Citation Nr: 1137814 Decision Date: 10/07/11 Archive Date: 10/11/11 DOCKET NO. 98-05 541A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Philadelphia, Pennsylvania THE ISSUES 1. Entitlement to service connection for a variously diagnosed psychiatric disability to include posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for erectile dysfunction claimed as secondary to PTSD. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD M. McPhaull, Counsel INTRODUCTION The appellant is a Veteran who served on active duty from August 1962 to November 1965. These matters are before the Board of Veterans' Appeals (Board) on appeal from a May 1997 rating decisions by the Newark, New Jersey, Department of Veterans Affairs (VA) Regional Office (RO). The case is now under the jurisdiction of the Philadelphia RO. In May 2007 a Travel Board hearing was held before the undersigned. A transcript of that hearing is associated with the claims file. In September 2007 and September 2009 these matters were remanded for further development. In May 2011, the Board sought an advisory medical opinion from the Veterans Health Administration (VHA). FINDINGS OF FACT 1. The evidence reasonably establishes that the Veteran has PTSD stemming from a stressor event in service. 2. The Veteran is reasonably shown to have erectile dysfunction as a complication of medications he takes for his service-connected PTSD. CONCLUSIONS OF LAW 1. Service connection for a PTSD is warranted. 38 U.S.C.A. § 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 4.125 (2011). 2. Secondary service connection for erectile dysfunction is warranted. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.310 (2011). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). It applies in this case. However, inasmuch as this decision grants the benefits sought, there is no reason to belabor the impact of the VCAA on these matters, since any notice error or duty to assist omission is harmless. Accordingly, the Board will address the merits of the claims. Legal Criteria, Factual Background and Analysis The Board notes that it has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence where appropriate and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claims. Service connection may be granted for disability due to disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.304. Service connection may be established on a secondary basis for a disability that is proximately due to, the result of, or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310(a); see also Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). Briefly, the threshold legal requirements for a successful secondary service connection claim are: (1) Evidence of a current disability for which secondary service connection is sought; (2) a disability which is service connected; and (3) competent evidence of a nexus between the two. Service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a) [i.e., a diagnosis under DSM-IV]; a link, established by medical evidence, between current symptoms and a stressor event in service; and credible supporting evidence that the claimed stressor event in service occurred. 38 C.F.R. § 3.304(f). Where the Veteran did not engage in combat with the enemy, or the claimed stressors are not related to combat, the Veteran's testimony alone is insufficient to establish the occurrence of the claimed stressors and the occurrence must be corroborated by credible supporting evidence. Cohen v. Brown, 10 Vet. App. 128 (1997). Service department records must support, and not contradict, the claimant's testimony regarding noncombat stressors. Doran v. Brown, 6 Vet. App. 283 (1994). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b). When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (e.g., a broken leg), (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). PTSD: The Veteran has identified two stressor events in service that are alleged to have resulted in PTSD, namely: (a) that in September or October 1964 he fell overboard, and (b) that while serving aboard a ship he was the victim of a sexual assault. There is no independent corroborating evidence of these alleged events. The available service treatment records (STRs) show that in August 1965 the Veteran was hospitalized for psychiatric complaints. He was noted to have latent schizophrenia with passive aggressive features. His complete STRs are unavailable. Hence, VA has a heightened duty to assist him in developing his claims. O'Hare v. Derwinski, 1 Vet. App. 365 (1991). Postservice private and VA outpatient treatment records show that since 1995 the Veteran has, at varying times, been assigned diagnoses of adjustment disorder with mixed emotional features, depression, generalized anxiety disorder, somatoform disorder, anxiety disorder with panic attacks, bipolar disorder, type I, bipolar disorder, NOS, and PTSD. The diagnosis of PTSD was based on the Veteran's accounts that during service he fell overboard, and was also a victim of a sexual assault. VA psychiatric outpatient treatment records show an October 2005 notation of rape-related PTSD with depression and loss of self-esteem. On March 2010 VA examination, the examiner found that the Veteran has a bipolar disorder, not otherwise specified, and PTSD (which