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M21-1, Part III, Subpart iv, Chapter 4, Section O – Mental Disorders

Overview

In This Section
This section contains the following topics:
Topic
Topic Name
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2
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4

1.  General Information on Mental Disorders

Introduction
This topic contains general information about rating mental disorders, including

Change Date
October 19, 2018

III.iv.4.O.1.a.  Sympathetic Reading and the Scope of Mental Disorders Claims
A claim for a particular mental disorder should be read as a claim for any mental disability that may be reasonably defined by
  • the description of the claim
  • the symptoms that the claimant describes
  • the information and evidence that the claimant submits, and
  • any other information and evidence obtained.
A sympathetic reading of pleadings cannot be based on a standard that requires legal sophistication and must consider whether all submissions taken together have articulated a claim.
Note:  Under 38 CFR 3.159, the duty to assist is triggered by a substantially complete application, which requires identification of the benefit claimed and any medical condition on which it is based, which could be a description of symptoms of a body part or system.
Reference:  For more information on sympathetic reading and scope of claims, see

III.iv.4.O.1.b.  Applying Guidance on Sympathetic Reading to Mental Disorders Claims
When reviewing a claim for service connection (SC) based on a mental disorder
  • do not limit consideration only to a particular mental disorder diagnosis or theory of SC identified by the claimant;
  • do sympathetically read the claim as including any chronic acquired mental disorder consistent with the analysis above.
If additional development is needed to address an alternative diagnosis in the evidentiary record, ensure that this is completed before making a decision.  It is impermissible to limit the scope of the claim for SC to the claimant’s lay hypothesis about the nature of a specific mental disorder disability.  Because the Veteran is reasonably requesting benefits for symptoms of a mental disorder that he/she is not competent to medically identify, it is insufficient for the Department of Veterans Affairs (VA) to simply deny benefits for the claimed diagnosis and not address evidence in the record of other mental disorder diagnoses as indicated in Clemons v. Shinseki, 23 Vet. App. 1 (2009).
References:  For more information on

III.iv.4.O.1.c.  Considering a Change in the Diagnosis of a Psychiatric Disorder
If the diagnosis of a psychiatric disorder is changed, the rating activity must determine if this represents
  • progression of the prior disorder
  • correction of an error in the prior diagnosis, or
  • development of a new and separate condition.
If this is not clear from the available records, a determination by an examiner is required.
Reference:  For more information on change in diagnosis of mental disorders, see

III.iv.4.O.1.d.  Making Reductions in Evaluations of Psychiatric Disorders
Do not make drastic reductions in evaluations in ratings for psychiatric disorders if a reduction to an intermediate rate is more in agreement with the degree of disability.
Observe the general policy of gradually reducing the evaluation to afford the Veteran all possible opportunities for adjustment.
Reference:  For more information on the stabilization of disability evaluations, see

III.iv.4.O.1.e.  Considering SC for Mental Unsoundness in Suicide
Whether a person, at the time of suicide, was so unsound mentally that he or she did not realize the consequences of such an act, or was unable to resist such impulse, is a question to be determined in each individual case, based on all available lay and medical evidence pertaining to the individual’s mental condition at the time.
The act of suicide or a bona fide attempt is considered to be evidence of mental unsoundness.  Therefore, where no reasonable adequate motive for suicide is shown by the evidence, the act will be considered to have resulted from mental unsoundness.
Notes:
  • In all instances, any reasonable doubt should be resolved favorably to support a finding of SC.
  • Mental unsoundness by itself without evidence of an underlying psychiatric disability is not a service-connectable disorder.  Therefore, when death from suicide has occurred after separation from active duty, SC may be granted only in the presence of a service-connectable disability that meets all of the requirements for SC.  When death from suicide has occurred while on active duty, the provisions of 38 CFR 3.302are for application in the determination as to whether the individual was mentally unsound at the time of the suicide or whether it was due to a service-connectable disability as indicated in Elkins v. Brown, 8 Vet.App. 391 (1995).
Reference:  For more information on developing claims for in-service suicide, seeM21-1, Part III, Subpart iii, 2.A.8.c.

