01-01. General. Since you are reading this manual one of the followings things is probably taking place:
a. You think you may have Post Traumatic Stress Disorder (PTSD).
b. You are being treated for PTSD.
c. You know someone who has PTSD.
Before you begin this journey you need to know what Post Traumatic Stress Disorder (PTSD) is.
Approximately eight year ago I did not know what PTSD was and I believed that Veterans who claimed to have PTSD were using their claims to shield them from the consequences of their own stupidity or alcohol/drug abuse. Boy was I wrong.
In this chapter I will present a brief history of PTSD and define PTSD in language you can understand so that;
a. You can determine whether or not you may be afflicted with PTSD.
b. When the time comes you will be better equipped to express your symptoms to your doctor, justify your claim in your stress letter, and explain your condition to your interviewer.
01-02. General. Prior to the studies done on Vietnam veterans, there were very few scientific studies of what we today call Post Traumatic Stress Disorder (PTSD).
01-03. The 1800’s. During the early 1800’s military doctors began diagnosing soldiers with “exhaustion” following the stress of battle. This “exhaustion” was characterized by mental shutdown due to individual or group trauma. Like today, soldiers during the 1800’s were not supposed to be afraid or show any fear in the heat of battle. The only treatment for this “exhaustion” was to bring the afflicted soldiers to the rear for a while then send them back into battle. Through extreme and often repeated stress, the soldiers became fatigued as a part of their body’s natural shock reaction.
During that time, in England, there was a syndrome know as “railway spine” or “railway hysteria” that bore a remarkable resemblance to what we call PTSD today, exhibited by people who had been in the catastrophic railway accidents of the period. In 1876 DR. Mendez DaCosta published a paper diagnosing Civil War combat veterans with “Soldiers Heart“: The symptoms included startle responses, hyper-vigilance, and heart arrhythmia’s.
01-04. The 1900’s. During WWI overwhelming mental fatigue was diagnosed as “soldier’s heart” and “the effort syndrome“. An article published on a now restricted Internet web site maintained by Med. Access entitled “Chronic Fatigue Syndrome” states that “…some 60,000 of the British forces were diagnosed with the problem and 44,000 of these were retired from the military because they could no longer function in combat”. (www.medaccess.com/cfs/cfs_02.htm (this page is no longer accessible without a password)
The term “shell shock” emerged during WWI followed in WWII by the term “combat fatigue.” These terms were used to describe those veterans who exhibited stress and anxiety as the result of combat trauma. The official designation of “Post Traumatic Stress Disorder” did not come about until 1980 when the Third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) was published.
01-05. The Diagnostic and Statistical Manual of Mental Disorders (DSM). This “bible”, published by the American Psychiatric Association (APA), provides the “official” definition of all mental illnesses. When first published in 1952 what we now know as PTSD was called “stress response syndrome” and was caused by “gross stress reaction”.
In the second edition (DSM-II), 1968, trauma-related disorders were lumped together in an area called “situational disorders“. Mrs. Patience Mason, author of Recovering From The War: A woman’s Guide to Helping Your Vietnam Veteran, Your Family, And Yourself, and After The War, points out that those Vietnam Veterans treated for the disorder during that period were informed that if their symptoms lasted more than 6 months after their return from Vietnam they had a “pre-existing” condition, making it a “transient situational disorder“, and the problem was deemed not service connected. This resulted in a lot of “walking wounded” and I am certain attributed to the high suicide rate suffered by Vietnam Veterans of that time. More Vietnam Veterans have committed suicide than were killed in the war.
Finally, in the third edition, 1980, DSM-III the title “Post-traumatic Stress disorder” was used and placed under a sub-category of “anxiety disorders“. In the current edition, 1994, DSM-IV, “Post-traumatic Stress Disorder” is again used but has been placed under a new “stress response” category and remains in the “anxiety disorder” category.
You may have noticed above that what started out as a “syndrome” turned into a “disorder“. According to Taber’s Cyclopedic Medical Dictionary a “syndrome” is “a group of signs and symptoms that collectively characterize or indicate a particular disease or abnormal condition” and a “disorder” is an illness. PTSD changed from being part of a collective indicator to a singular illness, a significant medical distinction.
