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Updated Jun 27, 2022

In This Section

  
This section contains the following topics:
  
Topic
Topic Name
1
2
 

 

1.  General Information on Rating PTSD

 
 

Introduction

  
This topic contains general information about rating PTSD, including

Change Date

  
July 29, 2021

VIII.iv.1.D.1.a.  Responsibility of the RVSR or DRO in Deciding SC for PTSD

  
Deciding the issue of service connection (SC) 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:  Decision makers may request an opinion or guidance from Compensation Service on complex cases.
 
Reference:  For more information about requesting Compensation Service assistance, see M21-1, Part X, Subpart v. 1.A.

VIII.iv.1.D.1.b.  Requirements for Establishing SC for PTSD From In-Service Stressors

  
Under 38 CFR 3.304(f), SC for PTSD associated with an in-service stressor requires
  • credible supporting evidence that the claimed in-service stressor actually occurred
  • medical evidence diagnosing the condition in accordance with 38 CFR 4.125, and
  • a link, established by medical evidence, between current symptomatology and the claimed in-service stressor.
Reference:  For more information on establishing SC for PTSD, see

VIII.iv.1.D.1.c.  Considering the Relationship Between Stressor and Symptoms

  
To establish SC for PTSD based on an in-service stressor, the relationship between stressor and symptoms must be
  • specifically addressed in the examination report, and
  • supported by documentation.
Reference:  For more information on PTSD examination requirements, see M21-1, Part VIII, Subpart iv, 1.C.2.

VIII.iv.1.D.1.d.  Handling an In-Service Diagnosis of PTSD

  
When PTSD is properly diagnosed in service, the Veteran’s testimony alone may establish that the claimed in-service stressor occurred, as long as the claimed stressor is
  • related to the Veteran’s service, and
  • consistent with the circumstances, conditions, or hardships of that service.
References:  For more information on

VIII.iv.1.D.1.e.  In-Service Diagnosis of PTSD Related to a Pre-Service Stressor

  
If a Veteran is sound on enlistment and develops delayed or late-onset PTSD in service related to a pre-service stressor, the claim may be granted under 38 U.S.C. 1110, which contains the general criteria for establishing SC for a chronic disability.
  
Notes:
  • The existence of a pre-service stressor does not rebut the presumption of soundness under 38 U.S.C. 1111.
  • There is no statutory or regulatory requirement for credible supporting evidence of a pre-service stressor.
  • Do not cite 38 CFR 3.304(f), as the existing regulatory language only provides standards for establishing SC for PTSD due to in-service stressors.  Also, do not cite 38 CFR 3.303(a), which relates to general principles of SC.

 

2.  Evaluating Evidence and Deciding a Claim for SC for PTSD

 
 

Introduction

  
This topic contains information about deciding a claim for SC for PTSD, including

Change Date

  
June 27, 2022

VIII.iv.1.D.2.a.  Determining the Occurrence of Stressors When Making the Decision

  
When determining the occurrence of stressors to establish SC 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.
  • 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 SC.
  • 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.
Reference:  For more information on developing claims of PTSD, see M21-1, Part VIII, Subpart iv, 1.A.

VIII.iv.1.D.2.b.  Determining Combat Service

  
Every decision involving the issue of SC 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 that 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 

VIII.iv.1.D.2.c.  Considering Evidence of Engagement in Combat

  
Although evidence from sources other than service records 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 determining combat service, see M21-1, Part VIII, Subpart iv, 1.A.

VIII.iv.1.D.2.d.  Establishing a Stressor Related to the Fear of Hostile Military or Terrorist Activity

  
When determining whether a stressor related to fear of hostile military or terrorist activity is established, consider places, types, and circumstances of service where risks or danger from such activity are most likely to exist.  Deployed service overseas related to combat, security, or support of combat or security missions is the most likely to involve risks or danger from hostile military forces or terrorist attacks.
  
The Veteran’s DD Form 214, Certificate of Release or Discharge From Active Duty, and other service records showing deployments, relevant awards or decorations, receipt of Combat/ Imminent Danger/ Hostile Fire Pay, and other conditions of service, will be key to proving service in an area of potential or actual hostile military or terrorist activity.
  
