ࡱ> #` bjbjmm 4Y$8dNj<~VV(~~~& ,$0h#+++#~~h8///+~~S/+//o+~J PqjUUDK,w N0~wNPNX+N+L$/flY$$$##k$$$~++++j<j<j<hj<j<j<  Section H. Mental Disorders  PRIVATE INFOTYPE="OTHER" Overview In this SectionThis section contains the following topics: TopicTopic NameSee Page27General Information on Mental Disorders4-H-228General Information on Posttraumatic Stress Disorder (PTSD)4-H-529Evaluating Evidence of an In-Service Stressor4-H-830Evaluating Evidence in Claims Based on Personal Trauma4-H-1831Handling Examinations in Claims for Service Connection for PTSD4-H-2232Deciding a Claim for Service Connection for PTSD4-H-25 27. General Information on Mental Disorders  PRIVATE INFOTYPE="OTHER"  IntroductionThis topic contains general information about rating mental disorders, including considering a change in the diagnosis of a psychiatric disorder making reductions in evaluations of psychiatric disorders considering attempted suicide a definition of psychosis handling a Veterans discharge from service for a mental disorder due to traumatic stress, and considering a Global Assessment of Functioning (GAF) score. Change DateAugust 3, 2011 PRIVATE INFOTYPE="PRINCIPLE"  a. Considering a Change in the Diagnosis of a Psychiatric Disorder If the diagnosis of a psychiatric condition is changed, return the examination and any appropriate records to the examiner to determine whether the new diagnosis represents progression of the prior disorder correction of an error in the prior diagnosis, or development of a new and separate condition. Reference: For more information on the diagnosis of mental disorders, see HYPERLINK "http://www.benefits.va.gov/warms/docs/regs/38CFR/BOOKC/PART4/S4_125.DOC"38 CFR 4.125. PRIVATE INFOTYPE="PRINCIPLE"  b. Making Reductions in Evaluations of Psychiatric DisordersDo not make drastic reductions in evaluations in ratings for psychiatric disorders if a reduction to an intermediate rate is more in agreement with the degree of disability. Observe the general policy of gradually reducing the evaluation to afford the Veteran all possible opportunities for adjustment. Reference: For more information on the stabilization of disability evaluations, see HYPERLINK "http://www.benefits.va.gov/warms/docs/regs/38CFR/BOOKB/PART3/S3_344.DOC"38 CFR 3.344.Continued on next page  STYLEREF "Map Title" 27. General Information on Mental Disorders, Continued  PRIVATE INFOTYPE="PRINCIPLE"  c. Considering Attempted SuicideIn the absence of any underlying psychiatric disability subject to service connection, a finding of mental unsoundness under the provisions of HYPERLINK "http://www.benefits.va.gov/warms/docs/regs/38CFR/BOOKB/PART3/S3_302.DOC"38 CFR 3.302 does not, in itself, constitute a disability subject to service connection. PRIVATE INFOTYPE="CONCEPT"  d. Definition: PsychosisFor the purpose of presumptive service connection under HYPERLINK "http://www.benefits.va.gov/warms/docs/regs/38CFR/BOOKB/PART3/S3_309.DOC"38 CFR 3.309(a), a psychosis is any of the following disorders: Brief Psychotic Disorder Delusional Disorder Psychotic Disorder Due to General Medical Condition Psychotic Disorder Not Otherwise Specified Schizoaffective Disorder Schizophrenia Schizophreniform Disorder Shared Psychotic Disorder, and Substance-Induced Psychotic Disorder. Note: The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, of the American Psychiatric Association (DSMIVTR), has designated the disorders listed above as psychotic disorders. Reference: For the regulation governing the definition of psychosis, see HYPERLINK "http://www.benefits.va.gov/warms/docs/regs/38CFR/BOOKB/PART3/S3_384.DOC"38 CFR 3.384. PRIVATE INFOTYPE="PRINCIPLE"  e. Handling a Veterans Discharge From Service for a Mental Disorder Due to Traumatic StressUnder HYPERLINK "http://www.benefits.va.gov/warms/docs/regs/38CFR/BOOKC/PART4/S4_127.DOC"38 CFR 4.129, when a mental disorder that develops in service from a highly stressful event is severe enough to result in the Veterans discharge from active military service assign a service-connected (SC) evaluation of at least 50 percent, and schedule an examination within six months of the Veterans discharge to determine whether a change in the evaluation is warranted. Note: In-service mental health treatment records are maintained by the military or civilian treating facility and are not stored by the Department of Defense with the traditional service treatment records (STRs). (Reference: For information on developing for in-service mental health treatment records, see HYPERLINK "C:\\adjatoml\\My Documents\\SharePoint Drafts\\pt04_sp02_ch01_secD.xml" \l "IV.ii.1.D.14.a"M21-1MR, Part IV, Subpart ii, 1.D.14.a and b.)Continued on next page  STYLEREF "Map Title" 27. General Information on Mental Disorders, Continued  PRIVATE INFOTYPE="PRINCIPLE"  f. Considering a GAF ScoreA Global Assessment of Functioning (GAF) score is an assessment of an individuals overall level of psychological, social, and occupational functioning on a scale of zero to 100. When considering a GAF score evaluate the score in light of all the evidence in the case, including symptomatology and manifestations shown at the mental status examination and in treatment records, and do not base the disability evaluation solely or primarily on the score. Note: The GAF score is shown on Axis V of a psychiatric diagnosis. Reference: For more information on the GAF score, see the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). 