Stressor Determinations for Posttraumatic Stress Disorder, 39843-39852 [2010-16885]

Agencies

• DEPARTMENT OF VETERANS AFFAIRS

[Federal Register Volume 75, Number 133 (Tuesday, July 13, 2010)]
[Rules and Regulations]
[Pages 39843-39852]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 2010-16885]



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DEPARTMENT OF VETERANS AFFAIRS

38 CFR Part 3

RIN 2900-AN32


Stressor Determinations for Posttraumatic Stress Disorder

AGENCY: Department of Veterans Affairs.

ACTION: Final rule.

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SUMMARY: The Department of Veterans Affairs (VA) is amending its 
adjudication regulations governing service connection for posttraumatic 
stress disorder (PTSD) by liberalizing in some cases the evidentiary 
standard for establishing the required in-service stressor. This 
amendment eliminates the requirement for corroborating that the claimed 
in-service stressor occurred if a stressor claimed by a veteran is 
related to the veteran's fear of hostile military or terrorist activity 
and a VA psychiatrist or psychologist, or a psychiatrist or 
psychologist with whom VA has contracted, confirms that the claimed 
stressor is adequate to support a diagnosis of PTSD and that the 
veteran's symptoms are related to the claimed stressor, provided that 
the claimed stressor is consistent with the places, types, and 
circumstances of the veteran's service.
    This amendment takes into consideration the current scientific 
research studies relating PTSD to exposure to hostile military and 
terrorist actions. The amendment acknowledges the inherently stressful 
nature of the places, types, and circumstances of service in which fear 
of hostile military or terrorist activities is ongoing. With this 
amendment, the evidentiary standard of establishing an in-service 
stressor will be reduced in these cases. The amendment will facilitate 
the timely processing of PTSD claims by simplifying the development and 
research procedures that apply to these claims.

DATES: Effective Date: This final rule is effective July 12, 2010.
    Applicability Date: This final rule applies to an application for 
service connection for PTSD that:
     Is received by VA on or after July 12, 2010;
     Was received by VA before July 12, 2010 but has not been 
decided by a VA regional office as of that date;
     Is appealed to the Board of Veterans' Appeals (Board) on 
or after July 12, 2010;
     Was appealed to the Board before July 12, 2010 but has not 
been decided by the Board as of that date; or
     Is pending before VA on or after July 12, 2010 because the 
Court of Appeals for Veterans Claims (Veterans Court) vacated a Board 
decision on the application and remanded it for readjudication.

FOR FURTHER INFORMATION CONTACT: Thomas J. Kniffen, Chief, Regulations 
Staff (211D), Compensation and Pension Service, Veterans Benefits 
Administration, Department of Veterans Affairs, 810 Vermont Avenue, 
NW., Washington, DC 20420, (202) 461-9725. (This is not a toll-free 
number.)

SUPPLEMENTARY INFORMATION: On August 24, 2009, VA published in the 
Federal Register (74 FR 42617) a proposal to modify the evidentiary 
standards for establishing an in-service stressor when a veteran files 
a claim for service connection for PTSD. We proposed to add a new 
paragraph (3) to 38 CFR 3.304(f) to state that, if a stressor claimed 
by a veteran is related to the veteran's fear of hostile military or 
terrorist activity and a VA psychiatrist or psychologist or contract 
equivalent confirms that the claimed stressor is adequate to support a 
diagnosis of PTSD and that the veteran's symptoms are related to the 
claimed stressor, in the absence of clear and convincing evidence to 
the contrary, and provided the claimed stressor is consistent with the 
places, types, and circumstances of the veteran's service, the 
veteran's lay testimony alone may establish the occurrence of the 
claimed in-service stressor. This evidentiary liberalization is 
consistent with the American Psychiatric Association's (APA) Diagnostic 
and Statistical Manual of Mental Disorders, Fourth Edition (1994) (DSM-
IV) criteria for a PTSD diagnosis, as explained in the notice of 
proposed rulemaking. The rule further re-designates former paragraph 
(f)(3) as (f)(4), governing PTSD claims from former prisoners of war, 
and re-designates paragraph (f)(4) as (f)(5), governing PTSD claims 
based on in-service personal assault or military sexual trauma (MST).
    Interested persons were invited to submit written comments on or 
before October 23, 2009. We received 126 comments on the proposed rule. 
VA received comments from veterans service organizations, including The 
American Legion, National Organization of Veterans' Advocates, Disabled 
American Veterans, Veterans for Common Sense, Paralyzed Veterans of 
America, and The Wounded Warrior Project; from public interest groups, 
including the Los Angeles Inner City Law Center and National Research 
Center for Women and Families; from government agencies, such as the 
New York City Department of Health and Mental Hygiene and the State of 
New York Division of Veterans Affairs; and from individuals. VA also 
received comments from members of the Subcommittee on Disability 
Assistance and Memorial Affairs of the House of Representatives 
Committee on Veterans' Affairs and other persons who participated in a 
roundtable discussion of the proposed rule, as well as from members of 
Congress.
    We also received numerous comments from veterans and surviving 
spouses regarding their individual claims for veterans benefits. We do 
not respond to these comments in this notice as they are beyond the 
scope of this rulemaking.

Presumption of Service Connection Based on Receipt of Certain Pay

    Some commenters suggested that VA revise the rule to create a 
presumption of service connection for PTSD based upon receipt of 
imminent-danger or hostile-fire pay. We make no change based on these 
comments because they are beyond the scope of the rule, which is 
limited to providing a reduced evidentiary standard for establishing 
occurrence of the stressor based upon a particular type of stressor.

Fear of Hostile Military or Terrorist Activity

    Some commenters suggested that the rule should be revised to reduce 
the evidentiary standard for veterans who had certain Military 
Occupational Specialties (MOS). A MOS may be considered as evidence of 
exposure to a stressor, including hostile military or terrorist 
activity. See Veterans Benefits Administration (VBA) Adjudication 
Procedures Manual Rewrite M21-1MR (Manual M21-1MR), Part IV, subpart 
ii, ch. 1, sec. D, para. 13.k. However, a particular MOS does not 
necessarily establish such an exposure. See Dizoglio v. Brown, 9 Vet. 
App. 163, 166 (1996). Therefore, we make no changes based on these 
comments.
    Some commenters interpreted the proposed rule as limited to fear of 
hostile or terrorist activity while serving in a combat zone, and 
others suggested that the rule should be revised to provide a reduced 
evidentiary standard on the basis of service in a combat zone. One 
commenter asked whether the rule applies to veterans who served on a 
submarine. The rule has no geographic requirement and is not limited to 
service in a combat zone or on land. Rather, it applies to all persons 
who served in active military, naval, or air service, as defined in 38 
U.S.C. 101(24), and were discharged or released from

