Disability Benefits Questionnaire - Initial Post Traumatic Stress Disorder (Ptsd) (Page 6 of 7) in pdf

Disability Benefits Questionnaire

Initial Post Traumatic Stress Disorder (PTSD)

* Internal VA or DoD Use Only*

Criterion B: The traumatic event is persistently reexperienced in 1 or more of the following ways:

Recurrent and distressing recollections of the event, including images, thoughts or perceptions

Recurrent distressing dreams of the event

Acting or feeling as if the traumatic event were recurring; this includes a sense of reliving the

experience, illusions, hallucinations and dissociative flashback episodes, including those that occur

on awakening or when intoxicated

Intense psychological distress at exposure to internal or external cues that symbolize or resemble

an aspect of the traumatic event

Physiological reactivity on exposure to internal or external cues that symbolize or resemble an

aspect of the traumatic event

The traumatic event is not persistently reexperienced

Criterion C: Persistent avoidance of stimuli associated with the trauma and numbing of general

responsiveness (not present before the trauma), as indicated by 3 or more of the following:

Efforts to avoid thoughts, feelings or conversations associated with the trauma

Efforts to avoid activities, places or people that arouse recollections of the trauma

Inability to recall an important aspect of the trauma

Markedly diminished interest or participation in significant activities

Feeling of detachment or estrangement from others

Restricted range of affect (e.g., unable to have loving feelings)

Sense of a foreshortened future (e.g., does not expect to have a career, marriage, children or a

normal life span)

No persistent avoidance of stimuli associated with the trauma or numbing of general

responsiveness

Criterion D: Persistent symptoms of increased arousal, not present before the trauma, as indicated by 2 or

more of the following:

Difficulty falling or staying asleep

Irritability or outbursts of anger

Difficulty concentrating

Hypervigilance

Exaggerated startle response

No persistent symptoms of increased arousal

Criterion E:

The duration of the symptoms described above in Criteria B, C and D are more than 1 month.

The duration of the symptoms described above in Criteria B, C and D are less than 1 month.

Veteran does not meet full criteria for PTSD

Criterion F:

The PTSD symptoms described above cause clinically significant distress or impairment in social,

occupational, or other important areas of functioning.

The PTSD symptoms described above do NOT cause clinically significant distress or impairment in

social, occupational, or other important areas of functioning.

Veteran does not meet full criteria for PTSD

b. Which stressor(s) contributed to the Veterans PTSD diagnosis?:

Stressor #1

Stressor #2

Stressor #3

Other, please indicate stressor number (i.e. stressor #4, #5, etc.) as indicated above): _________

Disability Benefits Questionnaire - Initial Post Traumatic Stress Disorder (Ptsd) Page 6

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