Citation Nr: 0502701 Decision Date: 02/04/05 Archive Date: 02/15/05 DOCKET NO. 03-05 736 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Reno, Nevada THE ISSUE Entitlement to service connection for post-traumatic stress disorder (PTSD) REPRESENTATION Appellant represented by: Louis M. DiDonato, Attorney- at-Law ATTORNEY FOR THE BOARD Ronald W. Scholz, Senior Counsel INTRODUCTION The veteran served on active duty from August 1965 to June 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2000 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Reno, Nevada, which denied service connection for PTSD. A Notice of Disagreement (NOD) was received in October 2000, and a March 2003 letter addressed to the Secretary of the Department of Veterans Affairs was accepted as a substantive appeal in lieu of a VA Form 9. A June 1999 Board decision denied a previous appeal for service connection for PTSD, finding that the veteran was subjected to combat stressors in service, but no probative diagnosis of PTSD had been made. FINDINGS OF FACT 1. A probative diagnosis of PTSD has been made. 2. The veteran was subjected to combat stressors in service. 3. There is medical evidence of a causal nexus between current PTSD symptomatology and the claimed in-service stressor. CONCLUSION OF LAW PTSD was incurred in service. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. § 3.304 (2004). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veterans Claims Assistance Act of 2000 (VCAA) In light of the favorable action taken herein, discussion of whether VA duties pursuant to the Veterans Claims Assistance Act of 2000 (VCAA) have been satisfied is not required. The Board finds that no further notification or assistance is necessary, and deciding the appeal at this time is not prejudicial to the veteran. Factual Background The veteran performed active service with the U.S. Coast Guard from August 1965 to June 1969. Service records reflect that he was awarded the National Defense Service Medal, the Viet Nam Service Medal, the Viet Nam Campaign Medal, the Navy Unit Commendation Ribbon, the Republic of Viet Nam Cross of Gallantry with Palm Unit Citation, and the Republic of Viet Nam Civil Action Unit Citation. The United States Armed Services Center for Research of Unit Records (USASCRUR) confirmed that, in 1967, a Coast Guard ship conducted coastal surveillance off the coast of Viet Nam, fired numerous rounds of ammunition against Viet Cong forces, encountered sampans and trawlers, and a round of ammunition detonated prematurely aboard the vessel in August 1967. Service records confirm that the veteran served on board that Coast Guard ship during that time period. The ship's deck log corroborates the veteran's statement that the ship ran over a Vietnamese boat, cutting it in half. A "buddy statement" corroborates the veteran's statement that his duties during the time his ship was patrolling off the coast of Viet Nam included serving as a gunner on a 5-inch gun mount and as a rescue swimmer. Service medical records do not reflect any complaints or findings pertaining to PTSD and the separation medical examination report does not note any psychiatric problems. The veteran was admitted to a VA medical facility in December 1995 for assessment upon referral from a Vet Center. The Axis I discharge diagnosis was no diagnosis established. The Axis II diagnosis was schizoid traits. June 1996 Vet Center records contain an Axis I diagnosis of PTSD. A VA psychiatric examination was conducted in October 1998. The examination report reflects that sub diagnostic PTSD was noted in December 1991 and that the veteran did not meet the criteria for PTSD while receiving outpatient treatment in a VA facility in February 1994. The diagnostic impression was generalized anxiety disorder. A June 1999 Board decision found that the veteran had been subjected to combat stressors in service, but that no probative diagnosis of PTSD had been made. The veteran submitted a February 2000 report from the Ridgeview Group, Counseling and Family Therapy, located in Reno, Nevada, signed by Michael R. Freda, Ph.D., (at the time of the report, Dr. Freda held an M.A.). The report reflects that the Minnesota Multiphasic Personality Inventory-2nd Edition (MMPI-2) was administered and showed a high T-score on the hysteria scale and a high T-score on the hypochondriasis scale. The Millon Clinical Multiaxial Inventory-Three (MCMI-III) was also administered. Test results showed a moderately severe mental disorder, and that the veteran appeared "to have experienced an event or events that . . . involved physical threat or serious injury to which he responded with intense fear or horror." The diagnostic impressions included: Axis I PTSD and Generalized Anxiety Disorder (GAD); Axis II Schizoid Personality Disorder and Antisocial Personality Disorder with Passive-Aggressive Personality Traits; and Axis V Current GAF of 60, with serious symptoms of depression. In the examiner's judgment, the veteran was "suffering from PTSD resulting from his military service in Viet Nam." The examiner's conclusion was based on his observations that the veteran exhibited all of the characteristic symptoms of PTSD, such as nightmares, flashbacks, intrusive thoughts, trouble with authority figures, problems keeping employment, and failed relationships. Additionally, he noted that the veterans Generalized Anxiety Disorder could stem from the PTSD, the veteran's history of substance abuse and alcohol problems were congruent with a PTSD diagnosis, and the veteran's Axis II diagnoses were congruent with an Axis I diagnosis of PTSD. The veteran submitted a January 2002 psychological examination report from the Nevada Bureau of Disability Adjudication, signed by Dr. Rebecca Mueller, Ph.D., a clinical psychologist. Diagnostic impressions were: Axis I PTSD and alcohol abuse in sustained full remission; Axis II deferred; and Axis V current GAF of 60 (psychological only). Dr. Mueller noted that the veteran's PTSD symptoms appeared to be moderately well controlled and recommended mental health counseling to assist him in managing his mild symptoms of PTSD. The veteran received a VA "Mental Disorders (Except PTSD and Eating Disorders) Examination" in January 2003. The examination was for the stated purpose of determining eligibility for nonservice-connected pension for mental disorders. The claims file was reviewed. The examiner found the previous VA medical examination of October 1998 to be "of particular note." With respect to stressor information, the examiner noted that there had been considerable deliberation regarding the adequacy of the veteran's stressors, and that DVA had not conceded the adequacy of the stressors. The examiner did not offer his own medical opinion as to the adequacy of the veteran's stressors. The examiner concluded that the veteran reported some symptoms of PTSD, but not enough to make a full diagnosis, and that many of the reported symptoms were also present in other disorders. The diagnosis was: Axis I Dysthymic disorder and PTSD symptoms; Axis II apparent history of antisocial personality disorder traits; and Axis V current GAF of 50. The veteran submitted a July 2003 letter from Dr. Freda of the Ridgeview Group stating his psychological opinion that the veteran was totally disabled without consideration of any past or present drug and/or alcohol use, and that drug and/or alcohol uses was not the material cause of the veteran's disability. Dr. Freda attached a copy of his previous February 2000 report, and a March 2003 psychiatric/psychological impairment questionnaire which confirmed his previous Axis I diagnoses of PTSD and GAD, and gave a prognosis that the veteran would continue to have problems with authority figures due to his PTSD. Of note, Dr. Freda provided his "best medical opinion" that the earliest date of PTSD symptoms was between May and December 1966. Legal Criteria Service connection may be granted for disability arising from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110 (West 2002). A showing of chronic disease in service requires a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. Isolated findings, or a diagnosis including the word "chronic," are not sufficient to establish service connection. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b) (2004). Service connection may be also granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2004). That a condition or injury occurred in service alone is not enough; there must be a disability resulting from that condition or injury. Degmetich v. Brown, 104 F.3d 1328, 1332 (Fed. Cir. 1997). Service connection for PTSD requires medical evidence establishing a diagnosis of PTSD, credible supporting evidence that the claimed in-service stressor actually occurred, and a link established by medical evidence between the current symptomatology and the claimed in-service stressor. 