P.T.S.D.

                                Information page

 

 

POST-TRAUMATIC STRESS DISORDER

 


 

Symptoms of PTSD

When does PTSD Occur?

Post-traumatic stress disorder was first diagnosed after World War I and called "shellshock." Over the years, the name changed to "combat fatigue" (during the Vietnam War) and finally became the least humanized term that we now know: post-traumatic stress disorder.

PTSD afflicts individuals who have experienced a horrifying event, usually one of significant duration in which the person was an active participant. PTSD has been found in soldiers as well as people who have been in terrible accidents or hostage situations.

Campaign Use of PTSD

PTSD is probably best used in a campaign as a result of a particularly difficult or long battle, specifically one in which the character had very little control or people the character knew died gruesomely.

At the very least, this kind of shellshock would make a character a little twitchy. At worst, it could make the character really, really difficult to be around; this would make for interesting roleplaying.

Other Possibilities

While not strictly considered PTSD, there is a "disorder" that many doctors and nurses acquire after working in difficult environments (such as the emergency room or in wartime). This disorder makes the victim need that kind of stimulation again. People with this disorder are unable to find any excitement in anything that isn't as fast and furious as whatever they used to do (ER, wartime work, other kinds of adrenalin-rush occupations).

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               Clinician-Administered PTSD Scale (CAPS)

The Clinician-Administered PTSD Scale (CAPS) is a structured clinical interview designed to assess adults for the seventeen symptoms for Post Traumatic Stress Disorder (PTSD) outlined in DSM-IV, along with five associated features (guilt, dissociation, derealization, depersonalization, and reduction in awareness of surroundings). Prior versions of the CAPS (CAPS-1 and CAPS-2) were designed to assess current or lifetime PTSD status or PTSD symptoms over the last week, respectively. The current version of the CAPS incorporates each of the previous versions' features. The CAPS provides a means to evaluate:

The CAPS consists of standardized prompt questions, supplementary follow-up (probe) questions, and behaviorally-anchored 5-point rating scales corresponding to the frequency and intensity of each symptom assessed. It also has clear behavioral indicators, a time frame concordant with that of DSM diagnostic criteria, and separate frequency and intensity ratings. (A sample CAPS question appears at the bottom of this page.)

The CAPS is available free to mental health professionals with advanced training in the administration of diagnostic instruments for clinical or research purposes. The manual for administration is still under development; a preliminary interrater reliability study has been completed and is awaiting publication. We are interested in collaborating with individuals who use the interview in order to learn more about its practical and psychometric properties. To obtain a copy of the CAPS, print out a copy of the request form and send it to:

Carole A. Goguen, Psy.D.

National Center for PTSD (116D) VA Medical Center & Regional Office Center 215 North Main St. White River Junction, VT 05009

or send an email message containing all the information specified on the request form to Carole.A.Goguen@dartmouth.edu

 

Sample CAPS Question

3. (B-3) Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated). Note: In young children, trauma-specific reenactment may occur. Frequency

Have you ever suddenly acted or felt as if (EVENT) were happening again? (Have you ever had flashbacks about [EVENT]?) [IF NOT CLEAR:] (Did this ever occur while you were awake, or only in dreams?) [EXCLUDE IF OCCURRED ONLY DURING DREAMS] Tell me more about that. How often has that happened in the past month (week)?

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VVA's GUIDE on PTSD


Table of Contents:

What is PTSD?
Tips on Working with Your Service Representative
Step 1: Get Help
Step 2: Apply
Step 3: Get Diagnosis
Changes Anticipated Soon
Step 4: Get Evidence of Stressor
How Much Money
Step 5: Present Evidence
If You Lose: Appeal
How VA Sets Level of Disability
Incarcerated Veterans
VA Medical Services
Help for Children
Social Security Benefits
Resources

The purpose of this guide is to assist you, the veteran or survivor, in presenting your claim based on the veteran's exposure to unusually stressful events that led to posttraumatic stress disorder (PTSD). The best way to present your claim to the U.S. Department of Veterans Affairs (VA) is to work with a trained veterans advocate.

This guide describes the VA's current programs for compensating veterans with PTSD or their survivors. Under current VA rules, you can be paid compensation for PTSD if you have a clear diagnosis of the condition, evidence that an in -service stressful event occurred and medical evidence that the "stressor" is linked to the PTSD. Once the VA agrees that your PTSD is service connected, it will then decide how seriously the condition impairs your ability to work.

