Nexus Letters for PTSD: Most Veterans Are Doing It Wrong
There’s no shortage of confusing information about nexus letters for PTSD. Many veterans do everything right — they research, find a doctor, gather evidence, wait months for a decision — only to get denied. Meanwhile, others seem to get high PTSD ratings without a letter at all.
As a veteran who’s been through the VA claim process myself, I get it. That’s why I made this guide: a clear, no-fluff breakdown of how to get a PTSD nexus letter that actually works.
You’ll learn when you really need one, where to get it, and what to include so your claim stands the best chance of approval.
Do I Need a PTSD Nexus Letter?
You may need a nexus letter for PTSD for two main reasons: an unfavorable C&P exam or a lack of evidence linking your condition to service.
Veterans generally fall into two groups — those with combat-related trauma and those with non-combat-related trauma. Nexus letters are usually more important for non-combat cases, but read this section carefully to see where you fit.
Combat-Related Causes (no nexus needed)
Combat-related PTSD is post-traumatic stress that develops from exposure to combat situations. The most common ones include:
Firefights
Ambushes
IED or blast injuries
Witnessing casualties within your unit
The VA assumes these events are traumatic, so you typically don't need a nexus letter. The exception? If your symptoms showed up more than a year later. In those cases, you might need a nexus demonstrating delayed onset of symptoms.
Non-Combat-Related Causes (nexus needed)
While not as common, plenty of you develop PTSD from non-combat events during service. These experiences include:
Training accidents
Vehicle or aircraft crashes
Base assaults
Military sexual trauma (MST)
These incidents can be just as brutal as combat trauma — especially when they involve unexpected deaths or suicides of fellow service members.
The problem? The VA doesn't automatically assume these are linked to PTSD, so you need a nexus letter establishing that connection.
Who Should Write a Nexus Letter for PTSD?
In most cases, your nexus letter needs to come from a specialist, not your primary care provider. They typically don't have the specialized training to provide the detailed VA-approved medical opinion you need.
What a PCP can do, and what I recommend, is gather a detailed history of your symptoms and medical background, as this will be important to reference in the letter.
Psychologist/Psychiatrist (Best)
The best option for a PTSD nexus letter is a psychologist or psychiatrist. These specialists know how to evaluate trauma-related conditions and understand how PTSD develops over time. Their opinion will carry the most weight with the VA.
While scheduling or cost could be hurdles, their expertise makes their evaluation far more effective for supporting your claim.
Many can also complete DBQs, which help document that the in-service event actually happened (more on that later).
Therapist (Decent)
If you can't get a letter from a psychologist or psychiatrist, a licensed therapist or counselor can be a solid backup — especially if you've been seeing them consistently over the years.
They can provide insight into your long-term symptoms, treatment progress, and how PTSD has messed with your daily life.
While their nexus letter might carry slightly less weight, their firsthand knowledge of your condition can still make a real difference in your claim.
What Should the Nexus Letter Include?
Before you ask a doctor to write your letter, you need to be deeply familiar with what the VA is looking for.
Give your doctor this checklist before they write it, and review the letter carefully yourself before submitting it.
DSM-5 PTSD Diagnosis from a Specialist
For PTSD cases, the VA only accepts diagnoses made by a qualified health professionals using DSM-5 criteria.
Your nexus letter must include:
The diagnosis from a Psychologist or Psychiatrist
A reference to DSM-5 in the letter
Approximate date of diagnosis
Luckily, Psychologists and Psychiatrists are trained to diagnoses PTSD this way, so it should be straightforward.
Proof of the In-Service Event
The VA must see clear documentation that the traumatic event actually occurred during service — especially for non-combat cases, which often go unrecorded.
Examples of acceptable evidence include:
Service treatment records documenting injuries from a training accident
Official reports of a vehicle or aircraft crash
Unit logs showing exposure to base assaults or other incidents
Personnel records indicating behavioral changes or performance drops
If documentation is limited, buddy statements can help fill the gaps.
These are statements from fellow service members, friends, or family who can confirm the event or describe how your behavior changed after it.
Documentation of Symptom Timeline
When preparing your nexus letter, be clear and specific about your symptom history. The VA looks for consistency over time — not short spikes that disappear. Use this checklist to organize your information:
When symptoms began: Ideally within one year of discharge. If onset occurred later, your doctor must explain why and how this delayed onset developed.