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such service under conditions other than dishonorable.
    One commenter stated the term ``stressor'' is ambiguous and may 
lead one to believe that the rule applies only if a veteran can 
identify a single specific event instead of hostile military or 
terrorist activity generally. One commenter suggested that the rule 
should apply as well to a series of events or the totality of 
circumstances of deployment to a combat zone. Another commenter 
questioned the meaning of the phrase ``consistent with the . . . 
circumstances of service'' and doubted whether an examiner would ever 
find that a traumatic event experienced by a veteran who had an MOS of 
cook is consistent with the circumstances of the veteran's service. 
Another commenter inquired about whether the examiner would be 
responsible for determining whether the stressor is consistent with the 
veteran's service.
    VA believes that the language in the proposed rule is not 
ambiguous. As stated in the rule, `` `fear of hostile military or 
terrorist activity' means that a veteran experienced, witnessed, or was 
confronted with an event or circumstance.'' (Emphasis added). The term 
``circumstance'' means ``a condition, fact, or event accompanying, 
conditioning, or determining another: an essential or inevitable 
concomitant.'' Webster's Ninth New Collegiate Dictionary, 242 (1990). 
Therefore, the rule provides that a veteran's ``fear'' need not emanate 
from a single event or be consistent with the veteran's MOS but rather 
the fear may result from conditions to which the veteran was exposed 
during service. The requirement that a claimed stressor be consistent 
with the places, types, and circumstances of the veteran's service 
originates in the statute that authorizes this regulation, 38 U.S.C. 
1154(a), which requires VA to duly consider the places, types and 
circumstances of the veteran's service. In addition, consistent with 
section 1154(a), VA regulations provide that consistency with the 
places, types, and circumstances of service is shown by the veteran's 
service records, the official history of each organization in which the 
veteran served, medical records, and all pertinent medical and lay 
evidence. 38 CFR 3.303(a). Finally, VA adjudicators, not examining 
psychiatrists and psychologists, will decide whether the claimed 
stressor is consistent with the veteran's service.
    One commenter stated that the term ``confronted with an event or 
events that involved actual or threatened death or serious injury, or a 
threat to the physical integrity of self or others'' implies that a 
veteran must experience an event that is close and highly lethal. As 
stated above, there is no geographic requirement for the regulation. 
However, the stressor must be consistent with the places, types, and 
circumstances of the veteran's service. 38 U.S.C. 1154. In addition, an 
event does not have to be lethal. As provided in the rule, the 
traumatic event can involve actual or threatened serious injury, as 
well as death, or a threat to the physical integrity of the veteran or 
others.
    One commenter stated that the list of examples in the definition of 
``fear of hostile military or terrorist activity'' is incomplete and 
would ``likely result in [VA] rejecting as adequate stressors such 
events as injuring or killing of civilians.'' Another commenter 
suggested adding language to clarify that an event or circumstance does 
not have to include one of the situations listed in the definition, 
e.g., ``an actual or potential improvised explosive device; * * * 
incoming artillery, rocket, or mortar fire; grenade.'' A list of 
examples cannot reasonably include every conceivable event or 
circumstance that would qualify as hostile military or terrorist 
activity under the rule. Nevertheless, we disagree that this 
``incompleteness'' would likely result in VA rejecting events such as 
the injuring or killing of civilians. The definition of ``fear of 
hostile military or terrorist activity'' is not limited to any 
particular class of individuals. Involvement of ``actual or threatened 
death or serious injury, or a threat to the physical integrity of the 
veteran or others,'' which is not limited to military personnel, is all 
that is required to qualify as ``an event or circumstance'' within the 
meaning of the rule. Therefore, if a veteran experienced, witnessed, or 
was confronted with an event involving actual or threatened death, 
serious injury, or a threat to the physical integrity of civilians, the 
event would qualify as a stressor. Also, by using the modifying phrase 
``such as,'' VA intends to present a list of examples to illustrate 
what qualifies as an event or circumstance, not a defining restriction. 
See Donovan v. Anheuser-Busch, Inc., 666 F.2d 315, 327 (8th Cir. 1981).
    A commenter suggested that the definition of ``fear of hostile 
military or terrorist activity'' be extended to include domestic as 
well as foreign activity. The regulation is not limited to events or 
circumstances perpetrated by a foreign enemy. Therefore, VA makes no 
change based on the comment.
    Some commenters said that VA should define when a stressor would be 
considered consistent with the places, types, and circumstances of the 
veteran's service. One commenter asked whether a veteran's claimed fear 
of hostile military activity during service in South Korea after the 
Korean Conflict ended or in the continental United States after 
September 11, 2001, would be consistent with the places, types, and 
circumstances of such service. Another commenter suggested that the 
rule should explain the types of evidence needed to establish 
consistency with the places, types, and circumstances of service.
    The question of consistency is a matter involving application of 38 
U.S.C. 1154(a) and 38 CFR 3.303(a) to the myriad of facts presented by 
individual claims. We note, however, that inclusion of the conjunction 
``and'' in the statute and regulation means that a stressor must be 
consistent with all three of the enumerated criteria. Watson v. Dep't 
of the Navy, 262 F.3d 1292, 1299 (Fed. Cir. 2001). Finally, the statute 
and regulation indicate that VA is to consider the places, types, and 
circumstances of service as shown by service records, the official 
history of each organization in which the veteran served, the veteran's 
medical records, and all pertinent medical and lay evidence. Some 
commenters suggested that the rule be broadened to provide a reduced 
evidentiary standard based solely on deployment to a war zone or fear 
of such deployment, rather than on fear of hostile military or 
terrorist activity. One commenter suggested that such a rule is 
supported by the Institute of Medicine (IOM), Gulf War & Health, Vol. 
6: Physiologic, Psychologic, and Psychosocial Effects of Deployment-
Related Stress, 319 (2008) (IOM Report), which states:

    The epidemiologic literature on deployed vs[.] nondeployed 
veterans yielded sufficient evidence of an association between 
deployment to a war zone and psychiatric disorders, including 
[PTSD], other anxiety disorders, and depression; alcohol abuse; 
accidental death and suicide in the first few years after return 
from deployment; and marital and family conflict, including 
interpersonal violence.

We do not adopt this suggestion because many of the hardships related 
to deployment, such as uncertainty about the length of a tour of duty 
and lack of companionship or family contact, do not satisfy the DSM-IV 
requirements for a PTSD diagnosis, i.e., experiencing, witnessing, or 
confronting an event involving actual or threatened death or serious 
injury or threat to the physical integrity of self or others. IOM 
Report at 35-38; DSM-IV at 427. We have instead focused the rule on 
factors associated with deployment that comport with the DSM-IV 
definition of PTSD.

