Without question, post-traumatic stress disorder (PTSD), a psychiatric disorder that occurs in people who have experienced or witnessed a traumatic event, is one of the most common impairments affecting veterans in the United States and elsewhere regardless of the era in which they served. According to a 2016 National Institutes of Health (NIH) study, approximately 500,000 U.S. troops who served in Iraq and Afghanistan were diagnosed with PTSD during the period from 2003 to 2016. Similarly, an estimated 700,000 Vietnam veterans have required some type of psychological or psychiatric care as a result of the exposure to combat trauma. Though common in veterans exposed to combat trauma, PTSD is also common among veterans who experienced numerous other stressors, including but certainly not limited to (1) witnessing deaths, accidents, violent attacks, and other traumatic events, (2) experiencing fear of hostile military or terrorist activity, (3) being personally assaulted, and (4) sustaining military sexual trauma, which can occur via sexual assault or sexual harassment. In fact, the VA’s National Center for PTSD has found that (1) 23 percent of all women serving in the military reported having been sexually assaulted while in service and (2) 55 percent of all women and 38 percent of all men serving in the military reported having been sexually harassed.
Unfortunately, PTSD can become disabling because its signs and symptoms, namely hypervigilance, avoidance, impaired impulse control, and unprovoked irritability, often leave veterans unable to interact effectively with all other people, even family members and loved ones. For this reason, many veterans with PTSD should be entitled to 100 percent compensation from the VA, via either a 100 percent schedular disability rating or a total disability rating based on individual unemployability (TDIU). In this guide, we will outline the VA’s requirements for service connection for PTSD, how the VA assigns veterans a disability rating percentage for PTSD, and how veterans can go about making their claim for service connection or an increased schedular disability rating for PTSD as strong as possible.
Service Connection For PTSD: What VA Requirements Do Veterans Need To Satisfy
For the VA to grant service connection for PTSD, a veteran must demonstrate that (1) he or she has been diagnosed with PTSD under the DSM 5, (2) his or her PTSD is a result of an in-service stressor that meets the DSM 5’s A criterion, and (3) his or her in-service stressor at least as likely as not occurred. Let’s break down each of these three criteria in detail.
- A Veteran Must Have Medical Evidence Diagnosing Him Or Her With PTSD.
Pursuant to 38 CFR 3.304(f), service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 CFR 4.125(a), which calls for a diagnosis that conforms to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM 5). Under the DSM 5, a veteran’s mental health symptomatology must meet all of the following criteria in order for a clinician to diagnose him or her with PTSD:
- Criterion A (one required): The person was exposed to: death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence, in the following way(s):
- Direct exposure
- Witnessing the trauma
- Learning that a relative or close friend was exposed to a trauma
- Indirect exposure to aversive details of the trauma, usually in the course of professional duties (e.g., first responders, medics)
- Criterion B (one required): The traumatic event is persistently re-experienced, in the following way(s):
- Unwanted upsetting memories
- Emotional distress after exposure to traumatic reminders
- Physical reactivity after exposure to traumatic reminders
- Criterion C (one required): Avoidance of trauma-related stimuli after the trauma, in the following way(s):
- Trauma-related thoughts or feelings
- Trauma-related reminders
- Criterion D (two required): Negative thoughts or feelings that began or worsened after the trauma, in the following way(s):
- Inability to recall key features of the trauma
- Overly negative thoughts and assumptions about oneself or the world
- Exaggerated blame of self or others for causing the trauma
- Negative affect
- Decreased interest in activities
- Feeling isolated
- Difficulty experiencing positive affect
- Criterion E (two required): Trauma-related arousal and reactivity that began or worsened after the trauma, in the following way(s):
- Irritability or aggression
- Risky or destructive behavior
- Heightened startle reaction
- Difficulty concentrating
- Difficulty sleeping
- Criterion F (required): Symptoms last for more than 1 month.
- Criterion G (required): Symptoms create distress or functional impairment (e.g., social, occupational).
- Criterion H (required): Symptoms are not due to medication, substance use, or other illness.
If a psychologist or psychiatrist feels that a veteran’s mental health signs and symptoms satisfy all of the above DSM 5 diagnostic criteria, then he or she will diagnose that veteran with PTSD. Though typically an extensive clinical interview may be enough for a clinician to diagnose PTSD, other psychologists and psychiatrists may administer psychometric testing or hold off on making a formal diagnosis until after he or she has been able to observe the veteran in multiple treatment sessions.
