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Cassandra Crosby, Claims Advocate

#MeToo: Reality of Sexual Assault in the US Military

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The Reality of Sexual Assault in the US Military

Sexual Assault victims, 2017

On April 27, 2018, the Department of Defense released its 2017 Fiscal Year Annual Report on Sexual Assault in the Military. Let me preface with a startling statistic….being someone who formally worked in the sexual assault prevention field; the cost of the DoD 2017 report was $3,345,000…..just for the report.  RAINN, one of the foremost national non-profit organizations working in sexual assault prevention and response has a total fiscal budget in 2015 of $6.6 million dollars.  Half of their entire annual budget was the equivalent of the DoD report.

The DoD reports that in FY 2017, sexual assault reporting increased by nearly 10%. A fact the DoD is so proud of they highlight it on the cover letter to the Charmian of the Armed Services Committee, Honorable William Thornberry. The DoD implies that the increase in reporting does not correlate with an increase in assault, but rather an increase in the confidence levels of those seeking services after an assault. They do not, however, discuss how they verify this fact.   And, there is a conspicuously and complete absence of the number of estimated actual sexual assaults in FY 2017.

Active duty service members make up 87% of the victims in the DoD report, the remanding victims are civilians/foreign nationals or unknown. It is significant to note that this report does not include statistics for those reporting the number of perpetrators being active duty military members, of which many active duty victims are prey. However, the data is lacking in its storytelling abilities across the board.

Where the numbers do not add up

The DoD report states that 6,797 active duty reported being a victim of sexual assault during the past fiscal year. The DoD report from 2014 showed 10,017 victims in 2017. This represents a Sexual Assault reportsdrop in sexual assault from 2014 by over 4,000, 49% in a two-year time span. However, national statistics by the Department of Justice show that sexual assault is only down by 0.98% from 2014 to 2015, and reports no significant changes for 2016. The Department of Justice’s numbers include military sexual assault.

What do the numbers really mean?

Higher percentages of sexual assault victims in the military are reporting sexual assaults than in any other demographic groups. When we gather numbers of sexual assault and the actual percentage reporting from the National Sexual Violence Resource Center and the Department of Justice’s National Crime Statistics Reports, the numbers really do not support the DoD’s report. The reporting rates for military men and women concerning sexual assault are still less than half of what they are for college students and the general population.

The reality is that sexual assault and harassment are still alive and well in the world, including the military. And as much as the military would like to profess that their programs are working, there are still reports of victims on active duty that are afraid for their careers, reprisals, and their personal well being if they report harassment or sexual assault.

Maybe the DoD’s money would be better spent on hiring an experienced, non-profit to run their sexual assault reporting programs? The Department of Defense needs to pass the baton of sexual assault prevention to an unbiased agency with the experience and knowledge to manage the program properly, where rank, status, and gender no longer play a role in whose report is believed, where confidentiality is actually observed, and where no one’s careers are in jeopardy for reporting.

Why Tell Now?

For those who have experienced sexual trauma, there are long-lasting effects that can change the course of one’s life.  These effects can include PTSD symptoms such as flashbacks and depression; suicidal thoughts and attempts; substance abuse; eating disorders; sleep disorders; and self-harm issues. There can also be medical issues that arise from sexual assault either from the assault itself or from the secondary conditions, for example, PTSD can lead to peripheral neuropathy.

For veteran’s who did not report sexual harassment or assault while still active duty, there is hope. While you cannot file a claim for the assault or harassment itself, you can file a claim for any conditions, mental or physical, you experience as a result of that trauma, up to and including unemployability. The VA has different rules of evidence to support claims of personal assault so even if it was never reported, there are ways to support the claim.  Getting ready to file a claim is also important, as veterans will have to go through some re-traumatization when having to retell their story. But there are ways to get help in dealing with this issue and getting through the claims process to try to ensure veteran’s who have been victims can get the medical and financial help they need to compensate for the damage that has been done.

If you are one of the members of this elite class of people who gave their all to defend our country and ended up having to defend themselves against unwanted advances, assault, harassment, or rape; please utilize the tools available to begin to protect yourself from the long term residuals that affect so many who do not get the emotional, medical, and financial assistance they need to become survivors.

Rachel Cheek, Attorney

PTSD Criteria & What the DSM-V Says

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In the first post in this series, we discussed the basic PTSD criteria found in the DSM-V. In this post, we will explore a few specifications of the condition and put all the criteria together.

It’s important to note that the DSM-V recognizes two specifications for PTSD diagnoses in addition to the eight initial diagnostic criteria. These specifications may not be present in every PTSD case.

Dissociative Specification

“Depersonalization is the experience of being detached from oneself and one’s surroundings.”

This specification applies to individuals who meet all PTSD criteria and who also experience dissociative symptoms when exposed to reminders about the traumatic event. One dissociative symptom is depersonalization, which is the experience of being detached from oneself and one’s surroundings or feeling like an outside observer or as if one is only dreaming. Someone experiencing depersonalization may have an “out of body” experience. Another symptom characteristic of a dissociative specification is derealization. With derealization, the individual may experience reminders of the trauma as though the reminders are not really happening, or believing the event or the reminders to be “unreal.” Similarly to depersonalization, derealization is a way for the individual to mentally distance themselves from the traumatic event.

Delayed Specification

This specification applies when the full diagnostic criteria are not met until at least six months after the initial traumatic event. In this specification, an individual may experience some symptoms immediately after the trauma, but not the full range of symptoms required for a diagnosis. In other cases, an individual may seem to be functioning perfectly normally with no symptoms at all until some time passes or a significant event such as the loss of a loved one or a life change such as a divorce or retirement brings on worsening symptoms. Regardless of when the symptoms appear, the individual must meet the full diagnostic criteria in order to receive a diagnosis of PTSD.