38 C.F.R. § 3.304(f) (2004). If the claimed stressor is related to combat, service department evidence that the veteran engaged in combat or that the veteran was awarded the Purple Heart, Combat Infantryman Badge, or similar combat citation will be accepted, in the absence of evidence to the contrary, as conclusive evidence of the claimed in-service stressor. See Cohen v. Brown, 10 Vet. App. 128, 138 (1997). Analysis Service connection for PTSD requires proof of three elements; the first of which is medical evidence establishing a diagnosis of PTSD. 38 C.F.R. § 3.304(f). At the time of the June 1999 Board denial of service connection for PTSD, the Board found that the medical evidence did not establish a diagnosis of PTSD; specifically, that although the veteran presented some symptoms of PTSD, the criteria for a diagnosis of PTSD were not met. Subsequent to that Board decision, the claim file has been augmented with additional medical opinions. A February 2000 report by a psychologist with the Ridgeview Group diagnosed PTSD, and the psychologist concluded that the veteran was suffering from PTSD as a result of his military service in Viet Nam. A January 2002 report by a psychologist with the Nevada Bureau of Disability Adjudication diagnosed PTSD, without attribution as to cause. A January 2003 VA mental disorders (except PTSD and eating disorders) examination did not diagnose PTSD, rather it diagnosed PTSD symptoms. In fact, no diagnosis for PTSD was possible, as the examining psychologist did not address the first requirement for such a diagnosis, a qualifying traumatic event. Rather the examiner simply noted that DVA had not conceded the adequacy of the stressors. A July 2003 letter, with attachments, from the psychologist with the Ridgeview Group confirmed his previous Axis I diagnoses of PTSD and gave a prognosis that the veteran would continue to have problems with authority figures due to his PTSD. The Board concludes that the first element of proof for establishing service connection for PTSD, medical evidence establishing a diagnosis of PTSD, has been met. Second, there must be credible supporting evidence that the claimed in-service stressor actually occurred. 38 C.F.R. § 3.304(f). In a September 2004 supplemental statement of the case (SSOC), the RO stated that the denial of service connection for PTSD was based on the facts that the veteran's claimed in-service stressors could not be verified, and the veteran's diagnosis of PTSD was based on his reported history without substantiating facts. The evidence of record, however, shows that the veteran's claimed stressors are verified by substantiating facts; service record entries, the USASCRUR report, and extracts from the ship's log. In its June 1999 decision, the Board noted these substantiating facts, and found that the veteran was subjected to combat stressors in service. The Board concludes that there is credible supporting evidence that the claimed in-service stressor actually occurred, and the second element of proof is established. Third, there must be a link established by medical evidence between the current symptomatology and the claimed in-service stressor. 38 C.F.R. § 3.304(f). The February 2000 report from the psychologist with the Ridgeview Group clearly and unambiguously links the current symptomatology to the claimed in-service stressors. Moreover, the July 2003 attachment to the psychologist's confirming diagnosis goes a step further and defines the most likely dates for the onset of the veteran's PTSD to the period from May to December 1966. In again denying the veteran's claim for service connection in the September 2004 SSOC, the RO concluded that the records did not establish a stressor that is outside the range of usual human experience. That, however, is not the proper test to be applied. Nor is there any competent medical evidence on that subject. The appropriate test to be applied is: (1) that the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others, and (2) the person's response involved intense fear, helplessness, or horror. American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM- IV); 38 C.F.R. § 4.125 (2004). In this case, the only medical evidence on that issue subsequent to the June 1999 Board decision are the February 2000 and July 2003 reports from the Ridgeview Group psychologist, both of which conclude that the veteran does have qualifying stressors as defined by the DSM-IV. The January 2003 VA mental disorders (except PTSD and eating orders) examination does not provide a medical opinion regarding a link, or the absence of a link, between the current symptomatology and the claimed in-service stressor. Rather, the report notes only that "DVA has not conceded the adequacy of the stressors" in meeting the criteria for a diagnosis of PTSD. There is no medical evidence contrary to Dr. Freda's two reports. The Board concludes that there is a credible link established by medical evidence between the current symptomatology and the claimed in-service stressor. Accordingly, the Board finds that the preponderance of the evidence establishes every element of evidentiary proof for service-connection for PTSD. ORDER Entitlement to service connection for post-traumatic stress disorder (PTSD) is granted. ____________________________________________ JAMES L. MARCH Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs