PAMPHLET. Texas Veterans Commission. Post-Traumatic (PTSD) Stress Distorder TXD V P /NO.3. No. 3, May/June 2008

Transcription

1 TXD V P /NO.3 Texs Veterns Commission PAMPHLET No. 3, My/June 2008 TH NVRIYOF TEXAS-PAN AMERICAN Post-Trumtic Stress Distorder (PTSD) The Texs Veterns Commission does not discriminte on the bsis of rce, color, ntionl origin, sex, religion, ge or disbility in employment or providing services.

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3 FOREWORD The U.S. militry's involvement in the current conflict in Irq nd Afghnistn, coupled with dvnced medicl techniques nd tools for dignosing diseses/conditions mong those returning from the theter of opertions, hve led to wht ppers to be significnt increse in the dignosis nd tretment of post-trumtic stress disorder (PTSD) relted to combt. We cn fully expect to be involved in more VA clims for PTSD thn in recent yers/periods, nd my hve lredy experienced significnt increse in such clims from our veterns. In ddition to ssisting in (combt-relted) PTSD clims for current (nd pst) conflicts, we continue to field PTSD clims bsed on non-combt nd personl/sexul ssult events. Those of us involved in ssisting veterns with such clims re keenly wre of the effects such condition cn hve on vetern. As with ny other type of condition (disbility), we owe the vetern our full mesure of professionlism, devotion nd understnding (prticulrly when deling with wht is typiclly very sensitive mtter.) This pmphlet hs been prepred in the hope tht it will ssist both you nd the vetern in the development of successful PTSD clim. The mjority of the informtion contined is tken directly from Deprtment of Veterns Affirs sources nd ws up to dte t time of publiction. We thnk TVC Veterns Counselor John J. Bker, Wco Regionl Office, for his ssistnce in prepring the informtion for this publiction. Tble of Contents Wht is Post-Trumtic Stress Disorder?... Pg. 1 Cuse nd Effect of PTSD... Pg. 2 Filing Successful Clim for PTSD... Pg. 3 Three Types of PTSD Clims... Pg. 5 In-Service Dignosis of PTSD... Pg. 8 TVC Pmphlet, No. 3, My/June 2008 W TVC Pmphlet, No. 3, My/June 2008 Pge I Pge i

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5 POST TRAUMATIC STRESS DISORDER (PTSD) Wht is Post-Trumtic Stress Disorder? Post-Trumtic Stress Disorder (PTSD) is defined s condition chrcterized by physiologicl ndbehviorl symptoms following exposure to n extremely trumtic event (know s trumtic stressor.) First identified in World Wr I s shell shock, it ws cliniclly dignosed s trumtic neurosis. Following World Wr II nd the Koren Wr, it ws re-identified s combt ftigue. The term Post-Trumtic Stress Disorder cme bout.following the Vietnm er. For purposes of U.S. Deprtment of Veterns Affirs (VA) compenstion (service-connected disbility), PTSD is mentl condition clssified mong the nxiety disorders (Dignostic Code 9411, 38 CFR Prt 4, Schedule for Rting Disbilities.) Some fcts nd estimtes regrding veterns nd PTSD my be of interest for those involved in ssisting veterns with their VA clims. According to December 2006 report entitled "Anlysis of Differences in Disbility Compenstion in the Deprtment of Veterns Affirs"1, over 200,000 veterns were receiving VA disbility benefits relted to PTSD. Estimtes of dignosis by VA medicl personnel for PTSD for veterns returning from Opertion Irqi Freedom (OIF) nd Opertion Enduring Freedom (OEF) rnge from 10% (British Medicl Journl, November 25, 2007) to 13% (Testimony of the Director, Ntionl Institute of Mentl Helth before the Committee on Oversight nd Government Reform, U.S. House of Representtives, My 24, 2007.) 1 Report prepred by The Institute for Defense Anlysis for the Deprtment of Veterns Affirs. Q TVC Pmphlet, No. 3, My/June Pge 1

