PTSD Archives - Hill & Ponton, P.A.

Peripheral Neuropathy: Not always an Agent Orange issue….

April 18, 2018/in Agent Orange, Gulf War Syndrome, PTSD, Veterans /by Cassandra Crosby, Claims Advocate

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.

Understanding the Criteria and Rating of PTSD

April 11, 2018/in PTSD, Veterans /by Cassandra Crosby, Claims Advocate

PTSD is caused by so many different events; personal trauma, sexual trauma, combat, reactions to training. It is the 6^th 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:

Directly experiencing the traumatic event(s);
Witnessing, in person, the event(s) as it occurred to others;
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.
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.

PTSD and the Military Community

January 3, 2018/in PTSD, Veterans /by Kylie Courtwright, Claims Advocate

Recently, there have been multiple incidents involving different branches of our military that have resulted in tragic outcomes. Unfortunately, too many of our Marines and Sailors have been killed due to the Marine cargo plane crashing and the two separate incidents of Navy ship collisions; USS Fitzgerald and USS John McCain. Although there is still some hope for some of the missing USS John McCain sailors, as not all remains have been found, seven sailors were killed onboard USS Fitzgerald and 16 Marines were killed in the plane crash. Regrettably, traumatic incidents such as these and loss of life are not a rare occurrence for members of the military and it is important to look at mental health within the military community, including veterans, and how it pertains to claims within the VA.

Verifying a Stressor

One of the most common claims the VA receives is for service connection of Post-Traumatic Stress Disorder (PTSD). When the VA receives a PTSD claim, the first thing they look for is an in-service stressor. This can be any sort of traumatic event that occurred directly to you, or that you witnessed. For example, being involved in direct combat action, or being onboard during a tragic collision and fighting through the damage control efforts would be a direct experience. Seeing an IED blow up, but not necessarily being injured or being on the communications channel as a plane crashed down are examples of witnessing a traumatic event.

When the incident in question was a major event, such as the military occurrences mentioned above, there will be news coverage and plenty of documents for the VA to verify that the event did in fact occur. If you were involved in direct combat, it is vital to ensure your Combat Action Ribbon is listed on your DD 214 as this concedes a PTSD stressor with the VA. However, there is also the personal trauma that can lead to PTSD, such as hazing or rape, which unfortunately is rarely reported, and there are also smaller incidents such as a gun misfiring and exploding in a soldiers face that aren’t as easily reported or able to be verified.

For these stressors, the VA will look into your Service Medical Records to see if you had received any mental health treatment in service. If the incident involved any physical injuries, they will also look for those reports to help prove the incident occurred if there are no mental health reports. The VA will also use your Service Records as evidence to see if they contain any major change in performance records, disciplinary issues, or unauthorized absences after the claimed date of your stressor; basically, they are looking for any behaviors that were not apparent before the incident occurred.

Verifying a Stressor without using Service Records/Service Medical Records

Sometimes military records are not always complete or there may just not be any evidence of your claimed stressor. There is a large stigma within the military community that if you seek mental health treatment you will be labeled as weak, unfit for duty, or even discharged. Therefore, many vets do not receive any treatment or even report their incident, and their military records may be completely void of any evidence to help their case with the VA. This does not mean your case cannot be won.

The VA will also take into account lay evidence such as buddy statements and personal medical records. Buddy statements can be from other service members who witnessed your claimed stressor or someone whom you confided in about the incident. They can also be from friends and family members who have noticed a drastic change in your personality and behavior from before you went into the service. For more information on buddy statements and how they can help your claim, see our blog “How To: Get the Most out of Buddy Statements”.

Showing Mental Health Treatment

An additional link to validating if your PTSD is linked to service that the VA will look at is continuity of treatment. They will determine when you were officially diagnosed with PTSD, whether it was in service, or sometime after your discharge. They will then look to see if you have received any mental health treatment for PTSD since your diagnosis. The VA is very strict on seeing a continuance of treatment to show the detail or your symptoms and the effect it has had throughout your life. This will also help to ensure you receive the correct rating from the VA the first time. However, even if you haven’t received any treatment yet, it is never too late; not only for your VA claim but also for your own state of mind.