28. General Information on Posttraumatic Stress Disorder (PTSD)  PRIVATE INFOTYPE="OTHER"  IntroductionThis topic contains general information about rating posttraumatic stress disorder (PTSD), including the responsibility of the Rating Veterans Service Representative (RVSR) or Decision Review Officer (DRO) in deciding service connection for PTSD requirements for establishing service connection for PTSD considering the relationship between stressor and symptoms, and handling an in-service diagnosis of PTSD. Change DateAugust 3, 2011 PRIVATE INFOTYPE="PRINCIPLE"  a. Responsibility of the RVSR or DRO in Deciding Service Connection for PTSDDeciding the issue of service connection for posttraumatic stress disorder (PTSD) is the sole responsibility of the appropriate decision maker at the local level, generally a Rating Veterans Service Representative (RVSR) or a Decision Review Officer (DRO). Note: Central Office opinion or guidance may be requested on complex cases.Continued on next page  STYLEREF "Map Title" 28. General Information on Posttraumatic Stress Disorder (PTSD), Continued  PRIVATE INFOTYPE="PRINCIPLE"  b. Requirements for Establishing Service Connection for PTSDPer HYPERLINK "http://www.benefits.va.gov/warms/docs/regs/38CFR/BOOKB/PART3/S3_304.DOC"38 CFR 3.304(f), a finding of service connection for PTSD requires credible supporting evidence that the claimed in-service stressor actually occurred medical evidence diagnosing the condition in accordance with HYPERLINK "http://www.benefits.va.gov/warms/docs/regs/38CFR/BOOKC/PART4/S4_125.DOC"38 CFR 4.125, and a link, established by medical evidence, between current symptomatology and the claimed in-service stressor. Note: The lay testimony of a Veteran alone may, under certain circumstances, establish the occurrence of an in-service stressor if the stressor is related to the Veterans combat service POW experience in-service diagnosis of PTSD, or fear of hostile military or terrorist activity. References: For more information on establishing service connection for PTSD, see HYPERLINK "http://10.220.1.4/bl/21/M21-1MR/index.asp?id=pt04_sp02_ch01_secD.xml" \l "IV.ii.1.D"M21-1MR, Part IV, Subpart ii, 1.D HYPERLINK "http://www.benefits.va.gov/warms/docs/regs/38CFR/BOOKB/PART3/S3_304.DOC"38 CFR 3.304(f), and HYPERLINK "http://www.law.cornell.edu/uscode/html/uscode38/usc_sec_38_00001154----000-.html"38 U.S.C. 1154(b) handling an in-service diagnosis of PTSD, see M21-1MR, HYPERLINK "C:\\adjatoml\\My Documents\\SharePoint Drafts\\pt03_sp04_ch04_secH.xml" \l "III.iv.4.H.28.d"Part III, Subpart iv, 4.H.28.d, and when the Veterans testimony alone may establish the occurrence of an in-service stressor, see HYPERLINK "C:\\adjatoml\\My Documents\\SharePoint Drafts\\pt03_sp04_ch04_secH.xml" \l "III.iv.4.H.29.a"M21-1MR, Part III, Subpart iv, 4.H.29.a.  PRIVATE INFOTYPE="PRINCIPLE"  c. Considering the Relationship Between Stressor and SymptomsTo establish service connection for PTSD the relationship between stressor and symptoms must be specifically addressed in the Department of Veterans Affairs (VA) examination report, and supported by documentation.Continued on next page  STYLEREF "Map Title" 28. General Information on Posttraumatic Stress Disorder (PTSD), Continued  PRIVATE INFOTYPE="PRINCIPLE"  d. Handling an In-Service Diagnosis of PTSDWhen PTSD is properly diagnosed in service, the Veterans testimony alone may establish that the claimed stressor occurred, as long as the claimed stressor is related to the Veterans service, and consistent with the circumstances, conditions, or hardships of that service. Reference: For more information, see HYPERLINK "http://www.benefits.va.gov/warms/docs/regs/38CFR/BOOKB/PART3/S3_304.DOC"38 CFR 3.304(f)(1). 29. Evaluating Evidence of an In-Service Stressor  PRIVATE INFOTYPE="OTHER"  IntroductionThis topic contains information about evaluating evidence of an in-service stressor, including when a Veterans testimony alone may establish the occurrence of a stressor definitions of engaging in combat, and fear of hostile military or terrorist activity individual decorations as evidence of combat participation action to take if a Veteran received a combat decoration but does not state the nature of the stressor establishing the occurrence of a stressor related to the fear of hostile military or terrorist activity when stressor corroboration is not required when stressor corroboration is required primary evidence to corroborate a claimed in-service stressor secondary sources of evidence which may corroborate a claimed in-service stressor considering buddy statements, and obtaining evidence related to claimed stressors. Change DateAugust 3, 2011Continued on next page  STYLEREF "Map Title" 29. Evaluating Evidence of an In-Service Stressor, Continued  PRIVATE INFOTYPE="PRINCIPLE"  a. When a Veterans Testimony Alone May Establish the Occurrence of a StressorA Veterans lay testimony alone may establish the occurrence of the claimed in-service stressor for purposes of establishing service connection for PTSD if PTSD is diagnosed in service, and the stressor is related to that service, or the stressor is related to the Veterans engagement in combat with the enemy experience as a POW as defined by HYPERLINK "http://www.benefits.va.gov/warms/docs/regs/38CFR/BOOKB/PART3/S3_1.DOC"38 CFR 3.1(y), or fear of hostile military or terrorist activity, if a VA psychiatrist or psychologist, or contract equivalent, confirms the claimed stressor is adequate to support a diagnosis of PTSD, and the Veterans symptoms are related to the claimed stressor. Notes: For the Veterans testimony alone to establish the occurrence of a claimed stressor the stressor must be consistent with the circumstances, conditions, or hardships of service for claims based on an in-service PTSD diagnosis or POW or combat service, or places, types, and circumstances of service for claims based on a fear of hostile military or terrorist activity, and there must be no clear and convincing evidence to the contrary. For claims decided prior to July 13, 2010, a Veterans testimony alone could not establish the occurrence of a claimed stressor that was related to the Veterans fear of hostile military or terrorist activity. The July 13, 2010, amendment of HYPERLINK "http://www.benefits.va.gov/warms/docs/regs/38CFR/BOOKB/PART3/S3_304.DOC"38 CFR 3.304(f) is not considered a liberalizing rule under HYPERLINK "http://www.benefits.va.gov/warms/docs/regs/38CFR/BOOKB/PART3/S3_114.DOC"38 CFR 3.114(a). References: For more information on evidence requirements for claims based on a diagnosis of PTSD in service, see HYPERLINK "http://www.benefits.va.gov/warms/docs/regs/38CFR/BOOKB/PART3/S3_304.DOC"38 CFR 3.304(f)(1) combat service, see HYPERLINK "http://www.benefits.va.gov/warms/docs/regs/38CFR/BOOKB/PART3/S3_304.DOC"38 CFR 3.304(f)(2) and HYPERLINK "http://vbaw.vba.va.gov/bl/21/Advisory/PRECOP/99op/Prc12_99.doc"VAOPGCPREC 12-99 a fear of hostile military or terrorist activity, see HYPERLINK "http://www.benefits.va.gov/warms/docs/regs/38CFR/BOOKB/PART3/S3_304.DOC"38 CFR 3.304(f)(3), and POW service, see HYPERLINK "http://www.benefits.va.gov/warms/docs/regs/38CFR/BOOKB/PART3/S3_304.DOC"38 CFR 3.304(f)(4), and a definition of engaging in combat, see HYPERLINK "C:\\adjatoml\\My