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    Some commenters inquired whether the rule would cover a service 
member who experienced fear of hostile military or terrorist activity 
after learning about the experiences of others with such activity but 
before being deployed to a war zone. It is not our intention that the 
new evidentiary standard apply in such a situation, and we do not 
interpret the rule to cover that situation. Such a claim would be 
adjudicated under the generally applicable standard set forth in the 
introductory text of 38 CFR 3.304(f). The IOM Committee ``defin[ed] 
deployment-related stress as deployment to a war zone'' and 
``considered that military personnel deployed to a war zone, even if 
direct combat was not experienced, have the potential for exposure to 
deployment-related stressors that might elicit a stress response.'' IOM 
Report at 13. Consistent with these findings, the rule is intended to 
apply only when the veteran's service is proximate in time and place to 
the traumatic event to which the veteran has responded with intense 
fear, helplessness, or horror. This is consistent with current 
provisions of 38 CFR 3.304(f) that do not require corroborating 
evidence of occurrence of a stressor if a veteran was diagnosed with 
PTSD in service, engaged in combat with the enemy, or was a prisoner of 
war, i.e., circumstances of service in which it is undisputed that the 
veteran was personally exposed to a stress-inducing event, making it 
unnecessary to obtain supporting documentation. See Proposed Rule, 57 
FR 34536 (Aug. 5, 1992) (not requiring corroborating evidence that a 
stressor occurred if evidence establishes that the veteran engaged in 
combat or is a former prisoner of war). A non-deployed veteran who 
learns that others were subject to a hostile military or terrorist 
activity in a war zone cannot be said to have ``experienced, witnessed, 
or [been] confronted with an event or circumstance'' within the 
contemplation of the new regulation. In such cases, the claimed 
stressor (the hostile military or terrorist activity) would not be 
consistent with the places, types, and circumstances of the veteran's 
service when the activity occurred or the veteran learned that others 
were subjected to such activity.

Coverage of Other Stressors

    VA also received comments suggesting that the rule should cover 
stressors such as MST, abuse by military personnel of subordinate 
military personnel, harassment, suicide of a fellow service member, 
witnessing a military vehicle accident in the United States, a fellow 
soldier's or sailor's post-service suicide, and social, political, and 
economic discrimination. One commenter suggested that VA should 
promulgate a similar rule to assist those with physical injuries due to 
hostile military or terrorist activity. These comments are outside the 
scope of this rule. Therefore, we make no change based on them. 
However, regarding MST, we note as well that 38 CFR 3.304(f)(5) (before 
this rulemaking codified at 38 CFR 3.304(f)(4)) permits evidence other 
than a veteran's service records to corroborate the occurrence of an 
in-service personal assault and prohibits VA from denying a claim for 
service connection for PTSD based on in-service personal assault 
without first advising the claimant that evidence from sources other 
than a veteran's service records may prove the stressor occurred.

Post-Combat Stress Disorder

    A number of commenters suggested that use of the term PTSD is 
socially stigmatizing, is embarrassing to combat veterans, and may 
cause veterans to forego needed professional treatment. One commenter 
suggested that VA re-categorize PTSD rated as 70 percent or more 
disabling as post-combat stress disorder to diminish the stigma 
associated with a diagnosis of PTSD, encourage veterans to seek 
treatment, and prevent possible suicide. As explained in 38 CFR 4.130, 
the nomenclature in the VA schedule of ratings for mental disorders is 
based upon the DSM-IV, and 38 CFR 4.125 requires that a diagnosis of a 
mental disorder conform to the DSM-IV in order to substantiate a claim. 
Because the DSM-IV does not include post-combat stress disorder as a 
diagnosis, we make no change based on these comments.

Opposition to Liberalizing Evidentiary Standard

    VA received written comments objecting to the liberalizing 
evidentiary standard for PTSD claims based on fear of hostile military 
or terrorist activity. Several commenters alleged that the rule implies 
that all a veteran must do to be granted service connection is 
communicate that he or she experienced ``fear'' to corroborate a 
stressor, will invite frivolous or fraudulent claims against the 
Federal Government, is offensive to heroic combat veterans of current 
and past wartime periods, and will delay adjudication of their claims. 
One commenter suggested that VA should re-evaluate veterans diagnosed 
with PTSD.
    The reduced evidentiary standard provided by the rule is not 
applicable solely because a veteran reports that he or she experienced 
fear. Under the rule, VA will not rely on a veteran's lay testimony 
alone to establish occurrence of the stressor unless the following 
requirements are satisfied. First, the veteran must have experienced, 
witnessed, or have been confronted by an event or circumstance that 
involved actual or threatened death or serious injury, or a threat to 
the physical integrity of the veteran or others, and the veteran's 
response to the event or circumstance must have involved a 
psychological or psycho-physiological state of fear, helplessness, or 
horror. Second, a VA psychiatrist or psychologist, or a psychiatrist or 
psychologist with whom VA has contracted, must confirm that the claimed 
stressor is adequate to support a diagnosis of PTSD and that the 
veteran's symptoms are related to the claimed stressor. Third, there 
must be in the record no clear and convincing evidence to the contrary, 
and fourth, the claimed stressor must be consistent with the places, 
types, and circumstances of the veteran's service. Because all of these 
requirements must be met for the veteran's lay testimony alone to 
establish the occurrence of the claimed stressor, we believe the 
likelihood of fraud to be minimal. Finally, 38 CFR 3.327(a) requires a 
reexamination whenever VA determines there is a need to verify either 
the continued existence or the current severity of a disability.
    This rule is not intended to discount the heroic efforts of combat 
veterans, but rather is VA's response to scientific studies related to 
PTSD and military troop deployment. As noted in the proposed rule:

    Combat is one of the most potent stressors that a person can 
experience, but as military conflicts have evolved to include more 
guerilla warfare and insurgent activities, restricting the 
definition of deployment-related stressors to combat may fail to 
acknowledge other potent stressors experienced by military personnel 
in a war zone or in the aftermath of combat. Those stressors include 
constant vigilance against unexpected attack, the absence of a 
defined front line, the difficulty of distinguishing enemy 
combatants from civilians, the ubiquity of improvised explosive 
devices, caring for the badly injured or dying, duty on the graves 
registration service, and being responsible for the treatment of 
prisoners of war.

Proposed Rule, 74 FR at 42618 (quoting IOM Report at 2). Finally, we 
believe that this rule will improve the timeliness of the adjudication 
of claims of all veterans by eliminating the need to search for 
corroborating evidence in certain cases. For these reasons, we

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make no change based on these comments.

