REAR ADMIRAL PATRICK W. DUNNE, USN (RET)
ACTING UNDER SECRETARY FOR BENEFITS
VETERANS BENEFITS ADMINISTRATION
DEPARTMENT OF VETERANS AFFAIRS
SENATE COMMITTEE ON VETERANS' AFFAIRS
JUNE 4, 2008
Mr. Chairman and members of the Committee:
Thank you for providing me the opportunity to appear before you today to testify on the important issue of post-traumatic stress disorder (PTSD). I am pleased to be accompanied by Mr. Brad Mayes, the Veterans Benefit Administration's (VBA) Director of Compensation and Pension Service. We all share the goal of preventing and minimizing the impact of this disability on our veterans and providing those who suffer from it with just compensation for their service to our country. Today I will explain how VBA processes claims for service connection of PTSD and the relationship between VBA and the Veterans Health Administration (VHA) in the processing these claims.
The number of veterans submitting claims for PTSD has grown dramatically. From FY 1999 through May 2008, the number of veterans receiving disability compensation who are service-connected for PTSD increased from 120,000 to nearly 329,000 (328,923). These veterans represent veterans of World War II (24,087), the Korean Conflict (12,229), the Vietnam Era (222,191), Peacetime (11,220), and the Gulf War Era (59,196). The Gulf War Era number includes 37,460 OIF/OEF veterans.
When a VBA regional office receives an initial claim for service connection of PTSD, a series of steps are followed which include: (1) providing the veteran with notice of what evidence is required to substantiate the claim, commonly referred to as a Veterans Claims Assistance Act or VCAA notice, and providing assistance with gathering that evidence; (2) researching the evidence needed to support the claimed in-service stressor; (3) providing the veteran with a PTSD examination; and (4) assigning a disability rating percentage for compensation purposes. These steps will be explained in detail.
Providing the veteran with notice of evidence required to substantiate the claim and assistance with gathering that evidence
When an initial claim for PTSD is received, the regional office will respond to the veteran with a letter outlining the information and evidence needed to substantiate the claim and the actions VBA will take to assist the veteran with developing for that evidence and the veteran's responsibility for providing evidence. VBA will then obtain the veteran's service medical and personnel records and any post-service medical or hospital records identified by the veteran. These procedures are the same for all claims, regardless of the disability. However, in PTSD claims, the veteran will generally be asked to provide a description of the in-service stressor that has caused the current PTSD symptoms.
Researching for evidence to support the claimed stressor
The processing of PTSD claims is governed by our regulation at 38 C.F.R. § 3.304(f). This regulation states that, in order for service connection to be granted, there must be medical evidence diagnosing the condition, there must be medical evidence establishing a link between current symptoms and an in-service stressor, and there must be credible supporting evidence that the claimed in-service stressor occurred. The first two requirements involve medical assessments, while the third requirement generally involves investigation by VBA personnel into the nature of the stressor.
The steps required to establish service connection for PTSD can be affected by the specific circumstances in the claim.
In cases where PTSD is diagnosed in service and the nature of the stressful event is not apparent, VA will request that the examiner detail the circumstances surrounding the development of PTSD. If those circumstances are consistent with military service, evidence of the stressful event will be accepted without further development.
Even if PTSD is not diagnosed in service, under certain conditions established by sections 3.304(f)(1) and (2), the veteran's lay testimony alone can establish the occurrence of the stressor. When sufficient evidence shows that the veteran engaged in combat with the enemy or was a prisoner of war (POW) and the claimed stressor is related to that combat or POW status, the veteran's statement describing the stressor will allow the claim to go forward without corroborating evidence. VBA will accept certain military awards received by the veteran that designate participation in combat, such as a Combat Infantryman Badge, Combat Action Ribbon, Purple Heart Medal, etc., as evidence of exposure to combat-related stressors.
When evidence for combat status is not readily apparent or where the claimed stressor is not directly related to combat, VBA is obligated to search for evidence to corroborate the combat status or the non-combat stressor before the claim can go forward. Such evidence can come from additional military records, from the "buddy statements" of individuals who served with the veteran, or from on-line documents available at official military or government websites. In addition, VBA personnel have access to thousands of declassified military unit reports and histories from all periods of war on the Compensation and Pension Service Intranet website. These reports and histories document unit combat actions and can serve to corroborate a stressor when the veteran's records show assignment to a particular unit at the time covered in the report or history.
When VBA personnel cannot find sufficient credible evidence to support a claimed stressor, the stressor information is forwarded to the Army's Joint Services Records Research Center (JSRRC). This DoD activity with full time researchers has access to multiple sources of military documents, not readily available to VBA personnel. If JSRRC is able to find evidence supporting the claimed stressor, it will be provided to VBA. In all cases where there is an approximate balance of evidence for and against occurrence of the stressor, the veteran will be given the benefit of doubt and VA will find that the stressor occurred.
Where PTSD is due to military sexual trauma and evidence of the trauma is not of record, VA has developed processes to develop this extremely sensitive issue. These include a search for potential "markers" of sexual assault such as sudden degradation in performance, seeking duty station changes, visits to clinics for sexually transmitted disease testing, provost marshal records, and seeking out of medical or spiritual assistance.
