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Nicholas Simpson, Attorney

The Evidence Requirement for a Claim of PTSD

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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.

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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.

Matthew Hill

Video Blog – Getting a Proper Rating for PTSD

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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.
Cassandra Crosby, Claims Advocate

Understanding the Difference between PTSD and other Mental Health Disorders

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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:

  1. Generalized Anxiety Disorder (GAD)
  2. 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

  1. Restlessness or being on edge
  2. Being easily fatigued, having low energy
  3. Difficulty concentrating
  4. Irritability
  5. Excessive worry
  6. Difficulty falling or staying asleep
  7. Sudden and repeated attacks of intense fear
  8. Feelings of panic or panic attacks
  9. 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

  1. Major Depressive Disorder;
  2. Psychotic Depression;
  3. Seasonal Depressive Disorder;
  4. Post-Partum Depression; and
  5. Bipolar Disorder

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

  1. Auditory and visual hallucinations;
  2. Anxiety;
  3. Feelings of guilt;
  4. Loss of interest in previously pleasurable activities;
  5. Decreased energy, fatigue;
  6. Difficulty concentrating;
  7. Memory problems, difficulty making decision;
  8. Suicidal or homicidal ideations; and
  9. 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, 5th 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.

Robin Rosenblad, Claims Advocate

Delayed Onset PTSD & “LOSS”

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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.

Matthew Hill

Video Blog – VA Mental Health Ratings

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Matthew Hill: Hello and welcome to the Hill & Ponton Video Blog. I’m Matthew Hill.
Carol Ponton: I’m Carol Ponton.
Matthew Hill: Today we want to talk to you about the mental health diagnostic code ratings, one of the tricky little areas in there involves suicidal and homicidal thoughts and, basically, plans is kind of the next step up. But, we see a lot of veterans get tricked up on this. By tricked up, I mean that even if they’re having these a lot of times they won’t admit that to the doctors, which in the end hurts their claim because the VA is going to underrate them.
Carol Ponton: Right. If you have suicidal or homicidal thoughts, that is going to give you a much higher rating with the VA. It can often expedite your case. But, I find veteran after veteran will not admit that to the VA, because they have a fear. They have a fear that they will be Baker Acted and put in the hospital. I want to make sure that people understand, you will not be Baker Acted unless you have a present intention of going out and killing someone or killing yourself. If you just have thoughts and you have plans, but you don’t have a present plan to do those things, they’re not going to Baker Act you. They’re going to put that down and that shows the extent of your PTSD or your mental illness. When you don’t tell them, you get a much lower rating, and that’s not fair to you. But it’s this fear that keeps people from doing that. That, the fear of being Baker Acted and fear of having their guns taken away, neither one is going to happen. Okay?
Matthew Hill: And I’d also say, one of the hardest things about a C and P Exam in a mental health setting. The care you’ve had previously, hopefully, is with a doctor or a licensed mental social worker, someone you’ve developed a relationship with and you’ve learned to talk with, learn to trust. The problem is you go in and see a C and P Examiner, never seen this person before, don’t know what their intentions are, don’t know where they’re coming from, and it’s hard just to open up and to just be real and let them know what’s going on. And that’s just something you got to realize going in there, and you got to still rise above that. Because that examiner, they’re not going to prod you, they’re not going to really look into you like somebody’s treating you, like somebody’s has invested-
Carol Ponton: An interest.
Matthew Hill: Yeah. An interest. They’ve got a bunch of exams to do all day, and they’re going to ask you questions, and if you don’t open up and volunteer information like this, they’re going to give you the rating that looks nice on their little sheet. You know, again, this is your claim, these are your benefits, you just need to … it’s going to be uncomfortable, but it’s something that you need to do and they need to know what you’re going through.
Carol Ponton: And it’s not just the Compensation and Pension Exam, many don’t even tell their treating doctor because of these fears that they have. If don’t have a doctor you can tell that to, you need to get another doctor, but you need to tell them. And I’m telling you, they don’t want to Baker Act anybody, they just want to make sure that you’re not going to go out and shoot yourself or somebody else. There’s a big difference between that and just having thoughts, because of the depression. Please make sure they know the full extent of what’s going on with you.
Matthew Hill: Thank you for listening today. Matthew Hill and Carol Ponton for the Hill and Ponton Video Blog. We look forward to seeing you on this space sometime soon.
Mary Klements, Claims Advocate

