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Matthew Hill

Video Blog – Buddy Statements For Increased Rating

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

Carol Ponton: Yes.

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

Carol Ponton: Right.

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

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

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

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

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

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

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

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

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

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

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

Shannon Brewer, Senior Attorney

How Does VA Determine A Psychiatric Disability Rating?

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

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

0% Rating

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

10% Rating

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

30% Rating

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

50% Rating

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

70% Rating

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

100% Rating

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

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

Rachel Cheek, Attorney

PTSD: Basic Criteria

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

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

Criterion A: Stressor

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

Criterion B: Intrusive symptoms

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

Criterion C: Avoidance symptoms

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

Criterion D: Negative alterations in cognition and mood

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

Criterion E: Alterations in arousal and reactivity

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

Criterion F: Duration of symptoms

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

Criterion G: Functional significance

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

Criterion H: Exclusion

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

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

Anne Linscott, Attorney

Age, PTSD, & Your VA Disability Claim

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

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

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

  • Retirement:

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

  • Increased health problems:

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

  • Unhealthy methods of coping:

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

  • Social isolation:

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

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

Cassandra Crosby, Claims Advocate

Peripheral Neuropathy: Not always an Agent Orange issue….

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

Toxin Exposures

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

Diabetes Mellitus II

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

Lupus and Autoimmune Diseases/Rheumatoid Arthritis

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

Hyperthyroidism and Metabolic or Endocrine disorders

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

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

Small Vessel Disease

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

Kidney Disorders

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

Cancers and Neuromas

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

Infections

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

Medications

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

Trauma, Injury, or Repetitive Stress

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

PTSD and TBI

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

Alcoholism

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

PN as a Secondary Condition

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

Cassandra Crosby, Claims Advocate

Understanding the Criteria and Rating of PTSD

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

Incorrect Rating Decisions:

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

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

Understanding Criterion A of PTSD

 

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

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

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

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

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

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

Understanding the General Rating Formula for Mental Health Conditions

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

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

Kylie Courtwright, Claims Advocate

PTSD and the Military Community

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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.

Amanda Dejesus

Service Dogs for Veterans Struggling with PTSD

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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.

Amanda Dejesus

Disability Compensation for Military Sexual Trauma

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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.

Shannon Brewer, Senior Attorney

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

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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:

  1. Medical evidence of a diagnosis of PTSD
  2. A link, established by medical evidence, between the current symptoms and an in-service stressor
  3. 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:

  1. 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.
  2. 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.
  3. 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.

  1. 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.
  2. 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.