A Veteran Must Have Medical Evidence Linking His Or Her PTSD With An In-Service Stressor.
If a veteran has been diagnosed with PTSD, 38 CFR 3.304(f) also requires “a link, established by medical evidence, between current symptoms and an in-service stressor.” Practically speaking, this means that the VA requires not only a diagnosis of PTSD but also medical evidence showing that a veteran’s PTSD is the result of an in-service stressor. Typically, such evidence can be found in the same treatment note or examination report in which a clinician has diagnosed a veteran with PTSD under the DSM 5 because Criterion A requires that the veteran must have been exposed to a traumatic event involving actual or threatened harm. However, because many treatment and examination records are written by psychologists or psychiatrists for treatment purposes and not for the purpose of bolstering a veteran’s disability claim before the VA, many psychologists and psychiatrists neglect even to state the stressor which he or she believes has caused the veteran’s PTSD, even if the doctor expressly states that the veteran has experienced a stressor that satisfies Criterion A under the DSM 5. For this reason, it is important for treating and examining psychologists and psychiatrists to provide clearly in their records (1) a brief description of the veteran’s in-service stressor, (2) an explanation of how the veteran’s in-service stressor satisfies Criterion A under the DSM 5, and (3) a statement directly linking the veteran’s PTSD signs and symptoms to the veteran’s in-service stressor.
A Veteran Must Have Credible Supporting Evidence That His Or Her In-Service Stressor Occurred.
If a veteran has medical evidence demonstrating that both he or she has been diagnosed with PTSD and that his or her PTSD is the result of an in-service stressor, one last requirement must be satisfied under 38 CFR 3.304(f) in order for the VA to grant the veteran’s claim for service connection for PTSD: there must be credible supporting evidence that a veteran’s in-service stressor occurred. Under 38 CFR 3.304(f), what constitutes credible supporting evidence demonstrating that an in-service stressor occurred varies by both when PTSD has been diagnosed and the type of stressor:
- PTSD Diagnosed In Service
Though PTSD diagnosed while a veteran is still in service is generally subject to direct service connection, if the veteran’s PTSD is caused by a stressor related to his or her service, a veteran’s lay testimony alone may establish that the veteran’s in service stressor occurred under 38 CFR 3.304(f): “If the evidence establishes a diagnosis of posttraumatic stress disorder during service and the claimed stressor is related to that service, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran’s service, the veteran’s lay testimony alone may establish the occurrence of the claimed in-service stressor.”
- PTSD Diagnosed After Service
- Fear Of Hostile Military Or Terrorist Activity
The VA defines fear of hostile military or terrorist activity as the psychological state of fear, helplessness, or horror that a veteran might have experienced in response to experiencing, witnessing, or confronting “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-imbedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon friendly military aircraft.” If a veteran’s PTSD is caused by his or her fear of hostile military or terrorist activity, the veteran’s lay testimony alone may establish his or her fear of hostile military or terrorist activity so long as his or her fear is consistent with the places, types, and circumstances of the veteran’s service and there is no clear and convincing evidence contradicting the veteran’s testimony. For the VA to grant a veteran service connection for PTSD caused by fear of hostile military or terrorist activity, a VA examining psychologist or psychiatrist (including a doctor with whom the VA has contracted) must confirm that the veteran’s fear of hostile military or terrorist activity satisfies Criterion A under the DSM 5 and that the veteran’s PTSD is caused by his or her fear of hostile military or terrorist activity.
- Combat With The Enemy
If the evidence of record substantiates that a veteran was engaged in combat with the enemy, and his or her claimed stressor is related to such combat, then the veteran’s lay testimony alone may establish that his or her claimed stressor occurred so long as (1) the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran’s service and (2) there is no clear and convincing evidence contradicting the veteran’s lay testimony.
- Prisoner-of-war experience
If the evidence of record establishes that a veteran was a prisoner of war under 38 CFR 3.1(y), and his or her claimed stressor is related to his or her prisoner-of-war experience, then the veteran’s lay testimony alone may establish that his or he claimed stressor occurred so long as (1) the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran’s service and (2) there is no clear and convincing evidence contradicting the veteran’s lay testimony.
- Personal Assault, Including Sexual Assault
If a veteran’s PTSD is caused by an in-service personal or sexual assault, 38 CFR 3.304(f) allows that evidence from sources other than the veteran’s service personnel and medical records may corroborate the occurence of an in-service assault:
- “Examples of such evidence include, but are not limited to: records from law enforcement authorities, rape crisis centers, mental health counseling centers, hospitals, or physicians; pregnancy tests or tests for sexually transmitted diseases; and statements from family members, roommates, fellow service members, or clergy. Evidence of behavior changes following the claimed assault is one type of relevant evidence that may be found in these sources.”
