Combat PTSD Stressor Guide



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Veteran's GUIDE on PTSD and finding information on stressor letters!

This information has been excerpted from the Vietnam Veterans Home page.

Suggestions for veterans or their survivors seeking VA benefits.

You can find more information on the VVA at this Link


Table of Contents:

What is PTSD?
Step 1: Get Help
Step 2: Apply
Step 4: Get Evidence of Stressor
Step 5: Present Evidence
How VA Sets Level of Disability
VA Medical Services
Resources


The purpose of this guide is to assist you, the veteran or survivor, in presenting your claim based on the veteran's exposure to unusually stressful events that led to posttraumatic stress disorder (PTSD). The best way to present your claim to the U.S. Department of Veterans Affairs (VA) is to work with a trained veterans advocate.

This guide describes the VA's current programs for compensating veterans with PTSD or their survivors. Under current VA rules, you can be paid compensation for PTSD if you have a clear diagnosis of the condition, evidence that an in -service stressful event occurred and medical evidence that the "Stressor" is linked to the PTSD. Once the VA agrees that your PTSD is service connected, it will then decide how seriously the condition impairs your ability to work.

This guide does not address treatment techniques but does give you suggestions for getting medical care. Additional resources are available to help you understand whether other VA programs may be available to you.

PTSD is not a new problem. It is simply a new name for an old disorder that has been around for thousands of years. The new name has been in use since 1980 when the American Psychiatric Association citation began to use it in its manual of mental disorders. Although it is often associated with Vietnam veterans, it is being increasingly reported in WWII veterans, perhaps as a consequence of publicity surrounding the 50th anniversaries of WWII events.


WHAT IS PTSD?

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (1994) states:

Diagnostic Features

The essential feature of Posttraumatic Stress Disorder is the development of characteristic symptoms following exposure to an extreme traumatic Stressor involving direct personal experience of an event that involves actual or threatened death or serious injury, or other threat to one's physical integrity; or witnessing an event that involves death, injury, or a threat to the physical integrity of another person, or learning about unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or other close associate.

  • (Criterion A1). The person's response to the event must involve intense fear, helplessness, or horror (or in children, the response must involve disorganized or agitated behavior)
  • (Criterion A2). The characteristic symptoms resulting from the exposure to the extreme trauma include persistent reexperiencing of the traumatic event
  • (Criterion B), persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness
  • (Criterion C), and persistent symptoms of increased arousal
  • (Criterion D). The full symptom picture must be present for more than 1 month
  • (Criterion E), and the disturbance must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (Criterion F).

Traumatic events that are experienced directly include, but are not limited to, military combat, violent personal assault (sexual assault, physical attack, robbery, mugging), being kidnapped, being taken hostage, terrorist attack, torture, incarceration as a prisoner of war or in a concentration camp, natural or manmade disasters, sever automobile accidents, or being diagnosed with a life-threatening illness. For children, sexually traumatic events may include developmentally inappropriate sexual experiences without threatened or actual violence or injury. Witnessed events include, but are not limited to, observing the serious injury or unnatural death of another person due to violent assault, accident, war, or disaster or unexpectedly witnessing a dead body or body parts. Events experienced by others that are learned about include, but are not limited to, violent personal assault, serious accident, or serious injury experienced by a family member or a close friend; learning that one's child has a life-threatening disease. The disorder may be especially severe or long lasting when the Stressor is of human design (e.g., torture, rape). The likelihood of developing this disorder may increase as the intensity of and physical proximity to the Stressor increase.

The traumatic event can be reexperienced in various ways. Commonly the person has recurrent and intrusive recollections of the event (Criterion B1) or recurrent distressing dreams during which the event is replayed (Criterion B2). In rare instances, the person experiences associative states that last from few seconds to several hours, or even days, during which components of the event are relived and the person behaves as though experiencing the event at that moment (Criterion B3). Intense psychological distress (Criterion B4) or physiological reactivity (Criterion B5) often occurs when the person is exposed to triggering events that resemble or symbolize an aspect of the traumatic event (e.g., anniversaries of the traumatic event; cold snowy weather or uniformed guards for survivors of death camps in cold climates; hot, humid weather for combat veterans of the South Pacific; entering any elevator for a woman who was raped in an elevator).