Now that we have explored the DSM-V criteria as well as possible specifications, let’s put it all together with an example.

The DSM-V Criteria in Action

Psychologist discusses PTSD Criteria

Many veterans struggle with PTSD and how this disorder can affect many aspects of their lives.

An Army veteran witnessed the death of fellow soldiers and enemies in combat (Criterion A) and suffers from flashbacks and nightmares about the combat (Criterion B). The veteran hates talking about war or being exposed to any depictions of violence because she does not like to be reminded of her experiences (Criterion C). The veteran tends to blame herself for what happened and is often depressed, showing little interest in her former activities (Criterion D). Ever since the veteran’s combat experience, she is “jumpy” and often has an outsize response to relatively small surprises. The veteran does not sleep well and is often irritable. (Criterion E). The combat happened fifteen years ago, but the veteran began experiencing her current symptoms ten years ago, after the death of an Army buddy (Criterion F, with Delayed Specification). The veteran has experience working in an office but has had a hard time keeping a job because it is difficult for the veteran to be around people without snapping at them and the veteran struggles with concentrating during tasks (Criterion G). The veteran’s healthcare professionals have determined that the veteran’s symptoms do not stem from alcohol abuse, medication, or any other condition (Criterion H).

While the above example is somewhat simplistic, it is intended to provide a picture of what many veterans struggling with PTSD experience and how this disorder can affect many aspects of life. With the exception of Criterion H, each individual case may fulfill the criteria in totally unique ways. Recall that Criterion F requires the duration of symptoms longer than one month, but there is no upper diagnostic limit to how long PTSD symptoms may last.

If you are wondering how the VA rates PTSD and other mental disorders, you can read more in our other recent blog post.

Rachel Cheek, Attorney

How the VA Rates Mental Disorders

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rating va mental disorders

How the VA Rates Mental Disorders

The VA determines ratings for hundreds of different disabilities according to very specific criteria based on federal law. If you are interested, you can access the schedule of ratings for yourself here at the Electronic Code of Federal Regulations. Today, we’ll look at the rating schedule for general mental disorders. Many physical disabilities have rating schedules that are based on objective, measurable criteria. For example, ankylosis (a term for a fusion of joint bones that causes immobility) of the knee can be rated anywhere from 30% (if the knee is able to be fully extended despite the ankylosis or if the knee can be flexed between 0 and 10 degrees of movement) to 60% (if the knee cannot be flexed past 45 degrees).  The rating criteria for general mental disorders are more subjective. This is due to the fact that the severity of mental disorders is usually not as easy to evaluate as the severity of physical disorders.

This schedule covers a variety of mental disorders from PTSD to obsessive-compulsive disorder. Eating disorders have their own specific schedule. The schedule ranges from 0% (non-compensable) to 100% (in which an individual is considered unemployable and entitled to receive the maximum level of compensation).

General VA Rating Formula for Mental Disorders

  • 0% – This category is for veterans who have the diagnosis but do not show enough symptoms to impair work performance or social functioning or to require regular medication. No compensation is awarded at this level.
  • 10% – In order to meet this rating, a veteran must have mild symptoms that impair work performance and social function only during times of high stress. This rating is also appropriate for veterans whose symptoms are managed by continuous medication.
  • 30% – This rating requires a generally regularly functioning veteran to have work and social impairment with occasional decreases in work performance due to symptoms from their diagnosed disorder. At times, veterans in this category may be unable to do certain tasks related to work due to their symptoms. These symptoms range from depressed mood, anxiety, suspiciousness, weekly or less frequent panic attacks, trouble sleeping, to mild memory loss.
  • 50% – This rating requires a veteran to have regular impairment of work and social functioning due to their symptoms. The symptoms may range from a flattened affect (not being able to show any emotion, good or bad); “talking in circles;” panic attacks that happen more than once a week; trouble understanding complex commands; poor short- and long-term memory; impaired judgment; trouble with abstract thinking; disturbances in motivation or mood; and trouble making and maintaining relationships.
  • 70% – In order to meet the criteria for this rating, a veteran must suffer from
    US soldier struggling with mental disorder

    “There are many symptoms that may cause impairment such as continuous depression and others.”

    impairment in most, if not all, of the following areas: work, school, family relations, judgment, thinking, or mood. There are many symptoms that may cause impairment, among them suicidal ideation (thoughts of suicide); obsessive rituals interfering with daily activities (for example, compulsive hand-washing); illogical, obscure, or irrelevant speech; continuous panic or depression affecting the ability to function on one’s own; impaired impulse control (for example, irritability with periods of violence in response to minor inconveniences); spatial disorientation (getting lost or disoriented); neglect of personal appearance or hygiene (intentionally or unintentionally not showering or brushing one’s teeth); difficulty adapting to stressful circumstances, including at work; and inability to make or keep up professional and personal relationships. Even if you do not have any other disabilities, a single mental condition rated at 70% means you may be qualified to receive individual unemployability benefits.

  • 100% – The highest possible rating. A veteran rated at 100% is considered totally disabled. As such, the requirements for this category are very severe.  A veteran who receives this rating must be totally impaired due to symptoms such as overall impairment in thought processes or communication; persistent delusions or hallucinations (believing things that are not true or seeing and/or hearing things that are not there); inappropriate behavior (for example, undressing oneself in public); persistent danger of hurting self or others (including suicide attempts); recurrent inability to perform activities of daily living (this includes feeding oneself, bathing oneself, dressing oneself, and using the toilet); disorientation to time (being unsure of time of day, date, or year) or place; memory loss to the degree of forgetting the names of close relatives, one’s own occupation, or one’s own name. This rating entitles you to the same benefits as an award of individual unemployability.

Why are mental disorders so hard to measure?

 

Rating VA Mental disorders

As discussed above, mental conditions are harder to measure than most physical conditions. It is not uncommon for a person to have symptoms that fit into two different rating categories.  Applicable law states that when a veteran displays symptoms that could fit into two different rating categories, the higher rating should be assigned if the disability overall fits the criteria for that rating.  Take the example of Mr. X, a veteran who has been diagnosed with PTSD.  Mr. X’s PTSD symptoms include trouble sleeping (30% category) and weekly panic attacks (30% category). He also gets lost very easily (70% category), which never happened before his diagnosis. Mr. X’s wife has to remind him to brush his teeth and take regular showers (70% category). Mr. X is retired from his former job as an office manager. He had to retire because dealing with employees and clients every day got to be too stressful (70% category). He also had trouble remembering to make calls, even if his secretary reminded him about them (50% category). Even though Mr. X has PTSD symptoms that could fall into three different rating categories, he should be assigned the 70% rating because he fits the overall criteria for that category.

Mental disorders are very common for veterans to experience, and can be just as disabling as a physical condition. If you have been diagnosed with a mental disorder and any of these symptoms sound familiar to you, you should apply for VA benefits to receive the compensation you deserve.

Cassandra Crosby, Claims Advocate

Why Your MST Case May Have Been Denied

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Why Your MST Case May Have Been Denied Incorrectly

The VA has a duty to assist in claims and when it comes to a case of military sexual trauma (MST), there are different rules to carry out that duty to assist.  The VA is mandated to review records with a more liberal hand to corroborate a case of MST, meaning they do not have to find hard evidence that it occurred, just evidence that can corroborate a trauma occurred.

The evidence in question involves such things as evidence of a stressor, behavioral changes, and outside records that can identify a possible stressor. The VA has a relaxed standard of evidence required for MST than other claims, understanding that many victims do not, or cannot, report the crime. Evidence that can be considered “markers” in an MST claim includes:

  1. Records from law enforcement, sexual assault centers, mental health counseling, hospitals, or physicians
  2. Pregnancy tests or tests for STDs
  3. Statements from family members, roommates, fellow Service members, clergy members, or counselors
  4. Requests for transfer to other duty stations
  5. Substance abuse
  6. Episodes of depression, panic attacks, or anxiety without identifiable causes
  7. Unexplained economic or social behavioral changes
  8. Relationship issues such as divorce
  9. Sexual dysfunction.

When a veteran files a claim for a condition related to MST, the VA is required to assign staff specially educated in identifying markers of trauma in a records review. Once the markers are identified, a medical exam (C&P exam) is scheduled and the evidence is sent to the Regional office for review.  However, this has not been the standard practice of the VA and, according to a recent report to the Office of the Inspector General, nearly half of the MST cases are not being handled properly resulting in not only denials of valid claims, but increased traumatization and stress of the victims.

What Happened?

The VA can only deny a medical exam in these cases if there is no evidence of a stressor, no evidence of a behavioral marker, or no evidence of a mental disorder. The VA did not use experienced staff to review medical and personnel records of claimants, missing the above criteria, so many claims were denied without calling for a medical exam. In FY 2017, this equated to about 5,500 claims, or 46% of all MST claims filed.

This first mistake caused undue stress for MST victims already suffering from PTSD, anxiety disorders, or any number of mental health conditions, let alone any physical conditions that may have been related to their attack. Many of these claimants also cannot work due to the residuals of their attacks and have just lost valuable time gaining access to much needed financial assistance in paying for things like rent and electric and food. If not service connected, they may also be piling up medical bills or, it not getting treatment, getting closer and closer to hospitalization or even potential suicide.

When the OIG went back to review the claims denied, the following was found:Why MST Cases were denied incorrectly

  1. Evidence was found that was sufficient to call for a medical exam but the staff did not call for one in 28% of cases;
  2. Evidence-gathering issues were inadequate such as not requesting personal medical records in 13% of cases;
  3. MST Coordinators did not call veterans or use language in letters sent to veterans to determine whether the incident was reported in service or attempt to obtain a copy of the report in 11% of cases;
  4. Reviewers decided veterans’ claims based on contradictory or otherwise insufficient medical opinions in 10% of cases.

The OIG is recommending changes to the process to ensure that these issues are corrected, including a review of all past denied MST-related claims from 2017.

Why MST Cases Get Denied Often

MST is difficult to process because most victims do not want anyone to know they were assaulted. In the military, even in the 21st century, there is still a stigma and whether the DoD wants to believe it or not, people lose their careers over reporting, especially if their perpetrator is senior to themselves or someone who has influence. The military does not do as good of a job dealing with sexual assault as they like to pat themselves on the back for. If they did, there would be many more reports in veterans’ service records of MST being reported to officials than there are.

In a recent report, we just learned how the VA spent over $24,000,000 in FY 2017 in unnecessary C&P exams and yet, in the same fiscal year, they are denying needed exams and denying claims leading to an increased mental health crisis among our most vulnerable populations of veterans.

Service members are not only afraid for their careers if they report the assault, but they are also afraid of the residuals from not only the attack such as continued harassment, getting their careers sidelined, or getting poor details; also the residuals of the mental health trauma attached to the assault. Going to mental health clinics for assistance in dealing with trauma, be it counseling or medication treatment, can also lead to a call for “unfit for duty” and an end to someone’s career, for something that was perpetrated by another person. From the victims’ point of view, it is unfair that their life be ruined because someone else did something so wrong. Yet the DoD has made no moves to correct this imbalance of power perpetrators have in a substantial manner.