DSM-IV Definition of PTSD

    Some commenters stated that the proposed rule is inconsistent with 
DSM-IV, which does not require ``a psychological or psycho-
physiological state of fear, helplessness, or horror'' to a traumatic 
event. Another commenter stated that VA is prohibited from using terms 
in the regulation that do not appear in DSM-IV.
    The commenters are incorrect. In order to satisfy the DSM-IV 
diagnostic criteria for PTSD, a person's response to a traumatic event 
must involve ``intense fear, helplessness, or horror.'' DSM-IV at 428. 
In addition, the traumatic event must be persistently reexperienced in 
one or more of several ways, including ``intense psychological distress 
at exposure to internal or external cues that symbolize or resemble an 
aspect of the traumatic event'' and ``physiologic reactivity on 
exposure to internal or external cues that symbolize or resemble an 
aspect of the traumatic event,'' all of which involve intense 
psychological stress or psycho-physiological response. Id. In any 
event, nothing prohibits VA from using in this regulation a term that 
does not appear in the DSM-IV. As indicated above, the nomenclature 
employed by VA in the schedule for rating mental disorders ``is based 
upon the [DSM-IV].'' 38 CFR 4.130. This rule, however, does not concern 
the evaluation of mental disorders. It liberalizes the evidentiary 
standard for corroboration of a stressor in certain cases. Using a term 
that does not appear in the DSM-IV is well within VA's authority to 
prescribe exactly which cases may benefit from the liberalized 
evidentiary standard.
    A commenter expressed concern that the rule is limited to ``fear of 
hostile or terrorist activity'' and asked whether a veteran would be 
entitled to the reduced evidentiary standard if the veteran manifested 
flashbacks and nightmares long after service. Both this rule and 
flashbacks and nightmares are related to the diagnostic criteria for 
PTSD, but they relate to distinct criteria. The rule relates to the 
criterion of a person's exposure to a traumatic event and the person's 
response to that event. See DSM-IV at 427-428. Flashbacks and 
nightmares relate to the criterion of the person's re-experiencing of 
the traumatic event. DSM-IV at 428.
    Another commenter asserted that the requirement in the rule that 
the stressor must be consistent with the places, types, and 
circumstances of a veteran's service renders the rule narrower than the 
DSM-IV definition of PTSD and that the requirement that the stressor 
relate to a veteran's fear of hostile military or terrorist activity 
narrows the DSM-IV definition of PTSD.
    As indicated above, in replying to a comment about the meaning of 
the phrase ``consistent with the * * * circumstances of service,'' 
under 38 U.S.C. 1154(a), VA must duly consider the places, types, and 
circumstances of a veteran's service as shown by the veteran's service 
record, the official history of each organization in which such veteran 
served, the veteran's medical records, and all pertinent medical and 
lay evidence. Such consideration is a general requirement that applies 
to any service connection claim, not just claims for service connection 
of PTSD. Because section 1154 is the authority for this rule, we 
incorporate the statutory requirement into the rule.
    Because the requirement that a claimed stressor relate to a 
veteran's fear of hostile military or terrorist activity has no effect 
on the diagnostic criteria for PTSD, the requirement does not narrow 
the DSM-IV definition of PTSD. The effect of the rule is to relax the 
evidentiary standard for establishing the occurrence of an in-service 
stressor for certain veterans, and the rule is limited to cases in 
which the claimed stressor is related to the veteran's fear of hostile 
military or terrorist activity for the reasons given in the notice of 
proposed rulemaking. Proposed Rule, 74 FR at 42618 (explaining that the 
rule is consistent with scientific studies related to PTSD and military 
troop deployment). The rule focuses on the procedure for establishing 
service connection for PTSD, not the criteria for establishing a 
legitimate diagnosis. Therefore, there is no inconsistency with the 
medical community at large, and we make no change based on the comment. 
In addition, the rule defines ``fear of hostile military or terrorist 
activity'' as ``involv[ing] a psychological or psycho-physiological 
state of fear, helplessness, or horror.''
    One commenter stated that fear of hostile military or terrorist 
activity may not be sufficient to give rise to a diagnosis of PTSD in 
accordance with DSM-IV absent occurrence of an actual event. We agree 
that the occurrence of an actual event or circumstance is necessary. In 
fact, as the commenter noted, the first DSM-IV diagnostic criterion for 
PTSD is exposure to a traumatic event. DSM-IV at 427. The rule does not 
permit diagnosis of PTSD in the absence of exposure to a traumatic 
event or circumstance. The rule lists several examples of events or 
circumstances that could give rise to the requisite fear. The rule 
eliminates the need for corroborating evidence of the event if the 
requirements of the rule are met.
    Another commenter asserted that the Global Assessment of 
Functioning (GAF) score has limited use and should be replaced. Axis V 
of the DSM-IV multiaxial diagnosis system measures the overall severity 
of psychiatric disturbance based on the GAF Scale, which rates an 
individual's social, occupational, and psychological functioning. VA 
regulations do not require a GAF score for purposes of determining 
whether PTSD is service connected, although the score may be required 
or requested by the Veterans Court, the Board, or a rating specialist 
for purposes of assessing the extent of disability after service 
connection has been established. This comment is therefore beyond the 
scope of this rulemaking.

Psychiatrist or Psychologist Employed by VA or With Whom VA Has 
Contracted

    The majority of comments that VA received expressed disagreement 
with the requirement that the evidentiary standard for establishing 
occurrence of the stressor will be liberalized only if ``a VA 
psychiatrist or psychologist, or a psychiatrist or psychologist with 
whom VA has contracted, confirms that the claimed stressor is adequate 
to support a diagnosis of [PTSD] and that the veteran's symptoms are 
related to the claimed stressor.'' We have grouped these comments 
together by subject matter and address them below.

Consistency With 38 U.S.C. 5125

    Some commenters asserted that the rule is contrary to 38 U.S.C. 
5125, which one commenter contended means that VA must accept the 
opinion of a private physician if the opinion is adequate for rating 
purposes. In support of this contention, the commenter relied upon the 
heading of section 5125, ``Acceptance of reports of private physician 
examinations.''
    Section 5125 provides that, ``[f]or purposes of establishing any 
claim for benefits under chapter 11 or 15 of [title 38], a report of a 
medical examination administered by a private physician that is 
provided by a claimant in support of a claim for benefits * * * may be 
accepted without a requirement for confirmation by an examination by a 
physician employed by the Veterans Health Administration [(VHA)] if the 
report is sufficiently complete to be adequate for the purpose of 
adjudicating such claim.'' (Emphasis added). Generally, use of the word 
``may''

[[Page 39847]]

suggests that a provision is permissive, not mandatory. Jama v. 
Immigration & Customs Enforcement, 543 U.S. 335, 346 (2005). See 60 FR 
27409 (May 24, 1995) (final rule amending 38 CFR 3.326 to reflect 
section 5125's authorization of private physician's examination reports 
if adequate for rating purposes). The meaning of section 5125 is plain, 
and therefore, the heading of the section cannot be used to limit its 
meaning. Bhd. of R.R. Trainmen v. Baltimore & O.R. Co., 331 U.S. 519, 
528-29 (1947). Thus, VA is not required to accept the report of a 
private physician as sufficient for rating a claim in all 
circumstances.

Alternative Qualifications for Psychiatrists and Psychologists

    Commenters wrote that VA should accept the opinion of any 
psychiatrist or psychologist who evaluates the claimed condition based 
on the DSM-IV protocol or VA's protocol for PTSD examinations or who is 
certified by the APA. Several commenters asserted that private 
physicians provide more comprehensive and/or better examinations. Other 
commenters alleged that VA examiners refuse to diagnose PTSD and that 
their examinations are inconsistent and do not comply with DSM-IV. 
Also, one commenter contended that no confirmatory evidence from a VA 
psychiatrist or psychologist should be required because these examiners 
are often biased against claimants and likely to diagnose a mental 
disorder other than PTSD.
    We decline to expand the rule to include the opinion of any 
psychiatrist or psychologist whose diagnosis conforms to DSM-IV or VA's 
protocol or who is certified by the APA because we believe that VA or 
contract examiners are uniquely qualified for the following reasons.