Verifying Personal Trauma and Military Sexual Trauma Stressors

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When a veteran files a claim for PTSD, the VA must make reasonable efforts to verify the occurrence of the event which caused the mental disorder. Because not all stressors are the same, the VA has guidelines for different types of stressors. In a previous post, we discussed the circumstances under which the VA is and is not required to corroborate stressors. In this post, we will discuss another type of stressor: personal trauma.

How the VA Classifies Personal Trauma

Personal trauma for the purposes of VA disability claims refers to stressor events involving harm perpetrated by a person who is not considered part of an enemy force. This can include assault, battery, domestic violence, robbery, mugging, stalking, harassment, etc. Military sexual trauma (MST) is a subset of personal trauma and refers to sexual harassment, sexual assault, or rape that occurs in a military setting.

VA Requires Credible Evidence

In order for the VA to consider a claim for service-connection for PTSD due to personal trauma, there must be credible evidence to support the veteran’s assertion that the stressful event occurred. This, however, does not mean that the veteran must be able to supply actual proof that the incident occurred. This just means that there needs to be at least a proximate balance of positive and negative evidence that the event occurred.

Note: Personal trauma cases are a rare exception to the active/inactive duty rule. The VA has allowed that veterans whose stressor occurred during inactive duty for training are eligible to service connection in the same manner as those whose stressor occurred during active duty or active duty for training.

What qualifies as “credible evidence”?

In many cases of personal trauma, especially in MST cases, there are often coinciding factors which prevent the veteran from being able or willing to report a personal trauma incident. Therefore many incidents of personal trauma are not officially reported, and the victims of personal trauma may find it difficult to produce evidence to support the occurrence of the stressor.

The VA has recognized this reality and has determined that, in the absence of official reports, claim developers should look for alternative evidence that may demonstrate the presence of markers. These markers include signs, events, or circumstances indicating the possibility that the claimed stressor occurred. This would be considered secondary evidence.

According to the VA’s internal manual, secondary evidence may include the following:

  • Lay statements
  • Indicating increased use or abuse of leave without an apparent reason, such as family obligations or family illness, or
  • Describing episodes of depression, panic attacks, or anxiety, but no identifiable reasons for the episodes, and
  • Evidence of behavioral changes that occurred around the time of the incident, including
  • Visits to a medical or counseling clinic or dispensary without a specific diagnosis or specific ailment
  • Use of pregnancy tests or tests for sexually-transmitted diseases around the time of the incident
  • Sudden requests that the veteran’s military occupational series or duty assignment be changed without other justification
  • Changes in performance and performance evaluations
  • Increased or decreased use of prescription medications
  • Increased use of over-the-counter medications
  • Evidence of substance abuse, such as alcohol or drugs
  • Increased disregard for military or civilian authority
  • Obsessive behavior such as overeating or undereating
  • Increased interest in tests for HIV or sexually transmitted diseases
  • Unexplained economic or social behavior changes
  • Treatment for physical injuries around the time of the claimed trauma, but not reported as a result of the trauma, and/or
  • The breakup of a primary relationship.

This is why it is very important to have a family member, spouse or significant other, or close friend write a statement about any behavior changes that they might have noticed during or after the veteran’s period of service. These become valuable testimonials that can significantly help the veteran obtain compensation benefits his or her mental disorder.

Cassandra Crosby, Claims Advocate

Changing an “Other Than Honorable Discharge” due to PTSD related Symptoms

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The character of a discharge is paramount in determining eligibility for a veteran when it comes to VA benefits. If a veteran has not been discharged according to the VA’s criteria, they will be ineligible for any benefits. However, there is a glimmer of hope for some who were victims of trauma.

Veterans who were discharged from the military prior to 1980, under “other than honorable” conditions for such issues as personality disorder, failure to adjust, or unsuitable for military duty due to symptoms that were related to PTSD, even though that was unknown at the time of their discharge, are able to request a change to their discharge under a ruling due to a case brought forth by students at Yale Law School. The class action suit, Monk v. Mabus, sought to grant changes to discharges to allow veterans who suffered from PTSD access to VA benefits they were entitled to due to the effects of the trauma they experienced as a part of their military service.

