                               COURT OF APPEALS OF VIRGINIA


Present: Chief Judge Fitzpatrick, Judges Elder and Bumgardner
Argued at Richmond, Virginia


PETERSBURG (CITY OF) FIRE & RESCUE AND
 VIRGINIA MUNICIPAL GROUP
 SELF-INSURANCE ASSOCIATION
                                                              MEMORANDUM OPINION* BY
v.     Record No. 0328-04-2                                     JUDGE LARRY G. ELDER
                                                                   OCTOBER 5, 2004
BARRY WAYNE WELLS


              FROM THE VIRGINIA WORKERS’ COMPENSATION COMMISSION

                 Ralph L. Whitt, Jr. (Michael P. Del Bueno; Whitt & Associates, on
                 briefs), for appellants.

                 Jean M. McKeen (Fitzgerald, Tomlin & McKeen, PLLC, on brief),
                 for appellee.


       The City of Petersburg Fire & Rescue and Virginia Municipal Group Self-Insurance

Association (employer) appeal from a decision of the Workers’ Compensation Commission

awarding benefits to Barry Wayne Wells (claimant) for the occupational disease of

post-traumatic stress disorder (PTSD). Employer contends no credible evidence establishes that

claimant had PTSD. In the alternative, it argues no evidence proved that his PTSD was a disease

as opposed to an injury by accident or that it was caused by his employment. We hold credible

evidence supported the commission’s findings, and we affirm the award of benefits.

                                                  I.

       Guided by well-established principles, we construe the evidence in the light most

favorable to the party prevailing below, claimant in this instance. Crisp v. Brown’s Tysons


       *
           Pursuant to Code § 17.1-413, this opinion is not designated for publication.
Corner Dodge, Inc., 1 Va. App. 503, 504, 339 S.E.2d 916, 916 (1986). “If there is evidence, or

reasonable inferences can be drawn from the evidence, to support the Commission’s findings,

they will not be disturbed on review, even though there is evidence in the record to support a

contrary finding.” Morris v. Badger Powhatan/Figgie Int’l, Inc., 3 Va. App. 276, 279, 348

S.E.2d 876, 877 (1986); see Code § 65.2-706. In determining whether credible evidence exists

to support the commission’s findings of fact, “the appellate court does not retry the facts,

reweigh . . . the evidence, or make its own determination of the credibility of the witnesses.”

Wagner Enters. v. Brooks, 12 Va. App. 890, 894, 407 S.E.2d 32, 35 (1991).

       The commission’s determination regarding causation is a finding of fact. Marcus v.

Arlington County Bd. of Supervisors, 15 Va. App. 544, 551, 425 S.E.2d 525, 530 (1993). A

finding of causation need not be based exclusively on medical evidence. Dollar Gen’l Store v.

Cridlin, 22 Va. App. 171, 176, 468 S.E.2d 152, 154 (1996). “The testimony of a claimant may

also be considered in determining causation, especially where the medical testimony is

inconclusive.” Id.; see also Lee County Sch. Bd. v. Miller, 38 Va. App. 253, 260, 563 S.E.2d

374, 378 (2002). Unless we can say as a matter of law that claimant failed to sustain his burden

of proving causation, the commission’s findings are binding and conclusive upon us. Marcus, 15

Va. App. at 551, 425 S.E.2d at 530; Tomko v. Michael’s Plastering Co., 210 Va. 697, 699, 173

S.E.2d 833, 835 (1970).

                                                 A.

                               CREDIBLE EVIDENCE OF PTSD

       Employer contends first that the record contains no credible evidence to establish

claimant had PTSD. Employer acknowledges claimant was diagnosed with PTSD. However,

employer argues that claimant’s reports to health care providers regarding his symptoms were




                                              -2-
inconsistent and that these inconsistencies call the diagnosis into doubt. We hold credible

evidence supports the PTSD diagnosis.

       Three of the four health care providers who treated claimant for his condition opined that

he suffered from PTSD. Gary Gaulin, L.P.C., formulated a diagnosis of PTSD when he first saw

claimant on November 12, 2001. When claimant was referred to Dr. Richard Bowers, a licensed

clinical psychologist, for confirmation of this diagnosis in February 2002, Bowers interviewed

claimant, performed a battery of tests, and “confirm[ed] the diagnosis,” writing “it is fair to

characterize [claimant’s ‘symptoms of depression, anxiety, and intrusive thoughts’] as PTSD.”