Service Dogs for Veterans Struggling with PTSD

December 4, 2017/in PTSD, Veterans /by Amanda Dejesus

Veterans who are dealing with the everyday stress of Post Traumatic Stress Disorder (PTSD) know that living with this condition certainly does not make life any easier. Some veterans experience symptoms such as nightmares, flashbacks, or feelings of anger and irritability. When the treatment and medications do not seem to work, a service dog may be a great alternative to help deal with the symptoms of PTSD.

Right now there is insufficient research to know if dogs can actually help treat PTSD and its symptoms. However, there are great emotional benefits that may help veterans who are dealing with symptoms of PTSD. Some of the benefits include the following:

Dogs can be trained to take orders or commands. This can be very comforting for veterans who were used to giving orders in the military.
Dogs can help reduce stress.
They are great companions.
They are a good reason to get out of the house, especially for those who struggle with PTSD.

It is very important to note the difference between a service dog and an emotional support dog. A service dog is a trained to do a specific task for a person that he/she cannot do because of their disability. For example, service dogs are able to pick things up; they can be used to guide a person with poor vision or one that is blind. They are also used to help someone who falls and loses balance easily. An emotional support dog or animal is a pet that helps their owner with a mental health condition. The emotional support animal can give friendship and companionship. Depending on the severity of the mental health condition, it is good to understand which kind of support dog may be needed.

What is Important to know about dogs and PTSD?

Like any animal or pet, a service or emotional support dog would need an owner who can provide for them. Dogs require constant attention and care. For a veteran who is struggling with PTSD and is worried that it may be too hard to provide and take care of the animal, it may be a good idea to seek other treatment first before considering a service or emotional support dog.

Where is the VA in all of this?

Currently, the VA is undergoing research to better understand if a dog can provide a disability service for veterans with PTSD. The VA has already started a research study to help determine if there are things that a dog can do that would qualify the animal as a service dog specifically for PTSD. This research is expected to take a few years to complete. As of right now, the VA does not provide service dogs for veterans with physical or mental health conditions. Veterans who are approved for a guide or service dogs are referred to accredited agencies. If research supports the use of service dogs for PTSD, the VA will provide veterinary care for the service dog.

Disability Compensation for Military Sexual Trauma

October 16, 2017/in PTSD, Veterans /by Amanda Dejesus

A topic that is rather difficult to discuss is military sexual trauma. Some veterans may have experienced sexual trauma while serving in the military. Veterans who have experienced this, often have issues concerning their mental and physical health. Most times, the effects of this unfortunate experience can last several years after leaving the service.

A very important component to understand is how the VA defines Military Sexual Trauma. MST is defined by the VA as a “personal assault.” Personal assault, according to the VA, can also encompass domestic battery, stalking, and harassment.

Now that MST has been defined, the most common question regarding VA compensation for MST is: Are veterans granted compensation for MST? The answer is no. Veterans are not granted compensation for the traumatic event itself but can be granted disability compensation for the condition(s) that result from the MST. There are a number of mental health conditions that can result from MST. One of the most common conditions resulting from MST can be posttraumatic stress disorder or PTSD.

The National Center for PTSD defines PTSD as a mental health problem that some people develop after experiencing or witnessing a life-threatening event, like combat, a natural disaster, a car accident, or sexual assault. Veterans who are looking to receive disability compensation need to provide evidence to prove that they have a diagnosis of a mental health condition, that is due to the MST.

Next, veterans who are looking for disability compensation after MST need to prove evidence to support their claim. Many times MST in service goes unreported. This may prevent a veteran from trying to prove that this event occurred.