Stimuli associated with the trauma are persistently avoided. The person commonly makes deliberate efforts to avoid thoughts, feeling, or conversations about the traumatic event (Criterion C1) and to avoid activities, situations, or people who arouse recollections of it (Criterion C2). This avoidance of reminders may include amnesia for an important aspect of the traumatic event (Criterion C3). Diminished responsiveness to the external world, referred to as "psychic numbing" or "emotional anesthesia," usually begins soon after the traumatic event. The individual may complain of having markedly diminished interest or participation in previously enjoyed activities (Criterion C4), of feeling detached or estranged from other people (Criterion C5), or of having markedly reduced ability to feel emotions (especially those associated with intimacy, tenderness, and sexuality) (Criterion C6). The individual may have a sense of foreshortened future (e.g., not expecting to have a career, marriage, children, or a normal life span) (Criterion C7).

The individual has persistent symptoms of anxiety or increased arousal that were not present before the trauma. These symptoms may include difficulty falling or staying asleep that may be due to recurrent nightmares during which the traumatic event is relived (Criterion D1), hyper vigilance (Criterion D4), and exaggerated startle response (Criterion D5). Some individuals report irritability or outbursts or anger (Criterion D2) or difficulty concentrating or completing tasks (Criterion D3).


STEP 1: GET HELP

It is a good idea to get a representative to help you present your claim to the VA. VA rules and procedures are very complicated. It can be frustrating and hazardous to go it alone.

Many veterans service organizations and state and county veterans service agencies offer free assistance. No matter who you select to represent you, it is important that you be personally involved in your case and make certain that everything that should be done, is done.

Although it can be a difficult task, shop around for the best advocate. Talk to the prospective representative; ask if there are any limits on his service; get a feel for the person who will be working for you before you sign a power of attorney appointing the person as your representative.


STEP 2: APPLY

  • When to Apply: You should notify the VA of the benefits you want at the earliest possible time. From anywhere in the U.S., you can call the nearest VA Regional Office (VARO) by using the following number: 1-800-827-1000. Do not wait until you have gathered all the evidence you think you need. Every day you delay can mean another day of benefits lost forever.
  • Warning: Do not be discouraged by a VA employee who says you are not entitled to benefits. Put your claim in writing and insist on a written reply from the VA.

  • How to Apply: To apply, send the VA a letter stating that you have a problem with your nerves that arose out of your military service. This is called an informal claim and will count as an application (although you will eventually be re required to fill out some VA forms). If you have not heard back from the VA within a month you should call to confirm that your application has been received. If you applied before, send a letter that says you are "reopening" your claim.
  • What to Apply For: The VA offers cash benefits to veterans with service-connected disabilities (under the compensation program) and to veterans with serious nonservice-connected disabilities (under the pension program). Survivors may be entitled to death benefits.
  • Who Can Apply: A claim for PTSD is not limited to veterans who saw combat in Vietnam. You may have been assaulted or raped or involved in an auto accident or plane crash or other catastrophe, while in service.
  • Sometimes survivors of veterans including spouses or children and parents can apply for service-connected death benefits (the Dependency and Indemnity Compensation or DIC program) or for the nonservice-connected death benefits (pension program). A survivor might be able to show that a veteran with PTSD who commits suicide did so as a result of the PTSD and then qualify for DIC.

Frequently, veterans with PTSD may have other diagnoses: for example, personality disorder or substance abuse. It is very important that your doctor explain how your current diagnosis of PTSD relates to these other disorders. If alcohol or drug abuse was "self-medication" to lessen the symptoms of PTSD, that should be stated.