VA Examiners Are Trained To Provide Forensic Opinions Necessary To 
Decide PTSD Claims

    By making 38 U.S.C. 5125 discretionary rather than mandatory, 
Congress clearly recognized that there may be circumstances in which VA 
would require a confirmatory medical opinion. The situation described 
in this rule is such a circumstance because it eliminates the 
requirement of credible supporting evidence of the occurrence of an 
alleged non-combat stressor under 38 CFR 3.304(f) in the situation 
described. Because the rule permits the proof of an in-service stressor 
based on the claimant's lay statement alone, VA believes that it is 
reasonable to limit this liberalization to medical opinions from 
practitioners who it knows are well-skilled and well-equipped to 
provide such forensic evidence, rather than broaden the rule to include 
opinions from private physicians.
    VA's need for such forensic evidence is particularly important in 
the case of a claim for service connection for a mental disorder.

    When the DSM-IV categories, criteria, and textual descriptions 
are employed for forensic purposes, there are significant risks that 
diagnostic information will be misused or misunderstood. These 
dangers arise because of the imperfect fit between the questions of 
ultimate concern to the law and the information contained in a 
clinical diagnosis. * * *
    Nonclinical decision makers should also be cautioned that a 
diagnosis does not carry any necessary implications regarding the 
causes of the individual's mental disorder or its associated 
impairments.

    DSM-IV at xxiii; see VHA Directive 2008-005 (Jan. 29, 2008). 
Consistent with the DSM-IV, VA has limited the mental health 
professionals who are qualified to perform initial Compensation and 
Pension (C&P) examinations for mental disorders to highly trained 
professionals. See VBA Fast Letter 06-03 (Mar. 15, 2006).
    A C&P examination for PTSD is particularly complex because an 
examiner must: (1) Make complex judgments about potential malingering 
in the context of an administrative evaluation that will have obvious 
financial implications for a veteran;
    (2) Comprehensively diagnose all comorbid mental disorders and 
apportion disability to various disorders in veterans who increasingly 
have co-occurring mental disorders; and
    (3) Render an informed opinion about the effects of PTSD on social 
and occupational functioning, requiring a careful and often time-
consuming review of a veteran's history. Department of Veterans 
Affairs, Best Practice Manual for Posttraumatic Stress Disorder (PTSD) 
Compensation and Pension Examinations (Best Practice Manual) 21-22, 
https://www.avapl.org/pub/PTSD%20Manual%20final%206.pdf.

VA Examiners Are Well-Trained in How To Perform PTSD Examinations

    VA provides extensive guidance to VHA examiners about how to 
perform C&P examinations and gives specific guidance about PTSD 
examinations. Id. at 13-22; C&P Service Clinician's Guide (Clinician's 
Guide), ch. 14 (Mar. 2002), https://www.warms.vba.va.gov/21guides.html.

VA Certifies VA Examiners and Reviews the Quality of Examinations by VA 
and Contract Examiners

    In addition, all PTSD C&P evaluations are performed by qualified 
examiners who utilize evidence-based instruments, as recommended in the 
Fiscal Year 2007 report of the VA Special Committee on PTSD. The Under 
Secretary for Health's Post-Traumatic Stress Disorder Special 
Committee: FY 2006 Annual Report, 9 (Jun. 5, 2007). In response to the 
Special Committee's recommendation, the Compensation and Pension Exam 
Program (CPEP), in conjunction with the Employee Education System and 
VHA/DoD Program Coordination Office, established a program requiring 
training and certification of all VHA clinicians who conduct C&P 
examinations, including Fee-for-Service Providers, which program 
includes special modules and tests for initial examinations for PTSD. 
VHA Directive 2008-005. In a May 2009 report to Congress, the Special 
Committee advised that the recommendation had been ``met.''
    The CPEP office also reviews the quality of examinations of 
claimants conducted by VHA clinicians, including PTSD examinations, and 
when CPEP identifies problems in the quality of examinations, steps are 
taken to improve the quality via CPEP-sponsored conferences and 
training.
    VBA provides contract examiners with information regarding the 
requirements of C&P examinations, and the quality of examinations 
provided by VA contractors is reviewed quarterly by a physician and 
nurse employed by VBA.

VA and Contract Examiners Are Often Better Informed About the Veteran.

    In addition, VA psychiatrists and psychologists and contract 
examiners are often better informed about a veteran being examined than 
private practitioners are. When VBA requests a mental-disorder 
examination, including an examination for PTSD, it sends the claims 
folder to the examiner for the examiner's review. Manual M21-1 MR, Part 
III, subpart iv, ch. 3, sec. A, para. 1.e. The C&P examination 
worksheet for an initial evaluation for PTSD requires review of the 
veteran's claims file. The worksheet states, ``A diagnosis of PTSD 
cannot be adequately documented or ruled out without obtaining a 
detailed military history and reviewing the claims folder.'' 
Clinician's Guide at 207. A private psychiatrist or psychologist would 
not have access to such documentation before opining about whether a 
claimed stressor is adequate

[[Page 39848]]

to support a PTSD diagnosis and whether the veteran's symptoms are 
related to the claimed stressor.

VA Examiners Perform More Examinations, Thereby Ensuring Consistency in 
Evaluations.

    Finally, VA believes that the requirement in the rule for a 
confirmatory opinion from a VA psychiatrist or psychologist, or a 
psychiatrist or psychologist with whom VA has contracted, will ``ensure 
standardization and consistency of mental health evaluations and 
reporting of these evaluations.'' Proposed Rule, 74 FR at 42618. VHA 
performs over 700,000 C&P examinations annually, VHA Directive 2008-
005, at 1, and contract physicians provide approximately 120,000 C&P 
examinations annually. As explained above, CPEP reviews VHA examination 
reports, and VBA reviews the reports of contract examiners. The review 
of these reports helps to guarantee the quality and consistency of PTSD 
examinations. However, VA has no control over the quality of 
examinations performed by private healthcare providers. Because VA is 
willing to liberalize the evidentiary standard for proving a stressor 
only in cases on which it can depend on the quality of the medical 
opinion, we decline to accept the opinion of any psychiatrist or 
psychologist as suggested.
    With regard to the assertion that private physicians provide more 
comprehensive and/or better examinations, we believe that the protocol 
for initial VA examinations for PTSD, to which all VA and contract 
examiners must adhere, ensures comprehensive examinations addressing 
all aspects of a veteran's medical, social, and psychological history 
and the veteran's current mental status. Clinician's Guide at 206-12. 
We therefore make no change based on this comment.
    We are unaware of VA examiners who refuse to diagnose PTSD, are 
biased against claimants, or are likely to diagnose a mental disorder 
other than PTSD, as other commenters alleged. In fact, a VBA review 
revealed that, when C&P examinations were conducted, PTSD was diagnosed 
in 77% of initial claims. Best Practice Manual at 1, 5, 57. We believe 
that the CPEP and VBA reviews of VA and contract examinations ensure 
consistency in examinations, and if CPEP assessments identify problems, 
steps are taken to improve quality and consistency, such as CPEP-
sponsored training or recommendations to revise examination templates 
and/or worksheets. Also, if a VA examination does not comply with DSM-
IV, as the commenter alleges, the examination is returned to the 
examiner for substantiation, as required by 38 CFR 4.125(a). We 
therefore make no changes to the regulation based on these comments.

