VA Compensation, PTSD 1: How is Post-Traumatic Stress Disorder (PTSD) Diagnosed?

Service-Connected Post-Traumatic Stress Disorder (PTSD) for veterans is most often associated with combat, however, it can also be the result from other traumatic events (stressors) that occurred in service.

According to 38 CFR 3.304(f) For PTSD to be service connected three elements must be present.

1. The veteran must have a current diagnosis of PTSD
2. The in-service event/stressors must be supported by credible evidence
3. A connection (called a nexus) between the current diagnosis of PTSD and the in-service event/stressor must be supported by medical evidence.

This post will focus on the first element: Diagnosis of PTSD.

Under 38 CFR 4.125, for a diagnosis of PTSD the VA uses the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). DSM-5 lists 8 Criterion dealing with a PTSD, classified as Criterion A through H.

8 Criterion dealing with a PTSD

The first Criterion (A) is the stressor, defined as a person exposed to death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence. The stressor can be direct, witnessed in person, indirect through a close relative or friend, or repeated extreme exposure to aversive detail of the traumatic event usually in the course of professional duties. Therefore, indirect non-professional exposure through electronic media, television, movies, or pictures is not included.

The second Criterion (B) is intrusion symptoms associated with the stressor. The veteran must have one or more of the following:

1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s)
2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s)
3. Dissociative reactions(e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring (such reactions may occur on a continuum with the most extreme expression being a complete loss of awareness of present surroundings)
4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s)
5. Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s)

The third Criterion (C) is avoidance symptoms associated with the stressor. The veteran must demonstrate one of the following:

1. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s)
2. Avoidance or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s)

The fourth Criterion (D) is negative alterations in cognitions and mood associated with the stressor. The veteran must demonstrate at least two of the following:

1. Inability to recall key features of the traumatic event (usually dissociative amnesia; not due to head injury, alcohol, or drugs).
2. Persistent (and often distorted) negative beliefs and expectations about oneself or the world (e.g., “I am bad,” “The world is completely dangerous”).
3. Persistent distorted blame of self or others for causing the traumatic event or for resulting consequences.
4. Persistent negative trauma-related emotions (e.g., fear, horror, anger, guilt, or shame).
5. Markedly diminished interest in (pre-traumatic) significant activities.
6. Feeling alienated from others (e.g., detachment or estrangement).
7. Constricted affect: persistent inability to experience positive emotions.

The fifth Criterion (E) is alterations in arousal and reactivity associated with the stressor. The veteran must demonstrate at least two of the following:

1. Irritable or aggressive behavior
2. Self-destructive or reckless behavior
3. Hypervigilance
4. Exaggerated startle response
5. Problems in concentration
6. Sleep disturbance

The sixth Criterion (F) is the duration of the disturbance of symptoms from criterion B, C, D, and E. The veteran must demonstrate that the symptoms have lasted at least one month.

The seventh Criterion (G) is functional impairment. The veteran must demonstrate that the disturbances listed in criterion F cause significant distress or social impairment in social, occupational, or other important areas of functioning.

The eight criterion (H) is the disturbance is not attributable to the physiological effects of substance, such as medication, drugs, alcohol, or other medical conditions.
With dissociative symptoms: The individual’s symptoms must meet the criteria for PTSD and in addition, in response to the stressor, the individual experiences persistent or recurrent symptoms of either of the following:

1. Depersonalization: Persistent or recurrent experiences of feeling detached from, and as if one were an outside observer of, one’s mental processes or body (e.g., feeling as though one were in a dream, feeling a sense of unreality of self or body, time moving slowly)
2. Derealization: Persistent or recurrent experiences of unreality of surroundings (e.g., the world around the individual is experienced as unreal, dreamlike, distant, or distorted)

A diagnosis of PTSD must be made by a competent and qualified medical professional. The VA Clinician’s Guide states that professionals qualified to make a diagnosis of PTSD must have doctoral level training in psychopathology, diagnostic methods, and clinical interview methods. Board certified psychiatrists and licensed psychologists have the requisite professional qualifications to conduct compensation and pension examinations for PTSD. Psychiatric residents and psychology interns are also qualified to perform these examinations, under close supervision of attending psychiatrists or psychologists.

Statements regarding a veteran’s PTSD from counselors, social workers, or other therapists that are not doctors will not be considered a diagnosis of PTSD by the VA.