That could soon change.
The Veterans Affairs Department has proposed reducing the paperwork required for veterans to show their experience caused combat-related stress. Even just the fear of hostile action would be sufficient, as long as a VA psychologist or psychiatrist agreed.
The VA says the change would streamline claims and recognize the "inherently stressful nature" of war service. The agency is accepting comment until Oct. 23.
Sen. Patty Murray, D-Wash., called it a significant shift in policy.
"Before, and for a long time, I've been fighting many times over for the VA not to discourage people from saying they have PTSD," said Murray, who serves on the Senate Veterans' Affairs Committee. "We've have many cases where veterans were told it's all in your head."
Post-traumatic stress disorder can affect anyone who is traumatized by an experience. From the Iraq and Afghanistan wars, more than 134,000 veterans have sought help at a VA facility for possible PTSD, the VA says. The symptoms include flashbacks and anxiety, and for some, it's so debilitating that it makes it difficult to work after they leave the military.
While praising the VA's effort, veterans service organizations have questioned the requirement for a VA psychologist or psychiatrist to agree the experience caused the disorder. Rep. John Hall, D-N.Y., who chairs a subcommittee with oversight over the disability claims system, said he's concerned that the proposed rule isn't comprehensive enough.
The debate is a reflection of the changing battlefield.
A World War II-era law established that veterans who "engaged in combat with the enemy" receive special treatment when they seek disability compensation, so it's less burdensome to prove an injury was from war service.
Troops from an infantry or special forces unit are awarded a badge that makes it easier to prove they engaged in combat.
Truck drivers, cooks and others in support roles aren't eligible for the badge but can use other types of documentation or medals, such as a Purple Heart, to prove they were in combat.
But veterans and service organizations that work with them have said doing so is often incredibly difficult, in part because of the lack of paperwork kept by many units. About half of all post-traumatic stress disability claims filed by veterans are denied - with the majority of denials coming because the veteran lacks sufficient documentation, the VA has said.
The VA said it does not have an estimate of the number of veterans who would likely fall under the policy change, nor does it have a cost estimate.
In 2008, a Congressional Budget Office estimate, on legislation that would have made a similar change, concluded it would cost billions over a nine-year period. Based on 2006 figures, it said the average payout for a PTSD claim was $543 a month.
Natalie MacLeod, 51, a mother of five from Lowell, Mass., who served in Iraq is among the veterans hopeful that the proposed rule change will help her. She said she's been denied PTSD disability benefits because of a lack of documentation, even though she's been diagnosed with PTSD.
"The VA will diagnose you with the PTSD and then the VA will turn you down, which is what I'm fighting right now," said MacLeod, who said she was a cook and did administrative work for her Army Reserves unit.
At a hearing last week on the issue, representatives from veterans service organizations testified that many veterans go to private mental health providers for treatment. They said the law requires the VA to consider private medical evidence when considering claims, and asked the VA to allow that in these types of cases.
Hall said he thinks that in addition to fear, if veterans could show feelings of helplessness or horror while at war caused their PTSD, they should also be eligible under the new rule.
Bradley G. Mayes, director of compensation and pension service at the Veterans Benefits Administration, who attended the hearing, said the VA is considering all meaningful comments.
Christina Roof, national deputy legislative director for advocacy group AMVETS, said while the rule change isn't perfect, "it's a step forward. It's not a cure-all, but we need to so something now."