With few exceptions, up until DSM-IV, most combat veterans were diagnosed with “shell shock“, which didn’t warrant long term treatment. Other combat veterans were merely diagnosed with “bad nerves” which not only didn’t warrant long term treatment, but also induced a “get over it” attitude from the military and medical communities. This type attitude was personified in the movie “Patton” when General Patton, played by George C. Scott, threatened apparently uninjured military hospital patients with malingering.
The initial definition of PTSD described a psychological condition experienced by a person who had faced a traumatic event which caused a catastrophic stressor outside the range of usual human experience (an event such as war, torture, rape, or natural disaster). This definition separated PTSD stressors from the “ordinary stressors” that were characterized in DSM-III as “Adjustment Disorders“, such as divorce, failure, rejection and financial problems.
01-06. American Psychiatric Definition. The following is a quote, references to children excluded, from The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), Washington, DC, American Psychiatric Association, 1994, section 309.81, beginning on page 427. The supplemental information, in parenthesis and bold, is provided by Mrs. Patience Mason.
This disorder is described as occurring when:
“A. The person has been exposed to a traumatic event in which both of the following were present:
(1) the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self (i.e. combat, friendly fire, being mortared or rocketed, wounded, captured, driving a truck on a mined road, flying in a helicopter that was shot at, jumping out of a helicopter into a hot LZ) or others (if you had a buddy who was wounded or lost squad members, family member, or seeing anyone who has recently been killed or injured such as being a medic or nurse on a trauma ward, body bagging, seeing someone you didn’t know killed, seeing kids, women or other Americans or civilians who had been killed, or wounded, etc.)
(2) the person’s response involved intense fear, helplessness or horror.”
According to the DSM-IV, “B. The traumatic event is persistently re-experienced in one (or more) of the following ways:
(1) recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions.
(2) recurrent distressing dreams of the event.
(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).
(4) intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event
(5) physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event
C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by at least three (or more) of the following:
(1) efforts to avoid thoughts, feelings or conversations associated with the trauma (If you try not to think about the war or if you try not to feel love because you lost a beloved buddy, try never to feel guilt because you think you fucked up over there, try never to be happy because you were ambushed when you were feeling fine, trying never to get angry because you’re afraid of what you might do)
(2) efforts to avoid activities, places, or people that arouse recollections of the trauma (never watch war movies, don’t hunt, don’t go to veterans day parades or associate with other vets, can’t stand authority figures because of the REMF’s or the lifers, etc.)
(3) inability to recall an important aspect of the trauma (particular battles or periods of time that you can’t remember or whether those guys were killed or just wounded)
(4) markedly diminished interest or participation in significant activities (what did you used to do that you don’t since your PTSD came on? Lots of guys with PTSD stay home watching TV which is this symptom. Others still get out but they’ve given up hunting, or going places where there are crowds or whatever)
(5) feelings of detachment or estrangement from others (No one can understand what it’s like. I’m on the outside looking in at all these people who haven’t a clue. I don’t care about things or people the way I used to)
(6) restricted range of affect (e.g., unable to have loving feelings) (unable to cry when parent dies or kid dies, told you have no feelings, can’t feel love for wife, etc.)
(7) sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or even a long life span).” (may be still driving drunk or stoned, still jumping out of airplanes or taking other risks, afraid to commit to anyone or anything, etc.)
The Diagnostic criteria in section 309.81, DSM-IV, goes on the state:
“D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following:
(1) difficulty falling or staying asleep;
(2) irritability or outbursts of anger;
(3) difficulty concentrating (Read a page and can’t remember it? Forget what your wife just told you or constantly hear “I told you that yesterday!” Feel dumb because you don’t follow a lot of conversations, etc., or just can’t focus because part of you is scanning for danger all the time?)
(4) hypervigilance (always looking for danger, worrying about people getting hurt, still looking for tripwires and sitting with your back to the wall, avoiding crowds, etc.)
(5) exaggerated startle response (hit the dirt at the sound of a backfire, can’t be touched when asleep, etc.)