III.iv.4.O.1.f.  Definition:  Psychosis
For the purpose of presumptive SC under 38 CFR 3.309(a), a psychosis is any of the following disorders:
  • brief psychotic disorder
  • delusional disorder
  • psychotic disorder due to another medical condition
  • other specified schizophrenia spectrum and other psychotic disorder
  • schizoaffective disorder
  • schizophrenia
  • schizophreniform disorder, and
  • substance/medication-induced psychotic disorder.
Reference:  For the regulation governing the definition of psychosis, see 38 CFR 3.384.

III.iv.4.O.1.g.  Handling a Veteran’s Discharge From Service for a Mental Disorder Due to Traumatic Stress
Under 38 CFR 4.129, when a mental disorder that develops in service from a highly stressful event is severe enough to result in the Veteran’s discharge from active military service,
  • assign a service-connected (SC) evaluation of at least 50 percent, and
  • schedule an examination within six months of the Veteran’s discharge to determine whether a change in the evaluation is warranted.
Note:  In-service mental health treatment records are maintained by the military or civilian treating facility and are not stored by the Department of Defense with the traditional service treatment records (STRs).
References:  For more information on

III.iv.4.O.1.h.  Evaluating a Disability Diagnosed as Both a Physical and Mental Disorder
Avoid assigning separate evaluations for SC disabilities based on the same manifestations as this constitutes pyramiding.  To warrant separate evaluations, symptoms considered must be distinct and not overlap.
Situation:  A Veteran is SC for PTSD with anxiety considered in the assigned evaluation.  The Veteran later files a claim for SC for fibromyalgia.  The evidence associates fibromyalgia with service and anxiety is considered as a manifestation upon which fibromyalgia is diagnosed.
Result:  Fibromyalgia will be SC and rated separately from PTSD.  However, anxiety may only be considered in determining the rating to be assigned for PTSDor fibromyalgia.
Rationale:  Consideration of anxiety in rating both disabilities would constitute pyramiding as the symptoms are obviously overlapping and would involve rating the same manifestations twice.
References:  For more information on

III.iv.4.O.1.i.  Somatic Symptom Disorder as a Disability for VA Compensation Purposes
A diagnosis of somatic symptom disorder, which is widely recognized as a disabling condition, is accepted by VA as a disability for compensation purposes.  Because somatic symptom disorder may also stem from an underlying disease such as multiple sclerosis or arthritis, and variations of somatic symptom disorder may be found throughout all body systems, the condition should be evaluated under the most appropriate diagnostic code (DC) based on the clinical picture demonstrated.
Notes:
  • VA already recognizes conditions such as fibromyalgia and low back pain syndrome, which are forms of somatic symptom disorder, as disabilities for compensation purposes.
  • Originally diagnosed as chronic pain syndrome, terminology was revised to somatic symptom disorder in the Diagnostic and Statistical Manual of Mental Disorders, fifth version (DSM-5).
Important:  Adequate medical evidence must be of record that identifies the specific manifestations of the disease present in order to accurately evaluate the condition.
Reference:  For additional guidance on considerations for conditions which may be characterized by both physical and mental symptoms, see M21-1, Part III, Subpart iv, 4.O.1.h.

III.iv.4.O.1.j.  Removal of the GAF Score From DSM and Assigning Evaluations Based on Prior GAF Score
A Global Assessment of Functioning (GAF) score is a number between 0 and 100 representing an assessment of an individual’s overall level of psychological, social, and occupational functioning.  The GAF score was part of the multi-axial analysis used in prior versions of DSM.  DSM-5 no longer uses the GAF score.
Notes:
  • The removal of the GAF score in DSM does not change the application of the Rating Schedule.  It merely alters the format in which diagnostic information is presented.
  • When assigning an evaluation based on psychological assessments made under prior versions of DSM
    • do not base the disability evaluation solely or primarily on the GAF score.
    • evaluate the score in light of all the evidence in the case, including symptomatology and manifestations in examination reports (to include disability benefits questionnaires) and treatment records.

III.iv.4.O.1.k.  Considering SC for Neurodevelopmental Disorders
Neurodevelopmental disorders are a group of conditions with onset in the developmental period.  According to the DSM-5, they typically manifest in early development and are characterized by developmental deficits in several functional domains.  This group of disorders includes, but is not limited to, the following diagnoses:  Attention-Deficit/Hyperactivity Disorder (also referred to as Attention Deficit Disorder), Autism Spectrum Disorder, Specified Learning Disorder, Tic Disorder, Child-Onset Fluency Disorder (Stuttering), and Intellectual Disability (Intellectual Developmental Disorder).
Neurodevelopmental disorders are not considered diseases or injuries under 38 CFR 3.303(c).  Since they are not diseases or injuries, they are not generally subject to direct SC.
Exception:
  • If evidence clearly demonstrates the diagnosis developed as a result of an in-service injury, for example as a result of a TBI, consider SC for any diagnosis directly related to the in-service injury.
  • If there is progression of the condition at an abnormally high rate during service as discussed in M21-1, Part IV, Subpart ii, 2.B.4 and 6, consider SC under 38 CFR 3.306.
References:  For more information on

III.iv.4.O.1.l.  Considering SC for Insomnia
Carefully consider the evidence of record when deciding SC for insomnia.  Insomnia is generally considered a symptom of another disability due to coexisting medical or neurological conditions.  Insomnia can occur as an independent condition or can be a symptom associated with another mental disorder (for example, major depressive disorder), medical condition (for example, pain), or another sleep disorder (for example, a breathing-related sleep disorder).
When insomnia is adequately identified as a symptom of another underlying disability, SC should be established for that diagnosis rather than for “insomnia.”  However, SC can be established for “insomnia” in the absence of a known or established underlying etiology if there is
  • an event in service (such as a diagnosis of primary insomnia in service)
  • a current diagnosis of primary insomnia
  • a nexus establishing primary insomnia post service is connected to the event in service, and
  • the condition is not associated with any other disease or injury.
Note:  When evaluating primary insomnia, rate analogously under an appropriate DC in 38 CFR 4.130.
Reference:  For more information on analogous ratings, see

2.  General Information on Rating PTSD

Introduction
This topic contains general information about rating PTSD, including

Change Date
June 14, 2018

III.iv.4.O.2.a.  Responsibility of the RVSR or DRO in Deciding SC for PTSD
Deciding the issue of SC for 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 CompensationService on complex cases.
Reference:  For more information about requesting Compensation Service assistance, see M21-1, Part III, Subpart vi. 1.A.

III.iv.4.O.2.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

III.iv.4.O.2.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 III, Subpart iv, 4.O.2.f and g.

III.iv.4.O.2.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

III.iv.4.O.2.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.

III.iv.4.O.2.f.  Handling Insufficient PTSD Examination Reports
When a PTSD examination report is insufficient for rating purposes follow procedures in M21-1, Part III, Subpart iv, 3.D.3.
Reasons that a PTSD examination report may be insufficient for VA purposes include
  • the assessment does not conform to current DSM standards
  • it does not identify or adequately describe the claimed stressor(s)
  • it does not sufficiently describe symptomatology, social and occupational functional impairment or other facts required by the regulatory diagnostic criteria
  • the examiner did not discuss the significance of, and reconcile, any differential diagnoses or changes in diagnosis
  • the claims folder was not provided or the examiner did not review provided claims folder material
  • the examiner did not offer a requested comment or opinion
  • the examiner was not sufficiently qualified to render an initial diagnosis as specified in M21-1, Part III, Subpart iv, 3.D.2.h
  • the examiner did not justify a conclusion that an opinion could not be provided without resorting to mere speculation, or
  • the examination was not conducted by a properly-qualified examiner.
Notes:
  • The diagnosis of PTSD must be made by a competent (properly qualified) medical professional and should be unequivocal.
  • The examining psychiatrist or psychologist should comment on whether the Veteran has experienced other traumatic events and, if so, indicate the relevance of these events to the current symptoms.
References:  For more information on

III.iv.4.O.2.g.  PTSD Examination Reports and DSM Criteria 
Based on the May 2013 publication of DSM-5, 38 CFR 4.125 was updated to specifically refer to DSM-5 effective August 4, 2014.
Important:  Mental health examinations conducted after August 2014, to include PTSD examinations, must comply with DSM-5 standards.
References:  For more information on

3.  Evaluating Evidence and Deciding a Claim for PTSD Based on Personal Trauma

Introduction
This topic contains information about evaluating evidence in claims based on personal trauma, including

Change Date
January 16, 2019

III.iv.4.O.3.a.  General Information on Personal Trauma
Personal trauma, for the purpose of VA disability compensation claims based on PTSD, refers broadly to stressor events involving harm perpetrated by a person who is not considered part of an enemy force.
Examples:  Assault, battery, robbery, mugging, stalking, harassment.
Military sexual trauma (MST) is a subset of personal trauma and refers to sexual harassment, sexual assault, or rape that occurs in a military setting.
Reference:  For more information on processing claims for PTSD based on personal trauma, see

III.iv.4.O.3.b.  Importance of Obtaining and Analyzing Available  Evidence of Personal Trauma
Prior to deciding a claim based on personal trauma, claims processors must 
  • obtain all relevant primary and alternative sources of evidence identified by the claimant, and
  • review the claim for credible supporting evidence, including evidence of markers, as detailed in M21-1, Part IV, Subpart ii, 1.D.5.d.
References:  For more information on

III.iv.4.O.3.c.  Alternative Sources of Evidence of In-Service Personal Trauma
If primary evidence, such as STRs and service personnel records, contain no explicit documentation that personal trauma, including in-service sexual assault, occurred, evidence from alternative sources other than the Veteran’s service records may corroborate the Veteran’s account of the stressor incident.
Examples of such alternative sources of evidence include, but are not limited to
  • a rape crisis center or center for domestic abuse
  • a counseling facility or health clinic
  • family members or roommates
  • a faculty member
  • civilian police reports
  • medical reports from civilian physicians or caregivers who treated the Veteran immediately following the incident or sometime later
  • a chaplain or clergy
  • fellow service members, and
  • personal diaries or journals.
Note:  38 CFR 3.304(f)(5) provides that in PTSD claims based on in-service personal assault, evidence from sources other than the Veteran’s service records may be used to corroborate the Veteran’s account of the stressor incident.  However, VA Office of General Counsel concluded in VAOPGCPREC 3-2012 that PTSD personal assault regulation changes and guidance are not a sufficient basis for invocation of liberalizing law effective date rules.
Important:  VA may not treat the absence of a service record documenting an unreported sexual assault as evidence that the sexual assault did not occur as indicated in AZ and AY v. Shinseki, 731 F.3d 1303 (Fed. Cir. 2013).  In addition, VA may not rely on a Veteran’s failure to report an in-service sexual assault to military authorities as pertinent evidence that the sexual assault did not occur.  Therefore, do not use the absence of service record documentation or lack of report of in-service sexual assault to military authorities as evidence to conclude that a sexual assault did not occur.
Reference:  For more information on negative evidence, see

III.iv.4.O.3.d.  Evidence That May Constitute a Marker of Personal Trauma
If primary evidence, such as STRs and service personnel records, contain no explicit documentation that personal trauma occurred, and alternative sources of evidence do not provide credible supporting evidence of the trauma, evidence of behavioral changes around the time of, and after, the incident(s), may constitute a marker of a personal trauma PTSD stressor.
The term marker means an indicator of the effect or consequences of the personal trauma on the Veteran.  A marker could be one or more behavioral events, or a pattern of changed behavior.  Even if there is no reference to the personal trauma, evidence of the behavior changes below may circumstantially support thepossibility that the claimed stressor occurred.
Evidence that may be a marker of trauma includes but is not limited to
  • increased use or abuse of leave without an apparent reason, such as family obligations or family illness
  • episodes of depression, panic attacks, or anxiety without identifiable reasons
  • visits to a medical or counseling clinic or dispensary without a specific diagnosis or specific ailment
  • use of, or increased interest in, pregnancy tests or tests for sexually-transmitted diseases (including the human immunodeficiency virus (HIV)) around the time of the incident
  • sudden requests that the Veteran’s military occupational series or duty assignment be changed without other justification
  • changes in performance and performance evaluations
  • increased or decreased use of prescription medications
  • increased use of over-the-counter medications
  • alcohol or drug abuse
  • increased disregard for military or civilian authority
  • obsessive behavior such as overeating or undereating
  • unexplained economic or social behavior changes
  • treatment for physical injuries around the time of the claimed trauma, but not reported as a result of the trauma, and/or
  • the breakup of a primary relationship.
Notes:
  • Behavioral change evidence may include lay statements or documentary evidence.
  • Although the examiner’s opinion is not determinative of the outcome of the claim, it will be accepted as significant probative evidence when evaluating SC for the diagnosed mental disorder.
References:  For more information on