For this reason, for claims involving PTSD resulting from MST, the VA looks for the following signs, events or circumstances that can provide evidentiary proof to show that the MST event actually occurred:

Records from:
- Law enforcement authorities
- Rape crisis centers
- Mental health counseling centers, hospitals, or physicians
Pregnancy tests or tests for sexually transmitted diseases
Statements from family members, roommates, fellow service members, or counselors
Records that document the veteran’s requests to transfer to another military duty station
Records that document decreases in work performance
Substance abuse
Episodes of depression, panic, attacks, or anxiety without an identifiable cause
Unexplained social behavioral changes
Relationship issues, such as divorce

One of the most important pieces of evidence that can be provided to the VA to help support a claim for PTSD resulting from MST is medical treatment which verifies that there is a mental health condition that is due to MST.

The good news is that the VA provides free health care for physical and mental health conditions related to experiences of MST. No documentation of the MST experiences or disability compensation rating is required in order to establish treatment. Some veterans may be able to receive this free MST related health care even if they are not eligible to receive other health care from the VA.

The take away is that veterans pursuing service connection for military sexual trauma sometimes have an uphill battle; however, these claims can be won, with the proper development.

The PTSD Presumption – How this is Important for Your VA Claim

October 3, 2017/in Featured, PTSD, Veterans /by Shannon Brewer, Senior Attorney

As the medical world continues to evolve and improve with advancements in research and treatment, so also the realm of mental health has significantly improved in identifying and treating psychiatric disorders. With that, too, has come an increased awareness of mental health conditions, such as post-traumatic stress disorder (PTSD), that have been plaguing veterans for decades, largely undiagnosed or often misdiagnosed with ineffective treatment. The most common misdiagnosis we see as advocates is some form of a personality disorder (versus PTSD), and we see this most often with Viet Nam veterans. Recent updates to the Diagnostic Statistical Manual (DSM) have improved accuracy and clarity in diagnosing psychiatric conditions, along with treatment appropriate for the diagnosis. Clinicians now are identifying mental health disorders, previously misdiagnosed as personality disorders, as actually early stages of PTSD.

The heightened awareness of the psychiatric toll that the Viet Nam war took on veterans has led to increasingly prevalent mental health claims in the landscape of VA claims. In recent years, the VA has taken significant measures to ensure that PTSD claims are adjudicated sympathetically, especially those related to Viet Nam veterans.

To that end, the VA created a special presumption for PTSD claims. This presumption dictates that in order to obtain service connection for PTSD, the following is necessary:

Medical evidence of a diagnosis of PTSD
A link, established by medical evidence, between the current symptoms and an in-service stressor
Credible evidence that the claimed in-service stressor occurred

If any of the above criteria are missing from the claim, the VA will be unable to grant service connection for the PTSD claim.

The VA has also recognized that, in light of criteria #2, it may be very difficult for a veteran to prove that the stressor actually occurred. In times of war, stressful events or circumstances were not always documented by the military, so there would be no way for a veteran to obtain any kind of proof that an event happened. To alleviate this difficulty, the VA established five scenarios in which a veteran would not be obliged to prove the occurrence of the stressor via service records. These are as follows:

A veteran’s lay statement alone (i.e., his/her own testimony/description of the event) may establish the occurrence of the stressor if the evidence establishes a diagnosis of PTSD during service, and if the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran’s service.
A veteran’s lay statement alone may establish the occurrence of the stressor when the evidence establishes that the veteran engaged in combat with the enemy, and the stressor is related to that combat, provided that claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran’s service.
A veteran’s lay statement may establish the occurrence of the stressor if the stressor is related to the veteran’s fear of hostile military or terrorist activity. For the VA to recognize this, a VA psychologist or psychiatrist (or a VA-contracted clinician) must confirm that the stressor would be adequate (severe enough) to support a diagnosis of PTSD and that the veteran’s symptoms are related to that stressor.

For VA purposes, fear of hostile military or terrorist activity means that a veteran experienced, witnessed, or was confronted with 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, such as from:

an actual or potential improvised explosive device
vehicle-embedded explosive device
incoming artillery, rocket, or mortar fire
grenade
small arms fire, including suspected sniper fire
an attack upon friendly military aircraft

The final criterion is that the veteran’s response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror.