6 Cuse nd Effect of PTSD The cuse of PTSD is exposure to n overwhelming environmentl stress. Since not every individul responds to such stress with post-trumtic stress syndrome (set of symptoms), vriety of fctors in clinicl combintion re required to produce the pthologic (indictive of the disese/condition) stte. These include:. The suddenness nd unexpectedness of the stress, s in mjor fires, explosions nd irplnes crshes; personl or sexul ssults; or s those in nturl dissters such s torndoes;. Brutlity nd horror of events ssocited with rmed combt or terrorism;. The more prolonged nd chronic stress of exposure to inhumne tretment ssocited with POW or concentrtion cmps. The risk of PTSD increses for those with physicl trum nd is influenced by the mount of direct exposure to combt trum. The condition is chrcterized by recurrent episodes of re experiencing the trumtic event(s.) Commonly, the person hs recurrent distressing drems during which the event is re-experienced.. Along with re-experiencing the event, the person my persistently void stimuli ssocited with the trum (crowds, loud noises, wr movies, etc.) or numbing of generl responsiveness not present before the trum. A person suffering from PTSD my lso experience persistent symptoms of incresed rousl not present before the trum, including difficulty flling/stying sleep, hyper-vigilnce, exggerted strtle response, difficulty in concentrting or completing tsks nd chnges in ggression. Filing Successful Clim for PTSD Three elements must exist for ny service-connected clim to be successful with VA, including those for PTSD. Those elements re: 1. An in-service event (stressor); 2. A current dignosis of the disbility; nd TVC Pmphlet, No. 3, My/June 2008 Pge 2

7 3. A link or nexus between the in-service event nd the dignosis. In-Service Event (Stressor) The in-service event must be documented by officil records, or in most cses, t lest supported by prepondernce of the evidence. For PTSD clims, even more so thn for other clims for presumptive disbilities, the "who, wht, why, when nd where" surrounding the stressor is vitl to the success of the clim. The vetern must provide VA with s full nd complete description of the in-service event(s) s possible, prticulrly in cses where the stressor is not conceded by VA, such s in combt situtions (discussed in detil on pge 5 of this Pmphlet). The vetern's sttement should include:. Full description of the event(s);. Full nme(s) of ll person(s) involved;. Dte(s) [t lest the month nd yer]; " Unit(s) of ssignment (compny/bttlion/squdron level, depending on brnch on service); nd. Plce(s) (t lest city or province, nd stte or country. VA hs forms specificlly developed for PTSD clims: " VA Form , Sttement in Support of Clim for Service Connection for Post-Trumtic Stress Disorder (PTSD), nd. VA Form , Sttement in Support of Clim for Service Connection for Post-Trumtic Stress Disorder (PTSD) Secondry to Personl Trum (used only in PTSD clims relting to personl ssult/sexul hrssment. The use of either form (s pplicble to the vetern's cse) is not mndtory, but it should be noted the forms were devised to ensure vetern does not leve out ny criticl informtion, i.e., "who, wht, why, when nd where". If vetern chooses not to use the pproprite form (usully sent to the vetern by the VA Regionl Office [RO] with the cknowledgement letter [VCAA/Duty to Assist]), he/she cn submit the informtion s stressor letter, hndwritten or printed. In this cse, the nme nd VA file/clim number should be t the top of ech pge. The vetern should sign nd dte the lst pge. The most importnt CA TVC Pmphlet, No. 3, My/June 2008 Pge 3

8 thing bout the stressor is tht it must be specific in nture. Prticulr event(s) or sitution(s) tht cused the symptoms of the condition must be fully documented. Generlities such s "I ws in Vietnm" or "My best friend died in my rms" hve no vlue to VA in estblishing stressor, s it does not provide sufficient informtion to permit VA to verify the event(s.) Current Dignosis The second fctor needed for successful PTSD clim is current dignosis of the condition. If vetern hs stressor but no dignosis, the clim will not be successful. A dignosis of the condition from privte medicl source is useful, but VA will not estblish service-connection bsed on privte medicl evidence lone. Of importnce for our purpose is to note tht VA will not consider ordering VA (Compenstion nd Pension) medicl exmintion until/unless the stressor is confirmed/verified (except for PTSD clims bsed on personl trum or in-service dignosis, [ref VA "Fst Letter"08-08, April 7, 2008.]). Link or Nexus Between Stressor nd Dignosis The third element for successful PTSD clim is the estblishment of nexus, or link, between the stressor nd dignosis of PTSD. By lw, only the VA exminer cn relte the dignosis to the in-service event (stressor). VA Regionl Office personnel involved in the decision process cnnot mke this connection. It is importnt to note for severl resons tht the lw requires the VA exminer for PTSD clims to be specilist, typiclly either bord certified (or bord eligible) psychitrist or licensed doctorte-level psychologist. Three Types of PTSD Clims There re three principl types of PTSD clims: 1. PTSD bsed on combt incidents, events, or trum 2. PTSD bsed on non-combt incidents, events, or trum 3. PTSD bsed on personl or sexul ssult or sexul hrssment 0 TVC Pmphlet, No. 3, My/June 2008 Pge 4

