M21-1 Manual / Part VIII, Subpart iv, Chapter 1, Section D

Evidence Evaluation and Decisions for Posttraumatic Stress Disorder (PTSD) Claims

M21-1, Part VIII, Subpart iv, Chapter 1, Section D

Overview

In This Section

This section contains the following topics:

Topic	Topic Name
1	General Information on Rating PTSD
2	Evaluating Evidence and Deciding a Claim for Service Connection (SC) for PTSD

1. General Information on Rating PTSD

Introduction

This topic contains general information about rating PTSD, including

responsibility of the Rating Veterans Service Representative (RVSR) or Decision Review Officer (DRO) in deciding SC for PTSD
requirements for establishing SC for PTSD from in-service stressors
considering the relationship between stressor and symptoms
handling an in-service diagnosis of PTSD, and
in-service diagnosis of PTSD related to a pre-service stressor.

Change Date

July 29, 2021

VIII.iv.1.D.1.a. Responsibility of the RVSR or DRO in Deciding SC for PTSD

Deciding the issue of service connection (SC) for posttraumatic stress disorder (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 Compensation Service on complex cases.Reference: For more information on requesting Compensation Service assistance, see M21-1, Part X, Subpart v. 1.A.

VIII.iv.1.D.1.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 occurred

Reference: For more information on establishing SC for PTSD, see

VIII.iv.1.D.1.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 VIII, Subpart iv, 1.C.2.

VIII.iv.1.D.1.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
considerations to make when the evidence establishes a diagnosis of PTSD during service, see 38 CFR 3.304(f)(1)
when a Veteran’s testimony alone may establish a claimed stressor, see M21-1, Part VIII, Subpart iv, 1.A.3.b, and
developing for in-service mental health records, see
M21-1, Part VIII, Subpart iv, 1.A.2, and
M21-1, Part III, Subpart i, 2.E.1.e.

VIII.iv.1.D.1.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.

2. Evaluating Evidence and Deciding a Claim for SC for PTSD

Introduction

This topic contains information about deciding a claim for SC for PTSD, including

determining the occurrence of stressors when making the decision
determining combat service
considering evidence of engagement in combat
establishing a stressor related to the fear of hostile military or terrorist activity
establishing SC for PTSD related to drone aircraft crew member duties
requirement for credible supporting evidence of a stressor
identifying credible supporting evidence of a stressor when lay testimony is not sufficient
reviewing evidence for corroboration of a stressor
denying a PTSD claim because of an uncorroborated stressor, and
disposition of an issue claimed and/or developed as SC for PTSD.

Change Date

June 30, 2025

VIII.iv.1.D.2.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 VIII, Subpart iv, 1.A.

VIII.iv.1.D.2.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 (serves to establish the fact at issue) of 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
determining combat service, see M21-1, Part VIII, Subpart iv, 1.A
when to proceed with an examination in a PTSD claim, see M21-1, Part VIII, Subpart iv, 1.C.1.a
the need to determine combat involvement in PTSD claims, see Gaines v. West, 11 Vet. App. 113 (1998), and
what evidence may be used to support a determination that a Veteran engaged in combat, see VAOPGCPREC 12-1999.

VIII.iv.1.D.2.c. Considering Evidence of Engagement in Combat

Although evidence from sources other than service records 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 determining combat service, see M21-1, Part VIII, Subpart iv, 1.A.