This guide does not address treatment techniques but does give you suggestions for getting medical care. Additonal resources are available to help you understand whether other VA programs may be available to you. (See last page.)

PTSD is not a new problem. It is simply a new name for an old disorder that has been around for thousands of years. The new name has been in use since 1980 when the American Psychiatric Asso ciation began to use it in its manual of mental disorders. Although it is often associated with Vietnam veterans, it is being increasingly reported in WWII veterans, perhaps as a consequence of publicity surrounding the 50th anniversaries of WWII events.

There have been many changes in the VA's rules involving PTSD since 1980 and some addi tional changes are expected soon as a result of new understanding about PTSD. Recent decisions by the U.S. Court of Veterans Appeals have also forced changes in how the VA processes these claims. Keep in touch with your representative for additional changes that occur after the publication of this guide.

We include in this guide a short description of what to do if the VA denies your claim or sets only a low percentage for the disability. For more infor mation on how to appeal a denial,VVA has prepared a guide on VA Claims and Appeals 


WHAT IS PTSD?

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (1994) states:

Diagnostic Features

The essential feature of Posttraumatic Stress Disorder is the development of characteristic syptoms following exposure to an extreme traumatic stressor involving direct personal experience of an event that involves actual or threatened death or serious injury, or other threat to one's physical integrity; or witnessing an event that involves death, injury, or a threat to the physical integrity of another person, or learning about unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or other close associate (Criterion A1). The person's response to the event must involve intense fear, helplessness, or horror (or in children, the response must involve diorganized or agitated behavior) (Criterion A2). The characteristic symptoms resulting from the exposure to the extreme trauma include persistent reexperiencing of the traumatic event (Criterion B), persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (Criterion C), and persistent symptons of increased arousal (Criterion D). The full sympton picture must be present for more than 1 month (Criterion E), and the disturbance must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (Criterion F).

Traumatic events that are experienced directly include, but are not limited to, military combat, violent personal assault (sexual assault, physical attack, robbery, mugging), being kidnapped, being taken hostage, terrorist attack, torture, incarceration as a prisioner of war or in a concentration camp, natural or manmade disasters, sever automobile accidents, or being diagnosed with a life-threatening illness. For children, sexually traumatic events may include developmentally inappropriate sexual experiences without threatened or actual violence or injury. Witnessed events include, but are not limited to, observing the serious injury or unnatural death of another person due to violent assault, accident, war, or disaster or unexpectedly witnessing a dead body or body parts. Events experienced by others that are learned about include, but are not limited to, violent personal assault, serious accident, or serious injury experienced by a family member or a close friend; learning that one's child has a life-threatening desease. The disorder may be especially severe or long lasting when the stressor is of human design (e.g., torture, rape). The likelihood of developing this disorder may increase as the intensity of and physical proximity to the stressor increase.

The traumatic event can be reexperienced in various ways. Commonly the person has recurrent and intrusive recollections of the event (Criterion B1) or recurrent distressing dreams during which the event is replayed (Criterion B2). In rare instances, the person experiences dissociative states that last from few seconds to several hours, or even days, during which components of the event are relived and the person behaves as though experiencing the event at that moment (Criterion B3). Intense psychological distress (Criterion B4) or physiological reactivity (Criterion B5) often occurs when the peron is exposed to triggering events that resemble or symbolize an aspect of the traumatic event (e.g., anniversaries of the traumatic event; cold snowy weather or uniformed guards for survivors of death camps in cold climates; hot, humid weather for combat veterans of the South Pacific; entering any elevator for a woman who was raped in an elevator).

Stimuli associated with the trauma are persistently avoided. The person commonly makes deliberate efforts to avoid thoughts, feeling, or conversations about the traumatic event (Criterion C1) and to avoid activities, situations, or people who arouse recollections of it (Criterion C2). This avoidance of reminders may include amnesia for an important aspect of the traumatic event (Criterion C3). Diminished reponsiveness to the external world, referred to as "psychic numbing" or "emotional anesthesia," usually begins soon after the traumatic event. The individual may complain of having markedly diministed interest or participation in previously enjoyed activities (Criterion C4), of feeling detached or estranged from other people (Criterion C5), or of having markedly reduced ability to feel emotions (especially those associated with intimacy, tenderness, and sexuality) (Criterion C6). The individual may have a sense of foreshortened future (e.g., not expecting to have a career, marriage, children, or a normal life span) (Criterion C7).