Dr. James Wooldridge, the psychiatrist who monitored claimant’s medication, subsequently

agreed with Dr. Bowers’s diagnosis, writing that claimant’s “depression, anxiety, [and] sleep

problems [are] best described at this point with a [diagnosis of] Post Traumatic Stress Disorder”

that is “chronic.”

       The fact that claimant never told Barbara Cabrinha, L.P.C., or Chief James Wallace about

his nightmares and flashbacks and did not tell Counselor Gaulin and Dr. Wooldridge about them

until after he had met with each of them several times does not compel a different result.

Claimant testified that he did not tell Cabrinha, the employee assistance program counselor with

whom he had only four sessions, about his work-related nightmares because he did not feel

comfortable with her or because he simply was not ready to discuss them. Both claimant’s

testimony and the opinions of his physicians, viewed in the light most favorable to claimant,

established that the work incidents about which claimant had flashbacks and nightmares were

traumatic to him, and Dr. Wooldridge noted that claimant “tries to avoid talking about these

episodes.” Thus, claimant’s testimony and medical records provided credible evidence to

support the commission’s implicit finding that claimant suffered from PTSD, despite claimant’s

delayed reporting of some of his symptoms.

                                              -3-
                                                  B.

                  CREDIBLE EVIDENCE THAT CLAIMANT’S PTSD WAS
                            A DISEASE UNDER THE ACT

       Employer contends next that claimant failed to prove his condition was a disease as that

term is defined in the Act. It also contends he failed to prove it was not an injury by accident,

another necessary component to proving his entitlement to compensability of the condition as a

disease under the Act. We hold the Court’s decision in Fairfax County Fire & Rescue Dep’t v.

Mottram, 263 Va. 365, 559 S.E.2d 698 (2002), aff’g in part and rev’g in part 35 Va. App. 85,

542 S.E.2d 811 (2001), stands for the proposition that an ailment diagnosed as PTSD may be

classified as either a disease or an injury by accident under the Act, depending on the facts of

each case, but that if a claimant proves the ailment did not occur as a result of a specific injury,

the commission may, without further proof, infer that it is a disease under the Act, absent

evidence to the contrary.

       “[W]hether a claimant suffers from a disease within the contemplation of the Act is a

mixed question of law and fact, and whether a proper definition has been used to test the

authenticity of a doctor’s opinion is strictly a legal one.” Stenrich Group v. Jemmott, 251 Va.

186, 198, 467 S.E.2d 795, 801 (1996).

       “PTSD may be compensable as an ‘injury by accident’ or as an ‘occupational disease,’

depending on how it develops.” Mottram, 35 Va. App. at 93, 542 S.E.2d at 814; see also

Mottram, 263 Va. at 375, 559 S.E.2d at 703.

               “A disease is a condition which may arise from any number of
               causes, including trauma, that impairs the function of the body or
               any part thereof. . . . The distinction between injury and disease
               lies in the ‘obvious sudden mechanical or structural’ aspect of
               injury.” Ogden Aviation Serv[s.] v. Saghy, 32 Va. App. 89, 97,
               526 S.E.2d 756, 760 (2000) (citation omitted)[; see also] 1B Arthur
               Larson, The Law of Workers’ Compensation § 41.31, at 7-491 to
               7-492 (1991) (noting that the traditional distinction between
               “occupational diseases” and “accidental injuries” was “both the
                                               -4-
               fact that [diseases] could not honestly be said to be unexpected,
               since they were recognized as inherent hazard[s] of continued
               exposure to conditions of the particular employment, and the fact
               that [diseases] were gradual rather than sudden in onset”).

                          *      *       *       *      *       *       *

                       Although, when based upon a single physical injury or
               obvious sudden shock or fright, PTSD may be considered an injury
               by accident, when it is suffered as a result of ongoing stress, it
               qualifies as a disease.

Mottram, 35 Va. App. at 92-96, 542 S.E.2d at 814-15 (emphasis added). This was so, we

concluded, because the disorder was “the body’s response to irritating stimuli” rather than a

“physical impairment based on cumulative trauma resulting from repetitive motion.” Id. at 95,

542 S.E.2d at 815.

       We held under this definition that, once the commission “identified Mottram’s condition

as resulting from multiple stressful events,” it “erred in designating [the PTSD] an injury and in

refusing to consider it as a disease.” Id. at 96, 542 S.E.2d at 815. The Supreme Court agreed

with our rationale, holding generally that “PTSD qualifies as a disease” when incurred from

“repeated exposure to traumatic stressors[,] which caus[es] reactions in [the individual’s]

neurobiological systems.” Mottram, 263 Va. at 373, 559 S.E.2d at 702. Because “credible

evidence establishe[d] that Mottram’s repeated exposure to traumatic stressors caused reactions

in his neurobiological systems” that were “‘related to many of the chronic symptoms of PTSD,’”

the Court affirmed the commission’s finding that Mottram’s PTSD was a disease. Id.

