PTSD Diagnosis can be complicated
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What is Post Traumatic Stress Disorder?
The term Post Traumatic Stress Disorder or PTSD is bandied around quite a bit but how is PTSD medically defined? If you are veteran with PTSD, how do you go about getting diagnosed and the proper are for this debilitating disorder? What is the recourse if you might consider if don’t get the care or benefits you need?
The Dept. of Veterans Affairs’ PTSD experts, who bill themselves as being “the world's leading research and educational center of excellence on PTSD and traumatic stress, explain that PTSD is a “mental health problem that some people develop after experiencing or witnessing a life-threatening event, like combat, a natural disaster, a car accident, or sexual assault. It's normal to have upsetting memories, feel on edge, or have trouble sleeping after this type of event.”
The American Psychiatric Institute (API) defines PTSD similarly: PTSD is a psychiatric disorder that can occur in people who have experienced or witnessed a traumatic event such as a natural disaster, a serious accident, a terrorist act, war/combat, rape or other violent personal assault.
According to the API, symptoms of PTSD fall into four categories with specific symptoms varying in severity.
- Intrusive thoughts such as repeated, involuntary memories; distressing dreams; or flashbacks of the traumatic event. Flashbacks may be so vivid that people feel they are re-living the traumatic experience or seeing it before their eyes.
- Avoiding reminders of the traumatic event may include avoiding people, places, activities, objects and situations that bring on distressing memories. People may try to avoid remembering or thinking about the traumatic event. They may resist talking about what happened or how they feel about it.
- Negative thoughts and feelings may include ongoing and distorted beliefs about oneself or others (e.g., “I am bad,” “No one can be trusted”); ongoing fear, horror, anger, guilt or shame; much less interest in activities previously enjoyed; or feeling detached or estranged from others.
- Arousal and reactive symptoms may include being irritable and having angry outbursts; behaving recklessly or in a self-destructive way; being easily startled; or having problems concentrating or sleeping.
PTSD symptoms may last for a month or persist for much longer, even years. Many times, the symptoms will develop shortly after the negative occurrence but they may not manifest until much longer after the traumatic event has occurred.
The VA has posted the VA/DoD Clinical Practice Guidelines for treating PTSD on its website. Issued in 2017, the 200 page Management of Posttraumatic Stress Disorder and Acute Stress Reaction is found online along with other resources for veterans and their family members.
Here are the DSM-V criteria
Criterion A: stressor: The person was exposed to: death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence, as follows: (one required)
- Direct exposure.
- Witnessing, in person.
- Indirectly, by learning that a close relative or close friend was exposed to trauma. If the event involved actual or threatened death, it must have been violent or accidental.
- Repeated or extreme indirect exposure to aversive details of the event(s), usually in the course of professional duties (e.g., first responders, collecting body parts; professionals repeatedly exposed to details of child abuse). This does not include indirect non-professional exposure through electronic media, television, movies, or pictures.
Criterion B: intrusion symptoms: The traumatic event is persistently re-experienced in the following way(s): (one required)
- Recurrent, involuntary, and intrusive memories.
- Traumatic nightmares.
- Dissociative reactions (e.g., flashbacks), which may occur on a continuum from brief episodes to complete loss of consciousness.
- Intense or prolonged distress after exposure to traumatic reminders.
- Marked physiologic reactivity after exposure to trauma-related stimuli.
Criterion C: avoidance: Persistent effortful avoidance of distressing trauma-related stimuli after the event: (one required)
- Trauma-related thoughts or feelings.
- Trauma-related external reminders (e.g., people, places, conversations, activities, objects, or situations).
Criterion D: negative alterations in cognitions and mood: Negative alterations in cognitions and mood that began or worsened after the traumatic event: (two required)
Inability to recall key features of the traumatic event (usually dissociative amnesia; not due to head injury, alcohol, or drugs).
Persistent (and often distorted) negative beliefs and expectations about oneself or the world (e.g., “I am bad,” “The world is completely dangerous”).
Persistent distorted blame of self or others for causing the traumatic event or for resulting consequences.
Persistent negative trauma-related emotions (e.g., fear, horror, anger, guilt, or shame).
Markedly diminished interest in (pre-traumatic) significant activities.
Feeling alienated from others (e.g., detachment or estrangement).
Constricted affect: persistent inability to experience positive emotions.
Criterion E: alterations in arousal and reactivity: Trauma-related alterations in arousal and reactivity that began or worsened after the traumatic event: (two required)
Irritable or aggressive behavior
Self-destructive or reckless behavior
Exaggerated startle response
Problems in concentration
Criterion F: duration: Persistence of symptoms (in Criteria B, C, D, and E) for more than one month.
