Department of Veterans Affairs - VA - Combat Post-Traumatic Stress Disorder - PTSD - Identification...

Combat Post-Traumatic Stress Disorder (PTSD)

Identification and Compensation Brief

Mintcho E. Mintchev

Contents

Combat PTSD Identification– PTSD Detection– Signs and Symptoms of PTSD– PTSD Degrees of Severity– PTSD Specifiers– DSM-IV Diagnostic Criteria– Six Diagnostic Criteria for PTSD

Contents (Cont.)

Combat PTSD Compensation– Significance of Combat Service– Decorations as Evidence of Combat– Granting Service Connection– Schedule of PTSD Disability Ratings– How to Seek Compensation

Combat PTSD Identification

PTSD Detection

PTSD is hard to detect in the work place Many who suffer from PTSD

– Hold full-time jobs – Seem to function "normally“– BUT

May not be able to maintain relationships with family or friends

In the long run may not be able to function at work at all

Signs and Symptoms of PTSD

Feeling of detachment or estrangement from others Inability to recall an important aspect of the trauma Markedly diminished interest or participation in

significant activities Restricted range of affect (e.g., unable to have loving

feelings) Sense of a foreshortened future (e.g., does not expect

to have a career, marriage, children, or a normal life span)

An individual who engaged in combat with the enemy avoids war movies or a particular nationality representative of the wartime enemy

PTSD Degrees of Severity

Mild– Occasional thoughts

Severe– Intense and constant thoughts

PTSD Specifiers

The following specifiers may be used to describe the onset or the duration of PTSD symptoms– Acute: Duration of symptoms is less than 3 months– Chronic: Symptoms last 3 months or more– Delayed Onset: Onset of symptoms occurs at least

6 months following the traumatic stressor

DSM-IV PTSD Diagnostic Criteria

Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition

Diagnostic Criteria– Response to the stressful event, or stressor,

must involve feelings of intense fear, helplessness, or horror

– Witnessing an event that involves death, injury, or a threat to the physical integrity of another person

Six Diagnostic Criteria for PTSD

1 - At Least 2 Basic Aspects of the Event– Direct personal experience with a traumatic stressor– Response to the stressful event, or stressor, must

involve feelings of intense fear, helplessness, or horror

Six Diagnostic Criteria for PTSD (Cont.)

2 - Re-experiencing the Traumatic Event– Despite efforts to avoid traumatic stressors, re-

experiencing of the traumatic event is persistent– Recurrent and intrusive distressing recollections of

the event, including images, thoughts, and perceptions

– Recurrent distressing dreams of the event– Acting or feeling as if the traumatic event were

recurring (e.g., illusions, hallucinations, and flashback episodes)

Six Diagnostic Criteria for PTSD (Cont.)

2 - Re-experiencing the Traumatic Event (Cont.)– Intense psychological distress when exposed to

internal or external cues that symbolize or resemble an aspect of the traumatic event

– Manifestations often occur when the person is exposed to triggering events that resemble or symbolize an aspect of the traumatic event

E.g. hearing a car backfire may be a trigger for Veterans who have been in combat

Six Diagnostic Criteria for PTSD (Cont.)

3 - Stimuli Avoidance– Persistent avoidance of stimuli associated with the

traumatic event and a numbing of general responsiveness

– Deliberate efforts to avoid thoughts, feelings, or conversations associated with the traumatic event

– Avoid activities, situations, or people who arouse recollections of the traumatic event

Six Diagnostic Criteria for PTSD (Cont.)

4 - Increased Arousal– Difficulty falling or staying asleep that may be due to

recurrent nightmares during which the traumatic event is relived

– Hypervigilance– Exaggerated startle response– Some individuals report irritability or outbursts of

anger and/or difficulty concentrating or completing tasks

Six Diagnostic Criteria for PTSD (Cont.)

5 - Duration of Signs and Symptoms– Symptoms must have been present for at least 1

month

6 - Social and Occupational Impairment– Lack of interest in and withdrawal from

relationships, work, and/or hobbies– Unable to communicate with family members or

socialize with neighbors and co-workers– Repeatedly misses days of work due to severe

symptoms of PTSD

Combat PTSD Compensation

Significance of Combat Service

Veteran's testimony may establish claimed in-service stressor if the evidence confirms that– Veteran engaged in combat– Was a prisoner-of-war (POW) as defined by

38 CFR 3.1(y) – Claimed stressor related to combat experience– No clear and convincing evidence to the contrary – Claimed stressor consistent with circumstances,

conditions, or hardships of respective service

Significance of Combat Service (Cont.)

No limitations to type of evidence that may be accepted to confirm engagement in combat

Any evidence probative of combat participation may be used to support engagement in combat

Engaging in combat– Participation in events constituting actual fight or

encounter with a military foe, hostile unit or instrumentality

– Includes presence during such events either as a Combatant Service member performing duty in support of combatants

Decorations as Evidence of Combat

Veteran in receipt of designated combat decorations

Presumed to have engaged in combat unless there is clear and convincing evidence to the contrary

Decorations as Evidence of Combat (Cont.)

Air Force Achievement Medal with "V" Device Air Force Combat Action Medal Air Force Commendation Medal with "V"

Device Air Force Cross Air Medal with "V" Device Army Commendation Medal with "V" Device Bronze Star Medal with "V" Device

Decorations as Evidence of Combat (Cont.)

Combat Action BadgeCombat Action Ribbon

– Prior to February 1969, the Navy Achievement Medal with "V" Device

Combat Aircrew Insignia Combat Infantry/Infantryman Badge Combat Medical Badge Distinguished Flying Cross

Decorations as Evidence of Combat (Cont.)

Distinguished Service Cross Joint Service Commendation Medal with "V"

Device Medal of Honor Navy Commendation Medal with "V" Device Navy Cross Purple Heart Silver Star

Granting Service Connection

3 requirements must be met to grant service connection– 1 - Medical Evidence

Evidence must show a diagnosis of PTSD in accordance with 38 CFR 4.125(a)

– 2 - In-Service Traumatic StressorMust have credible supporting evidence that the

claimed in-service traumatic stressor occurredA traumatic stressor may not be limited to just

one single episode

Granting Service Connection (Cont.)

– 3 - Link: nexus must be established by medical evidence between current symptoms and in-service traumatic stressor

Relationship between traumatic stressors during military service and current problems or symptoms will answer the question of whether service connection can be established

Symptoms must have a clear relationship to the military traumatic stressor as described in the medical reports

PTSD can occur hours, months, or years after a military traumatic stressor

Schedule of PTSD Disability Ratings

100% Disability – 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

Schedule of PTSD Disability Ratings (Cont.)

70% Disability – 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

Schedule of PTSD Disability Ratings (Cont.)

50% Disability– 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

Schedule of PTSD Disability Ratings (Cont.)

30% Disability– 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)

Schedule of PTSD Disability Ratings (Cont.)

10% Disability– 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 % Disability

– A mental condition has been formally diagnosed– Symptoms are not severe enough either to

Interfere with occupational and social functioning Require continuous medication

How to Seek Compensation

To Seek Compensation One May– Complete VA Form 21-526

Claim is not formal unless form is signed and dated Mail or take application to the closest VA Regional Office

– Addresses available at http://www.va.gov/directory

– Apply Electronically http://vabenefits.vba.va.gov/vonapp/main.asp

QUESTIONS?