Notes: 
  • As of July 28, 2021, for PTSD claims granted under the authority of 38 CFR 3.304(f)(3), adjudicators must determine if an effective date under 38 CFR 3.114(a)(3) is warranted.
  • Historically, the Department of Veterans Affairs (VA) did not consider the July 13, 2010, amendment of 38 CFR 3.304(f) a liberalizing rule under 38 CFR 3.114(a).  However, on July 28, 2021, the court in Ortiz v. McDonough, 6 F. 4th 1267 (Fed Cir. 2021) found that the addition of 38 CFR 3.304(f)(3) in 2010 was a liberalizing regulatory change under 38 CFR 3.114(a).
  • Decisions that were final prior to July 28, 2021, and that were based on VA’s interpretation of its regulations in place at that time, are not a clear and unmistakable error (CUE) under 38 CFR 3.105(a).
Example:  A Veteran filed an initial claim for SC of PTSD on June 20, 2009.  Evidence shows the Veteran served in an area of hostile military and terrorist activity in 2005 and that he was diagnosed with PTSD in June 2009 by VA examination.  The June 2009 examiner confirmed that the claimed stressor was adequate to support a diagnosis of PTSD and that the Veteran’s symptoms were related to the claimed stressor; however, the claim was denied because the stressor could not be verified.  On May 5, 2021, the Veteran filed a supplemental claim with new and relevant evidence.  The supplemental claim is being decided after July 28, 2021.
 
Result:  The Veteran is entitled to an effective date of May 5, 2020, one year retroactive to the date of claim, under 38 CFR 3.114(a), because
  • the claim was pending on or after July 28, 2021, the date of the court’s decision
  • the supplemental claim was filed after the prior claim became finally adjudicated
  • the Veteran met all eligibility criteria for the liberalizing change at the time it took effect in July 2010, specifically,
    • there was a diagnosis of PTSD
    • the stressor related to the PTSD satisfied the regulatory requirements for fear of hostile military or terrorist activity provided in 38 CFR 3.304(f)(3), and
    • a VA or VA-contracted psychiatrist or psychologist confirmed that the claimed stressor was adequate to support a diagnosis of PTSD and that the Veteran’s symptoms were related to the claimed stressor
  • PTSD is being granted based on a fear-based stressor under 38 CFR 3.304(f)(3), and
  • the Veteran’s claim was filed more than one year after the July 2010 liberalizing change.
References:  For more information on

VIII.iv.1.D.2.e.  Establishing SC for PTSD Related to Drone Aircraft Crew Member Duties

  
Recent military operations and warfare have involved the expansive use of armed drone aircraft, such as the Predator and Reaper.  SC for PTSD is warranted under 38 CFR 3.304(f) when the evidence shows that the Veteran
  • served as a drone aircraft crew member
  • has a medical diagnosis of PTSD, and
  • has received a medical link between PTSD and service as a drone aircraft crew member.
References:  For more information on

VIII.iv.1.D.2.f.  Requirement for Credible Supporting Evidence of a Stressor

  
The requirement for credible supporting evidence of a stressor means that there must be some believable evidence that tends to support the Veteran’s 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.
Reference:  For more information on reviewing for credible supporting evidence, see M21-1, Part VIII, Subpart iv, 1.A.3.c.

VIII.iv.1.D.2.g.  Identifying Credible Supporting Evidence of a Stressor When Lay Testimony Is Not Sufficient

  
If the claimed stressor is not related to combat, experience as a former prisoner of war, fear of hostile military or terrorist activity, or drone aircraft crew member duties, a claimant’s 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 records (STRs) or service 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 Veteran’s medical treatment after an accident. 

VIII.iv.1.D.2.h.  Reviewing Evidence for Corroboration of a Stressor

  
When 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.  If these sources do not contain the necessary information, review other 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 commander’s narrative is likely of greater relevance and specificity than a battalion commander’s, and
  • a Navy ship’s deck log would likely yield more probative information than a fleet log.
Reference:  For more information on the stressor verification review procedure, see M21-1, Part VIII, Subpart iv, 1.A.3.d.

VIII.iv.1.D.2.i.  Obtaining Evidence Related to Claimed Stressors

  
For more information on obtaining service records, medical treatment records, and evidence of stressors, see M21-1, Part VIII, Subpart iv, 1.A.

VIII.iv.1.D.2.j. Denying a PTSD Claim Because of an Uncorroborated Stressor

  
When corroborating evidence of a stressor is required because the stressor may not be established by lay evidence alone and credible supporting evidence from other sources is not of record, a denial solely because of an unconfirmed stressor is improper unless
  • the Military Records Research Center (MRRC) has confirmed there is no corroborating evidence of a claimed stressor, or
  • the Veteran has failed to provide the basic information required to conduct research.
If MRRC requests a more specific description of the stressor in question, follow the procedures in M21-1, Part VIII, Subpart iv, 1.A.2.g-i to 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

VIII.iv.1.D.2.k.  Disposition of an Issue Claimed and/or Developed as SC for PTSD Case

  
Use the table below in order to arrive at the proper disposition of an issue claimed and/or developed as SC for PTSD diagnosed after service and claimed as related to an in-service stressor.
  
If …
Then …
there is no current diagnosis of PTSD or of another mental disorder
deny the claim on that basis.
  
Notes:  If the existence of a stressor has not been determined, do not include a discussion of the alleged stressor in the rating decision.
  
References:  For more information on
  • there is current PTSD, but
  • either
    • the claimant failed to provide sufficient information about a claimed in-service stressor, or
    • a sufficiently described stressor was not proven
deny the claim on the basis that a stressor has not been proven.
  
Note:  The rating decision should note the request(s) for information.
  
References:  For more information on
  • there is current PTSD, and
  • there is either
    • credible supporting evidence of the claimed in-service stressor, or
    • sufficient proof of an in-service stressor falling into one of the types listed in M21-1, Part VIII, Subpart iv, 1.A.3.b, but
  • the evidence proves that PTSD is not due to the in-service stressor 
deny the claim on the basis that the current PTSD does not have a nexus to service. 
  • there is current PTSD
  • there is either
  • the diagnosis of PTSD is based upon the proven in-service stressor
grant the claim.
  
Note:  This includes fact patterns where there is an in-service stressor as well as stressors before and/or after service but based on the medical evidence the in-service stressor is considered the predominant cause of the disability. 
  • the claim is based on personal assault/military sexual trauma (MST)
  • service records (and alternative evidence, if any was identified and obtained) do not show the claimed in-service personal assault, and
  • the examiner
    • interprets markers as supportive of the occurrence of personal assault, and
    • links the diagnosis to the claimant’s reported personal assault, but
    • determines that a diagnosis other than PTSD (depression, chronic adjustment disorder, generalized anxiety disorder, bipolar disorder) more accurately describes the current disability
deny the claim.
  
Explanation:  Non-PTSD diagnoses must be adjudicated under the general provisions of 38 CFR 3.303, which requires actual documentation of the in-service event.
  
There is no provision for establishing the occurrence of a personal assault/MST event in service based only on a marker and the examiner’s acceptance of the Veteran’s lay statement of the event.
  
References:  For more information on
  • the claim is based on personal assault/MST
  • service records and/or alternative evidence shows the claimed in-service personal assault occurred, and
  • the examiner
    • links a diagnosis to the claimant’s history of personal assault, but
    • determines that a diagnosis other than PTSD (depression, chronic adjustment disorder, generalized anxiety disorder, bipolar disorder) more accurately describes the current disability
grant the claim.
  
Explanation:  Non-PTSD diagnoses must be adjudicated under the general provisions of 38 CFR 3.303, which requires actual documentation of the in-service event. 
  
Here there are records supporting that the in-service event occurred.
  
References:  For more information on
  • the claim is based on fear of risks from hostile military or terrorist activity 
  • stressor development supports that the Veteran served in an area and time where there were risks of hostile military or terrorist activity, and
  • the examiner
    • links a diagnosis to the claimant’s history, but
    • determines that a diagnosis other than PTSD (depression, chronic adjustment disorder, generalized anxiety disorder) more accurately describes the current disability
before making a decision, proceed with development research as described in M21-1, Part VIII, Subpart iv, 1.A.3.d, if possible, on whether any claimed in-service events (beyond mere service in an area of hostile military or terrorist activity) that formed the basis for the examination diagnosis actually occurred.
  
Deny the claim if either
  • no specific experiences are claimed beyond service in an area of hostile military or terrorist activity, or
  • additional research does not support that the claimed in-service event(s) forming the foundation for the examination diagnosis occurred.
Grant the claim only if further development is possible and that development permits a finding that the in-service event(s) forming the basis for the diagnosis occurred. 
  
Explanation:  Non-PTSD diagnoses must be adjudicated under the general provisions of 38 CFR 3.303, which requires actual documentation of the in-service event. 
  
There is no provision for establishing the occurrence of a fear related “event” in service based only on the Veteran’s lay statement and its acceptance by an examiner.
 
Note:  This table is intended to cover PTSD arising after service and claimed to be related to an in-service stressor event.
  
References:  For more information on