Documents\\SharePoint Drafts\\pt03_sp04_ch04_secH.xml" \l "III.iv.4.H.29.b"M21-1MR, Part III, Subpart iv, 4.H.29.b, and fear of hostile military or terrorist activity, see HYPERLINK "C:\\adjatoml\\My Documents\\SharePoint Drafts\\pt03_sp04_ch04_secH.xml" \l "III.iv.4.H.29.c"M21-1MR, Part III, Subpart iv, 4.H.29.c.Continued on next page  STYLEREF "Map Title" 29. Evaluating Evidence of an In-Service Stressor, Continued  PRIVATE INFOTYPE="CONCEPT"  b. Definition: Engaging in CombatEngaging in combat with the enemy means personal participation in events constituting an actual fight or encounter with a military foe or hostile unit or instrumentality. It includes presence during such events either as a combatant, or service member performing duty in support of combatants, such as providing medical care to the wounded. PRIVATE INFOTYPE="CONCEPT"  c. Definition: Fear of Hostile Military or Terrorist ActivityFear of hostile military or terrorist activity means the Veteran experienced, witnessed, or was confronted with 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, and the Veterans response to the event or circumstances involved a psychological or psycho-physiological state of fear, helplessness, or horror. Examples of exposure to hostile military or terrorist activity include presence at events involving actual or potential improvised explosive device (IED), vehicle-imbedded explosive devices, incoming artillery, rocket, or mortar fire, small arms fire, including suspected sniper fire, or attack upon friendly aircraft. Continued on next page  STYLEREF "Map Title" 29. Evaluating Evidence of an In-Service Stressor, Continued  PRIVATE INFOTYPE="PRINCIPLE"  d. Individual Decorations as Evidence of Combat ParticipationConsider the receipt of any of the following individual decorations as evidence of personal participation in combat: 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 Combat Action Badge Combat Action Ribbon (Note: Prior to February 1969, the Navy Achievement Medal with V Device was awarded.) Combat Aircrew Insignia Combat Infantry/Infantryman Badge Combat Medical Badge Distinguished Flying Cross Distinguished Service Cross Joint Service Commendation Medal with V Device Medal of Honor Navy Commendation Medal with V Device Navy Cross Purple Heart, and/or Silver Star. Important: Receipt of one of the decorations cited above is not the only acceptable evidence of engagement in combat. PRIVATE INFOTYPE="PROCEDURE"  e. Action to Take if a Veteran Received a Combat Decoration but Does Not State the Nature of StressorIf a Veteran received one of the combat decorations cited in HYPERLINK "C:\\adjatoml\\My Documents\\SharePoint Drafts\\pt3_sp4\\pt03_sp04_ch04_secH" \l "III.iv.4.H.29.d"M21-1MR, Part III, Subpart iv, 4.H.29.d but does not expressly state the nature of the stressor assume the stressor is combat related order an examination, if necessary to decide the claim, and in the examination request state that VA has verified the Veterans combat service, and specify any details regarding the combat stressor contained in the record.Continued on next page  STYLEREF "Map Title" 29. Evaluating Evidence of an In-Service Stressor, Continued  PRIVATE INFOTYPE="PRINCIPLE"  f. Establishing the Occurrence of a Stressor Related to Fear of Hostile Military or Terrorist ActivityUnder HYPERLINK "http://www.benefits.va.gov/warms/docs/regs/38CFR/BOOKB/PART3/S3_304.DOC"38 CFR 3.304(f)(3), a Veterans lay statement alone may establish the occurrence of a stressor related to the fear of hostile military or terrorist activity if evidence shows the Veteran served in an area of potential hostile military or terrorist activity, and a VA psychiatrist or psychologist (or contract equivalent) accepts the Veterans statement as being adequate to support a diagnosis of PTSD, and relates the Veterans symptoms to the claimed stressor. Schedule an examination if there is evidence of a PTSD diagnosis or symptoms, and the Veterans DD Form 214, Certificate of Release or Discharge From Active Duty, or other service records, shows service in an area of potential hostile military or terrorist activity. Notes: The receipt of military awards such as, but not limited to, the Vietnam Service or Campaign Medal, Kuwait Liberation Medal, Iraq Campaign Medal, and Afghanistan Campaign Medal is generally considered evidence of service in an area of potential hostile military or terrorist activity. The receipt of service medals such as the National Defense, Armed Forces, and Global War on Terrorism (GWOT) Service Medals does not indicate service in locations that involve exposure to hostile military or terrorist activity, because these are general medals that do not denote service in a particular area or campaign. If the Veteran served in an area of potential hostile military or terrorist activity, he/she would have received a more specific medal for such service. Reference: For more information on scheduling examinations in PTSD cases, see HYPERLINK "imi-internal:M21-1MRIII.iv.4.4.H.31"M21-1MR, Part III, Subpart iv, 4.H.31.Continued on next page  STYLEREF "Map Title" 29. Evaluating Evidence of an In-Service Stressor, Continued  PRIVATE INFOTYPE="PRINCIPLE"  g. When Stressor Corroboration Is Not Required In the absence of clear and convincing evidence to the contrary, corroboration of the details of the claimed stressful event or circumstances, including the Veterans personal participation, is not required if PTSD is diagnosed in service, and the claimed stressor is related to that service the claimed stressor is consistent with the circumstances, conditions, or hardships of the Veterans verified combat or POW service, or the claim is based on fear of hostile military or terrorist activity, and the claimed exposure to such activity is consistent with the places, types, and circumstances of the Veterans service, and PTSD has been diagnosed by a VA psychiatrist or psychologist, or contract equivalent, who confirms that the claimed stressor is adequate to support a diagnosis of PTSD the Veterans symptoms are related to the claimed stressor, and the claimed stressor is related to fear of hostile military or terrorist activity (see HYPERLINK "C:\\adjatoml\\My Documents\\SharePoint Drafts\\pt03_sp04_ch04_secH.xml" \l "III.iv.4.H.29.c"M21-1MR, Part III, Subpart iv, 4.H.29.c). Note: For claims decided prior to July 13, 