Act Now

If you were denied a claim for PTSD due to MST, please call us to review your case and see if there were mistakes made on your claim by the VA. We have experts that want to make sure that your life becomes your own again.

Matthew Hill

Video Blog – Buddy Statements For Increased Rating

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Matthew Hill: Hello and welcome to the Hill and Ponton VA Video Blog. I’m Matthew Hill here with Carol Ponton and today we are talking about buddy statements. This is the fourth part in our four-part series on buddy statements. The first one we discussed was how important they are.

Carol Ponton: Yes.

Matthew Hill: And then the second one was how to actually craft a buddy statement. The last one we just talked about was on service connection and how you can show through buddy statements your disability’s related service and this is going to be on rating so essentially, you’re already rated for a disability and now you’re trying to get an increased rating. You’re trying to get the VA to understand what the correct rating should be. And we were talking about this and we think one of the disabilities that lends itself to understanding this the best is actually PTSD.

Carol Ponton: Right.

Matthew Hill: A lot of times you have PTSD, it’s just the perfect storm when it comes to veterans who aren’t really self-aware, they don’t know how bad it is. On top of that, they don’t want to talk about it, they don’t want to think about it. When they go see their doctors, they don’t want their doctors to do something to them, put them on medication, lock them up and so they don’t tell their doctors how it’s going. And so a lot of times you’ll get a veteran to where you see exams, you even see discontinuing treatment records showing … guy seems pretty okay, he’s coping with it but once you talk to those around him, family, friends, bosses, you realize that’s not the case at all.

Carol Ponton: Right. We recommend buddy statements for, first of all, the veteran. When we talk to the veteran I pull out DBQs, or disability questionnaires that … benefit questionnaires that the VA has online and there’s a really good one for PTSD and it goes down all of the criteria they think you need in order to be service connected for PTSD and what they’re looking for as the problems that come with that. And so I like to ask the veteran about each one of those criteria and then I go through all the symptoms that people have. And I want to make sure they’re telling me the truth because, as you said, most people … It’s horrible to have to talk about it and think about it but I tell them this is the one time we really need to let the VA know what’s going on with you.

Carol Ponton: I go through all of that and then I ask who’s the person that knows you the best. Are you married? Do you have family members? And then we talk to them and we tell the veterans, don’t get upset with these people. These are the people that are helping us paint a picture of how this disease has really harmed your life and when you go to them and you need to know what issues to talk about and that’s why this form is so helpful because you start saying is he paranoid? Is he unable to be around people? Does he have trust issues? Anger issues? Give me examples of those.

Carol Ponton: This buddy statement really gives you an opportunity to create a wonderful picture of how PTSD has totally affected this veteran.

Matthew Hill: I like to think about it as a total … I don’t know if it’s necessarily wonderful but it’s a way to get information that the veteran just doesn’t see. One of the biggest things any veteran, any person with PTSD will tell you is, the most horrible are the nightmares, the night terrors, the flashbacks and as bad as those are, the VA caps the rating on those at 30%. So, unfortunately, a lot of times what I see on the DBQs from doctors is that that’s what they check. Oh, this person has really bad nightmares, that’s capped but on top of that, this person might have really bad anger issues. Yells and screams just gets in fights for no reason, isolates himself, nobody wants to be around him. That’s a significant problem. And that’s a problem that would get the veteran a much higher rating. And unfortunately, it’s also one that they might not be that self-aware of.

Carol Ponton: Right. They may feel they get angry because there’s a reason that they get angry and the people that look at him say, that was way out of line for what happened.

Matthew Hill: Right, right. The response is worse. I typically start, like Carol says, with the veteran to ask them how many anger issues they have and a typical response I’ll get is, I get irritated but I don’t get angry. And so I go to well, what happens when a guy cuts you off in traffic and then you get a list of expletives, a list of curse words, and some pretty interesting stories but they still might not be aware of how overreacting that is and that’s why working with the wife, working with children, working with friends, coworkers, you can get a really good statement. And again, it goes back to getting a competent statement. You just want them to list stories that happened, facts, observations. You don’t need them to say this guy deserves benefits, you need them to lay out what exactly happened or what they see or the children being on pins and needles all the time around their dad, and why.

Carol Ponton: And what to put in is just as important as what you leave out. And that’s really right, please don’t put this person deserves benefits, he’s a really nice guy. He may be all that and he may deserve that but when you put that in there, all of a sudden the VA says, is this subjective? Are you really trying to plead his case or are you … What are doing here? So don’t distract the VA. You can win his case by telling the truth. It’s like seeing a movie, you want to paint a picture of what you see with this veteran.

Matthew Hill: Right. There’s a time and place for the argument, the persuasion and that’s your VSO or your attorney actually writing a letter but the point of a buddy statement, the power of the buddy statement, is the reflection of the facts and of the stories because the VA can’t make that go away. What gets the veteran a proper rating is just showing the VA a day in the life and in a service connection case they might be able to hide the service records, they might be able to not get something but this is what’s really going on day-to-day and that’s the power of the buddy statement.

Carol Ponton: Well, the other power that I see is, think about the person, the decision review officer, he reads case after case after case. You want to make this personal, you want to make this so that the person knows what you’re living with and all of a sudden they can see, oh my gosh, this is really awful. This is your chance to tell your story so make sure it’s complete.

Matthew Hill: Well, thank you for tuning in. Again, this was the fourth part of the four-part series of buddy statements and the power they have on a veteran’s claim. Thank you.

Shannon Brewer, Senior Attorney

How Does VA Determine A Psychiatric Disability Rating?