A veteran’s lay statement may establish the occurrence of the stressor if the veteran was a prisoner of war and if the stressor is related to the veteran’s experiences as a prisoner of war.
If the veteran’s claim for PTSD is based on an in-service assault, evidence from sources other than the veteran’s service records may corroborate the veteran’s account of the stressor incident.

Thus we see the importance of a correct mental health diagnosis. The entire presumption for PTSD cases hinges on a diagnosis of PTSD. Very often we see that the VA compensation and pension (C&P) examiners will concede that a veteran’s stressor is adequate to support a diagnosis of PTSD, but they will diagnose the veteran with a mental health condition other than PTSD. This happens when the examiners find that the veteran does not meet enough of the symptoms of the diagnostic criteria for PTSD.

Therefore, it is important to seek a second opinion if you have the means to do so. While the regulations state that a VA psychologist/psychiatrist has to confirm that a stressor is adequate to support PTSD, the VA is required to consider the medical opinion of a qualified expert outside of the VA. If the C&P examiner provides an opinion that is unfavorable to your case, and the VA denies your claim, you can always obtain a second opinion. After all, C&P examiners are human, too; they can make mistakes. This is your case and your benefits. It is important to fight for your cause, to obtain the benefits that you deserve for serving our country.

The Evidence Requirement for a Claim of PTSD

September 6, 2017/in PTSD, Veterans /by Nicholas Simpson, Attorney

If you peruse our blog on a regular basis, you know that Post-Traumatic Stress Disorder (or PTSD) is a subject that is frequently discussed. PTSD is a mental health condition triggered by a traumatic event in the life of an individual. When you are seeking VA benefits, the regulations refer to the traumatic event as a stressor. For your claim to benefits to be successful, your PTSD claim must have three things:

A current PTSD diagnosis;
Evidence of a stressor in-service; and
A medical nexus opinion linking the current diagnosis to the in-service stressor.

If one of the above is missing from your claim, it will be denied. Today we are going to focus on how to meet the evidence requirement for a claim of PTSD. In regard to proving the stressor occurred, the VA specifically requires “credible supporting evidence that the claimed in-service stressor occurred” to establish that the veteran experienced it during service.

However, as with any rule, there are exceptions. These exceptions to the rule are as follows:

Receipt of a diagnosis of PTSD while still in service
The stressor occurred while the veteran was in direct combat with the enemy; or
The stressor was related to fear of hostile military or terrorist activity.

In regards to the third exception above, the veteran needs to have a VA psychiatrist or psychologist confirm that the stressor is sufficient to support a PTSD diagnosis. When there has been an in-service diagnosis or a combat stressor the veteran’s testimony alone is sufficient to prove the occurrence of the stressor.

Proof of Stressor

When a veteran files a claim, the VA has the duty to “make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate the claimant’s claim for a benefit.” This is referred to as the Duty to Assist and requires that the VA assist in retrieval of relevant records. Usually, these are in the form of medical records, service records, VA medical records and private medical records. However, the Duty to Assist can also extend to obtaining both medical examinations and opinions.

In their attempt to gather the necessary records to substantiate a veteran’s claim for benefits, the VA may ask the veteran to submit a statement providing the details of his claimed stressor including:

A stressor or incident that can be documented;
The location of the incident ;
The approximate date (within a two month time period) of the incident; and
The veteran’s unit at the time of the stressor/incident.

When providing a statement, the more information you can supply, the more helpful that statement will be. When the stressor or incident is not something that would be present in the records that the VA has already collected, a detailed statement can point them to the necessary records outside of their initial search.

Why might the necessary records not be in official documentation? Perhaps the veteran suffered from personal assault, or there was a traumatic incident in their personal life (i.e. loss of a spouse/significant other, child, or close friend). It is important to remember that the requirement for service connection is that the event “occurred in-service” and not specifically that the stressor is service related.

The duty to assist requires the VA to obtain medical examinations or opinions when there is insufficient evidence in the veteran’s file to determine if a veteran’s disability is service related. But in the case of PTSD, the VA must first corroborate the veteran’s claimed stressor. Once corroborated, the VA can schedule an examination to determine service connection. This examination may determine that the PTSD is not service connected. However, it is only the beginning of the fight.

Thank you for your service.

Video Blog – Getting a Proper Rating for PTSD

August 11, 2017/in Featured, PTSD, Veterans, Veterans Videos /by Matthew Hill

Matthew Hill:	Hello. This is Matthew Hill here with Carol Ponton for the Hill & Ponton Veterans’ Video Blog. Today we want to talk to you about PTSD, proper ratings for PTSD to include unemployability. We get a lot of vets asking us about this as far as how they get the highest rating.
	One of the things with the mental health diagnostic code, what they use to rate PTSD and other mental health problems, is that it’s really hard to get 100%, that they very rarely give 100%. The max rating you typically see is 70%. We’ll start there and go down, but what do you see? What does a veteran need to get unemployability from them?
Carol Ponton:	Well, first of all, you have to realize there is the regional office and the rules that they follow, and then there’s the Board of Ethics Appeals above them in the court, which is the law, and that’s what we think the regional office should be following, and that’s also when we go to the Board of Ethics Appeals or up, that’s what they follow.
Matthew Hill:	She’s talking about the statutes that are passed by Congress, but then also the case law passed by the Court of Appeals for Veterans Claims. Once you get to the BVA, the Board of Veterans Appeals, you’re dealing with a judge, somebody who is trained in the law, somebody who listens to the law. At the regional offices, they work off of a manual, which in our opinion, doesn’t quite follow how the law should be.
Carol Ponton:	For instance, the law says that if you have a 70% rating for PTSD and they know you’re not working, they should automatically consider you for unemployability. The regional office doesn’t do that. If you haven’t filed a claim, if you haven’t asked them to do that, they’re not going to do it. So a lot of people have been sitting there with 70, 80%, 90% rating for years, because they didn’t file the claim.
Matthew Hill:	And yet they can’t work …
Carol Ponton:	And yet they can’t work.
Matthew Hill:	… due to that service-connected experience.
Carol Ponton:	… and the VA knows it. It’s really important that if you feel you can’t work, whether you have a 50% or a 70% or a 30%, file an unemployability claim. That’s the form, VA 21-8940. All it asks is why you can’t work, name and address, and where you worked and how long ago that was.
Matthew Hill:	Previously, right. Just to put this in perspective, we’re talking about the difference between, I think, $1,300 for 70% and just about $3,000 for 100%.
Carol Ponton:	It’s significant.
Matthew Hill:	Yeah. 70% rating does not equal 70% of 100% compensation, if that makes more sense.
Carol Ponton:	Exactly.
Matthew Hill:	It’s really important to file that form. It’s also important when you are at 70% to let the VA know the symptoms that would affect your ability to work. What I mean by that, with PTSD in particular, you find that individuals, they do not like being around other people. They get angry easily, and the biggest one I see is they can’t put up with bosses who are idiots. They can’t just fall in line and keep their mouth shut when they’re hearing something they think is ridiculous. Maybe they can for a day, for a week, or a month, but pretty soon, they just let that person have it, let them know what they really think. That doesn’t do too well when you’re trying to stay in the workforce.
Carol Ponton:	Right.
Matthew Hill:	Again, we’d say file that claim for unemployability if that’s what’s keeping you working. Let them know what parts or how the PTSD in particular is affecting you at work, meaning how is it interfering with your ability to work with others or just to do your job.
Carol Ponton:	Maybe people who worked with you will do a letter for you and say, “This person is a really nice person, but I found that they didn’t trust other people. They didn’t want to be around them, and they became angry when other people would make mistakes. They wouldn’t put up with the boss when that boss seemed to be asking them to do something stupid.” It can really help you to have letters … And if your boss … Maybe your boss didn’t really want to let you go, but they had to. If they’ll do letters for you, put those in the file. That can help you enormously.
Matthew Hill:	Well, thank you so much for tuning in to the Hill & Ponton video blog, and we hope to see you again soon on this space.