- “Examples of behavior changes that may constitute credible evidence of the stressor include, but are not limited to: a request for a transfer to another military duty assignment; deterioration in work performance; substance abuse; episodes of depression, panic attacks, or anxiety without an identifiable cause; or unexplained economic or social behavior changes.”
In order for the VA to grant service connection for PTSD caused by an in-service personal or sexual assault, there must also be a medical opinion by a psychologist or psychiatrist opining that, based on his or her review of the above evidence, the veteran’s in-service assualt at least as likely as not occurred.
How The VA Assigns Disability Ratings For PTSD
Under the VA’s system, every service-connected condition is evaluated, i.e., assigned a percentage rating, under a rating schedule. While many impairments have a specific rating schedule, all mental health conditions, including PTSD, are evaluated under the VA’s General Rating Formula For Mental Disorders. Under the rating schedule, the VA assigns a veteran a disability rating of 0, 10, 30, 50, 70 or 100 percent based on whether the veteran has any of the symptoms listed under each percentage disability rating. Though the VA is supposed to assign a veteran the highest percentage disability rating for which he or she exhibits corresponding symptoms, in practice, the VA often improperly assigns veterans a lower percentage disability rating than what they are entitled to by basing their evaluation on the average of the veteran’s symptoms. The VA also improperly assigns veterans a lower percentage disability rating than what they are entitled to by (1) minimizing some of the veteran’s symptoms that would entitle him or her to a higher percentage disability rating or (2) ignoring entirely that the evidence of record shows the veteran has symptoms that would entitle him or her to a higher percentage disability rating.
- General Rating Formula For Mental Disorders
- 100 Percent Schedule Disability Rating
- Total occupational and social impairment,
- due to such symptoms as: gross impairment in thought processes 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.
- 70 Percent Schedule Disability Rating
- 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 worklike setting); inability to establish and maintain effective relationships.
- 50 Percent Schedule Disability Rating
- 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.
- 30 Percent Schedule Disability Rating
- 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).
- 10 Percent Schedule Disability Rating
- 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.
- 0 Percent Schedule Disability Rating (Non-compensatory)
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.
In assigning one of the above disability ratings, the VA is supposed to grant the veteran the highest percentage disability rating for which he or she meets the criteria. A veteran meets the criteria for a disability rating when his or her disability picture most closely fits the symptoms and limitations required by that disability rating. Furthermore, if a veteran’s PTSD symptoms and resultant limitations bring forth a disability picture that equally fits two different disability ratings, the VA should grant the veteran the higher of the two disability ratings by applying the benefit-of-the-doubt doctrine. For example, if a veteran’s disability picture for PTSD equally fits the criteria for both a 50 percent schedular disability rating and a 70 percent schedular disability rating, the VA should grant the veteran a 70 percent schedular disability rating. Under 38 CFR 4.126, in making such a determination, the VA should (1) “consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran’s capacity for adjustment during periods of remission” and (2) “assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner’s assessment of the level of disability at the moment of the examination.” However, in practice, because many VA decision-makers are under a significant amount of pressure to issue a large volume of decisions quickly, many VA decisions assigning a veteran an evaluation for his or her PTSD solely rely on the check-the-box findings of the VA’s C&P examining psychologist or psychiatrist instead of relying on a balanced review of the entire evidence of record.
What If I Am Unable To Work Due To My PTSD But Do Not Meet The Criteria For A 100 Percent Schedular Disability Rating?
If the VA has granted you a 70 percent schedular disability rating for PTSD, and you do not meet the criteria for a 100 percent schedular disability rating under the above General Rating Formula For Mental Disorders but are still unable to work, you may be eligible for a TDIU rating, which results in 100 percent compensation on permanent and total (P&T) basis. A veteran is entitled to a TDIU rating when he or she is unable to work due to the effects of his or her service-connected impairments on his or her occupational functioning. If you are unable to work due to your service-connected PTSD symptoms, you are eligible to receive a TDIU rating, which will pay you 100 percent compensation even though you do not meet the criteria for a 100 percent schedular disability rating, i.e., you are unable to work due to your PTSD but do not have persistent delusions or auditory or visual hallucinations, etc.