E. Duration of the disturbance (symptoms in Criteria B, C, and D) is more than 1 month.
F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Specify if:
Acute: if duration of symptoms is less than 3 months
Chronic: if duration of symptoms is 3 months or more
Specify if:
With Delayed Onset: if onset of symptoms is at lease 6 months after the stresssor”
(Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, fourth Edition. Copyright 1994 American Psychiatric Association.)
Experiencing any or all of these symptoms does not mean you are “crazy,” but that you are suffering the normal effects of trauma brought on by an abnormal event.
In order to establish service connection for PTSD, the evidence must establish that during active duty a veteran was subjected to a stressor or stressors that would cause characteristic symptoms in almost anyone. Evidence of combat or having been a prisoner of war may be accepted as conclusive evidence of a stressor incurred during active duty. Evidence of combat includes receipt of the Purple Heart, the CIB, or other similar citation.
01-07. Department of Veterans Affairs (VA) Definition, The Technical Versions. The following, issued by the Department of Veterans Affairs (VA) in the Code of Federal Regulation (CFR), part 38, offers the “official” definition you will be most concerned with:
a. “Post-Traumatic Stress Disorder. 3.304 (f) (f) Post-traumatic stress disorder. Service connection for post-traumatic stress disorder requires medical evidence diagnosing the condition in accordance with §4.125(a) of this chapter; a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. Although service connection may be established based on other in-service stressors, the following provisions apply for specified in-service stressors as set forth below:
(1) If the evidence establishes that the veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran’s service, the veteran’s lay testimony alone may establish the occurrence of the claimed in-service stressor.
(2) If the evidence establishes that the veteran was a prisoner-of-war under the provisions of §3.1(y) of this part and the claimed stressor is related to that prisoner-of-war experience, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran’s service, the veteran’s lay testimony alone may establish the occurrence of the claimed in-service stressor.
(3) If a post-traumatic stress disorder claim is based on in-service personal assault, evidence from sources other than the veteran’s service records may corroborate the veteran’s account of the stressor incident. Examples of such evidence include, but are not limited to: records from law enforcement authorities, rape crisis centers, mental health counseling centers, hospitals, or physicians; pregnancy tests or tests for sexually transmitted diseases; and statements from family members, roommates, fellow service members, or clergy. Evidence of behavior changes following the claimed assault is one type of relevant evidence that may be found in these sources. Examples of behavior changes that may constitute credible evidence of the stressor include, but are not limited to: a request for a transfer to another military duty assignment; deterioration in work performance; substance abuse; episodes of depression, panic attacks, or anxiety without an identifiable cause; or unexplained economic or social behavior changes. VA will not deny a post-traumatic stress disorder claim that is based on in-service personal assault without first advising the claimant that evidence from sources other than the veteran’s service records or evidence of behavior changes may constitute credible supporting evidence of the stressor and allowing him or her the opportunity to furnish this type of evidence or advise VA of potential sources of such evidence. VA may submit any evidence that it receives to an appropriate medical or mental health professional for an opinion as to whether it indicates that a personal assault occurred.
(Authority: 38 U.S.C. 501(a), 1154)
b. “Mental Disorders - 4.125 Diagnosis of mental disorders.
(a) If the diagnosis of a mental disorder does not conform to DSM-IV or is not supported by the findings on the examination report, the rating agency shall return the report to the examiner to substantiate the diagnosis.
(b) If the diagnosis of a mental disorder is changed, the rating agency shall determine whether the new diagnosis represents progression of the prior diagnosis, correction of an error in the prior diagnosis, or development of a new and separate condition. If it is not clear from the available records what the change of diagnosis represents, the rating agency shall return the report to the examiner for a determination.
(Authority: 38 U.S.C. 1155)
4.126 Evaluation of disability from mental disorders.
(a) When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran’s capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner’s assessment of the level of disability at the moment of the examination.
(b) When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment.
(c) Delirium, dementia, and amnestic and other cognitive disorders shall be evaluated under the general rating formula for mental disorders; neurologic deficits or other impairments stemming from the same etiology (e.g., a head injury) shall be evaluated separately and combined with the evaluation for delirium, dementia, or amnestic or other cognitive disorder (see §4.25).