Understanding the Difference between PTSD and other Mental Health Disorders

August 9, 2017/in PTSD, Veterans /by Cassandra Crosby, Claims Advocate

Many Veterans suffer from mental health disorders due to the events they have witnessed or experienced while serving their country. Many people automatically assume that if a person experiences a traumatic event and has a mental health condition because of that event, they must have PTSD. Many veterans specifically are surprised when they are not diagnosed with PTSD but are diagnosed with a different mental health condition instead. There has come to be a certain acceptance surrounding the diagnosis of PTSD; that it is an acceptable mental health diagnosis for a veteran to have, while other diagnoses are not yet acceptable even though they are just as valid and debilitating, and often arise from the same events. So what is the difference?

Why Do I Have Several Diagnoses?

One problem is that several mental health conditions have such similar symptoms that it is often difficult to determine, especially in one session, which diagnosis someone has. Add to that the fact that most of us do not want to go into a room and talk to a stranger about our most traumatic life events, and then the diagnosis is compounded even further. Therefore, often times a veteran may be diagnosed with one condition, then later be diagnosed with a different one, or an additional one, or two. There are also theories that some chronic trauma disorders such as PTSD cause a person to create coping skills that mimic other disorders such as Borderline Personality disorder or Bipolar disorder. If someone has been “coping” with PTSD for several years, or even decades, often times they have created coping mechanisms that hide their symptoms so well they are misdiagnosed with other disorders they may not actually have originally had but developed as a protective measure.

Post Traumatic Stress Disorder

PTSD is always associated with the experiencing, witnessing, or learning of a traumatic event that causes death or great bodily harm, or has the potential to cause death or great bodily harm, to ourselves or someone we care about. We often associate events such as combat, sexual assault, kidnapping, car accidents, natural disasters, major surgeries, acts of violence, and chronic abuse with PTSD.

PTSD must meet certain criteria when being diagnosed. The first is exposure to a traumatic event where the Veteran experienced, witnessed, or was confronted with an event that involved actual or threatened death or serious injury or a threat to the physical integrity of self or others; and the response was intense fear, helplessness, or horror. Our blog series on PTSD outlines; the elements of diagnosis, stressors, and how to link them for a VA Disability claim. However, PTSD is not the only mental health condition that veterans experience.

Anxiety Disorders

Anxiety disorders are also caused by traumatic and stressful situations. Because every person is different and reacts differently to situations based on their coping skills, morals, values, and experiences in life; reactions to those events will be different as well. Where one person may not have any lasting mental health condition to an event, another may develop PTSD and yet another may develop an anxiety or depressive disorder. We do not know what causes one person to develop certain conditions and others to not, but we continue to try to understand and treat them.

Anxiety disorders include several diagnoses. Some that are often confused with PTSD are:

Generalized Anxiety Disorder (GAD)
Panic Disorder

Anxiety disorders often have overlapping symptoms from PTSD, so often veterans who are experiencing anxiety disorders mistakenly feel they have PTSD. Some of the overlapping symptoms or symptoms that feel like PTSD include

Restlessness or being on edge
Being easily fatigued, having low energy
Difficulty concentrating
Irritability
Excessive worry
Difficulty falling or staying asleep
Sudden and repeated attacks of intense fear
Feelings of panic or panic attacks
Fear or avoidance of places where panic attacks have occurred in the past

Depressive Disorders

Depressive disorders are also similar to PTSD in the symptomology and often in etiology. Depression is not just being moody or sad. Depression is a serious illness where the depressive state can last months or even years and only treatment can help. A person cannot just “snap out of it.” Depressive disorders can be caused by the same traumatic events that cause PTSD, as well as difficult life circumstance, medical conditions, grief, and stress. Depressive disorders include such conditions as

Major Depressive Disorder;
Psychotic Depression;
Seasonal Depressive Disorder;
Post-Partum Depression; and
Bipolar Disorder

Different depressive disorders have different symptomology, but there are several symptoms that overlap with PTSD such as:

Auditory and visual hallucinations;
Anxiety;
Feelings of guilt;
Loss of interest in previously pleasurable activities;
Decreased energy, fatigue;
Difficulty concentrating;
Memory problems, difficulty making decision;
Suicidal or homicidal ideations; and
Irritability.