2010, it was necessary to corroborate the details of the claimed stressor if the stressor was related to the Veterans fear of hostile military or terrorist activity.Continued on next page  STYLEREF "Map Title" 29. Evaluating Evidence of an In-Service Stressor, Continued  PRIVATE INFOTYPE="PRINCIPLE"  h. When Stressor Corroboration Is RequiredDevelop to corroborate the details of a claimed stressful event or circumstances only when the claimed stressor is does not meet the one of the criteria in HYPERLINK "C:\\adjatoml\\My Documents\\III.iv_11-3-10\\pt03_sp04_ch04_secH.xml" \l "III.iv.4.H.29.g"M21-1MR, Part III, Subpart iv, 4.H.29.g. Examples of claimed stressors that must be corroborated are a plane crash caused by severe weather a severe motor vehicle accident a personal assault witnessing the death, injury, or threat to the physical being of another person caused by something other than hostile military or terrorist activity, and actual or threatened death or serious injury, or other threat to ones physical being, caused by something other than hostile military or terrorist activity. Reference: For more information on processing claims for PTSD based on personal assault, see HYPERLINK "C:\\adjatoml\\My Documents\\SharePoint Drafts\\pt03_sp04_ch04_secH.xml" \l "III.iv.4.H.30"M21-1MR, Part III, Subpart iv, 4.H.30 the  HYPERLINK "http://vbaw.vba.va.gov/bl/21/rating/rat06h.htm" PTSD Personal Assault Information site on the Compensation Service Interanet, and  HYPERLINK "http://www.benefits.va.gov/warms/docs/regs/38CFR/BOOKB/PART3/S3_304.DOC" 38 CFR 3.304(f)(5).Continued on next page  STYLEREF "Map Title" 29. Evaluating Evidence of an In-Service Stressor, Continued  PRIVATE INFOTYPE="PRINCIPLE"  i. Primary Evidence to Corroborate a Claimed In-Service StressorPrimary evidence is generally considered the most reliable source for corroborating in-service stressors and should be carefully reviewed for information to corroborate a claimed in-service stressor when corroboration is required. It is typically obtained from the National Archives and Records Administration (NARA) or Department of Defense (DoD) entities, such as service departments, the U.S. Army and Joint Services Records Research Center (JSRRC), and the Marine Corps University Archives (MCUA). Primary evidence includes service personnel records (SPRs) and pay records military occupation evidence (Note: A Veterans military occupation may be specified on his/her DD Form 214, Certificate of Release or Discharge from Active Duty, or in SPRs.) hazard pay records (Note: This information may be requested from the Department of Defense Finance and Accounting Service (DFAS).) service treatment records (STRs) military performance reports (Note: This information may be requested via PIES.) verification that the Veteran received Combat/Imminent Danger/Hostile Fire Pay (Note: This information may be requested through the Veterans Information Solution (VIS).) unit and organizational histories daily staff journals operational reports-lessons learned (ORLLs) after action reports (AARs) radio logs, deck logs, and ship histories deck logs and ship histories muster rolls command chronologies and war diaries, and monthly summaries and morning reports. Notes: Many of the unit documents listed above are available on the Compensation Service Intranet site,  HYPERLINK "http://vbaw.vba.va.gov/bl/21/rating/stressor/general.htm" Stressor Verification. While confirmation of receipt of Combat/Imminent Danger/Hostile Fire Pay through the VIS alone does not constitute verification of a combat-related stressor, it may, in combination with other evidence, "tip the scales" in favor of the Veteran's assertion of his/her involvement in combat. Reference: For more information on Combat/Imminent Danger/Hostile Fire Pay, see the HYPERLINK "http://vbaw.vba.va.gov/bl/21/rating/rat06.htm"PTSD Rating Job Aid website and HYPERLINK "http://vbaw.vba.va.gov/bl/21/Calendar/Agenda/FY06/Agenda0306.htm"VSCM Conference Call, March 16, 2006.Continued on next page  STYLEREF "Map Title" 29. Evaluating Evidence of an In-Service Stressor, Continued  PRIVATE INFOTYPE="PRINCIPLE"  j. Secondary Sources of Evidence That May Corroborate a Claimed In-Service StressorReview the following alternative sources of evidence critically and carefully for information confirming participation in combat or to otherwise corroborate a claimed in-service stressor when corroboration is required: buddy statements contemporaneous letters and diaries newspaper archives, and information from Veterans Benefits Administration (VBA)-sanctioned websites, which may be accessed through the HYPERLINK "http://vbaw.vba.va.gov/bl/21/rating/rat06.htm"PTSD Rating Job Aid website. Reference: For more information on Combat/Imminent Danger/Hostile Fire Pay, see the HYPERLINK "http://vbaw.vba.va.gov/bl/21/rating/rat06.htm"PTSD Rating Job Aid website, and HYPERLINK "http://vbaw.vba.va.gov/bl/21/Calendar/Agenda/FY06/Agenda0306.htm"VSCM Conference Call, March 16, 2006. Important: All sources of evidence obtained for purposes of stressor verification must be fully documented in the file. It may not be necessary to corroborate the claimed stressor if it is related to the Veterans fear of hostile military or terrorist activity, and consistent with the places, types, and circumstances of the Veterans service. PRIVATE INFOTYPE="PRINCIPLE"  k. Considering Buddy StatementsAccept a buddy statement as corroboration of a claimed in-service stressor, so long as the statement is consistent with the time, place, and circumstances of the service of both the Veteran and the buddy. If the evidence available calls into question the qualifications of the buddy to make the statement, ask the person to submit his/her DD Form 214 or other evidence of service with the claimant. Note: Upon receipt of a DD Form 214 (or other document containing personally identifiable information) from a fellow Veteran place the document in a separate envelope in the claims folder, and annotate on the envelope that the contents must not be reproduced, or reviewed by the Veteran to whom the claims folder pertains or his/her representative.Continued on next page  STYLEREF "Map Title" 29. Evaluating Evidence of an In-Service Stressor, Continued  PRIVATE INFOTYPE="FACT"  l. Obtaining Evidence Related to Claimed StressorsFor more information on obtaining service