аЯрЁБс>ўџ @Bўџџџ?џџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџьЅСG П0/bjbjŽйŽй 4>ьГьГр*Oџџџџџџ]       ДДДД8ь јДЖ  (HHH[[[ухххххх$дєШ\  [W[[[ Ÿ  HH ŸŸŸ[" H HуДД    [уŸъŸ‰ *•ќ  уH PіP)ЃРДД}"‘RDepartment of Memorandum Veterans Affairs Date: February 26, 2001 VAOPGCPREC 08-2001 From: Acting General Counsel (022) Subj: Meaning of “Injury” for Purposes of Active Service – 38 U.S.C. Ї 101(24) To: Director, Compensation and Pension Service (212) QUESTION PRESENTED: Whether a former member of the Naval Reserve who reports having been sexually assaulted on two occasions during inactive duty training and who alleges suffering from resulting post-traumatic stress disorder (PTSD) may be considered to have been disabled by an injury in determining whether the member had active service for purposes of 38 U.S.C. Ї 101(24)? DISCUSSION: 1. The claimant served in the Naval Reserve. The claimant had no active duty service, but did perform inactive duty training. The claimant reports having been raped on several occasions including two times during periods of inactive duty training. The incidents have not been substantiated. The claimant was discharged from the Naval Reserve under “other than honorable conditions” by reason of unsatisfactory participation. The claimant is seeking disability compensation for PTSD claimed to have resulted from sexual assault. 2. Pursuant to 38 U.S.C. ЇЇ 1110 and 1131, service-connected disability compensation may only be paid to a “veteran.” The term “veteran” is defined in 38 U.S.C. Ї 101(2) as “a person who served in the active military, naval, or air service, and who was discharged or released therefrom under conditions other than dishonorable.” Section 101(24) defines the term “active, military, naval, or air service” as including “active duty, any period of active duty for training during which the individual concerned was disabled or died from a disease or injury incurred or aggravated in line of duty, and any period of inactive duty training during which the individual concerned was disabled or died from an injury incurred or aggravated in line of duty.” (Emphasis added.) Thus, in the case of inactive duty training, only an “injury,” not a “disease,” incurred or aggravated in line of duty can be the basis of eligibility for disability compensation. 3. The question of what constitutes an “injury” for purposes of section 101(24) must be considered in light of two previous General Counsel opinions in which we analyzed the distinction between “injury” and “disease” under that statute. One such opinion, VAOPGCPREC 86-90, concerned whether a heart attack sustained during heavy exertion while on inactive duty training was an injury within the meaning of section 101(24). Medical evidence in that case indicated that the heart attack was the result of coronary artery disease, which existed prior to the training period, although the event may have been precipitated by physical exertion. On those facts, we concluded that the claimant’s heart attack was not caused by an injury, but rather was attributable to disease. 4. In VAOPGCPREC 86-90, we examined the medical cause of the heart attack. We noted that acute myocardial infarction is a condition in which a portion of the heart muscle dies because it is not getting enough blood. We also observed the consensus among medical specialists that excessive effort and strain cannot damage a normal heart and therefore considered the heart attack to be the result of a disease process. We then concluded that Congress intended to exclude “nontraumatic incurrence or aggravation of a disease process, and that manifestations of cardiovascular disease, such as heart attacks of nontraumatic origin, fall within the excluded class of disability, i.e., do not constitute injuries under the statute.” In Brooks v. Brown, 5 Vet. App. 484, 487 (1993), aff’d, 26 F.3d 141 (Fed. Cir. 1994), the Court of Appeals for Veterans Claims concluded that VAOPGCPREC 86-90 is consistent with the governing statutes and Congress’ policy reflected in those statutes. We note that the focus of our holding in VAOPGCPREC 86-90 was clearly on the non-traumatic nature of the cause of the heart attack. We may assume that a heart attack caused by a traumatic external event that is independent of a disease process, e.g., an electric shock, may be considered an injury. 5. VAOPGC 6-86 (3-27-86), despite its earlier date, which resulted from reissuance of VAOPGCPREC 86-90 (formerly Op. G.C. 1-81), followed and relied upon what is now designated as VAOPGCPREC 86-90. Although VAOPGC 6-86 is not precedential, it illustrates how VAOPGCPREC 86-90 has been applied. In VAOPGC 6-86, we determined that a claimant who received an influenza vaccination by injection while on inactive duty training and subsequently developed Guillain-Barre syndrome did not incur a disability resulting from an injury for purposes of section 101(24). We reasoned that, under VAOPGCPREC 86-90, the term “injury” denotes harm from external trauma, while the term “disease” refers to some type of internal infection or degenerative process. The opinion cited several sources for the proposition that the term “trauma” commonly refers to the application of external force or violence. We further reasoned that, under modern medical practices, the routine insertion of a hypodermic needle into the body is not commonly considered to involve application of external force or violence that is characteristic of injury. However, we recognized that an injection could be considered to have caused a traumatic injury if contact with the needle caused lasting nerve or tissue damage. 6. The concept exemplified by these opinions, that “injury” refers to the results of an external trauma, rather than a degenerative process, is significant in evaluating whether PTSD resulting from a sexual assault is a disability resulting from an injury. In this regard, we must consider the nature and cause of PTSD. 7. Pursuant to 38 C.F.R. Ї 4.130, the nomenclature currently employed in the schedule for rating mental disorders is based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, of the American Psychiatric Association (DSM-IV). The DSM-IV is an authoritative diagnostic tool used by medical professionals that provides standardized diagnostic criteria for diagnosing various mental disorders including PTSD. According to the DSM-IV, the essential feature of PTSD is “the development of characteristic symptoms following exposure to an extreme traumatic stressor involving direct personal experience of an event.” DSM-IV, section 309.81, Posttraumatic Stress Disorder, 424. It is clear that reaction to an event causes the symptoms of PTSD, and there is no indication of a latent disease process that becomes manifest as a result of the traumatic experience. 8. In order for PTSD to be diagnosed, one must have been “exposed to a traumatic event.” DSM-IV at 427 (diagnostic criterion A). Although a PTSD stressor need not involve direct physical harm to the affected person, the DSM-IV gives several examples of traumatic events that do involve such harm, including violent personal attacks such as sexual assault. DSM-IV at 424. Forcible rape involves sexual intercourse effected by force, duress, or intimidation. See Webster’s Third New International Dictionary 1882 (1981). Thus, it involves a malicious physical assault on the victim. Rape is a traumatic physical event that may cause both physical and psychological harm, although the effects of the psychological harm may be latent. 9. We have previously recognized that PTSD can result from a traumatic event in service even though the disorder is not manifested until much later. In VAOPGCPREC 26-97, we stated, “[w]ith the recognition of PTSD came the understanding that a veteran’s response to trauma may be delayed. Thus, the servicemember may not show signs of a psychiatric disorder during service, although the disorder was the result of service experiences.” (Citations omitted.) Stated another way, a claimant may be injured during service but the resulting disability may not be apparent until some time after service. PTSD is somewhat unique among psychological disorders because it requires experiencing a traumatic event. For instance, unlike PTSD, schizophrenia often involves a disease process that operates independently from any traumatic experience. See generally Lewis v. West, No. 97-1773, 1998 U.S. Vet. App. LEXIS 1446, at * 6 (Nov. 25, 1998) (“Schizophrenia is a mental disease or condition, not an injury.”); Broyles v. West, No. 99-346, 2000 U.S. App. Vet. Claims LEXIS 661, at * 13 (June 29, 2000) (delusional disorder “is considered a disease”); Morgan v. Brown, No. 93-564, 1994 U.S. Vet. App. LEXIS 1103, at * 7 (Dec. 8, 1994) (remanding for Board of Veterans’ Appeals to provide adequate statement of reasons and bases for conclusion that claimant’s schizophrenia was not an injury within the meaning of 38 U.S.C. Ї 101(24)). 10. Based on the foregoing, we conclude that, for purposes of section 101(24), PTSD resulting from sexual assault may be considered a disability caused by external physical trauma. We therefore hold that PTSD resulting from sexual assault may be considered a disability resulting from an injury for purposes of section 101(24). 11. We note that our opinion is limited to the legal issue of whether PTSD resulting from sexual assault may be considered to have resulted from injury rather than disease. We express no opinion on the numerous factual issues presented in the claim which gave rise to the subject opinion request. In this regard, we note that, pursuant to 38 C.F.R. Ї 3.304(f), if a veteran is diagnosed with PTSD, before the disability can be service connected, it must be determined that the current symptoms are related to an in-service stressor established by appropriate evidence. See, e.g., Schreier v. West, No. 96-1503, 1998 U.S. Vet. App. LEXIS 824 (June 22, 1998) (non-precedential) (claimant was diagnosed with PTSD based on claimant’s report of two sexual assaults during service; however, denial of service connection was affirmed due to lack of evidence to corroborate the alleged assaults). We also note that, to qualify as a veteran for purposes of service-connected disability benefits, an individual must have been “discharged or released . . . under conditions other than dishonorable.” 38 U.S.C. Ї 101(2). We defer to adjudication personnel on the character of discharge issue presented by the subject claim. HELD: Under 38 U.S.C. Ї 101(2) and (24), inactive duty training may provide a basis for veteran status for purposes of benefits administered by the Department only if the individual incurred disability or death from an injury incurred or aggravated in line of duty. An individual who suffers from post-traumatic stress disorder as a result of a sexual assault that occurred during inactive duty training may be considered disabled by an “injury” for purposes of section 101(2) and (24). John H. Thompson Attachment: C-file  PAGE 5. 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