9 Combt-Relted Combt-relted PTSD is the most common type of PTSD clim hndled by VA nd cn be one of the esiest clims for VA to process. It cn lso be time consuming for both the vetern nd VA, depending on the individul cse. VA procedures (38 CFR 3.304[f] [1]) stte tht if the evidence estblishes tht the vetern ws engged in combt with the enemy, the vetern's sttement (referred to by VA s "ly testimony") lone my estblish the in-service event, or stressor, s long s the sttement is not contrdicted by cler nd convincing evidence to the contrry. "Combt" is not defined by VA regultions, but in other guidnce used by VA. Exposure to combt cn be conceded by VA if it is shown the vetern engged in direct ction ginst the enemy. As n exmple, n infntrymn who ws involved in firefight with enemy forces ws in combt, but bomber pilot ws not unless it ws shown his/her plne ws ttcked by ground fire or enemy ircrft. VA must be ble to verify the vetern's involvement in combt by officil records. For exmple, records must plce the vetern in the unit involved t the time nd loction of the bttle. VA cn lso concede the stressor for combt-relted PTSD without need for stressor sttement bsed on n individul wrd tht demonstrtes prticiption in combt, such s the Combt Infntrymn Bdge (CIB), Silver Str, Bronze Str with "V" device (for vlor), Combt Action Bdge, Combt Action Ribbon, Purple Hert, etc., s so indicted on the vetern's dischrge ppers (DD 214.). It should be noted tht sometimes VA my erroneously request stressor sttement even though officil documenttion of such n wrd exists nd hs been submitted. To void this, it's helpful on initil submission of the clim to drw VA's ttention to such n wrd by tbbing the DD 214 to highlight the wrd or some other such method. If the vetern still receives VA Form with the VA's VCAA/ Duty to Assist letter, it's recommended tht VA be mde wre of such wrd by noting it on return correspondence (e.g., VA Form ), so s to keep the vetern from hving to "relive" the trumtic event(s). The fct tht vetern (s evidenced by officil records) ws prisoner of wr (POW) is lso sufficient for VA to concede the stressor. (More on VA's methods for confirming stressors lter in this Pmphlet.) W TVC Pmphlet, No. 3, My/June 2008 Pge 5

10 Noncombt-Relted The second most common type of PTSD clims VA receives is noncombt-relted. Unlike combt-relted clims, VA cnnot routinely estblish or concede the stressor bsed solely on the vetern's sttements. The stressor cn be relted to mny different fctors, either militry or non-militry duty-relted. Duty-relted stressor exmples include ship sinkings or collisions, ircrft crshes, trining ccidents, ssignment to grves registrtion or burn wrds. Non-duty relted exmples include nturl dissters, motor vehicle ccidents or incidents of terrorism. In either cse, the vetern's presence or involvement nd reltionship to the stressor must be shown by officil records. In ny cse, of course, the stressor must hve occurred while the vetern ws serving in the militry. VA's experience with non-combt relted PTSD clims indictes tht it tkes longer to develop.the evidence for these cses thn it does for combt-relted clims. In most cses, it is first necessry to estblish tht the event hppened nd then plce the vetern t the event by verifiction (officil records). The vetern's initil sttement (by VA Form or stressor letter) must be s complete s possible in providing ll pproprite informtion, i.e., "who, wht, why, when nd where." Dely in the processing of the clim by VA occurs if generl sttements without specifics re given. VA is then required to request, sometimes repetedly, further informtion. Submitting ll pproprite, specific informtion to VA with the initil clim is criticl to quick resolution of the clim. Personl or Sexul Assult or Sexul Hrssment The third type of PTSD clim is bsed on personl or sexul ssult or sexul hrssment. Clims of this type include rpe or ttempted rpe (femle or mle), sexul or non-sexul ssult, sexul hrssment or other such similr instnces where the vetern, using the "resonble person stndrd" could be considered to hve been in fer of deth, bodily hrm or severe mentl nguish or distress, nd, s result, suffer from PTSD. According to VA, these re usully the most time-consuming nd difficult PTSD clims VA processes. The principl reson for such 0 TVC Pmphlet, No. 3, My/June 2008 Pge 6