Other than Honorable discharges

These veterans, many of the Vietnam veterans discharged prior to the PTSD diagnosis was officially established in the Diagnostic and Statistical Manual of Mental Conditions (DSM-III) in 1980. Any veterans discharged prior to approximately that time frame for other mental health issues but whose symptoms at the time met the criteria for PTSD can file for an amended discharge and then proceed to file for benefits through the VA. Some of the discharges often given to those who actually suffered from PTSD were such things as “unsuitability,” “misconduct,” “unqualified for active duty,” “personality disorder,” ‘character or behavior disorder,” or similar issues. There is a section on the DD-214 called separation codes. This box usually has a 3 digit code in it that, when deciphered, tells the reason for discharge. Codes for the issues above usually start with the letter J. Reviewing the DD-214 and checking the codes can assist in determining the cause of discharge. Separation codes and their meanings can be found here.

PTSD Disability

PTSD is the third highest claimed disability among veterans. A psychologist or psychiatrist usually determines if Veterans meet the PTSD Criteria during a psychiatric evaluation. Criteria are broken up into several sections. However, because of the class action suit, the VA has been directed to give “liberal consideration” to various types of evidence relating to PTSD at the time of discharge including:

  • Service records documenting any symptoms that meet diagnostic criteria for PTSD or related conditions; and
  • A diagnosis of PTSD or PTSD related condition by a civilian provider.

Special consideration is also to be given to a VA determinations that document service-connected PTSD or PTSD related conditions. A veteran only has to apply with the information above to request a change in their discharge character.

How Does a Vet Know if They Should Apply for Change in Discharge?

PTSD determination is based on meeting criteria for several different aspects. Due to this ruling, not all aspects have to be met to have the discharge character changed. Remember though, if applying for VA benefits, all criteria will have to be met to meet the VA’s rating criteria. The criteria and expectations are as follows:

  • Criterion A: Both must be met:
    • The veteran was exposed to a traumatic event either by directly experiencing, witnessing, or confronted with an event that involved the threat of death or serious injury, including the death or serious injury of others; and
    • The veteran responded with intense fear, helplessness, or horror.
  • Criterion B: The traumatic event is re-experienced in one or more of the following ways:
    • Intrusive thoughts about the event;
    • Recurrent and distressing dreams of the event;
    • Acting or feeling that the event was recurring, having a sense of reliving the event (flashbacks or hallucinations);
    • Intense physical distress to reminders of the event; and/or
    • Intense emotional distress to reminders of the event.
  • Criterion C: The veteran avoids reminders of the event as indicated by three or more of the following:
    • Avoidance of thoughts, feelings, or conversations of the event;
    • Avoidance of activities, places, or people that remind the veteran of the event;
    • The inability to recall certain aspects of the event;
    • Diminished interest or participation in significant activities;
    • Feelings of detachment or estrangement from others;
    • Restricted range of affect (unable to feel love for others, etc.); and/or
    • Sense of foreshortened future (does not expect to have a future career, marriage, children, grandchildren, etc).
  • Criterion D: Feelings of increased arousal that were not present before the traumatic event indicated by two or more of the following:
    • Difficulty falling or staying asleep;
    • Irritability to outbursts of anger;
    • Difficulty concentrating;
    • Hypervigilance; and/or
    • Exaggerated startle response.
  • Criterion E: the symptoms have lasted for longer than one month, and;
  • Criterion F: the symptoms have caused significant distress of impairment in social, occupational, or other important areas of functioning

Applying for Review of Discharge based on PTSD

Veterans can download the Application for the Review of Discharge, DD-293 to apply for a change in their discharge. By filling out and attaching any evidence that identifies symptoms of PTSD experienced in service; trauma experienced in service; or lay evidence of behavior changes that can be identified by the criteria for PTSD, you can submit your application for a change in your discharge. Veterans can receive assistance with this process at their local VSO.