The individual has persistent sympoms of anxiety or increased arousal that were not present before the trauma. These symptoms may include difficulty falling or staying asleep that may be due to recurrent nighmares during which the traumatic event is relived (Criterion D1), hypervigilance (Criterion D4), and exaggerated startle response (Criterion D5). Some individuals report irritability or outbursts or anger (Criterion D2) or difficulty concentrating or completing tasks (Criterion D3).


TIPS ON WORKING WITH YOUR SERVICE REPRESENTATIVE

Keep in touch: You should talk to your representative at least once per month while your claim is pending. Whenever you get mail from the VA, call your representative to make sure s/he has gotten it and that you both understand it.

Ask questions: If you do not understand something about your case, ask about it. Don't worry about asking a stupid questionyour representative works for you and part of his or her job is making sure that you understand everything.

Be insistent: If something needs to be done, insist that it happen. Do not be talked out of anything unless you understand what is going on. Insist that your representative:

If your representative will not do these things, you should find another one.  
STEP 1: GET HELP

It is a good idea to get a representative to help you present your claim to the VA. VA rules and procedures are very complicated. It can be frustrat ing and hazardous to go it alone.

Many veterans service organizations and state and county veterans service agencies offer free assistance. No matter who you select to represent you, it is important that you be personally involved in your case and make certain that everything that should be done, is done.

Although it can be a difficult task, shop around for the best advocate. Talk to the prospective rep resentative; ask if there are any limits on his ser vice; get a feel for the person who will be working for you before you sign a power of attorney appointing the person as yo ur representative.


STEP 2: APPLY
STEP 3: GET DIAGNOSIS

You cannot get benefits from the VA for PTSD if you do not have a clear diagnosis of PTSD. That diagnosis should come from a mental health professional (psychiatrist, psychologist, social worker or therapist). You, your mother and your lawyer may know you have PTSD but the VA will not pay you unless a medical professional can firmly diagnose you as suffering from PTSD and can link the PTSD to a stressful event during your military service.

If at all possible, work with a private mental health professional who has had experience with PTSD patients and understands the requirements for a clear diagnosis and who is willing to write a detailed report for you that explains exactly the reasons he or she concludes you have PTSD.

Frequently, veterans with PTSD may have other diagnoses: for example, personality disorder or substance abuse. It is very important that your doctor explain how your current diagnosis of PTSD relates to these other disorders. If alcohol or drug abuse was "self-medication" to lessen the symp toms of PTSD, that should be stated.

You can expect the VA to contact you for evidence or for permission to write to your doctor for your medical records. Your response to any VA request for evidence should be made only after consulting with your representative.

The VA ordinarily schedules you for an examination by one of its doctor at a VA hospital or clinic. This "C&P exam" is intended to confirm a diagno sis of PTSD. If you bring a copy of your doctor's report with you, it will be easier for the VA doctor to complete the exam.

If you do not already have a private doctor's report, you should expect the VA doctor to ask many questions about what symptoms you have, when you began to have them, how often and how long you have had them. Some of the hardest questions will be about the stressful experience you had. You will need to be able to describe in detail (and sometimes painful detail) exactly what you experienced. You might also be asked to take a written, standardized test.

The VA doctor prepares a written report that is sent to the VARO in about a month.


STEP 4: GET EVIDENCE OF STRESSOR

To win a PTSD-based claim, you need (1) a diagnosis of PTSD and (2) evidence of a stressful event during your military service. Even if you convince 10 VA and 10 private psychiatrists that you have PTSD, the VARO can still deny your claim if it does not accept your evidence about the stressful event that caused the PTSD.

The stressor you experienced needs to be documented. If your stressor was related to combat while engaged in action with the enemy, your testimony alone should convince the VA that you experienced the event. The VA should not even question your statement if you had a combat MOS or you received a Purple Heart or other award indicating combat service.

On the other hand, if you did not have a combat MOS and simply state that you were often under mortar and rocket attacks, the VA may simply say that your experience was not stressful enough to have caused PTSD since nearly everyone stationed in Vietnam came under such attacks. If, however, you were next to a buddy who was killed or injured, the fact of the death or injury is something that can be confirmed.

If you are a Vietnam vet and you provide the VA with enough details about stressful events in your service, the VA will contact the U.S. Army and Joint Services Environmental Support Group and ask it to review records of the Vietnam war to try to corroborate your experiences. Your representative should be able to show you the guide for the Preparation of PTSD Research Requests that the Support Group offers to reps to help them make a request that the Support Group can work with.