III.iv.4.O.3.e.  Interpretation of Behavioral Changes as Markers of Personal Trauma
Evidence of behavioral changes typically needs interpretation by a clinician in personal trauma claims.
Submit evidence received for a medical opinion as to whether the credible factual evidence of behavior changes demonstrated by the Veteran is consistent with the expected reaction or adjustment of a person who has been subjected to an assault.
If the examiner offers a credible, unequivocal, and nonspeculative assessment that the evidence of record is consistent with the occurrence of the claimed assault, that opinion can constitute credible supporting evidence that the claimed in-service stressor occurred.  If the opinion is merely speculative, equivocal, contradictory, or otherwise insufficient for rating purposes, it should be returned for clarification.
References:  For more information on

III.iv.4.O.3.f.  MST During INACDUTRA
Veterans whose stressor occurred during inactive duty for training (INACDUTRA) are eligible for SC in the same manner as those whose stressor occurred during active duty or active duty for training.  The VA Office of General Counsel concluded in VAOPGCPREC 8-2001 that “PTSD resulting from sexual assault may be considered a disability resulting from an injury.”

III.iv.4.O.3.g.  Training and Signature Requirements for MST Decisions
All rating decisions that address an MST-related disability as an issue must only be worked/reviewed by an RVSR who has
  • completed the required MST Training Performance Support System module, and
  • been designated by a regional office as an MST claims processor.
Decisions for MST disabilities require two signatures until a decision maker has demonstrated an accuracy rate of 90 percent or greater based on a review of at least 10 MST cases.
Important:  To ensure accurate claims processing, the following checklists/worksheet are recommended for completion and uploading to the claims folder:
Reference:  For more information on two signature requirements in MST rating decisions, see M21-1, Part III, Subpart iv, 6.D.7.d.

4.  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 14, 2018

III.iv.4.O.4.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 IV, Subpart ii, 1.D.

III.iv.4.O.4.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

III.iv.4.O.4.c.  Considering Secondary Evidence of Engagement in Combat
Although secondary evidence 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 secondary sources of evidence, see M21-1, IV, Subpart ii, 1.D.1.d.

III.iv.4.O.4.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.
Primary evidence, such as 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.
Note:  The July 13, 2010, amendment of 38 CFR 3.304(f) is not considered a liberalizing rule under 38 CFR 3.114(a).
References:  For more information on

III.iv.4.O.4.e.  Establishing SC for PTSD Relatedto 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 under38 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 his/her PTSD and service as a drone aircraft crew member.
References:  For information on

III.iv.4.O.4.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 IV, Subpart ii, 1.D.3.b.

III.iv.4.O.4.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
  • 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.

III.iv.4.O.4.h.  Reviewing Evidence for Corroboration of a Stressor
When reviewing evidence for corroboration of a claimed stressor(s),
  • carefully analyze the most reliable sources of evidence first, and
  • if these sources do not contain the necessary information, review secondary sources of evidence carefully and critically for their adequacy and reliability.
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.
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 IV, Subpart ii, 1.D.3.c.

III.iv.4.O.4.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 IV, Subpart ii, 1.D.

III.iv.4.O.4.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 U.S. Army and Joint Services Records Research Center (JSRRC), the National Archives and Records Administration (NARA), or the Marine Corps, as appropriate, 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 JSRRC, NARA, or the Marine Corps requests a more specific description of the stressor in question, follow the procedures in M21-1, Part IV, Subpart ii, 1.D.2.g-ito 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

III.iv.4.O.4.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 IV, Subpart ii, 1.D.3.a, 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/MST
  • primary (and alternative evidence, if any was identified and obtained) does 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
  • primary evidence 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 IV, Subpart ii, 1.D.3.c, 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
Historical_M21-1III_iv_4_SecO_6-14-18.docx May 15, 2019 87 KB
1-4-18_Key-Changes_M21-1III_iv_4_SecO.docx May 15, 2019 88 KB
1-16-19_Key-Changes_M21-1III_iv_4_SecO.docx May 15, 2019 65 KB
6-14-18_Key-Changes_M21-1III_iv_4_SecO.docx May 15, 2019 118 KB
10-19-18_Key-Changes_M21-1III_iv_4_SecO.docx May 15, 2019 66 KB
in Chapter 4 Rating Specific Disabilities, Part III General Claims Process, Subpart iv General Rating Process
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