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For all service-connected disabilities, the VA references its own rating schedule, and the criteria listed therein, in determining the appropriate rating.  Most common disabilities are listed on the rating schedule, and for those that are not listed, the VA assigns an analogous rating by choosing a similar disability on the rating schedule which has the same types of symptoms as the unlisted disability.  For psychiatric, or mental, disabilities, the VA uses a General Rating Formula For Mental Disorders.  So whether your disability is PTSD, Bipolar Disorder, Anxiety, or Depression, the VA rates all of these disabilities on the same rating schedule, looking at the same range of symptoms.

This general formula can actually be beneficial to a veteran because psychiatric diagnoses can be fluid.   I have seen files where a veteran has been treated by multiple doctors, and each doctor assigned a different diagnosis, from schizophrenia to adjustment disorder to PTSD.  While it is important that your psychiatrist or other mental health professional knows all of the details of your condition so as to provide proper care, as far as the VA disability benefits system is concerned, the diagnosis is less important than the range of symptoms exhibited by the veteran.

0% Rating

Let’s discuss how the rating schedule for mental disorders works.  I don’t see a noncompensable rating assigned very often for mental disorders, but sometimes the VA will determine that a veteran, while diagnosed with a mental condition, does not have any symptoms that interfere with occupational and social functioning or require continuous medication.  In that case, the VA will assign a 0% rating.

10% Rating

A slightly higher rating of 10% is assigned where a veteran’s psychiatric symptoms are completely controlled by medications.  A 10% rating might also be assigned if the VA psychiatrist determines that the veteran has only mild symptoms or symptom that come and go which only impair the veteran very rarely, for instance under periods of high stress.

30% Rating

When a veteran’s psychiatric symptoms begin to impair the veteran’s work efficiency more often or more intensely, a 30% rating would be assigned.  For this rating, VA is looking at symptoms such as depression, anxiety, panic attacks which happen weekly or less often, chronic sleep impairment, or mild problems with memory.  This rating is assigned when the veteran is generally functioning well but does have occasional problems socially and occupationally.

50% Rating

The more often a veteran is experiencing psychiatric symptoms, or the more serious those symptoms are, the higher the rating.   A 50% rating is assigned in cases where the veteran is experiencing more consistent problems with work and socially.   Here, the VA would be looking for symptoms such as panic attacks more than once per week, impaired judgment or thinking or speech, disturbances of mood and motivation, or difficulty with effective work and social relationships.

70% Rating

A higher rating of 70% is assigned where the veteran has occupational and social difficulties in most areas, such as with work and school, family relationships, judgment, thinking or mood.  To assign a 70% rating, the VA must find symptoms such as suicidal ideation, ritualistic behaviors, illogical speech, nearly continuous panic or depression, impaired impulse control, difficulty adapting to stress, neglect of personal appearance or an inability to maintain relationships (work or social).

100% Rating

Finally, a total disability rating is assigned in only the most severe cases.  To be rated 100% for a mental disorder, the veteran must demonstrate gross impairments in thought or behavior, persistent delusions or hallucinations, an intermittent inability to maintain hygiene and/or perform personal functions, disorientation to time or place, or present a persistent danger of hurting self or others.  Of note, we find that many veterans who are at the 70% level of impairment still find themselves unable to work and 100% occupationally impaired even though they don’t meet the criteria for the 100% schedular rating.  For those veterans, it can be helpful to apply for individual unemployability as an alternate route to a total rating.

It’s important to know that for each of these categories, a veteran need not suffer from every symptom listed.  The VA is supposed to look at all of the veteran’s symptoms and determine into which category he or she most closely fits.   A veteran should make sure to report all of the symptoms he or she is experiencing, whether they are on the list or not, so that VA can appropriately consider the veteran’s entire disability picture when assigning a rating.

Rachel Cheek, Attorney

PTSD: Basic Criteria

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Post traumatic stress disorder (PTSD) is a recognized psychiatric disorder that a person may develop after exposure to a traumatic event. For many years, PTSD went widely undiagnosed or was not recognized as the serious condition it is. Thanks to advancements in research and the breakdown of social stigmas, we have more information about the condition than ever before. We know that the majority of people who are exposed to traumatic events do not develop PTSD, and we know that veterans of the U.S. military are disproportionately affected by PTSD when compared to American civilians.

This blog post is intended to serve as a brief breakdown of the required criteria for a diagnosis of PTSD as defined by the fifth edition of the Diagnostic and Statistics Manual of Mental Disorders (DSM V), published by the American Psychiatric Association.

Criterion A: Stressor

In the context of PTSD, the stressor is the traumatic event that leads to the development of PTSD. The precise definition of “traumatic event” is contested, but the DSM V requires exposure to death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence. This exposure must have occurred in one of the following ways: direct exposure; witnessing the trauma; learning that a relative or close friend was exposed to the trauma; or indirect exposure to details of the trauma, often in the course of professional duties (for example, a paramedic treating victims of a serious motor vehicle accident would be indirectly exposed to the traumatic event of the motor vehicle accident even if she did not witness the accident herself).

Criterion B: Intrusive symptoms

Not everyone who is exposed to a traumatic event will develop PTSD. In order for a person to receive a diagnosis of PTSD, the DSM-V requires the person to show at least one intrusive symptom. Intrusive symptoms can manifest in sudden upsetting memories; nightmares or bad dreams; flashbacks to the traumatic event; emotional distress after reminders of the traumatic event; or physical reactivity following reminders of the traumatic event (for example, an increased heart rate after exposure to reminders of the traumatic event).

Criterion C: Avoidance symptoms

The third criterion for a PTSD diagnosis is avoidance of reminders of the trauma. This could be an avoidance of thoughts or feelings about the event or avoidance of trauma-related reminders altogether. A person who suffered sexual assault may display avoidance of thoughts and feelings of the assault and do their best to never think about the event. Someone who witnessed a person drowning may avoid trauma-related reminders and stay away from pools or bodies of water. For a diagnosis of PTSD, the presence of at least one of these symptoms is required.

Criterion D: Negative alterations in cognition and mood

A person who receives a diagnosis of PTSD must display at least two of the following symptoms following the stressor: inability to recall key features of the stressor; overly negative thoughts or assumptions about oneself or the world; exaggerated blaming of self or of others for causing the trauma; negative affect (having a flat or depressed mood); decreased interest in regular activities; feelings of isolation; or difficulty experiencing a positive effect (having a hard time feeling happy).

Criterion E: Alterations in arousal and reactivity

For a diagnosis of PTSD, at least two of the following symptoms that began or worsened after the stressor must be present: Irritability or aggression; risky or destructive behavior (for example, driving recklessly); hypervigilance (for example, not being able to relax for fear that something bad will happen); increased startle reaction; difficulty concentrating; or difficulty sleeping. These alterations in arousal and reactivity are a defense mechanism for preventing further trauma.

Criterion F: Duration of symptoms

Even if a person fulfills all the required criteria, a diagnosis of PTSD requires persistence of the symptoms for more than one month. A person may fulfill all criteria immediately following a traumatic event but two weeks after the event may display fewer or none of the required symptoms. Although the criteria were present for a time, the person would not meet the duration requirement.

Criterion G: Functional significance

The PTSD symptoms experienced by the person with the diagnosis must create distress or functional impairment in a person’s life. For example, a veteran who suffers from PTSD and currently works in an office setting may find that his job performance is impacted by difficulty concentrating or increased irritability with his coworkers. A college student who experienced sexual assault at a party may find that their friendships are affected by their negative affect, hypervigilance, and their avoidance of other social events.

Criterion H: Exclusion

In order to meet the criteria for a PTSD diagnosis, the symptoms must not be caused by medication, substance abuse, or any other illness.

This is an extremely simplified discussion of PTSD intended to provide clarity to a frequently-discussed condition. Follow-up blogs will address specifications of the diagnosis as well as the issue of PTSD as it relates specifically to veterans seeking service connection.

Anne Linscott, Attorney

Age, PTSD, & Your VA Disability Claim

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PTSD is a psychiatric condition that is classified as a trauma and stressor-related disorder by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V). PTSD involves re-experiencing an extremely traumatic event (this event is referred to as the “stressor”) and is usually accompanied by increased arousal, nightmares, flashbacks, difficulty sleeping, difficulty concentrating, and difficulty with memory among numerous other symptoms.  A traumatic event is a life-threatening event such as military combat, natural disasters, terrorist incidents, serious accidents, or physical or sexual assault in adult or childhood. Symptoms of PTSD usually start soon after the traumatic event, but might not become apparent for weeks, months, or even years after the traumatic event. Some common symptom patterns of PTSD include:

  • Developing PTSD symptoms soon after returning from war, with those symptoms lasting into old age.
  • Developing severe PTSD symptoms right after their traumatic experience that decrease in severity over the years, and then worsen again later in life.
  • Developing PTSD symptoms later in life rather than soon after returning from war.

As the last two patterns suggest, PTSD symptoms may worsen later in life, and might not even develop until later in life. A study published by the VA contains some insight into why veterans are having more problems with PTSD symptoms as they age. This study explained how older veterans are faced with different factors which impact PTSD. Some of these factors include:

  • Retirement:

    Many veterans throw themselves into work upon returning home from serving as a way to cope with traumatic experiences they may have had. Work can be used as a way to keep the mind occupied. However, as the veteran gets older, retirement comes into the picture. Retirement can result in less structure, and more free time to think then the veteran had while they were distracted with work. Retirement can also be stressful because it might trigger feelings of different types of losses such as identity, activities, and/or income.

  • Increased health problems:

    With age comes increased medical problems. PTSD has been associated with other health problems such as cardiovascular disease, obesity, diabetes, and sleep apnea. These health problems then, in turn, can make the PTSD worse. It’s a cycle of PTSD causing secondary problems, and those secondary problems then impacting the PTSD. Another health problem that is of concern for older veterans is dementia. Veterans with dementia experience more severe PTSD symptoms and PTSD is a risk factor for dementia. So, the two can sometimes go hand in hand just like other health problems that impact the severity of PTSD.

  • Unhealthy methods of coping:

    It’s common for veterans to self-medicate with drugs or alcohol as a way of coping with traumatic experiences they went through in service. Years of substance abuse can wreak havoc on the body both physically and mentally forcing a veteran to give up alcohol and/or drugs. When this happens, the veteran no longer able to ignore the reality of their PTSD symptoms, and can see an increase in flashbacks, nightmares, or hypervigilance.

  • Social isolation:

    Oftentimes, veterans with PTSD may struggle with isolating themselves. This isolation can become an even bigger problem for older veterans. An article titled “The 2030 Problem: Caring for Aging Baby Boomers” states social connections are closely related to mental health and cognition. The article goes on to explain how “persons who had no social ties were twice as likely to experience cognitive decline compared to those persons with five or six social ties,” and approximately 6.4 million elderly people are socially isolated to a point that their health is at risk.” So, as a veteran gets older they are more likely to become isolated. Combine this with the fact that PTSD also makes someone more likely to become isolated, and it’s clear how a veteran with PTSD may see their symptoms increase with their age.

