There are times when people question whether a veteran’s experiences were stressful or traumatic enough to qualify for a diagnosis of posttraumatic stress disorder (PTSD). This process can actually harm a veteran’s disability case. While there are multiple criteria (requirements) that need to be satisfied to make a PTSD diagnosis, for this blog post I want to focus only on the first one; it is related to the experience that the PTSD comes from. For a good summary of all the DSM-5 diagnostic requirements for PTSD condensed to plain English check out this page from the National Center for PTSD.
Criterion A of the PTSD diagnostic criteria from the DSM-5 (published by the American Psychiatric Association) is related to “exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:
- Directly experiencing the traumatic event(s).
- Witnessing, in person, the event(s) as it occurred to others.
- Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental.
- Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse). Note: Criterion A4 does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related.”
Based on the diagnostic criteria alone, we can see that PTSD isn’t just about directly experiencing a trauma like getting shot. There are others ways PTSD can be triggered. For example, the fourth bullet point notes “experiencing repeated or extreme exposure to aversive details of the traumatic event(s)” and gives examples like “collecting human remains” or “police officers repeatedly exposed to details of child abuse.” We could likely come up with countless other examples of jobs from the military which could potentially fall into a category like this. One example appears on the Board of Veterans’ Appeals website Citation Nr: 1730584.
In this case the Veteran “alleged that his PTSD was related to stressors related to his military occupational specialty as a parachute rigger in the Air Force. ” The BVA noted that the “Veteran has received three VA examinations specific to PTSD, in June 2008, April 2012, and September 2014. In each examination, the examiners found all the criteria as delineated under DSM-IV or DSM-5, with the exception of Criterion A, which is defined as “exposure to actual or threatened: a) death, b) serious injury, c) sexual violation, in one or more way(s): direct exposure, witnessing the trauma, learning that a relative or close friend was exposed to a trauma, or experiencing repeated or extreme exposure to aversive details of the traumatic events (e.g., first responders, medics).” So in this case, VA examiners noted “all criteria” for PTSD were there except Criterion A. The BVA decision noted, howevever, that: The Veteran described his in-service stressor of a pilot who “got ejected out of an aircraft” brought his wife and children to him and reportedly told him “if it wasn’t for me, he wouldn’t be alive.” The Veteran learned of the threatened death or serious injury of this individual face-to-face; an individual he was responsible for since he packed his parachute.
The BVA noted: The Veteran and his attorney submitted a medical opinion of Dr. F. in July 2017. The March 2017 report indicated that Dr. F reviewed the Veteran’s entire claims file in its entirety and interviewed the Veteran. Dr. F. concluded that the Veteran has a current diagnosis of PTSD and that he met the criteria for PTSD. Dr. F. concluded that PTSD is at least as likely as not due to in-service stressors. It was noted that the VA examiners discounted his in-service stressor as not sufficient to cause PTSD. It was noted that this opinion was inconsistent with the opinion of the VA psychiatrist who diagnosed him with PTSD and provided treatment that was geared toward PTSD related symptoms. In addition, it was indicated that the VA disability examiners erred by failing to recognize that his repeated exposure to aversive details of the threatened deaths of pilots ejecting from airplanes is sufficient to meet the A criterion under DSM-5. Likewise, the in-service stressor meets the A criterion under DSM-IV in that he has been “confronted with an event or events that included the threatened death or injury of “self or others.” Dr. F noted that the Veteran wasn’t simply packing parachutes, he was repeatedly being confronted with the threatened death or injury of pilots ejecting from planes. It was indicated that the A criterion can be met experiencing repeated or extreme, exposure to aversive details of the traumatic event(s). It was stated that the Veteran did not need to be threatened with death or injury to meet the criterion, he just needed to be exposed to the aversive details of others being, exposed to threatened death or injury. This is consistent with the Veteran’s reports of multiple, emotion-filled work-related exposures to reports from pilots that they had to eject from their airplanes. He consistently reported finding this to be overwhelming. The examiner stated that the Veteran does not need to have experienced the threatened death of having to eject from an airplane himself to satisfy the A criterion for PTSD or have the threat of potentially having, to eject from an airplane someday. It was noted, for example, that the DSM-5 uses police officers exposed to details about child abuse as an illustration. The police officer could qualify for the PTSD A criterion simply by hearing the aversive details of the events (and despite the fact that the, police officer did not witness the event and also was not, in danger themselves of being a child who was abused). It was indicated that this is similar to the Veteran’s case where he qualifies for the PTSD A criterion because he was repeatedly exposed to the aversive details of pilots ejecting from their planes (he noted that he in fact saved 8 pilots and he was exposed to the aversive details of those incidents).
It is important to be sure that when it comes to VA examiners, they are using the correct diagnostic criteria. It is also important to be sure that they are not simply discounting someone’s experiences as not being stressful or traumatic enough for a PTSD diagnosis- when the PTSD diagnostic criteria would allow for those stressors. Veterans should be careful about this too, since many times I hear them say things like “I should just suck it up” or suggest that their traumatic experiences shouldn’t have been enough to lead to PTSD. If you’re a Veteran who could benefit from treatment for PTSD here is a page from the VA that outlines some options.
Thanks for visiting; I am a psychologist who offers nexus letters and/or independent medial opinions on VA disability claims. You can learn more about me on the website for my practice: www.toddfinnerty.com. If you’d like to receive news and resources from this blog in your email you can sign up for the mailing list here.