(d) When a single disability has been diagnosed both as a physical condition and as a mental disorder, the rating agency shall evaluate it using a diagnostic code which represents the dominant (more disabling) aspect of the condition (see §4.14).
(Authority: 38 U.S.C. 1155)
01-08. The European Description. If you are not confused enough have a look at the description offered by the World Health Organization in Geneva. The good part is that PTSD is now recognized world-wide as a “real” disorder. The bad part is found in their “Diagnostic Guidelines”. What follows is an excerpt from their Internet Home Page:
“Post-Traumatic Stress Disorder
F43.1 This arises as a delayed and/or protracted response to a stressful event or situation (either short- or long-lasting) of an exceptionally threatening or catastrophic nature, which is likely to cause pervasive distress in almost anyone (e.g. natural or man-made disaster, combat, serious accident, witnessing the violent death of others, or being the victim of torture, terrorism, rape, or other crime)….
Typical symptoms include episodes of repeated reliving of the trauma in intrusive memories (“flashbacks”) or dreams, occurring against the persisting background of a sense of “numbness” and emotional blunting, detachment from other people, unresponsiveness to surroundings, anhedonia, and avoidance of activities and situations reminiscent of the trauma. Commonly there is fear and avoidance of cues that remind the sufferer of the original trauma. Rarely, there may be dramatic, acute bursts of fear, panic or aggression, triggered by stimuli arousing a sudden recollection and/or re-enactment of the trauma or of the original reaction to it….
The onset follows the trauma with a latency period which may range from a few weeks to months (but rarely exceeds 6 months). The course is fluctuating but recovery can be expected in the majority of cases. In a small proportion of patients the condition may show a chronic course over many years and a transition to an enduring personality change.
Diagnostic Guidelines
This disorder should not generally be diagnosed unless there is evidence that it arose within 6 months of a traumatic event of exceptional severity. A “probable” diagnosis might still be possible if the delay between the event and the onset was longer than 6 months, provided that the clinical manifestations are typical and no alternative identification of the disorder (e.g. as an anxiety or obsessive-compulsive disorder or depressive episode) is plausible…..”
ICD-10 copyright 1992 by World Health Organization
Internet Mental Health (www.mentalhealth.com) copyright 1995-1997 by Phillip W. Long, M.D.
This is an excellent page and worthy of study.
01-09. Information You Can Use. According to a study (the National Vietnam Veterans Readjustment Study, NVVRS) performed in the mid 80’s 15.2% of the male Vietnam veterans, surveyed at that time, suffered from PTSD and 30% of heavy combat male Vietnam veterans suffered from PTSD. Even though no survey was done, 16,354,000 veterans served during WW-II and 5,700,000 served in Korea.
Lets split the difference and say that 20% of all the veterans then and now suffer from PTSD of some intensity.
The Veterans Administration confirms that approximately 19,196,000 veterans are still living. That would mean that some 3,838,200 veterans suffer from PTSD and as of July 1997 only approximately 500,000 were being treated and only 102,000 are receiving disability compensation. This means that only approximately 1.3% of those veterans are being treated and only.3% of those being treated are receiving disability compensation.
EIGHT months after I applied for PTSD I received my C & P (Compensation and Pension) examination for PTSD. Four months after that I received a decision and an award for 10% disability for PTSD.
During that YEAR My son forced me out of our small Internet business because I was becoming very combative with our customers and angry with him over everything, I was unable to drive my vehicle in heavy traffic without getting physically ill and VERY angry and I began to seclude myself in my home because of depression and anxiety.
Within 30 days I had submitted a Notice of Disagreement (NOD) for the PTSD based on my deteriorating mental condition. After SIX more miserable months I was granted a hearing with the Regional Decision Review Officer (DRO) and after SIX more months, I received an upgraded to my PTSD claim to 50%. It took 2 years and 5 days. I applied for and upgrade to my PTSD and for un-employability in the year 2000. In Mar 2001 I was awarded 70% for PTSD and un-employability (which makes me 100% disabled).