Just because a veteran may have a diagnosis of anxiety or depression does not mean that their service was any less traumatic than a veteran who was diagnosed with PTSD, it only means that their reaction to the trauma was different. Veterans are still eligible for compensation regardless of the name of the mental health condition they suffer from as a result of their service.

All mental health conditions are diagnosed by the standards of the criteria set forth by the Diagnostic and Statistical Manual of Mental Disorders, 5^th edition. The VA uses this standard for all diagnostic criteria in C&P exams and in its’ health care facilities. This article is not intended to be used to diagnose a mental health condition. If you are experiencing any of the symptoms listed above and feel you may have a mental health condition, please see your local mental health provider.

Delayed Onset PTSD & “LOSS”

August 8, 2017/in PTSD, Veterans /by Robin Rosenblad, Claims Advocate

We have seen numerous claims where veterans are seeking a disability rating for PTSD but it occurs years after they are out of the military. There are many reasons why a claim could be filed late. One is that a veteran had no idea what was wrong with him/her. Behavior that includes such things as avoidance of social activities or crowds, trigger temper, frequent nightmares, hypervigilance, etc. may not have been understood to be related to PTSD. Once a person better understands what has been happening to him/her, he/she may file a claim for PTSD.

Others may find that a life changing event exacerbates their earlier PTSD symptoms. People with PTSD often function best when their lives remain very stable and structured with few surprises. Life changing events such as loss of a job, retirement, death of a spouse, etc. can bring about a worsening of symptoms. Even if a vet voluntarily retires, it is not uncommon for PTSD symptoms such as nightmares, intrusive memories, difficulty sleeping, etc. to increase once they have more time on their hands and not be able to “block out” memories by staying busy as effectively as before. For example, simply having more time to watch TV can expose a person to news on TV or movies about war that help to bring up suppressed memories.

This is often called delayed onset PTSD. The Diagnostic and Statistical Manual of Mental Disorders (commonly called DSM-V) now includes a description of this phenomenon:

Delayed Specification. Full diagnostic criteria are not met until at least six months after the trauma(s), although onset of symptoms may occur immediately.

One researcher found that about a quarter of PTSD cases involved delayed onset.

The VA also recognizes a condition known as LOSS (Late-Onset Stress Symptomatology). LOSS differs from PTSD in its severity. The symptoms of LOSS are not as severe or disruptive to the person’s functioning and can actually assist a veteran in reviewing his/her life’s experiences and make sense of them. Those persons suffering from true PTSD, however, experience more severe distress and symptoms. The following chart explaining this phenomenon appeared in a 2016 article in Gerontologist, 2016, Vol 56, No. 1, 14-21:

If you end up filing a claim for PTSD, be aware that you must still meet the diagnostic criteria for PTSD to qualify for a disability award.

It is important for veterans who suddenly begin experiencing PTSD symptoms to seek help and use healthy coping strategies rather than rely on substances such as alcohol or drugs to numb their feelings. The VA offers a number of ways to assist veterans and provide guidance in this area

Does VA always grant PTSD in these instances where there has been a delayed onset? No, if the veteran’s conditions are not severe enough, they likely will not grant PTSD. If however, the veteran has had ongoing symptoms of PTSD for years, then that would increase the chance of proving the PTSD disability claim. The veteran should obtain copies of any past records for mental counseling he/she may have received. Use of Buddy Statements from friends and family to describe the veteran’s behavior in past years that exemplifies classic PTSD symptoms could also be very helpful.