records, medical treatment records, and evidence of stressors, see HYPERLINK "C:\\adjatoml\\My Documents\\SharePoint Drafts\\pt04_sp02_ch01_secD.xml" \l "IV.ii.1.D"M21-1MR, Part IV, Subpart ii, 1.D. 30. Evaluating Evidence in Claims Based on Personal Trauma  PRIVATE INFOTYPE="OTHER"  IntroductionThis topic contains information about evaluating evidence in claims based on personal trauma, including general information on personal trauma alternative evidence of in-service personal trauma evaluating the available evidence of personal trauma development requirements for secondary evidence interpretation of secondary evidence, and obtaining evidence of personal trauma. Change DateAugust 3, 2011 PRIVATE INFOTYPE="PRINCIPLE"  a. General Information on Personal TraumaPersonal trauma is an event of human design that threatens or inflicts harm, such as rape physical assault and domestic battering robbery and mugging stalking, and harassment. Note: Service connection for PTSD based on in-service personal trauma derives from the PTSD personal assault regulation,  HYPERLINK "http://www.benefits.va.gov/warms/docs/regs/38CFR/BOOKB/PART3/S3_304.DOC" 38 CFR 3.304(f)(5). Reference: For more information on processing claims for PTSD based on personal trauma, see the  HYPERLINK "http://vbaw.vba.va.gov/bl/21/rating/rat06h.htm" PTSD Personal Assault Information site on the Compensation Service Intranet.Continued on next page  STYLEREF "Map Title" 30. Evaluating Evidence in Claims Based on Personal Trauma, Continued  PRIVATE INFOTYPE="PRINCIPLE"  b. Alternative Evidence of In-Service Personal TraumaIf the military record contains no documentation that personal trauma, including in-service sexual assault, occurred, alternative evidence might still establish an in-service stressful incident. Sources of such evidence include a rape crisis center or center for domestic abuse a counseling facility or health clinic family members or roommates a faculty member civilian police reports medical reports from civilian physicians or caregivers who treated the Veteran immediately or sometime later a chaplain or clergy fellow service persons, and personal diaries or journals.Continued on next page  STYLEREF "Map Title" 30. Evaluating Evidence in Claims Based on Personal Trauma, Continued  PRIVATE INFOTYPE="PRINCIPLE"  c. Evaluating the Available Evidence of Personal TraumaRating Veterans Service Representatives (RVSRs) must carefully evaluate all of the available evidence. If the military records contain no documentation that personal trauma occurred, consider secondary evidence, such as lay statements indicating increased use or abuse of leave without an apparent reason, such as family obligations or family illness, or describing episodes of depression, panic attacks, or anxiety, but no identifiable reasons for the episodes, and evidence of behavioral changes that occurred around the time of the incident, including visits to a medical or counseling clinic or dispensary without a specific diagnosis or specific ailment use of pregnancy tests or tests for sexually-transmitted diseases around the time of the incident sudden requests that the Veterans military occupational series or duty assignment be changed without other justification changes in performance and performance evaluations increased or decreased use of prescription medications increased use of over-the-counter medications evidence of substance abuse, such as alcohol or drugs increased disregard for military or civilian authority obsessive behavior such as overeating or undereating increased interest in tests for HIV or sexually transmitted diseases unexplained economic or social behavior changes treatment for physical injuries around the time of the claimed trauma, but not reported as a result of the trauma, and/or the breakup of a primary relationship. Notes: Secondary evidence may need interpretation by a clinician in personal trauma claims, especially if the claim involves behavior changes. Evidence that documents behavior changes may require interpretation in relation to the medical diagnosis by a neuropsychiatric physician. Important: When preparing notices or rating decisions in personal trauma cases, use a tone that conveys sensitivity and compassion, regardless of whether the claim is granted or denied.Continued on next page  STYLEREF "Map Title" 30. Evaluating Evidence in Claims Based on Personal Trauma, Continued  PRIVATE INFOTYPE="PRINCIPLE"  d. Development Requirements for Secondary EvidenceDo not deny a PTSD claim that is based on in-service personal trauma without first advising the claimant that evidence from sources other than STRs, such as evidence of behavioral changes, may constitute credible supporting evidence of the stressor. Allow the Veteran the opportunity to furnish this type of evidence or indicate its potential sources. PRIVATE INFOTYPE="PRINCIPLE"  e. Interpretation of Secondary EvidenceIn personal trauma claims, interpretation of secondary evidence by a clinician may be required, especially if the claim involves behavioral changes. Evidence that supports such behavioral changes may require interpretation in relationship to the medical diagnosis, or an opinion by an appropriate medical or mental health professional as to whether it indicates that personal trauma occurred. Reference: For more information on VAs responsibility to obtain secondary evidence needed to corroborate a personal trauma claim, see HYPERLINK "http://vbaw.vba.va.gov/bl/21/Advisory/CAVCDAD.htm" \l "bmp"Patton v. West, 12 Vet.App. 272 (1999). PRIVATE INFOTYPE="FACT"  f. Obtaining Evidence of Personal TraumaFor more information on obtaining service records, medical treatment records, and evidence of personal trauma, see HYPERLINK "C:\\adjatoml\\My Documents\\SharePoint Drafts\\pt04_sp02_ch01_secD.xml" \l "IV.ii.1.D"M21-1MR, Part IV, Subpart ii, 1.D. 31. Handling Examinations in Claims for Service Connection for PTSD  PRIVATE INFOTYPE="OTHER"  IntroductionThis topic contains information about handling examinations in claims for service connection for PTSD, including when to proceed with an examination in a PTSD claim requesting initial PTSD examinations, and handling inadequate examination reports. Change DateJune 5, 2012 PRIVATE INFOTYPE="PRINCIPLE"  a. When to Proceed With an Examination in a PTSD ClaimIn PTSD claims alleging personal trauma, if