How To Make Your PTSD Claim As Strong As Possible
In order to give yourself the best chance of the VA granting you service connection for PTSD and assigning a proper disability rating percentage, it is important that you make sure that the medical and other evidence of record clearly demonstrates (1) how you meet all of three above criteria for service connection and (2) how your PTSD signs and symptoms affect your functioning on a daily basis and limit your occupational and social functioning, specifically. Below are a few tips that should help veterans make a strong claims for service connection for PTSD or increased disability ratings for PTSD. Gather and review all of your psychological and psychiatric treatment records. Make certain that your treating doctors have actually diagnosed you with PTSD and that PTSD is in fact the mental condition for which they are treating you. Many veterans mistakenly believe that their treating doctors have diagnosed them with and are treating them for PTSD when in fact their doctors have only diagnosed them with an adjustment disorder, anxiety, depression, or another mental health condition unrelated to PTSD. Even if your doctor has diagnosed you with PTSD and has prescribed your treatment and/or medications accordingly, he or she may not have given a full explanation of how your mental health symptoms meet all of the DSM 5 diagnostic criteria or expressly opined that your PTSD is caused by your particular in-service stressor. Because treatment notes are only for treatment purposes, many treating psychologists and psychiatrists, especially in the VA Medical Center (VAMC) system or other high volume facilities, only note that a veteran’s PTSD is caused by his or her military service, which is insufficient for VA rating purposes as detailed in the above. You need medical evidence that you have been diagnosed with PTSD under the DSM 5 and that your PTSD is caused by an in-service stressor that meets Criterion A.
Even if your treatment records fully address all of the above covered elements, ask your treating psychologist or psychiatrist to write a letter or treatment note (1) confirming that, based on his or her observations and treatment, he or she has diagnosed you with PTSD under the DSM 5, (2) explaining how your PTSD symptoms satisfy all of the DSM 5 diagnostic criteria, (3) describing your specific in-service stressor, (4) opining that your PTSD is caused by your specific in-service stressor, and (5) describing the effects of your PTSD symptoms on your occupational and social functioning. Your treating psychologist or psychologist may also complete and sign a copy of the VA’s PTSD Disability Benefits Questionnaire (DBQ), which is the form the VA asks its own examining psychologists and psychiatrists to complete for every veteran who is evaluated in a C&P examination. Though up-to-date versions of such DBQs are no longer publicly available, any DBQ completed and signed by treating doctor constitutes medical evidence that the VA must consider in adjudicating your claim.
Make sure that you have the records necessary to corroborate your in-service stressor and diligently complete your stressor statement via VA Form 21-0781, “Statement In Support of Claim for Service Connection for PTSD.” As detailed in the above, the VA will not grant your claim for service connection for PTSD unless you can corroborate the occurrence of your in-service stressor, according to the requirements set forth in 38 CFR 3.304(f). Depending on the type of stressor and when you were diagnosed with PTSD, the evidence that you will need to prove your stressor may differ. For instance, if you were exposed to combat and your service personnel and medical records confirm your exposure to combat, then your lay testimony alone is very likely sufficient to corroborate your stressor. Still, even in this circumstance, you need to complete properly VA Form 21-0781 and specify your unit, the dates of your unit assignment, the location of your exposure to combat, and any medals or citations you received as a result of your exposure to combat.
Once you have all of the above-described evidence and have reviewed it thoroughly, submit it to the VA in support of your claim. Keep in mind that, as noted in the above, you need to prove all three of the following criteria in order to win your claim for service connection for PTSD: (1) the veteran has been diagnosed with PTSD under the DSM 5, (2) the veteran’s PTSD is a result of an in-service stressor that meets the DSM 5’s A criterion, and (3) the veteran’s in-service stressor at least as likely as not occurred.
Lastly, in order to win service connection for PTSD, a veteran must attend a C&P examination with one of the VA’s examining psychologists or psychiatrists. Make certain that you attend this appointment, answer all questions in an honest and forthright manner, do not downplay the severity of your symptoms, and present yourself as you would to any other doctor’s appointment, i.e., take care of your personal appearance and hygiene in the same way that you would for any other doctor’s appointment so that you appear as an accurate representation of your normal self.
Contact An Attorney About Your PTSD Claim
If you or a loved one have been denied service connection for PTSD, the VA has assigned you a PTSD rating that you think is too low, or you are interested in filing a new claim for PTSD, please do not hesitate to contact our office via phone or submitting a contact form through this website. The Veterans Law Office is a nationside veterans disability law firm. Our attorneys will provide you with a free evaluation of your claim for veterans disability benefits.