VIII.iv.1.D.2.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. 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. Notes:
As of July 28, 2021, for PTSD claims granted under the authority of 38 CFR 3.304(f)(3), adjudicators must determine if an effective date under 38 CFR 3.114(a)(3) is warranted.
Historically, the Department of Veterans Affairs (VA) did not consider the July 13, 2010, amendment of 38 CFR 3.304(f) a liberalizing rule under 38 CFR 3.114(a). However, on July 28, 2021, the U.S. Court of Appeals for the Federal Circuit found in Ortiz v. McDonough, 6 F. 4th 1267 (Fed. Cir. 2021) that the addition of 38 CFR 3.304(f)(3) in 2010 was a liberalizing regulatory change under 38 CFR 3.114(a).
Decisions that were final prior to July 28, 2021, and that were based on VA’s interpretation of its regulations in place at that time, are not a clear and unmistakable error (CUE) under 38 CFR 3.105(a).
Example: A Veteran filed an initial claim for SC of PTSD on June 20, 2009. Evidence shows the Veteran served in an area of hostile military and terrorist activity in 2005 and that he was diagnosed with PTSD in June 2009 by VA examination. The June 2009 examiner confirmed that the claimed stressor was adequate to support a diagnosis of PTSD and that the Veteran's symptoms were related to the claimed stressor; however, the claim was denied because the stressor could not be verified. On May 5, 2021, the Veteran filed a supplemental claim with new and relevant evidence. The supplemental claim is being decided after July 28, 2021. Result: The Veteran is entitled to an effective date of May 5, 2020, one year prior to the date of claim, under 38 CFR 3.114(a), because
the claim was pending on or after July 28, 2021, the date of the Ortiz decision
the supplemental claim was filed after the prior claim became finally adjudicated
the Veteran met all eligibility criteria for the liberalizing change at the time it took effect in July 2010, specifically,
there was a diagnosis of PTSD
the stressor related to the PTSD satisfied the regulatory requirements for fear of hostile military or terrorist activity provided in 38 CFR 3.304(f)(3), and
a VA or VA-contracted psychiatrist or psychologist confirmed that the claimed stressor was adequate to support a diagnosis of PTSD and that the Veteran's symptoms were related to the claimed stressor
PTSD is being granted based on a fear-based stressor under 38 CFR 3.304(f)(3), and
the Veteran’s claim was filed more than one year after the July 2010 liberalizing change.
References: For more information on
supplemental claims received after the prior claim has become finally adjudicated, see M21-1, Part X, Subpart ii, 2.A.3.c
determining whether 38 CFR 3.114(a) applies, see M21-1, Part V, Subpart ii, 4.A.6.h
determining CUEs, see
M21-1, Part X, Subpart ii, 5.A, and
George v. McDonough, 991 F.3d 1227 (Fed. Cir. 2021)
stressors related to fear of hostile military or terrorist activity, see M21-1, Part VIII, Subpart iv, 1.A.3, and
when to proceed with an examination in a PTSD claim, see M21-1, Part VIII, Subpart iv, 1.C.1.a.

VIII.iv.1.D.2.e. Establishing SC for PTSD Related to 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 under 38 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 PTSD and service as a drone aircraft crew member.

References: For more information on

when the claimant’s lay testimony alone may establish duties as a drone aircraft crew member, see M21-1, Part VIII, Subpart iv, 1.A.3.b
establishing a stressor related to drone aircraft duties, see M21-1, Part VIII, Subpart iv, 1.A.3.l, and
when to proceed with an examination in a PTSD claim, see M21-1, Part VIII, Subpart iv, 1.C.1.a.

VIII.iv.1.D.2.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 VIII, Subpart iv, 1.A.3.c.

VIII.iv.1.D.2.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

service treatment records (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 a record of the Veteran’s medical treatment after an accident.

VIII.iv.1.D.2.h. Reviewing Evidence for Corroboration of a Stressor

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. If these sources do not contain the necessary information, review other sources of evidence carefully and critically for their adequacy and reliability. 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 VIII, Subpart iv, 1.A.3.d.

VIII.iv.1.D.2.i. 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

Records Acquisition and Research (RAR) 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 RAR requests a more specific description of the stressor in question, follow the procedures in M21-1, Part VIII, Subpart iv, 1.A.2.g-i to 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

reviewing for credible supporting evidence of a stressor, see M21-1, Part VIII, Subpart iv, 1.A.3.c
development for medical evidence, service records, and stressor information, see M21-1, Part VIII, Subpart iv, 1.A, and
requesting corroboration of an in-service stressor, see M21-1, Part VIII, Subpart iv, 1.A.4.