development fails to identify credible supporting evidence that the claimed stressor actually occurred, or fails to show in-service behavioral changes, deny the claim. Otherwise, request an examination if it is necessary to decide the claim. In PTSD claims alleging a stressor other than personal trauma, if development fails to identify credible supporting evidence that the claimed stressor actually occurred, then deny the claim. Request an immediate examination if evidence or records confirm the stressor occurred evidence (to include lay statements) indicates the Veteran currently suffers from symptoms consistent with a diagnosis of PTSD, and medical evidence adequate for rating purposes is not already of record. Notes: Do not request an examination until all development actions are complete, and all medical evidence requested has been received (or the specified time limit for submitting the evidence has expired). Forward the claims folder to the examining facility and request its review as part of the examination process anytime the issue is service connection for PTSD. References: For more information on requesting examinations, see HYPERLINK "C:\\adjatoml\\My Documents\\SharePoint Drafts\\pt03_sp04_ch03_secA.xml" \l "III.iv.3.A"M21-1MR, Part III, Subpart iv, 3.A PTSD examinations, see the Best Practice Manual in the HYPERLINK "http://vbaw.vba.va.gov/bl/21/Rating/rat01.htm"Rating Job Aids website, and requesting medical evidence, see HYPERLINK "C:\\adjatoml\\My Documents\\SharePoint Drafts\\pt01_ch01_secC.xml" \l "I.1.C"M21-1MR, Part I, 1.C.Continued on next page  STYLEREF "Map Title" 31. Handling Examinations in Claims of for Service Connection for PTSD, Continued  PRIVATE INFOTYPE="PRINCIPLE"  b. Requesting Initial PTSD ExaminationsWhen evidence of exposure to stressors related to combat, experience as a POW, or a fear of hostile military or terrorist activity is established by a Veterans individual decoration(s) or other military records, include a statement to that effect in the Remarks section of the examination request. This evidence allows VA (including the examiner) to accept the Veterans own description of the specific events without further corroboration. If the claimed stressor is related to a fear of hostile military or terrorist activity, add the following language to the examination request: Examiner, In addition to the other information provided in the examination report, please specifically state whether or not the claimed stressor is related to the Veterans fear of hostile military or terrorist activity. Important: Evidence of experience as a POW, exposure to combat, or a fear of hostile military or terrorist activity, in itself, does not satisfy the diagnostic criteria for PTSD stated in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). The examiner is still required to elicit details of a specific traumatic event or events described by the Veteran to determine whether the event is persistently reexperienced. This information is needed to support a diagnosis of PTSD, if found, in accordance with the DSM-IV diagnostic criteria. Note: When requesting a PTSD examination, specify that if possible, the Veterans treating mental health professional should not perform the examination. Reference: For more information on evidence of stressors related to combat, experience as a POW, or a fear of hostile military or terrorist activity, see HYPERLINK "http://10.220.1.4/bl/21/M21-1MR/index.asp?id=pt03_sp04_ch04_secH.xml" \l "III.iv.4.H.29"M21-1MR, Part III, Subpart iv, 4.H.29, and HYPERLINK "http://10.220.1.4/bl/21/M21-1MR/index.asp?id=pt04_sp02_ch01_secD.xml" \l "IV.ii.1.D"M21-1MR, Part IV, Subpart ii, 1.D.Continued on next page  STYLEREF "Map Title" 31. Handling Examinations in Claims of for Service Connection for PTSD, Continued  PRIVATE INFOTYPE="PRINCIPLE"  c. Handling Inadequate Examination ReportsIf an examination report is received with a diagnosis of PTSD that does not contain essential information return the examination report as inadequate for rating purposes note the deficiencies of the examination, and request a reexamination. Examples: An unacceptable examination report fails to sufficiently describe symptomatology identify or adequately describe the stressor acknowledge and consider prior reports demonstrating a mental disorder that do not support a diagnosis of PTSD, or conform to DSM-IV. Important: A PTSD examination based on fear of hostile military or terrorist activity that links a diagnosis of PTSD to the claimed, uncorroborated event (such as a rocket or mortar attack) rather than to fear should not be treated as inadequate on that basis. Fear (or helplessness or horror) is the reaction to the threat or stressor under the DSM-IV.  HYPERLINK "http://www.benefits.va.gov/warms/docs/regs/38CFR/BOOKB/PART3/S3_304.DOC" 38 CFR 3.304(f)(3) permits a decision maker to accept lay evidence of uncorroborated events associated with risks of death or serious injury from service in an environment where there is hostile military or terrorist activity. Notes: The diagnosis of PTSD must be made by a competent (properly qualified) medical professional and should be unequivocal. The examining psychiatrist or psychologist should comment on whether the Veteran has experienced other traumatic events and, if so, indicate the relevance of these events to the current symptoms. 32. Deciding a Claim for Service Connection for PTSD  PRIVATE INFOTYPE="OTHER"  IntroductionThis topic contains information about deciding a claim for service connection for PTSD, including considering stressors when making the decision determining combat service considering secondary evidence of engagement in combat requirement for credible supporting evidence of a stressor identifying credible supporting evidence of a stressor when lay testimony is not sufficient reviewing evidence for corroboration of a stressor determining the link between in-service stressor and diagnosis making a decision in a PTSD claim, and denying a PTSD claim because of an unconfirmed stressor. Change DateJune 5, 2012Continued on next page  STYLEREF "Map Title" 32. Deciding a Claim for Service Connection for PTSD, Continued  PRIVATE INFOTYPE="PRINCIPLE"  a. Considering Stressors When Making the DecisionWhen determining the occurrence of stressors to establish service connection for PTSD, consider the following: PTSD does not need to have its onset as a result of combat (for example, vehicular or airplane crashes, large fires, floods, earthquakes, and other disasters evoke significant distress in most involved persons) the trauma may be experienced alone, such as in cases of rape or assault, or in the company of groups of people, such as in military combat do not limit a stressor to just one single episode; a group of experiences also may affect an individual, leading to the development of PTSD PTSD can be caused by events that occur before, during, or after service, and PTSD can develop hours, months, or years after a stressor. Notes: The relationship between stressors during military service and current problems/symptoms will govern the question of service connection. Symptoms must have a clear relationship to the military stressor as described in the medical reports. Despite the possibly long latent period, PTSD may be recognizable by a relevant association between the stressor and the current presentation of symptoms. Continued on next page  STYLEREF "Map Title" 32. Deciding a Claim for Service Connection for PTSD, Continued  PRIVATE INFOTYPE="PRINCIPLE"  b. Determining Combat ServiceEvery decision involving the issue of service connection for PTSD that allegedly developed as a result of combat must include a factual determination as to whether or not the Veteran was engaged in combat, including the reasons or bases for that finding. Important: In order to conclude that a Veteran engaged in combat with the enemy, the evidence must establish that the Veteran was present during an encounter with a military foe either as a combatant or as a service member performing duty in support of combatants. Notes: There are no limitations as to the type of evidence may be accepted to confirm engagement in combat. Any evidence that is probative of (serves to establish the fact at issue) combat participation may be used to support a determination that a Veteran engaged in combat. Determining whether evidence proves a Veteran developed PTSD as a result of combat-related stressors requires an evaluation of all evidence in the case, including an assessment of the credibility of the evidence, and whether the evidence can establish that the stressful event occurred. Apply the benefit-of-the-doubt standard if the evidence is in equipoise. References: For more information on the need to determine combat involvement in PTSD claims, see HYPERLINK "http://vbaw.vba.va.gov/bl/21/Advisory/CAVCDAD.htm" \l "bmg"Gaines v. West, 11 Vet. App. 113 (1998), and what evidence may be used to support a determination that a Veteran engaged in combat, see HYPERLINK "http://vbaw.vba.va.gov/bl/21/Advisory/PRECOP/99op/Prc12_99.doc"VAOPGCPREC 12-99. PRIVATE INFOTYPE="PRINCIPLE"  c. Considering Secondary Evidence of Engagement in CombatAlthough secondary evidence may be used to confirm engagement in combat, it must be critically and carefully reviewed for sufficiency. Note: It may not be necessary to confirm engagement in combat if the evidence in the claim meets the lower threshold of a fear of hostile military or terrorist activity. Reference: For more information on secondary sources of evidence, see HYPERLINK "C:\\adjatoml\\My Documents\\SharePoint Drafts\\pt03_sp04_ch04_secH" \l "III.iv.4.H.29.j"M21-1MR, Part III, Subpart iv, 4.H.29.j.Continued on next page  STYLEREF "Map Title" 32. Deciding a Claim for Service Connection for PTSD, Continued  PRIVATE INFOTYPE="PRINCIPLE"  d. Requirement for Credible Supporting Evidence of a StressorThe requirement for credible supporting evidence means that there must be some believable evidence that tends to support the Veterans assertion. In determining whether evidence is credible, consider its plausibility consistency with other evidence in the case, and source. Note: Credibility is only a minimum requirement. (Evidence that is not believable is not entitled to any weight.) In addition to being credible, evidence must also be material or probative to the issue, and have enough weight to persuade the decision-maker that the stressor is sufficiently verified with some degree of specificity. PRIVATE INFOTYPE="PRINCIPLE"  e. Identifying Credible Supporting Evidence of a Stressor When Lay Testimony Is Not SufficientIf the claimed stressor is not related to combat, experience as a POW, or a fear of hostile military or terrorist activity, a claimants lay testimony regarding in-service stressors is not sufficient, by itself, to establish the occurrence of the stressor, and must be corroborated by credible supporting evidence. Credible supporting evidence of this type of stressor may include service treatment or personnel records private medical records lay statements police or insurance reports, or newspaper accounts of the traumatic event. Example: STRs may contain record of the Veterans medical treatment after an accident. Continued on next page  STYLEREF "Map Title" 32. Deciding a Claim for Service Connection for PTSD, Continued  PRIVATE INFOTYPE="PRINCIPLE"  f. Reviewing Evidence for Corroboration of a StressorWhen corroborating evidence of a stressor is required, there is no requirement that the evidence must, and may only, be found in official documentary records. In most cases, however, official documentary records are the most reliable source of stressor verification. When reviewing evidence for corroboration of a claimed stressor(s), carefully analyze the most reliable sources of evidence first, and if these sources do not contain the necessary information, review secondary sources of evidence carefully and critically for their adequacy and reliability. Note: Generally, documents written or recorded by the lowest possible unit in the chain of the command are the most probative source of information to verify a claimed stressor, because they tend to include details of events with greater precision. Examples: A platoon or company commanders narrative is likely of greater relevance and specificity than a battalion commanders, and a Navy ships deck log would likely yield more probative information than a fleet log. PRIVATE INFOTYPE="PRINCIPLE"  g. Determining the Link Between In-Service Stressor and DiagnosisEstablish service connection for PTSD only where the examination and supporting material indicate a link between current symptoms and a verified in-service stressful event(s).Continued