VA Social Workers, Counselors, and Former Clinicians

    Some commenters urged VA to accept confirmatory opinions from VA 
social workers, counselors, therapists, and former psychiatrists and 
psychologists. One commenter contended that consistency in examinations 
by such providers is guaranteed by VHA Handbook 1160.01, Uniform Mental 
Health Services in VA Medical Centers and Clinics, https://www1.va.gov/emshg/docs/VHA_CEMP_Uniform_Mental_Health_Services_Hndb_1160_01_61108.pdf, and VA Handbook 5005/23, Part II, Appendix G39, 
providing the requirements for appointment as a VHA social worker. As 
explained above, a C&P examination is forensic evidence for purposes of 
determining whether a veteran is entitled to disability compensation 
for PTSD and, if so, how much. This rule requires the medical opinion 
of a VA psychiatrist or psychologist, or a contract psychiatrist or 
psychologist, because VA can rely on the consistency and quality of 
examinations conducted by such individuals. These handbooks, on the 
other hand, pertain to care of VA patients, not C&P examinations, and 
to the appointment of personnel. They do not ensure the degree of 
training, information, and experience necessary to ensure quality and 
consistency in examinations.
    With regard to former VA psychiatrists and psychologists, some 
former clinicians may not have been CPEP-certified depending upon when 
they were employed by VA. In addition, their examinations would not be 
subject to ongoing CPEP review, nor would they have access to a 
veteran's claims file to conduct the review required by the PTSD 
examination protocol. Therefore, VA would be unable to ensure 
standardization, consistency, and quality of their examinations. For 
that reason, we decline to permit their medical opinions to qualify for 
the evidentiary liberalization provided by this rule.

Potential Conflict for VA Examiners

    Two commenters stated that the rule might present a conflict for a 
VA examiner who is required to act in the best interests of his or her 
patient. VBA Fast Letter 06-03 acknowledges that, ``[t]o maintain the 
integrity of the patient-provider relationship, it is preferable that a 
veteran's treating health care provider not perform the C&P 
examination,'' and advises that, when an adjudicator requests a mental-
disorder examination or opinion, the adjudicator ``specify that the 
veteran's treating health care provider should not perform the 
examination if possible.'' This should avert any conflict.

Training and Availability of VA Psychiatrists and Psychologists

    A commenter expressed concern about the training and education of 
psychiatrists or psychologists employed by VA or with whom VA has 
contracted and stated that it may be necessary for these examiners to 
receive training in military history. Another commenter said that the 
rule would require veterans to visit doctors who may be unfamiliar with 
their medical and treatment histories and could unnecessarily cause 
veterans to relive past stressors in order to establish service 
connection for a disability for which they have already been diagnosed. 
The commenter also said that the rule would impose on veterans who live 
in rural states an unreasonable burden to travel long distances to 
obtain the requisite examination by a VA psychiatrist or psychologist 
or an examiner with whom VA has contracted.
    VA examiners are well-trained in how to interact with veterans 
during a C&P examination. As explained above, the PTSD examination 
protocol requires examiners to review the veteran's claims file so that 
the examiner will be familiar with the veteran's medical and military 
history. See Best Practice Manual at 22. In addition, it is estimated 
that examiners should spend 20 minutes orienting the veteran to the 
interview, reviewing the veteran's military history, and conducting a 
trauma assessment. Id. The Best Practice Manual states at page 14 that

    it is important to explain to the claimant that it is necessary 
to obtain a detailed description of one or more traumatic events 
related to military service, in order to complete the examination. 
Further, it is helpful to alert him or her to the fact that trauma 
assessment, though brief (about 15-20 minutes), may cause some 
distress. The veteran should be advised that trauma assessment is a 
mutual and collaborative process, and that he or she is not required 
to provide unnecessarily detailed answers to all questions, if it is 
too distressing to do so.

Assessment of a personally relevant trauma proceeds only ``after 
sufficient rapport has developed and some cursory details regarding the 
context of the trauma situation(s) have been gathered.'' Id.

[[Page 39849]]

    VA recognizes that an accurate diagnosis of PTSD requires extended 
discussion of experiences that may have been extremely traumatic and 
that repression, denial, and general haziness of memories are often 
hurdles in obtaining an adequate military history. Clinician's Guide at 
196-97. Examiners are therefore advised that ``it is crucial that the 
examiner place emphasis on avoiding an authoritarian role, avoiding 
judgmental interventions, and establishing rapport through an initial 
focus on current life experiences or other discussion which encourages 
comfort in the interview.'' Id. at 197. Based upon the training 
provided to these examiners, which we have explained above, we believe 
that they are well-prepared to examine veterans while minimizing the 
risk of causing veterans undue distress through reliving of their 
traumatic experiences.
    As for the availability of examiners to provide the opinions 
required by the rule, VA intends to carefully monitor the need for 
examiners in various regions of the country and to make examiners 
available in response to demand. In fact, one reason for using contract 
examiners is to provide qualified examiners in places far from the 
closest VA medical facility.

Private Practitioners Other Than Psychiatrists and Psychologists

    Some commenters suggested that VA expand the rule to include the 
opinion of a private licensed therapist, counselor, or social worker 
who has treated the claimant. To ensure that examiners are competent to 
provide findings and opinions that are valid and necessary for rating 
purposes, VBA determined that individuals who conduct C&P mental 
disorder examinations must have specific qualifications. VBA Fast 
Letter 06-03. Only mental health professionals with the following 
credentials are qualified to perform initial C&P mental disorder 
examinations: (1) Board-certified psychiatrists or board-``eligible'' 
psychiatrists; (2) licensed doctorate-level psychologists; (3) 
doctorate-level mental health providers under the close supervision of 
a board-certified or board-eligible psychiatrist or licensed doctorate-
level psychologist; (4) psychiatry residents under the close 
supervision of a board-certified or board-eligible psychiatrist or 
licensed doctorate-level psychologist; and (5) clinical or counseling 
psychologists completing a one-year internship or residency (for 
purposes of a doctorate-level degree) under the close supervision of a 
board-certified or board-eligible psychiatrist or licensed doctorate-
level psychologist. Because VA has no guarantee that a private licensed 
therapist, counselor, or social worker who has treated a veteran has 
the qualifications required for a C&P mental disorder examination, we 
decline to adopt the commenters' suggestion.