01-10. In Very Simple Terms. What causes PTSD in combat veterans? A Traumatic Event and then MEMORIES of that event. These memories cause a chemical imbalance in the brain when they are TRIGGERED by conscious and sub-conscious events.
This is the worst part of untreated PTSD, not only do conscious reminders (war buddies, smells, sounds, movies) cause the brain to go GAGA but unconscious thoughts will trigger the chemical imbalance (anniversary dates, seeing someone who looks like a buddy lost in combat). Days, weeks, months and sometime years later you begin to have anxiety attacks or become depressed. In most of us these events are short lived and we go on as before, with no noticeable change in our lives.
In many of us the events build up and finally drag us down, as happened in my case and as has happened with some of you.
1. Contact the nearest VA hospital or clinic and make an appointment with the Mental Health department. The VA will not process your application unless you have been diagnosed with PTSD by a VA doctor.
2. File a “statement of Illness” letter. Send a letter to your Regional Office with a Subject line of “Statement of Illness”. Simply state that you are suffering from PTSD and need treatment.
3. If you are eligible, file a claim. There should be a Service Representative in the VA facility.
4. Continue your treatment program and start on your Stress Letter.
5. Submit your Stress Letter. (Do this even though you may not be required to so you can establish Evidence of Record)
Note: The extent to which you were stressed in combat has no major bearing on the amount of your disability determination (This does, however, establish service connection). The amount of disability you may eventually end up with will be determined by your CURRENT social in-adaptability.
6. C & P (Compensation and Pension ) Interview - This is where a medical doctor describes your current mental condition for the record.
7. Your Claim file is then returned to your regional office for review and determination.
Herein lies the heart of your disability determination. Your fate is decided by the comments of the C & P interviewing official, a VA “Rating Specialist”, and the VA Rating Board.
There is a serious problem in the system that you should be aware of. In Feb of 2000 I attended a resident PTSD program that lasted for 45 days. I was pretty strung out when I arrived and felt some better when I left. When you attend these programs you will be given an update of your GAF score when you depart. If you show some improvement and your GAF is changed (you could be asked how you feel or you may be rated on your conduct and attitude in the program), to a higher number, the VA may request you be re-evaluated to see if they can decrease your disability rating because of your improved condition.
Almost EVERYTHING you say to your Doctor, at ALL appointments, is noted in your files, even your demeanor is noted.
01-11. The Eye Opener. When I finally forced myself to go to a VA Clinic I was in a very high state of anxiety and depression had already begun to set in. I had had a bout with depression shortly after retirement so I was aware of some of the signs. I had never experienced a high state of anxiety before and did not even know what PTSD was. Some of you will have the same symptoms, most will not. Since my diagnosis I have been talking to more of my veteran friends about PTSD and finding out that most, if not all, of them have it to some degree and many of them have been under counseling for some time but had not spoken to me, or anyone else, about it because they thought their friends would think they were feigning illness.
SITREP- WWII Era (1939):
The cyclotron of John Ray Dunning splits an atom for the first time in America; The first commercial transatlantic passenger air service begins; New York’s La Guardia Airport opens; The first American made helicopter is flown; Hewlett-Packard is founded; FM radio receivers go on sale for the first time; “Batman” is launched by DC Comics; the books The Grapes of Wrath and How Green Was My Valley are released; the movies “Gone With The Wind” and “Drums Along the Mohawk” are released; the songs “I’ll Never Smile Again” and “South of the Border (Down Mexico Way)” are released; the New York Yankees win the World Series by defeating the Cincinnati Reds 4 games to 0.
WW II Era (1940):
Winston Churchill succeeds Neville Chamberlain as Britain’s prime minister; the first peacetime military draft in U.S. history begins October 29; President Roosevelt wins reelection to third term with 54 percent of popular vote; the first Social Security checks go out January 30; the new Chevrolet coupe sells for $659; the book For Whom the Bell Tolls, is written by Ernest Hemingway; the Broadway play Pal Joey opens at the Barrymore theater; the songs “The Last Time I saw Paris” and “You Are My Sunshine” were released; the Cincinnati Reds win the World Series by defeating the Detroit Tigers 4 games to 3.