What does all of this mean for your VA disability claim? As mentioned above, sometimes PTSD does not develop until later in life. If you have been denied service connection for PTSD because the VA says your diagnosis is too far removed from your service, a psychiatrist or psychologist may be able to provide their independent medical opinion explaining how, and why, your PTSD did not develop until years after the in-service traumatic event. Also, if you have already been service connected for PTSD, it is important to note any changes in your symptoms as time goes on. If your PTSD symptoms get worse as you get older (for example, after retirement), you may need to file a claim for an increased rating.

Cassandra Crosby, Claims Advocate

Peripheral Neuropathy: Not always an Agent Orange issue….

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Peripheral neuropathy is an illness often linked to Agent Orange and herbicide exposure. It is associated with pain, burning, and numbness in the upper and lower extremities such as the hands and feet. It is presumptive for those veterans who served in Vietnam and were exposed to Agent Orange, however, only if it manifested within one year of exposure. However many Gulf War veterans have also been exposed to similar agents, also known as organophosphates, in forms of pesticides, that have links to peripheral neuropathy. There are also several other toxins and illnesses that can lead to peripheral neuropathy as a primary or secondary condition. Veterans need to be aware that if they have peripheral neuropathy, there may be more than one reason and there could be a claim for service connection or secondary connection.

Toxin Exposures

Toxins associated with peripheral neuropathy are often thought of as being those Agent Orange and affiliate herbicides from the Vietnam era, including those used in Thailand, Guam, and even some US bases such as Anniston Army Depot in AL and Camp Pendleton in CA. Both these bases have been listed as EPA Superfund Cleanup Sites and one of the toxins listed is herbicides. Dozens of other bases, US and abroad, used pesticides that contained organophosphates linked to peripheral neuropathy (PN). However, again, these are linked to a specific type of neuropathy, one that manifests within a year or less. In order to be eligible for presumptive, or to have a good claim based on toxin exposure, there would need to be evidence of symptoms within a year of exposure. However, there are other ways that a veteran can get PN.

Diabetes Mellitus II

Most people are aware of the link between diabetes and PN. Diabetes causes blood to not reach the outer capillaries of the circulatory system, causing nerve damage in the feet, toes, hands, and fingers. As the damage increases with uncontrolled diabetes, the damage moves inward up the legs and arms and increases in pain levels. The neuropathy can lead to a person being unaware of wounds, causing infection and even leading to amputation.

Lupus and Autoimmune Diseases/Rheumatoid Arthritis

Many autoimmune diseases lead to PN. These diseases cause the body to attack its own tissue, often causing inflammation. That inflammation can often inflame the nerve fibers causing neuropathy. Some of these neuropathies can become severe and life-threatening such as Chronic inflammatory demyelinating polyneuropathy (CIDP) which damages the sensory and motor nerves. Autoimmune diseases are often found among Gulf War Veterans and some, such as MS, are presumptive for all veterans within a certain time frame from discharge.

Hyperthyroidism and Metabolic or Endocrine disorders

Diabetes is also a presumptive disease associated with herbicide exposure during Vietnam service. However, any veteran who was diagnosed with diabetes in service or whose diabetes manifested while on active duty is eligible for service connection. Veterans whose diabetes manifested within one year of discharge or who feel they were exposed to environmental toxins that may have been responsible for their diabetes are also welcome to file a claim, although they must be able to show a link between their service and their condition.

Diabetes is an endocrine disorder, but there are others that can also lead to PN. Hypothyroidism is another issue that is often seen in Gulf War veterans. Some metabolic liver conditions and hormonal imbalances can also cause PN. With thyroid conditions, underproduction of thyroid hormones slows the metabolism which leads to fluid retention and swollen tissue, putting pressure on peripheral nerves causing pain.

Small Vessel Disease

Diseases such as vasculitis cause blood vessel walls to harden, thicken, and develop scar tissue. When this happens, the vessels decrease in diameter and subsequently decrease the flow of blood to the peripheral extremities, leading to neuropathy in a similar fashion as diabetes. The lack of blood flow increased the nerve damage and it increases with time.

Kidney Disorders

Kidney disorders lead to increased levels of toxins in the blood that damage nerve tissues. Most people on dialysis have a form of neuropathy. The toxins damage the nerve fibers and the nerves are then unable to process signals correctly, leading to tingling, burning, pain, and numbness.

Cancers and Neuromas

Tumors, benign or not, and cancer cells, can increase pressure on nerve fibers depending on where they are growing, and can cause widespread pain. Treatment for cancer can also lead to extensive nerve damage as the chemotherapy medications and radiation kill nerve cells just as easily as cancer cells; 30-40% of people under cancer treatments have peripheral neuropathy and it is one of the leading reasons people stop cancer treatment earlier than recommended. Unfortunately, often stopping treatment does not stop or reverse the PN symptoms.

Infections

Several infectious diseases can cause PN such as those that attack nerve tissues. These include shingles, Epstein-Barr, West Nile, cytomegalovirus, and herpes simplex. Also, bacterial infections such as Lyme disease, diphtheria, leprosy are known for severe peripheral neuropathy issues. While diphtheria and leprosy are rare in the US, with our veterans traveling all over the world and often exposed to cultures that carry unknown diseases, there are risks. Lyme disease, shingles, and the other viruses are common in the US and can severely damage sensory nerves, causing pain, numbness, and may sometimes be permanent.

Medications

Not only do the medications used to treat cancer cause nerve damage, others do as well. Medications such as antiretroviral agents for HIV, some anticonvulsant agents, and some heart and blood pressure medications can cause PN. Check the side effects with your physician because often just adjusting the dosage can prevent the onset of PN.