In general, VBA procedures require that a claimed stressor must be corroborated by credible supporting evidence before an initial PTSD examination is scheduled with VHA. Generally, neither the examination report as such nor the examiner's opinion can serve as credible evidence to support occurrence of the stressor. However, under section 3.304(f)(3), when an in-service personal assault is involved, evidence that can corroborate the veteran's account of the stressor includes records from rape crisis centers and mental health counseling services. A VHA examination may be scheduled before there is sufficient evidence to corroborate the assault, and the examiner may be asked for an opinion as to whether the assault occurred based on the available evidence and the examination results. Also, where the veteran was diagnosed with PTSD in service, there is an assumption that the diagnosis was made by a competent military medical authority with a factual basis for recognizing the stressor. Therefore, VBA need not seek further credible evidence for the causative stressor. In these cases, a VHA examination can be scheduled immediately to evaluate the level of disability.
Providing the veteran with a PTSD examination
The VHA medical examination for PTSD, or an equivalent contract examination, essentially serves three purposes. First, it serves to establish whether the veteran has PTSD, or some other mental disorder for the veteran's presenting symptoms. Second, it provides an opinion as to the existence of a link between the current symptoms and the in-service stressor. Third, it serves to provide an assessment of the current level of disability resulting from the veteran's symptoms so that VA can provide a rating for the extent of the disability.
VBA and VHA have jointly developed a project to improve the delivery and oversight of medical examinations used for VBA disability rating purposes, referred to as the Compensation and Pension Examination Program (CPEP). This project involves monitoring the accuracy of the examination requests sent from VBA to VHA, as well as the quality of the examinations conducted by VHA examiners. Quality in this sense refers to the sufficiency of the examination report for VBA disability rating purposes. Examination worksheets have been developed to assist the VHA examiners with providing medical information that fits the disability criteria described in 38 CFR, Part 4, Schedule for Rating Disabilities. Specific information about these criteria is necessary for VBA adjudicators to provide accurate and fair disability rating evaluations for compensation purposes. Oversight efforts similar to those of CPEP are also in place to monitor the quality of contract examinations.
PTSD examinations are subject to the requirements of 38 C.F.R. § 4.125(a), which provides that the diagnosis must conform to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), published by the American Psychiatric Association and must be supported by the findings on the examination report. Although a veteran may have received a diagnosis of PTSD from a private mental health provider before submitting a claim to VBA, the VHA examination is still necessary to confirm the diagnosis in accordance with the DSM-IV and to provide the proper diagnostic criteria and level-of-disability assessment needed for rating purposes. To ensure that a qualified professional is responsible for the examination, VBA requires that the initial examination be conducted or supervised by a board-certified psychiatrist or licensed doctorate-level psychologist. Additionally, all potential examiners must now undergo specific training and become certified prior to performing PTSD examinations.
Assigning a disability rating percentage for compensation purposes
VBA personnel evaluate the examination reports and assign the veteran a percentage disability rating when the evidence supports initial service connection for PTSD. Rating personnel also evaluate PTSD reexamination reports for service-connected veterans who are claiming an increase in compensation due to a worsened condition. Ratings are based on the rating schedule for mental disorders found at 38 C.F.R. § 4.130. The schedule is a general rating formula for all mental disorders except eating disordersbased on the level of occupational and social impairment caused by the veteran's mental disorder. It provides for disability percentages of 10, 30, 50, 70, and 100, with a description of symptoms associated with each percentage level. VBA rating personnel must evaluate the examination report, and any other relevant evidence, to determine the most appropriate level of disability. The examination report must be carefully reviewed to match the examiner's description of the veteran's symptoms with a disability percentage most closely representing the severity of those symptoms. This is a complex process that involves an element of judgment. However, when a reasonable doubt arises as to which of two possible percentages to assign, 38 C.F.R. § 4.3 dictates that reasonable doubt will be resolved in favor of the veteran and the higher of the two percentages will be assigned.
In response to recommendations of the Veterans' Disability Benefits Commission and the Institute of Medicine, VBA is reviewing the mental disorders rating schedule with a particular focus on possibly providing specific criteria for rating PTSD based on the symptoms described in the DSM-IV.
As more veterans returning from Iraq and Afghanistan are turning to VA for benefits and medical care, including care for PTSD, it is critical that our employees receive the essential guidance, materials, and tools to meet the increasingly complex demands of their decision-making responsibilities. To accomplish this goal, VBA has deployed new training tools and centralized training programs that support accurate and consistent decision-making. New employees receive comprehensive training through the national centralized training program called "Challenge." The current curriculum consists of full lesson plans, handouts, student guides, instructor guides, and slides for classroom instruction. Recognizing the importance of continuing education, all Veterans Service Center employees are required to complete a mandatory cycle of training, consisting of 80 hours of annual coursework.
VBA has developed job aids and training sessions to provide employees the skills and tools essential to render fair and timely decisions on PTSD claims. All Veteran Service Representatives (VSRs) and Rating Veteran Service Representatives (RVSRs) are required to receive training on the proper development and analysis of PTSD claims. The training materials include medical and military references and pre-recorded video broadcasts pertaining to PTSD development and records research. VBA published PTSD guidance includes "Handling PTSD Claims Based on Stressors Experienced During Service in the Marine Corps" dated June 2005, "Military Sexual Trauma Training Letter" dated November 2005, and "JSRRC Stressor Verification Guide" dated January 2006. Additionally, VBA introduced the PTSD Training and Performance Support System (TPSS) module for VSRs and RVSRs in 2006. The TPSS module is an interactive learning tool in which employees complete self-guided lessons on PTSD development and verification of in-service stressors. Due to the success of the TPSS learning system, a second PTSD module titled, "Rate a Claim for PTSD" was released in July 2007.
The foregoing description of the PTSD claims process is a general outline of the procedures followed by VBA. I would be happy to answer any specific questions the committee members may have.
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