You can expect the VA to contact you for evidence or for permission to write to your doctor for your medical records. Your response to any VA request for evidence should be made only after consulting with your representative.

The VA ordinarily schedules you for an examination by one of its doctor at a VA hospital or clinic. This "C&P exam" is intended to confirm a diagnosis of PTSD. If you bring a copy of your doctor's report with you, it will be easier for the VA doctor to complete the exam.

If you do not already have a private doctor's report, you should expect the VA doctor to ask many questions about what symptoms you have, when you began to have them, how often and how long you have had them. Some of the hardest questions will be about the stressful experience you had. You will need to be able to describe in detail (and sometimes painful detail) exactly what you experienced. You might also be asked to take a written, standardized test.

The VA doctor prepares a written report that is sent to the VARO in about a month.


STEP 4: GET EVIDENCE OF STRESSOR

To win a PTSD-based claim, you need (1) a diagnosis of PTSD and (2) evidence of a stressful event during your military service. Even if you convince 10 VA and 10 private psychiatrists that you have PTSD, the VARO can still deny your claim if it does not accept your evidence about the stressful event that caused the PTSD.

The Stressor you experienced needs to be documented. If your Stressor was related to combat while engaged in action with the enemy, your testimony alone should convince the VA that you experienced the event. The VA should not even question your statement if you had a combat MOS or you received a Purple Heart or other award indicating combat service.

On the other hand, if you did not have a combat MOS and simply state that you were often under mortar and rocket attacks, the VA may simply say that your experience was not stressful enough to have caused PTSD since nearly everyone stationed in Vietnam came under such attacks. If, however, you were next to a buddy who was killed or injured, the fact of the death or injury is something that can be confirmed.

If you are a Vietnam vet and you provide the VA with enough details about stressful events in your service, the VA will contact the U.S. Army and Joint Services Environmental Support Group and ask it to review records of the Vietnam war to try to corroborate your experiences. Your representative should be able to show you the guide for the Preparation of PTSD Research Requests that the Support Group offers to reps to help them make a request that the Support Group can work with.

To understand what evidence the VA already has collected, get a free copy of your VA claims file from the VARO. If you need to document your service in Vietnam, get a free set of your complete military personnel records from the National Personnel Records Center in St. Louis using a Standard Form 180, Request Pertaining to Military Records. This form is available from your representative or any VA office.


STEP 5: PRESENT EVIDENCE

You do not help yourself if you simply dump a wad of loose records on the VA. Organize the records and explain their significance in a letter you and your representative prepare together.

If the VA Regional Office says your disability is not service-connected or if the percentage of disability is lower than what you think is fair, you have the right to appeal to the Board of Veterans' Appeals.

Once the VA agrees that your PTSD is service-connected, it must determine how impaired you are. The VA regulation that controls this determination is the VA Schedule for Rating Disabilities, 38 C.F.R. §4.130, Diagnostic Code 9411. Under this regulation, PTSD can be rated at 0, 10, 30, 50, 70 or 100%. The symptoms that the VA looks for to set a rating are listed below. Share this regulation with your therapist and ask him or her to write to the VA describing the severity of your condition. Also ask your therapist to use the Global Assessment of Functioning Scale listed in the Diagnostic and Statistical Manual of Mental Disorders.

Keep in mind that under another VA regulation (38 C.F.R. § 4.16), if you can't work be cause of your PTSD, the VA must set you at 100% even if you don't meet the criteria listed below for a 100% rating. If the VA evaluates your disability too low, you should appeal that.


