BVA9508671 DOCKET NO. 91-36 530 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in No. Little Rock, Arkansas THE ISSUES 1. Entitlement to service connection for post-traumatic stress disorder (PTSD). 2. Entitlement to an evaluation in excess of 10 percent for residuals of a service-connected skin disorder, characterized as tinea corporis. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The appellant ATTORNEY FOR THE BOARD Stephen F. Sylvester, Counsel INTRODUCTION The veteran had active duty for training from February to August 1962, and additional active military service from January 1963 to May 1968. This appeal to the Board of Veterans' Appeals (Board) originally arose from a November 1990 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. Since the time of that decision, the veteran has changed his residence, with the result that this appeal now comes to the Board from the Little Rock, Arkansas, RO. A review of the record discloses that, in February 1990, the Board denied entitlement to service connection for post-traumatic stress disorder. As of the time of the Board's February 1990 decision, the veteran had been shown to exhibit a depressive neurosis, but not a post-traumatic stress disorder. Since the time of that decision, the veteran has submitted additional evidence in an attempt to reopen his claim. That evidence shows varying psychiatric diagnoses, including post-traumatic stress disorder. The RO, apparently considering such evidence to be both new and material, has chosen to adjudicate the veteran's current claim on a de novo basis. The Board is in agreement with this determination and, accordingly, will likewise adjudicate the veteran's current claim as one of first impression. In June 1992 and June 1993, the veteran's case was remanded to the RO for additional development. Such development having been completed, the case is now, once more, before the Board for further review. CONTENTIONS OF APPELLANT ON APPEAL The veteran's argument is that the RO committed error in denying entitlement to service connection for post-traumatic stress disorder, in that such disorder is due to his period or periods of active military service. Specifically, it is alleged that, during that period of the veteran's service when he was assigned to the 106th General Hospital in Yokohama, Japan, he was exposed to numerous stressful incidents, with the result that he currently suffers from a post-traumatic stress disorder. It is alleged that, during the aforementioned period, the veteran assisted in the transportation and treatment of numerous casualties from the Republic of Vietnam, many of whom were seriously wounded and/or burned. He further alleges that more than a few of these casualties died in his presence. He contends that he served in the "med evac-unit" at the hospital. As to the veteran's service-connected tinea corporis, it is alleged that the various manifestations of that skin disorder are more severe than currently evaluated, and productive of a greater degree of impairment than is reflected by the 10 percent schedular evaluation presently assigned. It is asserted that, as a result of the veteran's service-connected tinea corporis, he experiences a constant itching. It is further alleged that the veteran must avoid the sun, inasmuch as sweating causes his back to "break out into sores which crust over." According to the veteran, lesions attributable to his service-connected skin disorder have, at times, spread to both his groin and buttocks. He further notes that he currently receives medication for his service-connected skin disorder. As to the veteran's service-connected tinea corporis, it is requested that the provisions of 38 C.F.R. § 4.7 (1994) be applied. DECISION OF THE BOARD The Board, in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991), has reviewed and considered all of the evidence and material of record in the veteran's claims files. Based on its review of the relevant evidence in this matter, and for the following reasons and bases, it is the decision of the Board that a preponderance of the evidence is against the claims for service connection for post-traumatic stress disorder, and for an increased evaluation for service-connected tinea corporis. FINDINGS OF FACT 1. All relevant evidence necessary to an equitable disposition of the veteran's appeal has been obtained by the RO. 2. The record does not show that the veteran engaged in combat with the enemy, nor is it otherwise alleged. Several attempts by the RO to obtain supportive evidence that the claimed inservice stressors actually occurred have been unsuccessful. 3. The evidentiary record does not support a diagnosis of post- traumatic stress disorder that is related to the veteran's period of service. 4. The veteran's service-connected tinea corporis is currently productive of not more than exfoliation, exudation, or itching, and involvement of an exposed surface or extensive area. CONCLUSIONS OF LAW 1. Post-traumatic stress disorder was not incurred in or aggravated by active military service, including active duty for training. 38 U.S.C.A. §§ 101(24), 106, 1110, 1131 (West 1991); 38 C.F.R. § 3.304(f) (1994). 2. An evaluation in excess of 10 percent for service-connected tinea corporis is not warranted. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. §§ 3.321(b)(1), 4.7, 4.20 and Part 4, Code 7806 (1994). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS At the outset, the Board has found that the veteran's claims are "well-grounded" within the meaning of 38 U.S.C.A. § 5107(a) (West 1991). That is, the Board finds that he has presented claims which are plausible. We are also satisfied that all relevant facts have been properly developed. In that regard, the Board notes that the veteran's case has been remanded on two separate occasions for additional development. Extensive efforts have been made to pursue all sources of medical or other evidence identified by the veteran. Accordingly, no further assistance to the veteran is required in order to comply with the duty to assist him mandated by 38 U.S.C.A. § 5107(a) (West 1991). I. Post-Traumatic Stress Disorder Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131, 1154(b) (West 1991); 38 C.F.R. § 3.303(a) (1994). In determining whether an injury or disease was incurred or aggravated in service, the evidence in support of the veteran's claim is evaluated based on the places, types, and circumstances of service, as shown by service records, the official history of each organization in which the veteran served, the veteran's medical records, and all pertinent medical and lay evidence. 38 U.S.C.A. § 1154(b) (West 1991); 38 C.F.R. §§ 3.303(a), 3.304 (1994). Even where there is a lack of official records to corroborate that an injury or disease was incurred in or aggravated during combat service (including a period of combat), the VA is required to accept as sufficient proof of service connection satisfactory lay or other evidence that an injury or disease was incurred or aggravated during such period of service, if the evidence is consistent with the circumstances, conditions, or hardships of such service. 38 U.S.C.A. §§ 1154(b) (West 1991); 38 C.F.R. §§ 3.303(a), 3.304 (1994). Service connection for post-traumatic stress disorder requires medical evidence establishing a clear diagnosis of the condition, credible supporting evidence that the claimed inservice stressor actually occurred, and a link, established by medical evidence, between current symptomatology and the claimed inservice stressor. 38 C.F.R. § 3.304(f) (1994). This regulation further provides that, 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 inservice stressor. 38 C.F.R. § 3.304(f) (1994); See also Zarycki v. Brown, 6 Vet.App. 91 (1993). Where the stressor or stressors in question are noncombat related, available service records must support, that is, must not contradict, the veteran's lay testimony concerning his noncombat- related stressors. Doran v. Brown, 6 Vet.App. 283 (1994). If the claimed stressor is not combat-related, the veteran's lay testimony regarding inservice stressors is insufficient to establish occurrence of stressor and must be corroborated by credible supporting evidence but there is no requirement that corroboration only be found in the service records. Id. In the present case, a review of the veteran's service personnel records reveals his military occupational specialties to have been those of cook and food inspection specialist. Awards and commendations given the veteran consist solely of the National Defense Service Medal, and various other awards based on expert marksmanship. The service personnel records show that, during the period from 1967 to 1968, the veteran was attached to the Medical Company of the 106th General Hospital, located in Japan. For a portion of that time, he apparently served as a member of the Transportation Section. The records also show that, in December 1967, he was on duty as a cook in a mess hall. His Record of Assignments shows his principal duty at the 106th General Hospital was cook. It is during this period that the veteran's claimed stressors allegedly occurred. Service medical records in this case fail to document the existence of a chronic psychiatric disorder. In that regard, while in 1965 and early 1966, the veteran was seen for complaints of tension, nervousness, and anxiety, this represented no more than an acute response to transient family-related situational stresses. Service medical records for the period from 1966 to the veteran's separation in 1968 are negative for any evidence whatsoever of a psychiatric disorder. Moreover, at the time of the veteran's service separation examination in February 1968, no psychiatric disability was in evidence. The Board acknowledges that, in February 1973, approximately five years following service discharge, the veteran was hospitalized at a VA medical facility for what was initially described as an "anxiety neurosis." However, following evaluation, it was subsequently determined that the veteran's true problem was alcoholism. VA psychiatric examinations in October 1983 and October 1985 failed to disclose the presence of any psychiatric diagnosis or condition. In January 1988, an additional VA psychiatric examination was undertaken. This examination was precipitated by the veteran's complaints of "recurring dreams" and "nightmares" concerning wounded with whom he dealt while a medic in Japan, and represents the first instance of alleged symptomatology consistent with a post-traumatic stress disorder. At the time of evaluation, it was noted that the veteran had received previous diagnoses of an antisocial personality disorder and alcohol dependence. Additionally noted was a history of 40 previous arrests for assault and battery, 13 arrests for driving under the influence of alcohol, and various others for disorderly conduct. Previous history disclosed that the veteran had utilized a number of drugs, including Valium, "crack," and marijuana. This history also showed previous complaints of "flashbacks" concerning the veteran's patients in Japan. On psychiatric examination, the veteran appeared somewhat underactive, depressed, and preoccupied. His complaints included trouble sleeping, and "walking the floor" at night. According to the veteran, were he to go to sleep, he would experience recurring dreams of wounded with whom he had dealt while a medic in Japan. The veteran stated that he experienced nightmares, during which he saw wounded on the hospital floor in Japan. The veteran stated that he had served with the 106th General Hospital in Yokohama, Japan, during the period from 1966 to 1968, a total of 1 1/2 years. Reportedly, he served on the "medevac" team. The veteran stated that he would meet planes coming in from Vietnam, transporting the patients by helicopter from these planes to the hospital. The veteran further stated that he worked with "Vietnam wounded who were coming straight to Japan for hospitalization." Reportedly, 3 to 4 of these men died in his arms. The veteran stated that many of the patients in question would call for help, though there was nothing he could do to help them. Reportedly, burn patients "bothered him the most." On mental status examination, the veteran appeared depressed. His speech was not spontaneous, though he promptly answered all questions. The veteran's thought processes were within normal limits. His sensorium was described as "quite alert." The veteran stated that he kept his drapes pulled, and that there were certain "vague things" that he felt he saw. However, he was uncertain as to whether these were true delusions or hallucinations. There was evidence of both depression and elevated anxiety. Insight and judgment were described as "probably" within normal limits. The veteran denied homicidal ideation, stating that, in his opinion, his "stressor" consisted of taking care of wounded from Vietnam, seeing their condition, and "seeing them dying." He reported intrusive thoughts nearly every day concerning how he handled these wounded men who had been shot and burned. According to the veteran, thinking about these men made him "tense and nervous." The pertinent diagnosis noted was depressive neurosis. In the opinion of the examiner, while the veteran exhibited "some symptoms" of post-traumatic stress disorder, that diagnosis should not be made, inasmuch as the veteran's social and vocational impairment was the "direct result" of his depressive neurosis. In January 1989, the veteran received a diagnosis of generalized anxiety disorder. Somewhat later, at the time of a period of VA hospitalization during the months of September and October 1989, the diagnosis noted was one of recurrent depression. Not until October 1990 was the veteran given a diagnosis of post-traumatic stress disorder. At that time, the veteran was hospitalized at a VA medical facility for complaints of nightmares, flashbacks, and depression. During the course of his hospitalization, the veteran was very cooperative. His main complaint was one of depression, for which he received medication. The veteran's response to this medication was quite good, with the result that his depression completely cleared. On discharge, the veteran exhibited no evidence of depression or anxiety, or any suicidal ideation. He was alert and well oriented, and insight and judgment were normal. Since the time of the veteran's hospitalization in October 1990, he has on various other occasions received a diagnosis of post- traumatic stress disorder. What is absent in this case is objective or supporting evidence of the veteran's alleged inservice traumatic stressors. In that regard, the Board notes that, as per the aforementioned discussion, the veteran's documented military occupational specialities were those of cook and food inspection specialist. According to the veteran, it was during his service as a cook in Japan that he witnessed the burned and wounded casualties from Vietnam which precipitated his post-traumatic stress disorder. The veteran does not claim to have engaged in combat with the enemy, nor does he allege the existence of a combat-related stressor. Rather, his claimed stressor or stressors consist solely of the aforementioned exposure to combat casualties, his working as a "medic," caring for the wounded and burn victims, and transporting them. The medical evidence of record also shows that the veteran has claimed that he assisted doctors, that he took bodies to the morgue, and that he was assigned to the bedside of terminally ill patients. As noted above, where a claimed stressor is not combat related, the veteran's lay testimony regarding that stressor is insufficient to establish its occurrence, absent corroboration by "credible supporting evidence." In the case at hand, no such evidence exists. Exhaustive attempts at development, both by the RO and the Board, have failed to document that the veteran served as other than a cook during his period of service in Japan. In a statement of November 1993, the United States Army and Joint Services Environmental Support Group stated that it was unable to document that the veteran had served as a medical attendant. Rather, the only verifiable information was to the effect that the veteran served as a cook assigned to the 106th General Hospital. At present, there exists no supportive evidence that the veteran was exposed to such traumatic incidents as might constitute a recognizable stressor or stressors for purposes of a diagnosis of post-traumatic stress disorder. Although the notation in the veteran's personnel records that he was assigned duty in the transportation section of the hospital is credible supporting evidence of his contention that he was assigned duty other than duty as a cook, this evidence is much too vague and imprecise to be considered credible supporting evidence that the claimed array of varied stressors actually, or in fact, occurred. The medical evidence shows that the diagnosis of post-traumatic stress disorder has been based primarily on the veteran's reports that he served as a "medic," assisted physicians in treating burn patients, and of men dying in his arms, experiences that one examining physician, who diagnosed post-traumatic stress disorder, described as "catastrophic." Duty in a transportation section provides no support for the claim that stressors such as these actually occurred. The Board acknowledges that the veteran has in the past, and at present carries, a diagnosis of post-traumatic stress disorder. However, this diagnosis is based upon history provided by the veteran. Though the veteran may have been exposed to some stressful situations in service, these situations are, at present, unverified. His lay testimony regarding the existence of such stressors is insufficient to establish the occurrence of the stressors in question, in the absence of corroborating "credible supporting evidence." Accordingly, service connection for post-traumatic stress disorder must be denied. In reaching this determination, the Board has given due consideration to the veteran's testimony at the time of a personal hearing in August 1994, a transcript of which is included in his claims folder. Such testimony, however, in the opinion of the Board, is neither credible nor probative when considered in light of the evidence as a whole. Specifically, the veteran's allegations of inservice stressors are at present insupportable in light of the objective evidence currently on file. That evidence is to the effect that the veteran served only as a cook and food inspection specialist, and at one time was assigned to a transportation section, but not as a medical attendant or medic. Finally, the Board wishes to make it clear that it has given due consideration to the veteran's recent statement regarding certain individuals who would, by his account, have firsthand knowledge of his duty in a "med evac unit." It should be noted that certain of these individuals have been mentioned on prior occasions during the course of the veteran's appeal. Moreover, the veteran himself has stated that he is unable to contact the individuals in question. In light of the exhaustive development already undertaken in this case, the Board is of the opinion that no further assistance to the veteran is required in order to comply with the duty to assist him mandated by 38 U.S.C.A. § 5107(a) (West 1991). In response to the representative's request for another psychiatric examination, the Board finds that another examination is not warranted, since the decision on the issue turns on the question of the validity of the claimed stressors. Accordingly, the veteran's claim for service connection for post-traumatic stress disorder remains denied. II. Tinea Corporis As to the issue of an increased rating for the veteran's service- connected skin disorder, the Board notes that disability evaluations, in general, are intended to compensate for the average impairment of earning capacity resulting from a service-connected disability. They are primarily determined by comparing objective clinical findings with the criteria set forth in the rating schedule. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. Part 4 (1994). In the present case, a review of the record discloses that, during service, the veteran received treatment on a number of occasions for various skin-related problems, including a rash and dermatitis, located at various times on his back, thighs, buttocks, hands, feet, and groin. However, on VA medical examination in January 1981, no significant abnormality of the skin was in evidence. On subsequent VA dermatologic examination in June 1983, the veteran complained of a chronic persistent purulent eruption on his buttocks and groin present since 1963. According to the veteran, this had been treated with a number of different creams in conjunction with ultraviolet therapy, without any particular improvement. On physical examination, there was noted the presence of erythema and scale in conjunction with a serpiginous border in the area of eruption over the veteran's buttocks and groin. The clinical impression was of tinea corporis. On VA medical examination in October 1985, there was present only a rash on the veteran's left buttock measuring approximately 9 cm. x 4 cm. No other areas of rash were noted. Subsequent VA medical examination in July 1988 was negative for any abnormalities of the skin. On VA dermatologic evaluation in June 1990, the veteran described his main skin problem as located on his back. Physical examination revealed the presence of scaly papules with no active border. The clinical impression was one of eczema with a history of tinea corporis. In October 1990, the veteran underwent an excisional biopsy of the skin of his back, resulting in a diagnosis of chronic inflammation. At the time of the veteran's most recent VA dermatologic examination in July 1992, the veteran complained of itching, which was made worse by heat. He denied the presence of either pain or anesthesia. Physical examination revealed the presence of diffuse, erythematous keratotic papules on the veteran's back and buttocks, involving approximately 70 percent of the veteran's back. It was recommended that a biopsy be conducted in order to rule out the presence of "Darier's" disease. The pertinent diagnosis was eczema versus "Darier's" disease. In July 1993, the veteran underwent a biopsy of the skin lesions located on his back. The pertinent diagnosis was subcorneal pustular dermatosis versus impetigo contagiosa. The Board observes that the veteran's service-connected tinea corporis is rated as analogous to eczema. Such is the most appropriate analogy, based on the closeness of the symptoms and the anatomical localization. 38 C.F.R. § 4.20. As such, the 10 percent evaluation currently in effect contemplates the presence of a skin disorder characterized by exfoliation, exudation, or itching, and involvement of an exposed surface or extensive area. A 30 percent evaluation would require documented evidence of constant exudation or itching, extensive lesions, or marked disfigurement. 38 C.F.R. Part 4, Code 7806 (1994). The Board acknowledges that, at the time of the veteran's most recent VA dermatologic examination, there were present diffuse papules involving the veteran's buttocks and approximately 70 percent of his back. However, as noted above, the veteran has, on various prior occasions, experienced problems not only with the skin of his back and buttocks, but with his hands, feet, thighs, and groin. Based upon current evidence, the evidence shows that the veteran's service-connected tinea corporis is not currently productive of constant exudation or itching, extensive lesions, or marked disfigurement. As such, the 10 percent evaluation currently in effect is appropriate. As it is not shown that the current manifestations of the veteran's service-connected skin disorder more nearly approximate the criteria for a 30 percent evaluation than a 10 percent one, the criteria of 38 C.F.R. § 4.7 (1994) are not for application. Consequently, we are unable to reach a favorable decision in this matter. In reaching this determination, we have given full consideration to the veteran's testimony at the time of a personal hearing in August 1994. Such testimony, while informative, fails to document the presence of skin-related symptomatology of a severity sufficient to warrant the assignment of an increased rating. Rather, the objective clinical evidence currently on file shows that the veteran presently experiences no more than exfoliation, exudation, or itching in conjunction with involvement of an exposed surface or extensive area. Consequently, notwithstanding the veteran's testimony, an increased rating is not warranted. Finally, the Board wishes to make it clear that consideration has been given to the potential application of the various provisions of 38 C.F.R. Parts 3 and 4, whether or not they were raised by the veteran, as required by Schafrath v. Derwinski, 1 Vet.App. 589 (1991). In particular, the Board finds that the evidence discussed above does not suggest that the veteran's service- connected skin disorder presents such an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards so as to warrant the assignment of an extraschedular evaluation pursuant to the provisions of 38 C.F.R. § 3.321(b)(1) (1994). For example, other than for biopsy purposes, the veteran's service-connected skin disorder has not recently required frequent periods of hospitalization, nor does it present a marked interference with employment which has not already been contemplated by the evaluation currently in effect. ORDER Service connection for post-traumatic stress disorder is denied. An increased evaluation for service-connected tinea corporis is denied. WILLIAM J. REDDY Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, ___ (1994), permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a determination. This proceeding has been assigned to an individual member of the Board. NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West 1991), a decision of the Board of Veterans' Appeals granting less than the complete benefit, or benefits, sought on appeal is appealable to the United States Court of Veterans Appeals within 120 days from the date of mailing of notice of the decision, provided that a Notice of Disagreement concerning an issue which was before the Board was filed with the agency of original jurisdiction on or after November 18, 1988. Veterans' Judicial Review Act, Pub. L. No. 100-687, § 402 (1988). The date which appears on the face of this decision constitutes the date of mailing and the copy of this decision which you have received is your notice of the action taken on your appeal by the Board of Veterans' Appeals.