Consideration of Veteran's Evidence

    Some commenters asserted that the requirement for a confirmatory 
opinion from a VA practitioner or contract examiner discriminates 
against veterans with PTSD or veterans whose claims are based on a 
particular type of stressor and potentially violates their right to 
equal protection under the law. Another commenter asserted that the 
rule violates due process by denying a claimant the ability to submit 
competent medical evidence from private mental health professionals to 
rebut the VA opinion. One commenter suggested that the rule should 
specifically provide for rebuttal of the VA examiner's opinion with 
non-VA evidence. Also, commenters asserted that the rule would not 
permit a veteran to submit evidence from a private physician or 
psychologist or would require VA to reject such an opinion, thereby 
conflicting with VA's obligation to consider all evidence of record, 
and would violate the benefit of the doubt rule. Another commenter 
asserted that, absent the opinion of a VA psychiatrist or psychologist 
confirming that the claimed stressor is adequate to support a PTSD 
diagnosis and that the veteran's symptoms are related to the claimed 
stressor, VA adjudicators would not weigh or analyze the evidence. 
Other commenters asserted that the rule would violate 38 CFR 3.303(a) 
and 38 U.S.C. 5107(b).
    These concerns are unfounded. Nothing in the rule precludes a 
claimant from submitting private medical evidence, permits VA to ignore 
any evidence that is submitted, or requires VA to reject an opinion 
from a private physician or psychologist. Statute and regulation 
require VA to consider all information and lay and medical evidence of 
record when deciding a claim for veterans benefits. 38 U.S.C. 5107(b); 
38 CFR 3.303(a). Service connection for PTSD requires medical evidence 
diagnosing the disability, medical evidence establishing a link between 
the veteran's current symptoms and an in-service stressor, and credible 
evidence corroborating occurrence of the stressor. 38 CFR 3.304. If a 
stressor claimed by a veteran is related to the veteran's fear of 
hostile military or terrorist activity, the evidentiary standard for 
establishing occurrence of the stressor can be reduced but only if a VA 
psychiatrist or psychologist, or a psychiatrist or psychologist with 
whom VA has contracted, confirms that the claimed stressor is adequate 
to support a PTSD diagnosis and that the veteran's symptoms are related 
to the stressor. If such confirmation is made in accordance with the 
rule, VA will not require evidence corroborating occurrence of the 
claimed stressor. Failure to obtain such confirmation, however, does 
not necessarily result in denial of the claim. If such confirmation is 
not made in accordance with the rule, VA will assist the claimant in 
obtaining evidence to corroborate occurrence of the claimed stressor. 
VA will consider all evidence of record, including evidence submitted 
by the claimant, give the claimant the benefit of the doubt when the 
evidence is in equipoise, and determine whether the requirements for 
establishing service connection for PTSD under 38 CFR 3.304(f) have 
been satisfied, notwithstanding any failure to satisfy the requirements 
of new section 3.304(f)(3). 38 U.S.C. 5103A and 5107(b); 38 CFR 
3.303(a) and 3.102.

Competent Medical Evidence

    Some commenters asserted that the requirement for confirmatory 
evidence from a VA psychiatrist or psychologist conflicts with 38 CFR 
3.159(a)(1), which defines ``competent medical evidence'' to include 
``evidence provided by a person who is qualified through education, 
training, or experience to offer medical diagnoses, statements, or 
opinions.''
    There is no conflict because the definition in Sec.  3.159(a)(1) 
concerns a matter different from the subject of this rule. This rule 
concerns whether ``credible supporting evidence'' will be required to 
establish the occurrence of a stressor in a claim for service 
connection of PTSD. Section 3.159(a)(1) defines the phrase ``competent 
medical evidence'' for purposes of explaining when VA will provide a 
medical examination or obtain a medical opinion in any service 
connection claim. See 38 U.S.C. 5103A(d)(2)(A) (VA ``shall'' provide 
medical examination or obtain medical opinion when several conditions 
are met, including that the record ``contains competent medical 
evidence'' that the claimant has a current disability or persistent or 
recurrent symptoms of disability); 38 CFR 3.159(c)(4)(i) (VA must 
provide a medical examination or obtain a medical opinion if several 
conditions are met, including that the information and evidence of 
record does not contain ``sufficient competent medical evidence''

[[Page 39850]]

to decide the claim, but contains ``competent lay or medical evidence'' 
of a current diagnosed disability or persistent or recurrent symptoms 
of disability). Thus, the existence of ``competent medical evidence'' 
in the record does not preclude VA from obtaining a medical examination 
but rather mandates an examination if the other regulatory requirements 
are satisfied. For these reasons, we make no change to the rule based 
on these comments.

Treating Physician Rule

    One commenter stated that the rule is in essence an ``anti-treating 
physician'' rule and that VA should adopt the ``treating physician'' 
rule used by the Social Security Administration. As explained above, 
the rule does not preclude a claimant from submitting and VA from 
considering evidence from the claimant's treating physician, if the 
claim cannot be granted under the new section 3.304(f)(3) procedures. 
Also, as the U.S. Court of Appeals for the Federal Circuit has 
recognized, adoption of the treating physician rule may conflict with 
the benefit of the doubt rule and would conflict with 38 CFR 3.303(a), 
which requires that service connection determinations will be based on 
the entire evidence of record and due consideration of VA's policy to 
administer the law under a broad and liberal interpretation, consistent 
with the facts of each case. White v. Principi, 243 F.3d 1378, 1381 
(Fed. Cir. 2001); 38 U.S.C. 5107 and 7104(a); 38 CFR 3.102. We 
therefore do not adopt this suggestion.

Claimant's Evidentiary Burden

    One commenter stated that the rule would increase the evidentiary 
burden on a claimant by requiring a confirmatory opinion by a VA 
psychiatrist or psychologist and a finding that the stressor is 
consistent with the places, types, and circumstances of the veteran's 
service.
    Section 3.304(f) currently requires a medical-nexus opinion linking 
a veteran's current symptoms and the claimed stressor. This rule merely 
provides a liberalized evidentiary standard in certain situations based 
on the opinion of a VA psychiatrist or psychologist. Further, the 
requirement for consistency is mandated by 38 U.S.C. 1154(a) and 38 CFR 
3.303(a). Also, pursuant to 38 U.S.C. 5103A(a) and (c), VA has a duty 
to assist a claimant for disability compensation in obtaining evidence 
necessary to substantiate the claim. In particular, VA is required to 
provide an examination or obtain a medical opinion when necessary to 
decide a claim for disability compensation. 38 U.S.C. 5103A(d). Section 
5103A(d)(3) states that an examination or opinion is necessary if the 
record contains competent evidence of a current disability or 
persistent or recurrent symptoms, indicates that the disability or 
symptoms may be associated with the claimant's active service, and does 
not contain sufficient medical evidence for VA to make a decision on 
the claim.
    One commenter asked whether the rule requires that the occurrence 
of a stressor be corroborated by evidence of a veteran's response to 
the stressor, such as behavioral changes as provided in former Sec.  
3.304(f)(4), or whether the veteran's lay testimony will be accepted as 
sufficient proof of the stressor. If the requirements of the rule are 
met, VA may accept the veteran's lay testimony as sufficient proof of 
the stressor. If, however, the requirements of the rule are not met, 
the record must contain corroborating evidence of the stressor. The 
rule does not require corroboration by evidence of the veteran's 
response, but evidence of the veteran's response is required for a 
legitimate diagnosis of PTSD resulting from exposure to the stressor. 
Furthermore, evidence of the veteran's response may be used to prove 
the occurrence of the stressor. Before deciding whether the stressor 
has been corroborated, VA will examine all the evidence of record to 
determine whether it corroborates occurrence of the stressor. See 38 
CFR 3.303(a). Also, Manual M21-1MR instructs adjudicators to review 
alternative sources of evidence that may corroborate a claimed in-
service stressor, such as a veteran's contemporaneous letters and 
diaries and performance reports. M21-1MR, Part III, subpart IV, ch. 4, 
sec. H, para. 29.i-k.