Trauma, Injury, or Repetitive Stress

Sports-related injuries, auto accidents, surgical procedures….sometimes any type of trauma can cause the nerves to be damaged, crushed, impinged, or have pressure put on them in such a way that it impedes their ability to process signals correctly, leading to PN. Cumulative damage from repetitive use can often cause tendons to become inflamed, leading to pressure on the nerve fibers such as in the case of carpal tunnel syndrome.

PTSD and TBI

Recent studies have started to link PTSD to PN. Scientists are trying to find out the ways that PTSD may cause PN but there are several theories. Some include the body’s chemical reaction to stress and how those chemicals change the pituitary and adrenal glands, resetting the hormonal balance of our body. This, in turn, causes such issues as explained in the section above on hormonal and endocrine conditions. Another theory concerns neurochemicals such as serotonin, amino acids, and peptides, which may deregulate the way that nerve signals are translated. When parts of the brain are damaged by TBI or PTSD, such as the cortex, these neurochemicals become unbalanced and they interpret nerve signals incorrectly, often leading to PN conditions. While this is still a new area of science, it is worth exploring if you are diagnosed with service-connected PTSD or TBI and are experiencing PN.

Alcoholism

Finally, alcoholism is a contributor to PN. Again, alcohol damages the peripheral nerves, reducing the blood flow and increases with extended use. However, many do not realize that often alcoholism is a secondary condition to a mental health problem that can be service connected. This is often worth filing a claim if there is a history of alcoholism that started in or after service.

PN as a Secondary Condition

If a veteran is service connected for any of the conditions above, or wants to file for service connection for one of the conditions, and has peripheral neuropathy, it may be a secondary condition and may be worth filing a claim. Secondary conditions are often overlooked and can lead to higher ratings and increased benefits for veterans.

Cassandra Crosby, Claims Advocate

Understanding the Criteria and Rating of PTSD

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PTSD is caused by so many different events; personal trauma, sexual trauma, combat, reactions to training. It is the 6th highest rated disability among veterans, with over 63,000 new claims in 2015 and a total of over 800,000 veterans receiving compensation for symptoms of PTSD at some level. Many veterans are told they have PTSD and submit all the evidence required, but then when they apply for benefits they see this on their rating decision, “Does not meet the criteria for PTSD.” In this blog, we will explore various reasons why veterans get denied for this reason and what they can do about it.

Incorrect Rating Decisions:

Often the rating decision is just incorrect. Not that the veteran does not meet the PTSD criteria, but that they are denying a mental health disorder because the veteran filed for one disorder and actually has a different one.

Veterans, unless they have a doctorate in psychology, are not able to officially diagnose their own mental health disorders. Therefore, if a claim is filed for PTSD and it is denied because a veteran does not meet the criteria, the VA should have determined if the veteran had another diagnosis, which they often do not. Veterans can often avoid this process by filing a claim for a more generic issue such as “acquired psychiatric disorder” or “service connected mental health disorder.” By filing for benefits in this manner, it puts the responsibility on the VA to diagnose through a C&P exam and/or utilizing medical records where a diagnosis may already exist.

Understanding Criterion A of PTSD

 

This is one of the most puzzling aspects of diagnosing for lay people. Criteria A is what determines if a stressor can be used to support a diagnosis of PTSD. If there is no Criteria A, there is no diagnosis. However, many people, even doctors, often misunderstand the requirements for this diagnostic step. The criteria broken down are:

Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:

  1. Directly experiencing the traumatic event(s);
  2. Witnessing, in person, the event(s) as it occurred to others;
  3. Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the events(s) must have been violent or accidental.
  4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g. first responders collecting human remains; police officers repeatedly exposed to details of child abuse.)

For many, the basic criteria listed above of 1 and 2 are easy to understand. Where we find mistakes most often are with criteria 3 and 4.

Criteria 3 states that the event must have happened to a family member or close friend. Often the VA will determine that members of a unit are not considered close friends if they have not served together for a certain period of time or were in a different geographical location. However, the culture of the military is one where even if unit members are on different continents, they are bound by a brotherhood and when members of a unit experience a trauma such as terrorism or a plane crash, the entire unit is affected; even support staff and support units, not just those who served directly together.

Criteria 4 is often mistaken for only being related to repeated events only such as those experienced by military security forces or convoy personnel. However, reading the criteria closer, it states, repeated or extreme. Extreme can mean a lot of things in the military world, terrorism, IEPDs, even having to write up the reports dealing with the death or losses of troops or civilians. And, extreme is about perception, what may be extreme may not be perceived as such by someone else, so discussing the events with a psychologist is important so that they can determine how the veteran perceived the event and if it meets Criteria A requirements for PTSD.

Understanding the General Rating Formula for Mental Health Conditions

Rating levels are determined by the General Rating Formula. This is where the VA takes the symptoms of any mental health condition and translates them into a rating of 10, 30, 50, 70, or 100%.  The VA often rates veterans by the average of their symptoms, so if a veteran has symptoms that fall in the 30, 50, and 70% ranges, they will often get a 50% rating. However, this is not the correct way to rate a mental health disorder. Ratings should be based on the highest level of symptoms, not an average. So, if a veteran has 6 symptoms at 30%, 3 at 50% and 2 at 70%, they should be rated at 70%. Also, the VA cannot downplay symptoms and give them a lower rating. For example, if a veteran has suicidal ideations, that is a 70% rating. However, if the doctor states that the veteran does not have intent, the ideations are fleeting, and intermittent, the VA will sometimes reduce the rating or ignore the symptom all together and not rate it. However, it is never less than a 70% rating if a veteran has suicidal ideations, regardless of intent, plan, past hospitalizations, or if they are fleeting or constant.

If you are a veteran with a mental health rating, make sure you are getting the correct rating and the highest benefits you are entitled to, you deserve it for the price you paid to defend your country.