       We hold this same rationale applies to claimant’s PTSD and, thus, credible evidence

supports the commission’s conclusion that it, too, is a disease under the Act. The reasonable

inference, absent evidence to the contrary, is that the psychological and psychiatric medical

professionals who treated claimant--Drs. Bowers and Wooldridge and Counselor Gaulin--used

the term PTSD in claimant’s case in a manner consistent with the standard medical definition of

                                             -5-
this term. Further, the commission concluded in Mottram that PTSD, under its standard medical

definition, meets the definition of a disease under the Act. Thus, the commission was entitled to

infer that claimant’s PTSD, if not incurred via an injury by accident, was the same disease that

the Court found covered by the Act in Mottram, even without additional medical evidence as to

the nature of PTSD generally or claimant’s PTSD in particular.

       In sum, the holding in Mottram was sufficient to establish that PTSD qualifies as a

disease under the Act as long as it is not incurred via an injury by accident. Thus, we proceed to

analyze whether credible evidence proves claimant’s PTSD was not an injury by accident.

                                                 C.

                   CREDIBLE EVIDENCE OF OCCUPATIONAL DISEASE
                           VERSUS INJURY BY ACCIDENT

       PTSD “may be considered an injury by accident” when it is “based upon a single

physical injury or obvious sudden shock or fright.” Mottram, 35 Va. App. at 96, 542 S.E.2d at

815. In contrast, when PTSD “is suffered as a result of” “multiple stressful events” or “ongoing

stress, it qualifies as a disease.” Id. The Virginia Supreme Court concluded in Mottram, based

on medical literature introduced in that case, that PTSD from “repeated exposure to traumatic

stressors cause[s] reactions in [an individual’s] neurobiological systems” and, thus, qualifies as a

disease rather than a noncompensable cumulative trauma injury. 263 Va. at 372-73, 559 S.E.2d

at 702 (citing A New Leaf, Inc. v. Webb, 257 Va. 190, 197-98, 511 S.E.2d 102, 105 (1999)).

Absent some medical evidence in this record to the contrary, we follow the Supreme Court’s

pronouncement that the medically recognized condition of PTSD qualifies as a disease under the

Workers’ Compensation Act. We conclude credible evidence supports the commission’s finding

that claimant’s PTSD resulted from ongoing stress and, thus, also qualified as a disease.

       Here, claimant both told his treating physicians and testified before the deputy

commissioner that, although he had nightmares and flashbacks about three particular calls to
                                              -6-
which he responded in the line of duty three to five years before the onset of his symptoms, he

was not bothered by these or any other calls at the time. Further, he could not think of any

specific incident in 2001 that might have triggered his symptoms. Even after claimant told

Gaulin and Wooldridge about these three specific calls, they each opined that claimant’s PTSD

was caused by ongoing job stress rather than a particular incident or incidents.

       Gaulin noted in January 2002 that claimant had reported dreaming about specific calls to

which he had responded and that he and claimant discussed the “difficulty of some calls” and the

“impact of 1 call in particular.” With this knowledge, Gaulin opined that claimant had “[n]o

specific job stressor, rather a combination of numerous stressors over the years . . . related to

specific emotionally charged calls [claimant] responded to.” On a disability certificate, Gaulin

opined that claimant’s PTSD was “associated with and caused by a long history of job stress.”

       Dr. Wooldridge noted in August 2002 that claimant, “[a]s a firefighter-EMS person, . . .

had exposure to many traumatic events such as car accidents, burned [and] disfigured people

(dead and alive), debilitated elderly people in institutions, deaths of infants [and] full term

pregnant women.” Dr. Wooldridge opined that “[t]hese traumatic episodes,” together, “triggered

a response of helplessness[,] utter horror [and other symptoms] in this [patient].”

Dr. Wooldridge diagnosed these symptoms as chronic PTSD.

       Although Dr. Bowers’s opinion was less clear than Gaulin’s and Wooldridge’s, it also

supports a finding that claimant’s PTSD was caused by a disease process rather than an injury by

accident. Dr. Bowers noted in February 2002 that claimant reported to him two specific

incidents about which he had flashbacks but that claimant seemed to have no triggers for his

PTSD symptoms “[o]ther than being in the firehouse.” Dr. Bowers opined that “a number of

disturbing things” claimant “obviously saw . . . in his firefighting career” caused his PTSD.




                                               -7-
       Thus, credible evidence supports the finding that claimant’s PTSD resulted from a

disease rather than an injury by accident.

                                                 D.

   CREDIBLE EVIDENCE THAT DISEASE WAS OCCUPATIONAL DISEASE RATHER
           THAN NON-COMPENSABLE ORDINARY DISEASE OF LIFE

       For a condition that qualifies as a disease under the Act to be compensable, a claimant

“must show either that [the disease] is an occupational disease under the provisions of Code

§ 65.2-400 or that it is an ordinary disease of life that may be treated as an occupational disease

pursuant to Code § 65.2-401.” Mottram, 263 Va. at 373-74, 559 S.E.2d at 702. “[T]he question

whether a condition or disease is an ordinary disease of life [or an occupational disease] is

essentially a medical issue to be decided by the trier of fact based on the evidence presented.”

Knott v. Blue Bell, Inc., 7 Va. App. 335, 338, 373 S.E.2d 481, 483 (1988), quoted with approval

in Mottram, 263 Va. at 375, 559 S.E.2d at 703.

               The term “occupational disease” is defined as “a disease arising
               out of and in the course of employment, but not an ordinary
               disease of life to which the general public is exposed outside of the
               employment.” Code § 65.2-400(A). The following six factors are
               necessary in order to establish that a disease arose out of the
               employment:

                              1. A direct causal connection between the
                       conditions under which work is performed and the
                       occupational disease;

                               2. It can be seen to have followed as a
                       natural incident of the work as a result of the
                       exposure occasioned by the nature of the
                       employment;

                               3. It can be fairly traced to the employment
                       as the proximate cause;

                              4. It is neither a disease to which an
                       employee may have had substantial exposure
                       outside of the employment, nor any condition of the
                       neck, back or spinal column;
                                              -8-
                             5. It is incidental to the character of the
                      business and not independent of the relation of
                      employer and employee; and

                              6. It had its origin in a risk connected with
                      the employment and flowed from that source as a
                      natural consequence, though it need not have been
                      foreseen or expected before its contraction.

              Code § 65.2-400(B). An ordinary disease of life may be treated as
              an occupational disease if it is “established by clear and convincing
              evidence” that it “arose out of and in the course of employment . . .
              and did not result from causes outside of the employment,” and
              that “[i]t follows as an incident of occupational disease” or “[i]t is
              characteristic of the employment and was caused by conditions
              peculiar to such employment.” Code § 65.2-401.

Mottram, 263 Va. at 373-74, 559 S.E.2d at 702-03.

       “PTSD is, in some situations, an ordinary disease of life[,]” such as when an “employee

had numerous sources of stress outside of the employment that contributed to his condition.”

Mottram, 263 Va. at 375, 559 S.E.2d at 703 (citing Teasley v. Montgomery Ward & Co., 14

Va. App. 45, 49-50, 415 S.E.2d 596, 598-99 (1992)). However, where credible medical

evidence establishes that an employee’s PTSD is “intimately related to his service-connected

activities” and “no evidence [indicates] that [the employee] was exposed to traumatic events

outside his employment,” we must affirm the commission’s conclusion that the PTSD is an

occupational disease under Code § 65.2-400. See id.

       In Mottram, the employer

              contend[ed] that PTSD can be caused by exposure to traumatic
              events found in everyday life, such as violent personal assaults,
              severe automobile accidents, or being diagnosed with a life
              threatening illness. However, the Employer acknowledge[d] that,
              of the six statutory factors required to establish an occupational
              disease, only number four [was] at issue in [that] appeal, whether
              PTSD is a disease to which Mottram may have had substantial
              exposure outside of his employment.

Id. at 374-75, 559 S.E.2d at 703. The Supreme Court then reasoned that,

                                             -9-
               [c]ontrary to the Employer’s argument, the focus is not on the
               many causes of PTSD and whether some of them may be found
               outside of an employment situation. Instead, the focus must be on
               the nature of the employee’s occupation and the relationship
               between that occupation and the specific disease, as contrasted to
               diseases that are readily found in other occupations or ordinary
               life.