Criterion G: functional significance: Significant symptom-related distress or functional impairment (e.g., social, occupational).
Criterion H: exclusion: Disturbance is not due to medication, substance use, or other illness.
Specify if: With dissociative symptoms.
Typically, a full diagnosis of PTSD cannot be made until at least six months after the trauma(s), although onset of symptoms may occur immediately. Sometimes, the VA will reject a competent diagnosis of PTSD because the diagnosis is not “clear” – this is not correct legal standard for denial and is an appealable issue.
With regards to therapy used to treat PTSD, the VA recommends talk therapy as one of the most important treatments. On their website, they recommend four antidepressant medications that have been proven effective for the treatment of PTSD.
“SSRIs (selective serotonin reuptake inhibitors) and SNRIs (serotonin-norepinephrine reuptake inhibitors) are types of antidepressant medication. There are four SSRIs/SNRIs that are recommended for PTSD:
The API makes similar treatment recommendations: “Both talk therapy (psychotherapy) and medication provide effective evidence-based treatments for PTSD. One category of psychotherapy, cognitive behavior therapies (CBT), is very effective. Cognitive processing therapy, prolonged exposure therapy and stress inoculation therapy (described below) are among the types of CBT used to treat PTSD.
Cognitive Processing Therapy
Prolonged Exposure Therapy
Other psychotherapies such as interpersonal, supportive and psychodynamic therapies focus on the emotional and interpersonal aspects of PTSD. These may be helpful for people who don’t want to expose themselves to reminders of their traumas.
Some antidepressants such as SSRIs and SNRIs (selective serotonin re-uptake inhibitors and selective norepinephrine re-uptake inhibitors) are commonly used to treat the core symptoms of PTSD. They are used either alone or along with psychotherapy or other treatments. Other medications may be used to lower anxiety and physical agitation, or treat the nightmares and sleep problems that trouble many people with PTSD.
Other complementary and alternative therapies are also increasingly being used to help people with PTSD
These approaches provide treatment outside the conventional mental health clinic and may require less talking and disclosure than psychotherapy. These types of alternative treatments include animal-assisted therapy and the use of marijuana to treat symptoms.
Some people experiencing PTSD find the mental health disorder so debilitating they are unable to function normally and hold down employment needed to support themselves or their family. If you find yourself in this situation, there are three things that need to occur in order to receive benefits from the VA:
To begin with, a diagnosis of PTSD is required from a clinical professional qualified to perform a PTSD Compensation and Pension examination (C&P exam). The evaluating individual must have doctoral level training in psychopathology, diagnostic methods, and clinical interviewing.
In addition, the clinical professional must have working knowledge of the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-V) and have extensive clinical experience in diagnosing and treating veterans with PTSD. Persons with the required professional qualifications include board-certified psychiatrists and licensed psychologists, as well as psychiatric residents and psychology interns under the close supervision of an attending psychiatrist or psychologist. The diagnosis must conform to the diagnostic criteria in the DSM-V in order to be found eligible for VA benefits. The DSM-V diagnostic criteria for PTSD may be found on the VA’s website.
Next, you must have evidence that the trauma occurred during your military service. This requires having a documented cause of the trauma. This may occur in a variety of ways:
You may be diagnosed with PTSD during your service.
You may also have documentation that you that you served active combat duty.
You may also have a fear of hostile military or terrorists.
You may have experienced in-service personal assault or trauma.
If none of the above occurred, you must find another way to corroborate the trauma. This can include buddy statements, letters to family and police reports. The Benefit of the Doubt doctrine applies to these situations. The statute, 38 USC § 5107(b), says:
“The [VA] shall consider all information and lay and medical evidence of record in a case before the [VA] with respect to benefits under laws administered by the [VA]. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the [VA] shall give the benefit of the doubt to the claimant.”
If official records contradict a veteran’s account of an event, the VA can reject the veteran’s account, but as long as the veteran produces evidence to back up his or her story, the benefit of the doubt rule still applies.
Finally, there must be a nexus – a connection -- between the PTSD symptoms and the trauma. This step requires another opinion by a medical expert. The evidence must show that the trauma was at least a contributory basis for the current symptoms. As long as there is a clear relationship between the traumatic event encountered in service and the current diagnosis of PTSD, a veteran whose service medical records show no evidence of a mental disorder may be be entitled to service connection for PTSD, even if the PTSD develops several years after the service has concluded.
If you need assistance with a PTSD claim or obtaining veterans health care or benefits please contact WS Law for your veteran legal needs.