Citation Nr: 0803402 Decision Date: 01/30/08 Archive Date: 02/08/08 DOCKET NO. 05-32 840 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston- Salem, North Carolina THE ISSUE Entitlement to service connection for post-traumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD Jason A. Lyons, Counsel INTRODUCTION The veteran served on active duty from August 1969 to August 1971, including in the Republic of Vietnam from September 1970 to August 1971. He also had several years of reserve duty with the Army National Guard. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2004 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. FINDINGS OF FACT 1. The veteran did not engage in combat with the enemy while serving on active duty. 2. The veteran does not have a verified in-service stressor that would support a medical diagnosis of PTSD. CONCLUSION OF LAW PTSD was not incurred or aggravated in service. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304(f), 4.125(a) (2007). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veterans Claims Assistance Act The requirements of the Veterans Claims Assistance Act of 2000 (VCAA) have been met. There is no issue as to providing an appropriate application form or completeness of the application. VA notified the veteran through several letters, including April 2004 and July 2006 correspondence, as well as the July 2005 statement of the case (SOC) and later supplemental SOCs (SSOCs) of the information and evidence needed to substantiate and complete a claim, to include notice of what part of that evidence is to be provided by the claimant, and notice of what part VA will attempt to obtain. VA has fulfilled its duty to assist the claimant in obtaining identified and available evidence needed to substantiate a claim. VA informed the claimant of the need to submit all pertinent evidence in his possession, and provided adequate notice of how disability ratings and effective dates are assigned. While the appellant may not have received full notice prior to the initial decision, after notice was provided the claimant was afforded a meaningful opportunity to participate in the adjudication of the claim, and the claim was readjudicated. The claimant was provided the opportunity to present pertinent evidence and testimony. In sum, there is no evidence of any VA error in notifying or assisting the appellant that reasonably affects the fairness of this adjudication. Analysis Service connection may be granted for any current disability for which it is established was caused by a disease or injury incurred or aggravated during active duty service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). The criteria for establishing service connection for PTSD are: (1) medical evidence diagnosing PTSD; (2) credible supporting evidence that the claimed in-service stressor actually occurred; and (3) medical evidence of a link between current symptomatology and the claimed in-service stressor. 38 C.F.R. § 3.304(f); Cohen v. Brown, 10 Vet. App. 128 (1997). A diagnosis of PTSD must be established in accordance with 38 C.F.R. § 4.125(a), which provides that, for VA purposes, all mental disorder diagnoses must conform to the fourth edition of the American Psychiatric Association's Diagnostic and Statistical Manual for Mental Disorders (DSM- IV). 38 C.F.R. § 3.304(f). Where it is determined that the veteran was engaged in combat with the enemy and the claimed stressors are related to such combat, his lay testimony regarding the claimed stressors is accepted as conclusive as to their actual existence, absent clear and convincing evidence to the contrary. Where, however, VA determines that a veteran did not engage in combat with the enemy, or the claimed stressor is not related to participation in combat, then the veteran's lay testimony, in and of itself, is insufficient to establish the occurrence of the alleged stressor. In such cases, the record must contain credible supporting information from another source which substantiates or verifies the veteran's testimony or statements as to the occurrence of the claimed stressors, including but not limited to service records and other objective bases. See Cohen v. Brown, 10 Vet. App. 128, 146- 47 (1997); Zarycki v. Brown, 6 Vet. App. 91, 98 (1993). Credible supporting evidence of the actual occurrence of an in-service stressor cannot consist solely of after-the-fact medical nexus evidence. See Moreau v. Brown, 9 Vet. App. 389, 396 (1996). That notwithstanding, corroboration does not require "that there be corroboration of every detail including the appellant's personal participation in the identifying process." Suozzi v. Brown, 10 Vet. App. 307, 311 (1997). The U.S. Court of Appeals for Veterans Claims (Court) similarly held in Pentecost v. Principi, 16 Vet. App. 124, 128-29 (2002) that while the veteran's unit records did not specifically show that he was present during the alleged rocket attacks, "the fact that he was stationed with a unit that was present while such attacks occurred would strongly suggest that he was, in fact, exposed to the attacks." A review of the current record does not establish that the criteria for service connection for PTSD are met. The report of a January 2004 psychiatric evaluation at a private clinic set forth a diagnosis of PTSD, thus providing at minimum competent evidence of the presence of the claimed disorder. The next requirement to substantiate the claim under consideration, by regulation, is that of a confirmed in- service stressor. See 38 C.F.R. § 3.304(f). Since the veteran has not alleged that he had participation in combat during service, nor does the record indicate receipt of any commendation or citation that are considered presumptive evidence of combat service, any identified stressor from service must be objectively confirmed. Thus far, there is no specific incident or event that the veteran has described as having transpired during service in support of his claim. The January 2004 psychiatrist's report includes the appellant's account that while in Vietnam, he witnessed injuries to and the deaths of numerous fellow soldiers and other individuals. Unfortunately, absolutely no detail is provided to verify these assertions. That is, no names, dates, places, or descriptions are provided. This statement provides the complete basis up to this point of information relevant to attempting to establish a verified stressor. Unfortunately, the extent of this information is not sufficient by itself to support independently corroborating a claimed in-service stressor, to include filing a request for confirmation of a specific incident with the U.S. Army and Joint Services Records Research Center (JSRRC). The preceding description of claimed in-service events rather does not set forth an objectively verifiable incident. The evidence pertaining to occupational assignments and medical history in service, including service medical records and personnel records on file, does not show an event warranting further examination as a stressor. The veteran did provide a statement from another individual who served with a unit in Vietnam describing a series of prior incidents. There is no indication, however, that the statement was offered in connection with the instant claim or by an individual familiar with the veteran, or that it even pertains to events that have a direct connection with this claim. The RO has undertaken continuing measures to assist with obtaining a verified stressor of record. An April 2004 development letter requested that the veteran identify stressful events from service, with supporting details including dates of occurrence, unit of assignment, and individuals involved, and enclosed a PTSD questionnaire for this purpose. This questionnaire was not returned. Similar correspondence was again sent in November 2005 and July 2006. The July 2005 SOC and later SSOCs indicated that an identifiable stressor was still necessary to substantiate the claim. The RO issued a formal finding in July 2006 that there was a lack of information required to verify stressors in connection with the veteran's PTSD claim, in that the level of detail provided was insufficient to send to the JSRRC for verification. This memorandum was issued in accordance with standard procedures for when a claimant has not provided the basic information required to conduct research, following notification and assistance to support stressor development. See VA Adjudication Procedure Manual, M21-1MR, Part IV, Subpart ii.1.D.15.l. Thus, at this stage of development it can reasonably be determined that further development is not warranted, and that the existence of a verified or verifiable stressor cannot be ascertained from the record. The criteria to establish service connection for the disability claimed require a confirmed stressor to support a competent diagnosis of PTSD. Accordingly, in the absence of a confirmed in-service stressor, the claim for service connection for PTSD must be denied. In reaching this decision, the Board has considered the doctrine of reasonable doubt. As the preponderance of the evidence is against the veteran's claim, the doctrine is not applicable. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Entitlement to service connection for PTSD is denied. ____________________________________________ DEREK R. BROWN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs