidentiary standard for

establishing occurrence of the stressor can be reduced but only if a VA

psychiatrist or psychologist, or a psychiatrist or psychologist with

whom VA has contracted, confirms that the claimed stressor is adequate

to support a PTSD diagnosis and that the veteran's symptoms are related

to the stressor. If such confirmation is made in accordance with the

rule, VA will not require evidence corroborating occurrence of the

claimed stressor. Failure to obtain such confirmation, however, does

not necessarily result in denial of the claim. If such confirmation is

not made in accordance with the rule, VA will assist the claimant in

obtaining evidence to corroborate occurrence of the claimed stressor.

VA will consider all evidence of record, including evidence submitted

by the claimant, give the claimant the benefit of the doubt when the

evidence is in equipoise, and determine whether the requirements for

establishing service connection for PTSD under 38 CFR 3.304(f) have

been satisfied, notwithstanding any failure to satisfy the requirements

of new section 3.304(f)(3). 38 U.S.C. 5103A and 5107(b); 38 CFR

3.303(a) and 3.102.

Competent Medical Evidence

Some commenters asserted that the requirement for confirmatory

evidence from a VA psychiatrist or psychologist conflicts with 38 CFR

3.159(a)(1), which defines ``competent medical evidence'' to include

``evidence provided by a person who is qualified through education,

training, or experience to offer medical diagnoses, statements, or

opinions.''

There is no conflict because the definition in Sec. 3.159(a)(1)

concerns a matter different from the subject of this rule. This rule

concerns whether ``credible supporting evidence'' will be required to

establish the occurrence of a stressor in a claim for service

connection of PTSD. Section 3.159(a)(1) defines the phrase ``competent

medical evidence'' for purposes of explaining when VA will provide a

medical examination or obtain a medical opinion in any service

connection claim. See 38 U.S.C. 5103A(d)(2)(A) (VA ``shall'' provide

medical examination or obtain medical opinion when several conditions

are met, including that the record ``contains competent medical

evidence'' that the claimant has a current disability or persistent or

recurrent symptoms of disability); 38 CFR 3.159©(4)(i) (VA must

provide a medical examination or obtain a medical opinion if several

conditions are met, including that the information and evidence of

record does not contain ``sufficient competent medical evidence''

to decide the claim, but contains ``competent lay or medical evidence''

of a current diagnosed disability or persistent or recurrent symptoms

of disability). Thus, the existence of ``competent medical evidence''

in the record does not preclude VA from obtaining a medical examination

but rather mandates an examination if the other regulatory requirements

are satisfied. For these reasons, we make no change to the rule based

on these comments.

Treating Physician Rule

One commenter stated that the rule is in essence an ``anti-treating

physician'' rule and that VA should adopt the ``treating physician''

rule used by the Social Security Administration. As explained above,

the rule does not preclude a claimant from submitting and VA from

considering evidence from the claimant's treating physician, if the

claim cannot be granted under the new section 3.304(f)(3) procedures.

Also, as the U.S. Court of Appeals for the Federal Circuit has

recognized, adoption of the treating physician rule may conflict with

the benefit of the doubt rule and would conflict with 38 CFR 3.303(a),

which requires that service connection determinations will be based on

the entire evidence of record and due consideration of VA's policy to

administer the law under a broad and liberal interpretation, consistent

with the facts of each case. White v. Principi, 243 F.3d 1378, 1381

(Fed. Cir. 2001); 38 U.S.C. 5107 and 7104(a); 38 CFR 3.102. We

therefore do not adopt this suggestion.

Claimant's Evidentiary Burden

One commenter stated that the rule would increase the evidentiary

burden on a claimant by requiring a confirmatory opinion by a VA

psychiatrist or psychologist and a finding that the stressor is

consistent with the places, types, and circumstances of the veteran's

service.

Section 3.304(f) currently requires a medical-nexus opinion linking

a veteran's current symptoms and the claimed stressor. This rule merely

provides a liberalized evidentiary standard in certain situations based

on the opinion of a VA psychiatrist or psychologist. Further, the

requirement for consistency is mandated by 38 U.S.C. 1154(a) and 38 CFR

3.303(a). Also, pursuant to 38 U.S.C. 5103A(a) and ©, VA has a duty

to assist a claimant for disability compensation in obtaining evidence

necessary to substantiate the claim. In particular, VA is required to

provide an examination or obtain a medical opinion when necessary to

decide a claim for disability compensation. 38 U.S.C. 5103A(d). Section

5103A(d)(3) states that an examination or opinion is necessary if the

record contains competent evidence of a current disability or

persistent or recurrent symptoms, indicates that the disability or

symptoms may be associated with the claimant's active service, and does

not contain sufficient medical evidence for VA to make a decision on

the claim.

One commenter asked whether the rule requires that the occurrence

of a stressor be corroborated by evidence of a veteran's response to

the stressor, such as behavioral changes as provided in former Sec.

3.304(f)(4), or whether the veteran's lay testimony will be accepted as

sufficient proof of the stressor. If the requirements of the rule are

met, VA may accept the veteran's lay testimony as sufficient proof of

the stressor. If, however, the requirements of the rule are not met,

the record must contain corroborating evidence of the stressor. The

rule does not require corroboration by evidence of the veteran's

response, but evidence of the veteran's response is required for a

legitimate diagnosis of PTSD resulting from exposure to the stressor.

Furthermore, evidence of the veteran's response may be used to prove

the occurrence of the stressor. Before deciding whether the stressor

has been corroborated, VA will examine all the evidence of record to

determine whether it corroborates occurrence of the stressor. See 38

CFR 3.303(a). Also, Manual M21-1MR instructs adjudicators to review

alternative sources of evidence that may corroborate a claimed in-

service stressor, such as a veteran's contemporaneous letters and

diaries and performance reports. M21-1MR, Part III, subpart IV, ch. 4,

sec. H, para. 29.i-k.

Relationship to Other Rules

One commenter stated that the rule could be viewed as restricting

or superseding the beneficial rule codified at 38 CFR 3.304(f)(2),

which states that a veteran's lay testimony alone is sufficient to

establish the occurrence of a claimed stressor if the veteran engaged

in combat with the enemy and the claimed stressor is related to that

combat. We make no change based on this comment because the new rule

merely provides another avenue by which veterans seeking disability

compensation for PTSD can establish service connection and does not

restrict or supersede any existing VA rules intended to assist

claimants. A qualifying veteran may still establish service connection

under 38 CFR 3.304(f)(2) without regard to the new rule.

Another commenter asked whether corroborating evidence of a

stressor would be required if a veteran is not a combat veteran or does

not qualify for the reduced evidentiary standard under this rule.

Section 3.304(f) relaxes the ordinary evidentiary standard in other

situations also, such as PTSD diagnosed in service, a former prisoner

of war as claimant, and a claim based on personal assault in service.

However, in the absence of such circumstances, VA

[Michellee]

I called the VARO to get some clarifications and the way it was explain to me is that PTSD will not just be decided for those that were in a combat area. It could be for anyone diagnosed by a VA doctor that could have also faced some sort of traumatic event to include being in a combat zone and suffering from whatever exposure causing the PTSD. So its like if you were on a ship and was attacked or CONUS and had a traumatic event while serving to cause you PTSD and then diagnosed with the blessings of the VA then you would be rated accordingly. So its not just for combat vets and I could see how this could also apply for MST (PTSD) trauma is trauma. Military accidents etc. Some near death experience could impact someone just as much as being in a combat zone. PTSD is PTSD. TBird is right is just that the diagnosis is not easy to come by with VA doctors. Plus from my experience I had to go through a series of MH testing, therapy, etc.

[Berta]

It looks to me that , per pages 10 and 11, the VA still maintain the present criteria for MST PTSD claims and this new reg will not impact on them.

http://www.vawatchdog.org/10/nf10/nfjul10/jul10files/DraftFinalRule2010.pdf

I cold be misinterpreting this part. Lots here to read.