To understand what evidence the VA already has collected, get a free copy of your VA claims file from the VARO. If you need to document your service in Vietnam, get a free set of your complete military personnel records from the National Personnel Records Center in St. Louis using a Standard Form 180, Request Pertaining to Military Records. This form is available from your representative or any VA office.  


HOW MUCH MONEY
 
1999 DISABILITY COMPENSATION RATES
 
Disability
Monthly Rate
10 percent
$ 96
20 percent
184
30 percent
282
40 percent
404
50 percent
576
60 percent
726
70 percent
916
80 percent
1,062
90 percent
1,196
100 percent
1,989
 
Note: Depending upon the disability rating of the veteran, allowances for a spouse range from $34 to $112; and for each additional child, $18 to $60.



STEP 5: PRESENT EVIDENCE

You do not help yourself if you simply dump a wad of loose records on the VA. Organize the records and explain their significance in a letter you and your representative prepare together.

You almost always want a hearing at the VA Regional Office if it denies your claim. The hearing will be before an official (the Hearing Officer) who was not involved in the earlier denial. Try to bring even more evidence with you to this hearing.

Read the VA's denial letter carefully to determine whether your claim is being rejected because the VA does not accept what you said about your stressful experience or whether the VA says you do not have a diagnosis of PTSD.

If the VA is rejecting your explanation of your stressful event go to the hearing and provide greater details about it. You also should bring additional evidence; for example, statements from buddies who were with you, newspaper accounts of the operations you were in.  


IF YOU LOSE: APPEAL

If the VA Regional Office says your disability is not service-connected or if the percentage of disability is lower than what you think is fair, you have the right to appeal to the Board of Veterans' Appeals.

The first step in appealing is to send the VA Regional Office a "Notice of Disagreement." This Notice is a letter saying that you "disagree" with the denial. Be sure to include in your letter the date of the VA's denial letter and be sure to list the benefits you are still seeking.

Deadline: The Notice of Disagreement must be mailed to the VA Regional Office within one year of the denial of your claim or you cannot appeal. (You still can reopen your claim if you miss this deadline but you lose an earlier "effective date" for an award of back benefits.)

If you win, one issue which you should examine carefully with your representative is whether the VA has set the correct effective date for your award. If you think an earlier effective date is appropriate, you can file a Notice of Disagreement on that issue. More help is available in VVA's Guide on VA Claims and Appeals 


HOW VA SETS LEVEL OF DISABILITY

Once the VA agrees that your PTSD is service-connected, it must determine how im paired you are. The VA regulation that controls this determination is the VA Schedule for Rating Disabilities, 38 C.F.R. 4.130, Diagnostic Code 9411. Under this regulation, PTSD can be rated at 0, 10, 30, 50, 70 or 100%. The symptoms that the VA looks for to set a rating are listed below. Share this regulation with your therapist and ask him or her to write to the VA describing the severity of your condition. Also ask your therapist to use the Global Assessment of Functioning Scale listed in the Diagnostic and Statistical Manual of Mental Disorders.

Keep in mind that under another VA regulation (38 C.F.R. 4.16), if you can't work be cause of your PTSD, the VA must set you at 100% even if you don't meet the criteria listed below for a 100% rating. If the VA evaluates your disability too low, you should appeal that. 


38 C.F.R. 4.130 (excerpt),
General Rating Formula for Mental Disorders:

Total occupational and social impairment, due to such symptoms as: gross impairment in thought process 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
....................................... 100

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
....................................... 70

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
....................................... 50

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)
....................................... 30

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
....................................... 10

A mental condition has been formally diagnosed, but symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication
....................................... 0


INCARCERATED VETERANS

Even if you win VA benefits, you are not going to be paid all the money while you are in prison if you were convicted of a felony. Benefits withheld from you, however, can be "ap portioned" to your family. If you cannot attend a VA examination, try to obtain a detailed medical report of an exam conducted by your facility's doctor. Ask the doctor to use the criteria in the VA Physician's Guide to Disability Evaluation Examinations and VA Schedule for Rating Disabilities in conducting the exam.  


VA MEDICAL SERVICES

The VA operates a network of 205 Vet Centers throughout the country that provides good treat ment for veterans suffering from PTSD. Treatment at Vet Centers is often conducted with a group of veterans. Sometimes the VA will pay for treatment through a local mental health profes sional if services through the nearest VA are not readily available. To apply for this "fee basis" care, contact the nearest VA medical center.

There are also a few VA medical centers that offer intensive in-patient care. If this is something you need, ask the nearest Vet Center to help arrange for your admission.