VIII.iv.1.D.2.j. Disposition of an Issue Claimed and/or Developed as SC for PTSD

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 the requirement for a current disability, see M21-1, Part V, Subpart ii, 2.A.1.b, and competent medical evidence, see M21-1, Part V, Subpart ii, 1.A.2.c.
there is current PTSD, *but* either the claimant failed to provide sufficient information about a claimed in-service stressor, or a sufficiently described stressor could not be established		deny the claim on the basis that a stressor has not been established. *Note: The rating decision should note the request(s) for information. References*: For more information on actions that must be completed to verify a claimed in-service stressor, see M21-1, Part VIII, Subpart iv, 1.A.3.d, and prerequisites to denying a claim because of an uncorroborated stressor, see M21-1, Part VIII, Subpart iv, 1.D.2.i.
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 VIII, Subpart iv, 1.A.3.b, *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 credible supporting evidence of the claimed stressor, or sufficient proof of a stressor falling into one of the types listed in M21-1, Part VIII, Subpart iv, 1.A.3.b, *and* the diagnosis of PTSD is based upon the established 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 trauma, including military sexual trauma (MST) service records (and alternative evidence, if any was identified and obtained) do not establish the occurrence of the claimed in-service personal traumatic event(s), *and* the examiner interprets markers as supportive of the occurrence of personal trauma, *and* links the diagnosis to the claimant’s reported personal traumatic event(s),*but* determines that a diagnosis other than PTSD (depression, chronic adjustment disorder, generalized anxiety disorder, bipolar disorder, for example) more accurately describes the current disability		deny the claim. *Explanation*: Non-PTSD diagnoses must be adjudicated under the general SC provisions of 38 CFR 3.303, which require sufficient documentary evidence of the in-service event.For non-PTSD diagnoses, there is no provision for establishing the occurrence of an MST or other personal traumatic event in service based only on a marker(s) and the examiner’s acceptance of the Veteran’s lay statement of the event.References: For more information on reviewing for credible evidence of a personal trauma stressor, see M21-1, Part VIII, Subpart iv, 1.B.2.c alternative sources of evidence of personal trauma, see M21-1, Part VIII, Subpart iv, 1.E.1.c, and evidence that may constitute a marker of a personal traumatic event to support a claim for PTSD, see M21-1, Part VIII, Subpart iv, 1.E.1.d.
the claim is based on personal trauma, including MST service records and/or alternative evidence is/are sufficient to establish that the claimed in-service personal traumatic event(s) occurred, and the examiner links a diagnosis to the claimant’s history of personal trauma, but determines that a diagnosis other than PTSD (depression, chronic adjustment disorder, generalized anxiety disorder, bipolar disorder, for example) more accurately describes the current disability		grant the claim. *Explanation: Non-PTSD diagnoses must be adjudicated under the general SC provisions of 38 CFR 3.303, which require sufficient documentary evidence of the in-service event. Here there are records supporting that the in-service event occurred. References*: For more information on reviewing for credible evidence of a personal trauma stressor, see M21-1, Part VIII, Subpart iv, 1.B.2.c, and alternative sources of evidence of personal trauma, see M21-1, Part VIII, Subpart iv, 1.E.1.c.
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, for example) more accurately describes the current disability		before making a decision, proceed with development research as described in M21-1, Part VIII, Subpart iv, 1.A.3.d, 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 SC provisions of 38 CFR 3.303, which require sufficient documentary evidence of the in-service event. For non-PTSD diagnoses, 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 or non-PTSD diagnoses arising after service and claimed to be related to an in-service stressor event. References: For more information on

PTSD developing in service due to
- an in-service stressor, see M21-1, Part VIII, Subpart iv, 1.D.1.d, and
- a pre-service stressor, see M21-1, Part VIII, Subpart iv, 1.D.1.e
general procedures for rating mental disorders, see M21-1, Part V, Subpart iii, 13
evaluating evidence and making a decision, see M21-1, Part V, Subpart ii, 1, and
sympathetic reading and determining the scope of a claim based on a mental disorder, see
- M21-1, Part V, Subpart iii, 13.1.a, and
- M21-1, Part V, Subpart ii, 3.A.1.g.

Source: VA M21-1 Adjudication Procedures Manual, M21-1, Part VIII, Subpart iv, Chapter 1, Section D (U.S. government work, reproduced for reference). Browse all sections →