Severity: Describe how symptoms impacted your daily functioning (sleep, work, relationships).
Progression: Note how symptoms worsened or changed over time, supported by medical or therapy records.
If your service records don’t fully capture your timeline, buddy or lay statements can fill those gaps.
These statements serve as credible secondary evidence showing the continuity of your symptoms after service.
Rule Out Alternative Causes
This is where many PTSD nexus letters fall short. The provider must explain why your PTSD isn’t caused by something else — like preexisting conditions or post-service events.
The letter should:
Acknowledge any prior medical or mental health history
Explain why those earlier issues did not cause or contribute to current PTSD
Emphasize how military service directly worsened or triggered symptoms
Example:
“While the veteran experienced mild anxiety before enlistment, the frequency and intensity of night terrors increased dramatically following the 2008 blast exposure, indicating aggravation by military service.”
Doctors often forget to include this reasoning, and the VA assumes another cause — leading to a denial.
Medical Rationale
This is the most important part of the nexus letter — the medical logic connecting your PTSD to your service.
The provider must explicitly write:
“It is at least as likely as not (50% or greater probability) that the veteran’s PTSD was caused by, or aggravated by, their military service.”
That single sentence carries enormous legal weight.
Without it, the VA can’t legally grant service connection — no matter how strong the rest of your evidence is.
To make it stronger, apply the “1:1 rule”: Every factual statement in the letter should be backed by a piece of supporting evidence — a record, date, or observed symptom
How to Get a Nexus Letter for PTSD
Finding the right doctor to write your letter is crucial, and is something that should not be rushed.
In many cases, it’s a numbers game. You might get some rejections initially, but it's absolutely worth the time to find a quality one.
Step 1: Start with Free Options
Begin at your local VA medical center. VA doctors rarely write nexus letters, but they can still point you towards qualified providers.
When you call or visit, ask for a social worker or mental health case manager and explain that you're looking for community providers who handle VA disability evaluations.
Pro tip: You're more likely to succeed if you phrase it as a "medical opinion connecting your condition to PTSD" instead of a "nexus letter". People often get confused by that term and might not want to deal with it.
Step 2: Check Local Directories
If the VA can’t help, search Psychology Today or your state licensing board for providers specializing in PTSD, veterans, or forensic evaluations.
On Psychology Today:
Get Help → Talk to Someone → Find a Psychiatrist/Psychologist, then search your city or state.
Prefer profiles with:
MD/DO (Psychiatrists) or PhD/PsyD (Psychologists)
Mentions of PTSD, veterans/military, or disability evaluations/IME reports
Forensic psychologists are often best — they’re familiar with legal-style documentation like nexus letters.
Step 3: Reach Out to VSOs
Veteran Service Organizations (VSOs) often maintain lists of trusted providers who understand VA standards.
Try:
Disabled American Veterans (DAV)
Veterans of Foreign Wars (VFW)
American Legion
A quick call can get you referrals to doctors experienced in VA evaluations.
Step 4: Paid Companies (last resort)
If you can’t find a local provider, some companies specialize in nexus letters — but quality varies dramatically.
Before paying, make sure to:
Verify credentials: Get the full name, license number, and specialty of the letter writer.
Review sample quality: Letters should include detailed reasoning, not generic statements.
Check reviews carefully: Use veteran forums, Trustpilot, or Google; watch for fake 5-star reviews or “guaranteed approval” claims.
A good company can save you time, a bad one can waste money and hurt your claim.
Step 5: Provide a Template or Example
Doctors often decline nexus letters because they’re complex and time-consuming. Writing a template is the single most important thing you can do to increase your chances of success.
Doing your own research not only takes some stress off your doctor's end, but also shows the VA your initiative and effort — which they love.
The template should include:
Relevancy of your medical information
VA specific language
How to phrase their reasoning
Keep it simple — you're not telling them what to write, just giving them the format that the VA recognizes.
PTSD Nexus Letter Example
This is an nexus letter example presents a fictional case of a veteran who experienced a serious training accident during basic training.
In this scenario, the veteran witnessed a live grenade malfunction, resulting in severe injuries to fellow trainees.
Dr. Jane Smith, PsyD – Licensed Psychologist
123 Main Street • City, State, ZIP
Phone: (555) 123-4567
Date: October 11, 2025
To Whom It May Concern:
I have evaluated and treated Sergeant First Class Michael Thompson for Post-Traumatic Stress Disorder (PTSD). I am a licensed psychologist with over 15 years of experience in trauma and stressor-related disorders.
Mr. Thompson’s PTSD diagnosis was confirmed using DSM-5 diagnostic criteria and documented on VA Form 21-0960P-3 (PTSD Disability Benefits Questionnaire). His symptoms include intrusive nightmares, avoidance behaviors, hypervigilance, irritability, and persistent negative mood and cognition.
Annotation: Listing symptoms directly from DSM-5 improves credibility and shows diagnostic alignment.
During basic training in 2008, Mr. Thompson was exposed to a live grenade malfunction during a supervised exercise. Several trainees sustained severe injuries, and he directly witnessed the event. This incident is recorded in his service treatment records (STRs) and supported by two buddy statements (VA Form 21-10210) submitted with his claim.
Annotation: Adding exact forms and evidence types signals strong documentary support.
Within weeks of the incident, he began experiencing nightmares related to the explosion, exaggerated startle response, and avoidance of training environments. These symptoms were noted in mental health clinic notes from Fort Benning (June 2008) and have persisted since that time.
Annotation: Linking symptom onset to dated records builds a clear nexus timeline.
I reviewed his entire C-file, service treatment records, prior VA mental health evaluations, and therapy progress notes (2020–2025). The continuity of symptoms from service to present day demonstrates a direct and ongoing connection to the in-service trauma.
Other potential causes for his symptoms were carefully ruled out. He has no documented pre-service psychiatric history, no traumatic brain injury, and no non-service trauma that could explain his condition. He also denies substance abuse or other lifestyle factors that might contribute to his PTSD.
Annotation: Eliminating other possible causes strengthens the “at least as likely as not” standard.
Based on my review and clinical evaluation, it is my professional opinion that Sergeant First Class Michael Thompson’s PTSD is at least as likely as not (50% or greater probability) caused by or aggravated by his military service, specifically the 2008 live-grenade training accident.
This opinion is rendered using the VA’s “at least as likely as not” evidentiary standard and is supported by objective documentation, consistent symptom presentation, and the absence of alternative explanations.
Annotation: Restating the VA standard verbatim ensures the letter meets adjudication requirements.
Sincerely,
[Signature]
Dr. Jane Smith, PsyD
Licensed Psychologist
This example is longer than what most veterans expect, but that’s intentional — the VA looks for detailed, well-supported letters that clearly connect your condition to your service.
This sample is for educational purposes only and should not be used as an official medical or legal document.
Final Thoughts on PTSD Nexus Letters
Navigating a PTSD claim with the VA can feel overwhelming, but a well-prepared nexus letter can make all the difference.
Whether you’re dealing with a non-combat trauma, a secondary PTSD claim, or an unfavorable C&P exam, the right letter connects your condition directly to your service and strengthens your case.
By understanding what the VA expects, finding the right provider, and ensuring your letter includes clear medical reasoning, you can give your claim the best chance of success.
Remember, a nexus letter is not just a form — it’s the key piece of evidence that turns your service and experiences into a compelling, service-connected claim
FAQ
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You can get a higher VA rating for PTSD if your symptoms have worsened or if you are claiming that your PTSD caused another condition. Secondary conditions can include hypertension, sleep apnea, or migraines. In both cases, a nexus letter is needed to show the connection to your service-related PTSD
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A 70% PTSD rating generally means your condition causes occupational and social impairment with deficiencies in most areas. This can include trouble completing tasks at work, difficulty maintaining relationships, periods of near-continuous depression or anxiety, and trouble handling stress. You might also experience withdrawal from family or friends, flattened affect, or occasional suicidal thoughts. The key is that your symptoms seriously disrupt most areas of your life, even if they aren’t constant
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Denials usually happen if another condition or life event is seen as the main cause of symptoms, or if a C&P exam is unfavorable. A strong nexus letter and supporting documentation are usually the key to avoiding these issues
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PTSD is diagnosed when a veteran has been exposed to a traumatic event and experiences symptoms like intrusive memories, avoidance, negative mood changes, or hyperarousal. These symptoms must last more than a month and cause significant problems in work, relationships, or daily life