Cassandra Crosby, Claims Advocate

Mental Health Care and OTH Discharges

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As we opened the newspapers the week of March 7th, 2017, we read the tragic story of another veteran who lost his life to desperation and hopelessness. The sad fact is that 22% of all suicides in the United States are veterans and we can prevent this.

The VA Secretary announced on March 8th, 2017 that the VA intends to expand provisions for mental health care to veterans with other than honorable administrative discharges. This is a show of force between the VA and the current administration that suicide is a top priority and shows that there is recognition that suicide among all veterans needs to be addressed by the VA, not just suicides among those with honorable discharges.

This plan will affect over 500,000 veterans who are currently ineligible for treatment because of their discharge status. But what about compensation rights as well?

Mental Health the cause of an OTH Discharge

For many of these veterans, their mental health issues were the cause of their other than honorable (OTH) discharge. Reviewing the circumstances of the discharge may be required to determine if an in-service event may have led to a mental health condition that, then, in turn, led to actions of behaviors causing grounds for an administrative discharge.  Unfortunately, with PTSD and other MH conditions, they do not always manifest the same in every person who experiences them. People also do not always react to the symptoms in the same way. Where one person may become reckless and start drinking and disobeying orders, another may become reclusive and start not showing up for work. Women also experience trauma differently than men, and people who have been traumatized previously again experience symptoms differently than those who are going through a trauma for the first time. Because of these differences, without screening every active duty member and veteran who has been exposed to trauma, we can’t possibly identify everyone who has PTSD or another MH disorder.

And we need to, identify everyone. Why? Because of what happened on March 7th, 2017, and every other day that over 20 veterans are committing suicide in this country. PTSD and other MH conditions, while not the cause of the suicides, increase the risk that someone who is experiencing frustration with jobs, family relationships, of the VA system itself is more likely to give up than seek help. It has been shown that the suicide rates among veterans who receive services from the VA are markedly decreased compared to those veterans who do not receive services (VA Benefits and Suicide among Veterans).  This proposed change by the VA Secretary and the administration of allowing OTH discharged veterans receive mental health care at VA facilities is a step in the right direction at reducing the suicide rates among our most valued heroes.

What You Can Do

If you know of a veteran who has been exposed to trauma, even if they do not seem to exhibit symptoms of PTSD or any other mental health disorder, please try to get them to get screened for services. Often times PTSD does not manifest immediately, it can sometimes take months or even years for symptoms to get to the point where the veteran is no longer able to control them or keep them hidden from others. This does not mean that all veterans who experienced trauma have a mental health condition, but it does mean that they should get checked at least as a preventative measure to ensure they are not at risk. Often times veterans will be screened and not even realize some of the things they are going through are symptoms of PTSD. Four out of five Vietnam Veterans experience PTSD symptoms 25 years post-war. This needs to be addressed and they need to be helped.

What about that OTH Discharge?

Veterans with an OTH discharge, while they will be eligible for MH services in the future under the new plan, will not be eligible for compensation benefits due to the character of their discharge.  However, if the veteran feels that they were discharged due to the effects of a traumatic experience and the mental health symptoms that arose from that trauma, they can file an Application for the Review of Discharge or Dismissal from the Armed Forces of the United States. The veteran will need to prove their case with documentation so having any medical records, evidence of a traumatic event or statements from witnesses, treatment for your mental health issues, and possibly a statement from your doctor that links your mental health condition to the traumatic event and the behaviors in-service that led to the discharge would be very helpful in supporting the case.  They may also retain assistance from a representative from a local veteran organization. If the veteran is able to change their discharge character to “other than dishonorable” or “general” then the veteran will be eligible to file for compensation benefits for the disability caused by the trauma experienced in-service.

Cassandra Crosby, Claims Advocate

Guide to Proving Service Connection of PTSD

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Service connection for an injury or illness seems easy to prove; medical records documenting that the injury or illness occurred or was first treated while in service is enough to show service connection. Some are easy such as falling off a ladder and connecting that with later back problems. However, some are much more difficult, especially when there may not be any treatment records at all. The most prevalent of these is PTSD.