If you are a Vietnam veteran you should know that in 1981 Congress authorized the VA to pro vide certain health care services for disabilities which may have been caused by exposure to herbicides. The VA must accept a veteran's statement that he or she was exposed and provide health care unless the VA can point to a cause for the problems other than Agent Orange. Veterans who qualify for treatment under this law do not have to pay for services received.  


HELP FOR CHILDREN

The VA generally offers no assistance to children of veterans unless the veterans have been rated at least 30% service-connected disabled. Such veterans receive a dependents' allowance. Children of veterans considered permanently 100% disabled can also receive education assistance and health care through its CHAMPVA program.

Children with disabilities may be eligible for Supplemental Security Income benefits. One of the Agent Orange-funded programs offers a16-page booklet discussing children's eligibility for SSI ("SSI: New Opportunities for Children with Dis abilities"). Contact:

Mental Health Law Project
1101 15th St., NW, Ste. 1212
Washington, DC 20005
The Agent Orange Program provided funding for a program for families with children with birth defects or other special health needs. The Center for Developmental Disabilities at the University of South Carolina offers a National Information Ser vice which consists of telephone access to trained counselors, to provide information and referral services for parents of children with disabilities, including information and referrals concerning genetic counseling. Contact: 1800922-9234, ext. 401.  
SOCIAL SECURITY BENEFITS

Some vets are able to show the Social Security Administration (SSA) they are disabled and re ceive benefits even if the VA refuses them. SSA offers both disability insurance and supplemental security income (SSI) benefits. Veterans can receive both SS disability insurance benefits and VA disability compensation. There is an offset of the VA pension or compensation with SSI benefits.

Unlike VA compensation benefits that are measured in degrees of disability, SSA benefits require a total disability that will last at least one year. If you cannot work because of your disability, contact the nearest district office of SSA (800-772-1213).  


RESOURCES

The following publications are a few of the resources that may give you additional help with your claim:


VIETNAM VETERANS OF AMERICA

The Vietnam Veterans of America (VVA) is a non-profit, congressionally chartered veterans service organi zation, dedicated to helping Vietnam-era veterans and their families obtain all the benefits and services to which they are entitled. VVA has accredited Service Representa tives in most states who can provide representation at the VARO level. A list of the nearest VVA Service Represen tatives can be obtained by writing to:

VVA Veterans Benefits Program
1224 M Street, NW
Washington DC 20005-5183
Many other veterans organizations offer a wide range of services. Most states operate a department of veterans affairs and many states have a network of county veterans representatives. To locate accredited representatives, call or visit the nearest VARO. 
LAWYERS

There are limits on when you can pay a lawyer to help you with a VA claim. Generally, you can hire a lawyer only after the BVA has decided your claim. Then you have only one year to hire a lawyer. Many lawyers work on a contingency basis that means you do not have to pay them a fee up front and if you do not win benefits, you will not have to pay a fee.

There are no limits on when someone else (a so-called third party) can use his or her own money to hire and pay a lawyer to represent you. This third party cannot be a family member who may benefit from your claim. If you use a third party to hire a lawyer, the lawyer can represent you at the beginning of a claim. Also, there are no limits on hiring a lawyer when the VA is coming after you because of a home loan guarantee debt.

Some private lawyers and some legal aid or legal services offices provide representation free of charge at all stages of a VA claim.

There is an organization of attorneys and nonattorneys who regularly practice before the Court of Veterans Ap peals. Its members are available to represent you at the Court or, through a third party contract, before a VARO or the BVA. For a list of these members, contact: Nat'l Organization of Veterans' Advocates, (800) 810-8387.

If no private practitioners are willing to represent you at the Court of Veterans Appeals, it might be possible to obtain pro bono representation through the Veterans Pro Bono Consortion. The Court will send you information about this opportunity. It is available only to a limited number of persons who meet income guidelines. 


Copyright 1996, Vietnam Veterans of America, Inc. All Rights Reserved. ISBN 0-964-3980-4-4.

Segments of this guide may be excerpted or reproduced for counseling, self-help, and scholarly purposes, but not for profit, without further permission; we request only that proper credit be given. Any other use requires written authorization of VVA, ATTN: Director, Veterans Benefits Program, 1224 M Street, NW, Washington DC 20005-5183. This guide is one of a series that is being published by VVA under a contract with Keith D. Snyder of the Veterans Education Project. 3/96 


E-mail us at veteransbenefits@vva.org

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     This information is provided for usage by those in need of questions answered.