Relationship to Other Rules

    One commenter stated that the rule could be viewed as restricting 
or superseding the beneficial rule codified at 38 CFR 3.304(f)(2), 
which states that a veteran's lay testimony alone is sufficient to 
establish the occurrence of a claimed stressor if the veteran engaged 
in combat with the enemy and the claimed stressor is related to that 
combat. We make no change based on this comment because the new rule 
merely provides another avenue by which veterans seeking disability 
compensation for PTSD can establish service connection and does not 
restrict or supersede any existing VA rules intended to assist 
claimants. A qualifying veteran may still establish service connection 
under 38 CFR 3.304(f)(2) without regard to the new rule.
    Another commenter asked whether corroborating evidence of a 
stressor would be required if a veteran is not a combat veteran or does 
not qualify for the reduced evidentiary standard under this rule. 
Section 3.304(f) relaxes the ordinary evidentiary standard in other 
situations also, such as PTSD diagnosed in service, a former prisoner 
of war as claimant, and a claim based on personal assault in service. 
However, in the absence of such circumstances, VA would not grant 
service connection for PTSD unless the record contains a medical 
diagnosis of PTSD, medical evidence of a nexus between current symptoms 
and the in-service stressor, and corroborating evidence of the 
occurrence of the stressor. 38 CFR 3.304(f).

Authority for Rule

    One commenter also suggested that VA should provide a legal 
foundation for the regulation and suggests the Persian Gulf War 
Veterans Act of 1998, Public Law 105-277, Div. C, tit. XVI, sec. 1603, 
112 Stat. 2681-742, 2681-745, and the Veterans Programs Enhancement Act 
of 1998, Public Law 105-368, sec. 105, 112 Stat. 3315, 3324, which 
authorized the 2008 IOM report.
    As explained in the notice of proposed rulemaking, the authority 
for this rulemaking is 38 U.S.C. 501(a)(1), which authorizes the 
Secretary to promulgate regulations ``with respect to the nature and 
extent of proof and evidence and the method of taking and furnishing 
them in order to establish the right to benefits under such laws,'' and 
38 U.S.C. 1154(a), which requires the Secretary to ``include in the 
regulations pertaining to the service-connection of disabilities'' 
provisions requiring ``due consideration'' of the places, types, and 
circumstances of a veteran's service. Proposed Rule, 74 FR 42617. We 
make no change to the rule based on this comment because the public 
laws cited by the commenter do not authorize regulations regarding the 
nature and extent of proof and evidence necessary to establish service 
connection for PTSD.

Applicability Date

    This final rule applies to an application for service connection 
for PTSD that is received by VA on or after the rule's effective date, 
was received by VA before the rule's effective date but has not been 
decided by a VA regional office as of that date, is appealed to the 
Board on or after the rule's effective date, was appealed to the Board 
before the rule's effective date but has not been

[[Page 39851]]

decided by the Board as of that date, or is pending before VA on or 
after the rule's effective date because the Veterans Court vacated a 
Board decision on the application and remanded it for readjudication.
    Some commenters suggested that the rule should be applied 
retroactively to claims that were finally denied by VA before the 
effective date of the regulation. Another commenter suggested that the 
effective date of an award of benefits under the rule should be the 
earlier of the date of the veteran's claim or October 21, 1998, the 
date of enactment of the Persian Gulf War Veterans Act of 1998. We do 
not adopt these suggestions.
    Congress has provided that, once a decision on a claim for veterans 
benefits becomes ``final,'' ``the claim will not thereafter be reopened 
or allowed, except as may otherwise be provided by regulations not 
inconsistent with [title 38, United States Code].'' 38 U.S.C. 7105(c). 
There are only two exceptions to this statutory rule of finality. Cook 
v. Principi, 318 F.3d 1334, 1339 (Fed. Cir. 2002) (en banc). The 
Secretary must reopen a previously denied claim if new and material 
evidence is submitted, and a final VA decision is subject to revision 
based on clear and unmistakable error. 38 U.S.C. 5108, 5109A, and 7111. 
Whether a final decision involves clear and unmistakable error is 
determined under the law that was in effect when the decision was made. 
Russell v. Principi, 3 Vet. App. 310, 313-14 (1992) (en banc). This 
rule was not and will not have been in effect for a claim that was 
finally denied before the rule's effective date. Therefore, VA will not 
apply the rule to claims that were finally denied before the effective 
date of the rule unless new and material evidence is submitted.
    The effective date of benefits awarded pursuant to this rule will 
be assigned in accordance with the facts found but will not be earlier 
than the date of claim. 38 U.S.C. 5110(a). Although 38 U.S.C. 5110(g) 
and 38 CFR 3.114(a) authorize in some circumstances an effective date 
of benefits before the date of claim, those provisions are applicable 
to ``administrative issue[s]'' that liberalize the basis for benefit 
entitlement. VAOPGCPREC 11-99, para. 10 (liberalizing issue is one 
which effects substantive change in regulation and creates a new basis 
for entitlement to a benefit); S. Rep. No. 87-2042, at 2, 4, 6 (1962) 
(enactment of former sec. 3010(g) (currently sec. 5110(g)) intended to 
eliminate, when feasible, VA practice of requiring ``specific 
application for the new benefit'' whenever new regulation was 
promulgated); H.R. Rep. No. 87-2123, at 2, 4, 6 (1962) (same). This 
regulation, however, governs procedural matters rather than creating a 
new basis for entitlement to service connection for PTSD because it 
merely relaxes under certain circumstances the evidentiary standard for 
establishing occurrence of a stressor. As a result, 38 U.S.C. 5110(a), 
rather than 38 U.S.C. 5110(g), is applicable to awards under this rule. 
Although VAOPGCPREC 7-92 held that provisions in the VBA Adjudication 
Procedures Administration Manual M21-1 relieving former prisoners of 
war and combat veterans of the burden of producing evidence to 
substantiate that they experienced a stressful event are substantive 
rules, the opinion concerns the dichotomy between substantive and 
interpretive rules for purposes of determining whether notice-and-
comment rulemaking is required pursuant to 5 U.S.C. 553, a dichotomy 
that is not relevant for purposes of determining whether section 
5110(g) applies.
    Another commenter asked whether the rule would constitute new 
evidence for purposes of reopening a finally denied claim for service 
connection for PTSD. The change in the evidentiary standard for 
establishing occurrence of an in-service stressor would not constitute 
a basis on which to reopen a finally denied claim for service 
connection for PTSD because it is procedural in nature and does not 
effect a substantive change in the law governing service connection for 
disabilities. Routen v. West, 142 F.3d 1434, 1442 (Fed. Cir. 1998).
    Another commenter stated that surviving spouses should be entitled 
to receive the accrued benefits due their spouses under the rule. 
Section 5121(a) of title 38, United States Code, authorizes an award to 
certain survivors of a beneficiary of periodic monetary benefits to 
which the beneficiary was ``entitled at death under existing ratings or 
decisions, or those based on evidence in the file at date of death * * 
* and due and unpaid.'' Eligible survivors of a veteran who had filed a 
claim f