Victims of PTSD often do not seek treatment

Because of stigma, denial, not knowing they have PTSD, or other issues, many service members do not seek out treatment for PTSD while they are in service or sometimes for years after discharge. PTSD is the third most prevalent disability claim in the VA system yet is probably the least treated.  Many veterans did not seek out mental health treatment in service due to the stigma and possibility of being discharged for mental instability. Often, if they were fortunate, they would seek help at a local community mental health agency or a private doctor whose records could be available to assist with filing their claim, showing in service treatment. However, this is not very often the case. Most often, service members go without treatment altogether.  Only about 50% of Veterans with PTSD seek treatment, and then only about 50% of those receive adequate treatment. When Veterans finally do seek services, it is often at a point where they have reached a very low point in their lives. Many have lost relationships, jobs, homes, and even their self-worth before they seek help. Some have been hospitalized, fallen victim to substance abuse, or have legal problems because of the symptoms of PTSD and how they manifest. Unfortunately, many also commit suicide before they can get help, or because they are not getting the help they need quick enough.

What Causes PTSD?

PTSD can be caused by many different issues and can manifest in very different ways for each individual. What may trigger PTSD symptoms in one person, may not cause any symptoms in another. The VA bases their PTSD definitions on the DSM-V Criteria. The criteria for PTSD are: whether the veteran was directly exposed to a traumatic event; if they witnessed a traumatic event; if they learned that a close friend or relative was exposed to a traumatic event (if involving death it must have been violent or accidental in nature); or repeated or extreme indirect exposure to aversive details of the event (such as first responders, medics, firemen, etc.).  There are also criteria for intrusion symptoms; avoidance, negative alterations in cognitions and mood; alterations in arousal and reactivity, duration, functional significance, and exclusion. When these areas are reviewed, a determination is then made if the Veteran meets the DSM-V criteria for PTSD.

Because everyone has different coping skills and reactions; someone who sees death and destruction on a daily basis serving as a medic in a war zone may meet no criteria for PTSD, yet someone who experiences a fire in their barracks during basic training may end up experiencing many criteria for PTSD. It doesn’t mean a person is strong or weak, only that their minds have reacted differently to different events and they may have different coping skills to deal with what they are exposed to.

Service Records v. Service Medical Records

One of the first things that the VA does when a Veteran files a claim for PTSD is request service medical records. If the Veteran has experienced a traumatic event that may have caused immediate injury or that the Veteran sought out medical or mental health treatment for, it would be present in their medical records. Also, since the onset of the Gulf War, pre- and post-deployment questionnaires address the questions of mental health issues as a course of record. However, again that stigma is present and someone who may not want to be medically discharged or sent back stateside may not seek treatment or tell the truth on forms in order to keep their job and duty station.

So, if there are no medical records, how can someone go about proving that the incident occurred in service? One way is be requesting that the VA review your Service Records as well as your medical records. By reviewing your service records, there may be what are called markers to PTSD or mental health issues such as sudden disciplinary issues, a sudden drop in performance review scores; a request for a change in duty station or different squad, company, or platoon; records of going AWOL; or other issues such as excessive drinking, dereliction of duty, insubordination, etc. Any types of behaviors that were not present before the incident but become prevalent after may be considered markers of a traumatic event.

Other forms of “Proof”

There are a few other ways to show that a traumatic event happened when you don’t have any “proof” of it. Stressor verification can be determined by:

  1. Buddy Statements – written statements from friends, other service members, or relatives who either witnessed the event, discussed it with you when it happened, or noticed a behavior change after the event.
  2. Help Program records – if you called any support groups, helplines, churches, or other programs that offered support and help, document it or try to get copies of your records with those agencies.
  3. Civilian reports such as police reports if the incident was reported to civilian authorities but not military authorities (for example, a car accident and the Veteran’s best friend is killed while he is home on leave);

A Veteran will also have to fill out a PTSD Stressor Statement form and attend a C&P Exam. There are tips on what to do to prepare for the C&P Exam here.

Getting Help

Getting help with filing your claim helps increase the chances of it getting approved. However, for those with PTSD, it can also relieve some of the stress that Veterans experience dealing with the claims process. If you need help filing your claim, please call your local Veteran’s Organization for assistance or an attorney if you have an initial denial. Professional help increases your chances of winning your claim by almost 25% and can greatly reduce the stress on you.

Most importantly, remember that no matter what happens with your claim, it is vital that you seek help to deal with your symptoms. PTSD is one of the leading causes of suicide among Veterans and seeking help will reduce the risk of suicide. If you are experiencing thoughts of harming yourself or others, please call 911 immediately. Other resources available for Veterans include:

  • 911 or go to the nearest emergency room;
  • Veterans Crisis Line – 1-800-273-8255 and press 1 or text 838255;
  • Wounded Warrior Project
  • The Soldier Project has a list of resources including homeless programs, financial assistance for medications, therapy programs, and support groups.
Allison Reddick, Attorney

Do sleep apnea and PTSD have overlapping factors?

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Around 8% of the US population will experience PTSD in their life. While it is more common for veterans to suffer from PTSD than the average person due to the variety of stressful situations they experience, the VA estimates that the number of veterans that suffer from PTSD varies by service era:

  • Operations Iraqi Freedom (OIF) and Enduring Freedom (OEF): About 11-20 out of every 100 Veterans (or between 11-20%) who served in OIF or OEF have PTSD in a given year.
  • Gulf War (Desert Storm): About 12 out of every 100 Gulf War Veterans (or 12%) have PTSD in a given year.
  • Vietnam War: About 15 out of every 100 Vietnam Veterans (or 15%) were currently diagnosed with PTSD at the time of the most recent study in the late 1980s, the National Vietnam Veterans Readjustment Study (NVVRS). It is estimated that about 30 out of every 100 (or 30%) of Vietnam Veterans have had PTSD in their lifetime.

As the statistics show, PTSD is a condition seen among many veterans. To learn more about PTSD, click here. With PTSD comes a variety of symptoms that affect sleep including difficulty falling asleep, nightmares, flashbacks, and insomnia. Scientific research now shows that there is another sleep disorder which is linked to PTSD: sleep apnea. Sleep apnea occurs when a person’s breathing repeatedly stops and starts during sleep.

Here are the common signs and symptoms of sleep apnea

  • Loud snoring, which is usually more prominent in obstructive sleep apnea
  • Episodes of breathing cessation during sleep witnessed by another person
  • Abrupt awakenings accompanied by shortness of breath, which more likely indicates central sleep apnea
  • Awakening with a dry mouth or sore throat
  • Morning headache
  • Difficulty staying asleep (insomnia)
  • Excessive daytime sleepiness (hypersomnia)
  • Attention problems
  • Irritability

So how is sleep apnea related to PTSD in veterans?

Research has shown that there are factors that overlap in both disorders which affect and aggravate each other. Overlapping factors include disturbed sleep in combat, excessive sleep deprivation, fragmented sleep, hyperarousal, and chronic stress. Although all of these symptoms contribute to the interaction between sleep apnea and PTSD, the main culprits seem to be sleep deprivation and chronic stress. Studies have shown that patients exhibiting these symptoms tend to have increased frequency and length of apneic events. Research has also shown that as the severity of PTSD increases in a person, the chances of developing sleep apnea increases as well because of the interplay between the shared factors of the two disorders. Although in this blog, we focused on PTSD, sleep apnea is also associated with other forms of mental illness, click here to learn more.

The important takeaway message is that if you are a veteran suffering from PTSD, it is important to get a screening for sleep apnea.            If you have undiagnosed sleep apnea, you could be suffering from symptoms that can be treated. Reports have also shown that receiving the appropriate treatment for sleep apnea can improve PTSD symptoms. It is also important to be screened for sleep apnea because if left untreated, sleep apnea can lead to the development of other health issues including:

  • High blood pressure
  • Stroke
  • Heart failure, irregular heartbeats, and heart attacks
  • Diabetes
  • Depression
  • Worsening of ADHD
  • Headaches

Although sleep apnea is commonly associated in society with older, overweight individuals, the interplay with PTSD has a lot of younger, fit individuals being diagnosed with sleep apnea. At the end of the day, regardless of your demographics, if you are suffering from PTSD, it is important to ask your doctor for a screening for sleep apnea to prevent further complications of your health as well as potentially treat some of your current symptoms.