Id. at 375, 599 S.E.2d at 703. Because the medical evidence in Mottram “emphasized that

Mottram’s PTSD was ‘intimately related to his service-connected activities’” and the record

contained “no evidence that Mottram was exposed to traumatic events outside his employment,”

the Court “conclude[d], as a matter of law, that Mottram’s PTSD [was] an occupational disease

under Code § 65.2-400.” In doing so, the Court rejected our conclusion that Mottram’s condition

was an ordinary disease of life “[b]ecause PTSD is a condition that may develop from the

general stresses of life and is not necessarily tied to occupational stress.” Mottram, 35 Va. App.

at 96, 542 S.E.2d at 816; see Mottram, 263 Va. at 376, 559 S.E.2d at 704.

       In claimant’s case, similar to Mottram’s, the record contained (1) credible evidence

establishing that claimant’s PTSD was caused by his work-related exposure to traumatic events

and (2) “no evidence that [claimant] was exposed to traumatic events outside his employment.”1

Counselor Gaulin and Drs. Wooldridge and Bowers all opined that the traumatic events to which

claimant was exposed at work caused his PTSD. Gaulin opined claimant’s PTSD was “caused

by a long history of job stress.” Dr. Bowers opined that “a number of disturbing things”

claimant saw “in his firefighting career” caused the symptoms diagnosed as PTSD. Finally,

Dr. Wooldridge opined that the “many traumatic events” claimant was exposed to “[a]s a

firefighter-EMS person” caused his PTSD. From this evidence, the commission could


       1
          In Mottram, the Supreme Court reached this conclusion as a matter of law. 263 Va. at
375, 559 S.E.2d at 703. In claimant’s case, because the commission has already addressed this
issue, at least implicitly, we need not consider whether the evidence supported such a ruling as a
matter of law. We conclude only that credible evidence supported the commission’s finding on
this point.
                                              - 10 -
reasonably conclude that claimant’s PTSD was caused by his work-related exposure to traumatic

events.

          Additional credible evidence supported a finding that claimant experienced no causative

events outside his employment that could have led to his PTSD. Claimant testified that the

levels of stress he experienced in his everyday personal life and while at work were “[t]otally

different” because, “at work[,] [he] was always under the stress of never knowing . . . what was

going to happen five minutes from then[,] . . . never knowing what [he] was going to get into.”

Claimant’s nightmares involved only work-related traumas, and claimant’s symptoms were

triggered or worsened by going to work at the firehouse, hearing the fire alarm, or

“approach[ing] his former job sites.” Claimant reported no family history of depression or panic

disorder, and a full physical performed by his primary care physician eliminated any purely

physical causes. Claimant told Chief Wallace that he had no family or financial problems “that

could possibly create undue stress.” Finally, claimant’s condition improved when he made the

decision to retire from his emergency services position and took employment as a delivery

driver.

                 Although statements from claimant’s doctors that [his PTSD] did
                 not result from any causes outside of the employment may have
                 strengthened claimant’s case, such statements were not critical to
                 the commission’s determination in light of claimant’s own
                 testimony [that he had little stress in his personal life and “medical
                 evidence . . . that claimant’s [PTSD] resulted from [work-related
                 traumas] rather than from [family history] or from any other
                 medical condition”]. See Cridlin, 22 Va. App. at 176-77, 468
                 S.E.2d at 154-55; see also Island Creek Coal Co. v. Breeding, 6
                 Va. App. 1, 11-12, 365 S.E.2d 782, 788 (1988) (where physician
                 could not state “‘to a reasonable medical certainty’ that
                 [claimant’s] hearing loss was not caused by non-employment
                 factors” but said “[claimant] did not give me a history of anything
                 [outside of work] I might interpret as having caused it,” the
                 commission “could and did draw the reasonable inference that
                 [claimant’s] hearing loss was not caused by non-employment
                 factors based on his negative history of noise exposure which

                                               - 11 -
              would cause such a hearing loss and the nonexistence of genetic or
              biological factors”).

Miller, 38 Va. App. at 264, 563 S.E.2d at 379-80.

       Thus, the commission’s conclusion is supported by (1) credible evidence establishing that

claimant’s PTSD was caused by his work-related exposure to traumatic events and (2) a lack of

“evidence that [claimant] was exposed to traumatic events outside his employment.”

                                               II.

       For these reasons, we hold credible evidence supports the commission’s findings that

claimant had PTSD, that his PTSD was a disease as opposed to an injury by accident, and that it

was caused by his employment. Thus, we affirm the award of benefits.

                                                                                      Affirmed.




                                           - 12 -