38 C.F.R. 4.130 (excerpt),
General Rating Formula for Mental Disorders:

Total occupational and social impairment, due to such symptoms as: gross impairment in thought process or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name
....................................... 100

Occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships
....................................... 70

Occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships
....................................... 50

Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events)
....................................... 30

Occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication
....................................... 10

A mental condition has been formally diagnosed, but symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication
....................................... 0


VA MEDICAL SERVICES

The VA operates a network of 205 Vet Centers throughout the country that provides good treatment for veterans suffering from PTSD. Treatment at Vet Centers is often conducted with a group of veterans. Sometimes the VA will pay for treatment through a local mental health professional if services through the nearest VA are not readily available. To apply for this "fee basis" care, contact the nearest VA medical center.

There are also a few VA medical centers that offer intensive in-patient care. If this is something you need, ask the nearest Vet Center to help arrange for your admission.

If you are a Vietnam veteran you should know that in 1981 Congress authorized the VA to provide certain health care services for disabilities which may have been caused by exposure to herbicides. The VA must accept a veteran's statement that he or she was exposed and provide health care unless the VA can point to a cause for the problems other than Agent Orange. Veterans who qualify for treatment under this law do not have to pay for services received.

The Agent Orange Program provided funding for a program for families with children with birth defects or other special health needs. The Center for Developmental Disabilities at the University of South Carolina offers a National Information Service which consists of telephone access to trained counselors, to provide information and referral services for parents of children with disabilities, including information and referrals concerning genetic counseling. Contact: 1.800.922.9234, ext. 401.


RESOURCES

The following publications are a few of the resources that may give you additional help with your claim:

  • Veterans Benefits 410pg paperback written for vet; sections on VA benefits, claims procedures, advocacy tips; published by HarperCollins; to order from VVA Veterans Collectibles, call 1-800-NAM-VETS.
  • Veterans Benefits News-bimonthly newsletter writ ten for VVA Service Reps and other advocates; one-year subscription is $25; to order, call: (800) VVA -1316.
  • Veterans Benefits Manual and Supplement written for representative; details on filing, presenting claims for full range of VA benefits; offered by National Veterans Legal Services Program; to order, call 202 -265-8305.
  • Title 38, Code of Federal Regulations the official set of VA regulations; available from the Government Printing Office; to order, call 202-512-1800.
  • Veterans Appeals Reporter contains decisions of Court of Veterans Appeals; published by West Publishing Co.; available at nearest VARO.
  • If you are having difficulties with your Combat PTSD please contact the nearest VA Vet center!


VIETNAM VETERANS OF AMERICA

The Vietnam Veterans of America (VVA) is a non-profit, congressionally chartered veterans service organization, dedicated to helping Vietnam-era veterans and their families obtain all the benefits and services to which they are entitled. VVA has accredited Service Representatives in most states who can provide representation at the VARO level. A list of the nearest VVA Service Representatives can be obtained by writing to:

VVA Veterans Benefits Program
1224 M Street, NW
Washington DC 20005-5183

Many other veterans organizations offer a wide range of services. Most states operate a department of veterans affairs and many states have a network of county veterans representatives. To locate accredited representatives, call or visit the nearest VARO.


If no private practitioners are willing to represent you at the Court of Veterans Appeals, it might be possible to obtain pro bono representation through the Veterans Pro Bono Consortion. The Court will send you information about this opportunity. It is available only to a limited number of persons who meet income guidelines.


Copyright © 1996, Vietnam Veterans of America, Inc. All Rights Reserved. ISBN 0-964-3980-4-4.

Segments of this guide may be excerpted or reproduced for counseling, self-help, and scholarly purposes, but not for profit, without further permission; we request only that proper credit be given. Any other use requires written authorization of VVA, ATTN: Director, Veterans Benefits Program, 1224 M Street, NW, Washington DC 20005-5183. This guide is one of a series that is being published by VVA under a contract with Keith D. Snyder of the Veterans Education Project. 3/96


Vietnam Veterans of America, Inc.®
1224 M Street, N.W., Washington, DC 20005-5183
202-628-2700, Fax 202-628-5880
1-800-VVA-1316
E-mail us at feedback@vva.org

Copyright © 2006 by the Vietnam Veterans of America. All rights reserved.


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