Psychiatric disability claims make up a large portion of the VA’s universe of disability claims. These claims tend to be more subjective and individual than those involving physical disability, as mental illness cannot be quantified as easily as physical disabilities. More often than not, individuals do not even know when they are suffering from mental illness – perhaps only realizing it many years, even decades, after the condition first manifested symptoms. Typically, a veteran may suffer from an anxiety disorder (e.g., Post-Traumatic Stress Disorder (PTSD), Generalized Anxiety Disorder (GAD) Panic Disorder), due to witnessing a traumatic event in service. During service, the veteran may not feel him/herself, but it is unlikely that he/she will be aware of a mental illness or seek mental health care. Moreover, veterans are proud people and are generally reluctant to admit to having a psychiatric problem, given the unfortunate and unfair stigma associated with mental illness. Only when the condition seriously disrupts their lives, (for example, a veteran engaging in alcohol and drug abuse, repeatedly finding him/herself at odds with the law or constantly fighting with family members and friends), do veterans typically seek mental health care, usually many years after service. Under this common scenario, the VA will usually deny the psychiatric claim, reasoning that the mental illness did not manifest in service and was too remote in time from service to be casually linked to any alleged in-service stressor. The Veterans Law Group (VLG) has represented many veterans who find themselves in this situation and have been very successful in obtaining their entitled benefits.
In this blog, the Veterans Law Group (VLG) covers some of the common claims for psychiatric disorder, offering strategies for obtaining service-connection for psychiatric illness.
1) Post-Traumatic Stress Disorder (PTSD)
Post-Traumatic Stress Disorder (PTSD) is an anxiety disorder with a wide variety of symptoms, running from subtle, less obvious types, (e.g., feeling edgy, slightly down, or detached) to more severe and florid symptoms, (e.g., experiencing flashbacks, horrific nightmares, suicidal thinking). Given the number of possible symptoms, PTSD is not always easy to diagnose.
PTSD, by definition, requires experiencing or witnessing a traumatic event, a series of traumatic events or a set of traumatic circumstances. Examples of such traumas are: dealing with a natural disaster like a hurricane, being a passenger or driver in a serious vehicular accident, being a victim of a terrorist act, participating in combat or combat-like situation, being a victim of a physical assault, a rape, or other sexual assault, being continuously subject to sexual harassment, or being subject to harsh or prolonged bullying. In VA terminology, these traumatic events are called in-service stressors.
To obtain service-connection for PTSD, three (3) elements must be established: 1) a present diagnosis of PTSD, 2) a presumed or corroborated occurrence of an in-service stressor, and 3) a medical nexus opinion, showing a causal relationship between the stressor and the veteran’s current PTSD. Elements 1 and 3 can only be established by a medical expert, that is, a mental health practitioner. Element 2 can be shown by official military documentation or by lay statement/testimony.
- Combat Veterans
In adjudicating claims for service-connected PTSD, the VA divides veterans in two groups: combat and non-combat veterans. Combat status is assigned (and therefore the in-service stressor is presumed) to veterans who personally participated in actual fighting or hostile encounters with a military foe or who were present during such combat activities (e.g., a medic providing emergency aid to a wounded combatant). Combat decorations are the surest way to establish combat status, and include, among other decorations: Purple Heart, Silver Star, Combat Action Medal, Commendations or Medals with a “V” Device, Combat Action Badge or Ribbon, and Medal of Honor.
If a veteran cannot establish combat status by his/her decorations, the veteran can do so by his/her own credible lay statements and testimony, so long as the alleged stressor (combat activity) is consistent with the circumstances, conditions, or hardships of the veteran’s service. This is the primary advantage of combat status over non-combat status.
As with all types of PTSD claims, the combat veteran must satisfy the present diagnosis and the nexus/causation requirements. Those requirements are discussed in the next section.
- Non-Combat Veterans
For non-combat veterans, in-service stressors must be corroborated/verified, the so-called corroboration requirement. This requirement is unique to PTSD claims and, in many cases, is the most difficult to establish. Notably, the veteran’s own lay statements or testimony cannot satisfy the corroboration requirement. This element can be shown by primary and secondary sources, primary sources being the most persuasive. Primary sources are official military records, such as: unit and organizational histories, daily staff journals, unit records, morning reports, radio logs, deck logs and ship histories, monthly summaries and reports. Secondary sources are records in the veteran’s military personnel file (including performance reports), service treatment records, buddy statements, newspaper articles and website blogs and articles.
Let’s go over an example. A veteran alleges that his unit came under mortar attack but was not engaged in combat. The best way to corroborate this stressor is to obtain unit records reflecting the veteran’s presence in the unit at the time of the mortar attacks. If such records are not available, then buddy statements are an acceptable alternative for corroborating the alleged mortar attack. Fellow soldiers who were in your unit can prepare a statement, describing the traumatic event. The Veterans Law Group (VLG) recommends that the fellow soldiers’ DD-214 or DA-20 form be attached to their buddy statement, placing them in the veteran’s unit during the mortar attack. Even better is to have the soldiers testify at a Board hearing, where the law judge can assess their credibility.
Once corroboration is established, the veteran must show that he has a current diagnosis of PTSD and that this condition was caused by his in-service stressor. Only a mental health practitioner is qualified to make a PTSD diagnosis. Often, VA examiner will provide a PTSD diagnosis in his report or Disability Benefits Questionnaire (DBQ) (the template used by VA examiners). If not, then the veteran can establish his/her PTSD diagnosis by treatment records, assuming the veteran is receiving (or has received) mental health care at a VA or private medical facility. If not, then VLG recommends going to a local psychologist for a one-time visit. The veteran must make it clear to the psychologist that the purpose of the visit is to determine whether he/she has PTSD. Importantly, the local therapist must be a psychologist or a psychiatrist. For the most part, the VA does not give much weight to the opinions of licensed social workers (LCSW) and nurse practitioners.
Causation is the last requirement, i.e., proving by medical evidence that the in-service stressor is one, but not necessarily the only, cause of the veteran’s PTSD illness. (Sometimes a mental health illness can be caused by several factors. The VA only requires a showing that the in-service stressor is one of several possible causes. Assuming all other requirements are met, causation is generally the least problematic. Even VA examiners will generally find causation if the stressor is corroborated, and a diagnosis of PTSD has been confirmed. If not, the VLG recommends going to a local psychologist for a one-time visit, requesting an opinion on whether the veteran’s PTSD was caused by the in-service stressor.
2) Bipolar Disorder & Schizophrenia
VLG discusses Bipolar Disorder and Schizophrenia together because they share a common characteristic: Neither has a known etiology or cause. Both tend to manifest (i.e., become symptomatic) in the late teens or early twenties, but medical science does not know why. As such, a different strategy is needed to obtain service-connection for these conditions. First, it is important to note that there are two general theories for service-connection: causal and temporal. As it names suggests, the causal theory alleges that the in-service incurrence was a cause of the present disability. The temporal theory, on the other hand, refers to the timing of the condition. For temporal service connection, a veteran need only show that his/her present mental illness first became symptomatic in service, even though nothing in service caused the illness.
The temporal theory is often overlooked by veterans and their representatives, and even by VA examiners and adjudicators. For example, many veterans try to prove service-connection for their Bipolar Bipolar or Schizophrenia conditions on a causation theory, namely, that an in-service stressor caused their Bipolar Disorder or Schizophrenia. THAT IS A MISTAKE. As previously noted, neither has a known cause. Thus, the temporal theory is the best (and perhaps the only) theory for service-connecting these conditions.
To this end, identifying early (in-service) symptoms of Bipolar Disorder and Schizophrenia is pivotal. Unfortunately, most VA examiners and adjudicators only look for the most obvious signs of these conditions, such as: auditory or visual hallucinations, manic episodes, suicidal gestures or other bizarre behavior. But these severe symptoms reflect a later stage of Bipolar Disorder and Schizophrenia. Identifying early symptoms of these conditions, known as prodromal symptoms, is key to proving service-connection. Examples of prodromal symptoms are: feeling on edge, moody or irritable, feeling tired or detached from others, and/or having periods of losing concentration and memory. These subtler symptoms are sometimes documented in the service treatment records and/or indirectly in the veteran’s personnel file. For instance, the personnel file may show a precipitous decline in job performance and/or sudden rash of military code violations. Such sudden performance problems or acts of insubordination are usually triggered prodromal symptoms and should be argued as manifestations of in-service symptoms of Bipolar Disorder or Schizophrenia.
In prosecuting the claim, the veteran should emphasize to the VA adjudicator that his/her in-service behavioral changes represent the prodromal symptoms of the Bipolar Disorder or Schizophrenia. In this way, the VA adjudicator will likely instruct the VA examiner to consider the possibility that these changes were early symptoms of the condition. Likewise, when obtaining his/her own private psychological examination, the veteran should flag to the psychologist these in-service behavioral changes.
3) Major Depressive Disorder (MDD) & Generalized Anxiety Disorder (GAD)
Claims for Major Depressive Disorder (MDD) and Generalized (and Unspecified) Anxiety Disorder (GAD) are underrated VA psychiatric claims. Veterans generally prefer a PTSD diagnosis over MDD or GAD, thinking PTSD is a more respectable mental illness. Yet, for purposes of VA disability compensation, the diagnosis does not matter. Rather, the disability level is determined by the severity of the symptoms. What is more, MDD, GAD and other psychiatric disorder claims are easier to prove than PTSD claims. For most PTSD claims, the veteran must corroborate the in-service stressor by means other than his/her own statements or testimony. Non-PTSD claims do not have a corroboration requirement. Moreover, a PTSD diagnosis has more stringent requirements, which do not apply to MDD or GAD.
To be sure, in all psychiatric claims based upon a theory of in-service causation, VA adjudicators want to be convinced that the veteran’s alleged traumatic event(s) actually occurred. But this can be proven by the veteran own credible statements and testimony. The Veterans Law Group (VLG) has prevailed on countless MDD and GAD claims by having the veteran testify at a hearing before the Board of Veterans’ Appeals. So long as the veteran is sincere and truthful, the Board judges will generally rule in his/her favor.
It is important to note that medical research has shown that GAD is a common illness caused by acute trauma and is frequently underdiagnosed, since PTSD is the more popular diagnosis. Ayazi, Lien et al., BMC Psychiatry. 2014; 14: 6, Association between exposure to traumatic events and anxiety disorders in a post-conflict setting (“Exposure to traumatic events and socio-economic disadvantage were significantly associated with having one or more anxiety diagnoses. After controlling for age, sex, rural/urban setting, and socio-economic disadvantage, exposure to trauma was independently associated with anxiety diagnosis. [¶]. In individuals with a history of war-related trauma exposure, attention should be given to symptoms of GAD and PD [panic disorder], in addition to PTSD symptoms.”).
Likewise, trauma has been found to cause MDD. This much has been acknowledged by the VA:
In any given year, almost 1 in 10 adult Americans has some type of depression (1). Depression often occurs after trauma. For example, a survey of survivors from the Oklahoma City bombing showed that 23% had depression after the bombing. This was compared to 13% who had depression before the bombing. . .
https://www.ptsd.va.gov/understand/related/depression_trauma.asp.