on next page  STYLEREF "Map Title" 32. Deciding a Claim for Service Connection for PTSD, Continued  PRIVATE INFOTYPE="PROCEDURE"  h. Making a Decision in a PTSD ClaimUse the table below when making a decision regarding service connection for PTSD. If Then the claimant has failed to provide a minimal description of the stressor, such as an indication of the time and place of a stressful event or experiencerefer the claim to the JSRRC coordinator for the actions described in HYPERLINK "C:\\adjatoml\\My Documents\\SharePoint Drafts\\pt04_sp02_ch01_secD.xml" \l "IV.ii.1.D.16"M21-1MR, Part IV, Subpart ii, 1.D.16, and deny the claim based on an unconfirmed stressor. Note: The rating decision should note the previous request for information. Reference: For more information on denying a claim because of an unconfirmed stressor, see HYPERLINK "C:\\adjatoml\\My Documents\\SharePoint Drafts\\pt03_sp04_ch04_secH" \l "III.iv.4.H.32.i"M21-1MR, Part III, Subpart iv, 4.H.32.i.the Veteran has provided at least a minimum description of the stressor, such as approximate time, place, and unit, and the Veterans lay testimony alone is not sufficient to establish the stressor, and the records contain prima facie evidence of a PTSD diagnosis, such as outpatient treatment reports showing treatment for PTSD or PTSD symptoms, or the Veterans description of symptoms indicative of PTSD Reference: For more information on when stressor corroboration is required, see HYPERLINK "C:\\adjatoml\\My Documents\\III.iv_11-3-10\\pt03_sp04_ch04_secH.xml" \l "III.iv.4.H.29.h"M21-1MR, Part III, Subpart iv, 4.H.29.h.request additional evidence from JSRRC, NARA, or the Marine Corps, as appropriate Notes: Do not schedule a VA examination before receiving evidence regarding the claimed stressor from JSRRC, NARA, or the Marine Corps. JSRRC researches Army, Navy, Air Force, and Coast Guard records only. Reference: For more information on requesting evidence from JSRRC, NARA, or the Marine Corps, see HYPERLINK "C:\\adjatoml\\My Documents\\III.iv_11-3-10\\pt04_sp02_ch01_secD.xml" \l "IV.ii.1.D.15"M21-1MR, Part IV, Subpart ii, 1.D.15.Continued on next page  STYLEREF "Map Title" 32. Deciding a Claim for of Service Connection for PTSD, Continued  STYLEREF "Block Label" h. Making a Decision in a PTSD Claim (continued) If Then  the Veteran has provided at least a minimum description of the stressor, as indicated above the stressor is related to verified combat or POW service, or a fear of hostile military or terrorist activity, and there is evidence of service in an area where such activity could have occurred, and the records contain prima facie evidence of a PTSD diagnosis, as indicated aboveschedule a VA examination, if needed, and consider the claim on the evidence of record. Reference: For more information on when the Veterans testimony alone may establish the occurrence of a stressor, see HYPERLINK "C:\\adjatoml\\My Documents\\III.iv_11-3-10\\pt03_sp04_ch04_secH.xml" \l "III.iv.4.H.29.a"M21-1MR, Part III, Subpart iv, 4.H.29.a, and HYPERLINK "C:\\adjatoml\\My Documents\\III.iv_11-3-10\\pt03_sp04_ch04_secH.xml" \l "III.iv.4.H.29.g"M21-1MR, Part III, Subpart iv, 4.H.29.g.the Veteran has provided at least a minimum description of the stressor, as indicated above the stressor is related to a fear of hostile military or terrorist activity, there is evidence of service in an area where such activity could have occurred, and the records contain prima facie evidence of a PTSD diagnosis, as indicated above, but a VA examination renders a diagnosis of a mental disorder other than PTSD and links the diagnosis to the claimed in-service event.before making a decision on whether service connection can be established for the mental disorder diagnosis made on examination, proceed with development research to corroborate the alleged stressor/event. Important: You cannot simply establish service connection for the diagnosis made on examination. Section 3.304(f)(3) applies only to the development of PTSD after service in an area with risks from hostile military or terrorist activity. Note: A claim for PTSD must be sympathetically read as a claim for any chronic acquired psychiatric disorder.  HYPERLINK "http://vbaw.vba.va.gov/bl/21/advisory/CAVCDAD.htm" \l "bmc" Clemons v. Shinseki, 23 Vet. App. 1 (2009). Continued on next page  STYLEREF "Map Title" 32. Deciding a Claim for of Service Connection for PTSD, Continued  STYLEREF "Block Label" h. Making a Decision in a PTSD Claim (continued) If Then a VA medical examination fails to establish a diagnosis of PTSD and no other mental disorder diagnosis is madedeny the claim on that basis. Note: If the existence of a stressor has not been determined, do not include a discussion of the alleged stressor in the rating decision. PRIVATE INFOTYPE="PRINCIPLE"  i. Denying a PTSD Claim Because of an Uncorroborated StressorWhen corroborating evidence of a stressor is required because the stressor may not be established by lay evidence alone, a denial solely because of an unconfirmed stressor is improper unless JSRRC, NARA, or the Marine Corps, as appropriate, has confirmed that is is unable to provide corroborating evidence of claimed stressor, or the Veteran has failed to provide the basic information required to conduct research, and the JSRRC coordinator has taken the actions described in HYPERLINK "C:\\adjatoml\\My Documents\\SharePoint Drafts\\pt04_sp02_ch01_secD.xml" \l "IV.ii.1.D.16"M21-1MR, Part IV, Subpart ii, 1.D.16. If JSRRC, NARA, or the Marine Corps requests a more specific description of the stressor in question, immediately ask the Veteran to provide the necessary information. If the Veteran provides additional substantive information, forward it to the requesting agency. Failure of the Veteran to respond substantively to the request for information will be grounds to deny the claim based on an unconfirmed stressor. References: For more information on when stressor corroboration is required, see HYPERLINK "C:\\adjatoml\\My Documents\\III.iv_11-3-10\\pt03_sp04_ch04_secH.xml" \l "III.iv.4.H.29.h"M21-1MR, Part III, Subpart iv, 4.H.29.h, and requesting corroboration of an in-service stressor, see HYPERLINK "C:\\adjatoml\\My Documents\\SharePoint Drafts\\pt04_sp02_ch01_secD.xml" \l "IV.ii.1.D.15"M21-1MR, Part IV, Subpart ii, 1.D.15. 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