11 difficulties is the fct tht in mny instnces, documenttion of the climed ssult or hrssment does not exist, mking it difficult to confirm the stressor. Knowing tht, VA llows use of lterntive evidence, known s "mrkers" to build cse. Such mrkers my reflect significnt chnge in the vetern's behvior fter the event, including but not limited to, behviorl chnges; tretment without specific dignosis; sudden requests for chnges in occuption or duty ssignment; buse of leve without pprent reson; chnges in performnce evlutions; disregrd for militry or civil uthority, etc. VA strives in PTSD clims ofthis nture to be sensitive in its correspondence with the vetern in its solicittion of descriptions of the stressful incident(s). Confirmtion of Stressors Even though this hs been previously discussed elsewhere in this Pmphlet, repetition is good reinforcement in our efforts to ssist veterns with PTSD clims. Confirmtion of the stressor simply mens tht the vetern's reported stressful incident is confirmed by officil records in one wy or nother. In the cse of combt-relted stressors, s noted erlier, if the officil records show the vetern ws ctully engged in combt with the enemy, the vetern's sttement(s) lone will confirm the stressor. One of the esiest wys for VA to confirm the stressor is if the vetern hs been wrded combt decortion or decortion of vlor. The lw permits the presence of specified decortions to confirm the stressor without further development. If vetern clims stressor relted to combt but no documenttion of record exists to substntite the clim (including individul wrds for vlor or brvery), VA must confirm the incident(s) through other officil sources. One such source is the Joint Services Records Reserch Center (JSRRC), used by RO personnel for ll brnches of service (except for veterns of the Mrine Corps, which hs its own reserch function, lso vilble to RO personnel.) Additionl guidnce for VA on the topic of PTSD nd veterns' clims for tht disbility ws published in VA's "Fst Letter" 08-08, dted April 7, Of note in tht letter were the issues 0 TVC Pmphlet, No. 3, My/June 2008 Pge 7

12 of "In-service initil dignosis of PTSD" nd "Rting mentl disorders tht led to relese from service." In-Service Dignosis of PTSD Advnces in militry/civilin wreness of PTSD symptoms hve led to n increse in dignosis nd tretment for the condition. 38 CFR 3.303() requires no verifiction of stressor if prim fcie (cler cut/unmbiguous) dignosis of PTSD ws ccomplished in service by mentl helth professionl. In this cse, VA will ccept ny resonble in-service stressor if it ppers consistent with the circumstnces of the vetern's prticulr service nd should grnt service-connection on direct bsis if the VA exmintion nd other evidence of record supports such decision. "Rting mentl disorders tht led to relese from service": 38 CFR 4.129, "Mentl Disorders Due to Trumtic Stress"requires VA to grnt n immedite 50% rting for mentl disorders (including PTSD) tht resulted in relese from the service. Generlly, these veterns re dischrged through the Medicl Evlution Bord/ Physicl Evlution Bord (MEB/PEB) process. VA is required to schedule n exmintion within six months of dischrge to determine if chnge in benefit level is wrrnted. Although such cses my not occur too often, we need to be wre of this lw nd its impct on veterns we serve, to ensure such benefits re provided without dely. Tking/developing clims for PTSD cn be mong the.most difficult of cses for both veterns nd veterns counselors like, but we owe it to veterns nd their fmilies to work this type of clim s we would ny other. The fct tht PTSD is clssified for rting purposes s mentl condition under nxiety disorders cn in nd of itself mke it difficult for the vetern to seek ssistnce from helth providers s well s those ssisting with clims for compenstion. Experience hs shown tht veterns re unwilling to discuss detils of the event(s) tht led to the condition, for mny resons, including prime one of not wnting to relive the event(s.) It therefore will tke gret ptience nd time on our prt to bring out ll the detils t the TVC Pmphlet, No. 3, My/June 2008 Pge 8

13 beginning so s to get the clim done right the first time. In this wy, we diminish the possibility of creting more stress for the vetern. A compssionte, understnding pproch is best in these'instnces. Involving the vetern's fmily in the process (with the vetern's pprovl) cn be beneficil for ll concerned, but most importntly, for the vetern. W TVC Pmphlet, No. 3, My/June 2008 Pge 9

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