was related to incidents in childhood). The examiner noted that the Veteran's bipolar disorder did not originate in service (as there was no evidence of bipolarity in service), and was likewise unrelated to service. This opinion was found to be inadequate (as the report did not adequately discuss the significance of the psychiatric symptoms noted/treated in service). Consequently, the Board sought a VHA medical expert advisory opinion in the matter. Pursuant to that request, a VA specialist in psychiatry reviewed the claims file and, in an opinion dated in July 2011, stated, in pertinent part: "Based on the factual evidence of the record, a chronic psychiatric disability manifested during the Veteran's service. He was psychiatrically hospitalized while in the service following his unprovoked assault on another service member and voiced homicidal ideation toward a commanding officer. He did not readily divulge what this change in behavior and anger was related to, which would be not unexpected following a sexual assault. However, there is certainly documentation of a change in his behavior which would be consistent with that seen in rape victims and would indicate a diagnosis of Acute Stress Reaction (the beginning of PTSD). . . . Neuropsychiatric testing in 2007 at the VA indicates PTSD which has now become chronic and persistent and substantially interferes with the Veteran's functioning. . . . The Veteran's symptoms are most consistent with PTSD, not a personality disorder or Bipolar Disorder. The stressor supporting the diagnosis of PTSD is sexual assault/trauma occurring while the patient was in active duty. The occurrence of the stressor is corroborated by the change in behavior and psychiatric hospitalization. . . The Veteran's current psychiatric illness, PTSD, is at least as likely as not related to the Veteran's service. . . .The [Veteran's] inpatient hospitalization is quite significant. He was initially diagnosed as Schizophrenic, due to his bizarre affect (numbing) and voiced homicidal thought. However, both would be consistent with the reported sexual trauma. PTSD would be differentiated most readily from Schizophrenia by the absence of a thought disorder. He did not have a thought disorder. It is clear at this point in time, all these years later that the [Veteran] does not suffer from schizophrenia. This strengthens the conclusion that this early hospitalization was in fact undiagnosed PTSD. The difficulty in this case has been linking the Veteran's PTSD to an event during the service. Several facts provide circumstantial evidence to support the Veteran's claim, including psychiatric hospitalization and a sudden desire to not return to his ship nor to re-enlist. In conclusion, I believe it to be more likely than not that the [Veteran's] present PTSD symptoms are related to events that occurred while he was in active military service." Whether behavior changes in service corroborate the occurrence of an alleged sexual assault is a medical question. The Board finds no reason to question the July 2011 expert opinion by a VA psychiatrist essentially to the effect that the Veteran's psychiatric hospitalization in service and his sudden desire to not return to his ship or to re-enlist corroborate that he was the victim of a sexual assault in service. As the record shows that the Veteran has a diagnosis of PTSD; and now includes credible supporting evidence corroborating the occurrence of a stressor event in service; and a persuasive medical opinion linking the Veteran's diagnosis of PTSD to the corroborated stressor event in service, all of the criteria for establishing service connection for PTSD are met, and service connection for PTSD is warranted. Sexual dysfunction: The record reflects that the Veteran reported impotence in service. Postservice treatment records continue to note the continuity of the Veteran's erectile dysfunction; they show that he has undergone a penile implant. Statements by the Veteran to examiners and counselors document that he has complained of impotence since the now-conceded sexual assault in service. On March 2010 VA examination, the examiner indicated in pertinent part that the medications the Veteran takes for his psychiatric disability appear to have been a factor. The Veteran's theory of entitlement to service connection for sexual dysfunction is essentially one of secondary service connection. As noted, there are three basic requirements for substantiating a claim of secondary service connection: (i) There must be evidence of current disability [i.e., for which service connection is sought]; (ii) there must be disability that is already service-connected; and (iii) there must be competent evidence that the disability that is already service-connected either caused or aggravated the disability for which secondary service-connection is sought. At the outset, the Board notes that whether or not the Veteran can maintain an erection is something capable of his own lay observation. See Jandreau v. Nicholson, 492 F 3d. 1372, 1377 (Fed. Cir. 2007). Furthermore, that he was provided a penile implant tends to corroborate that he cannot maintain an erection. As the Veteran now has service connected PTSD, the remaining question is whether or not he has sexual dysfunction that was caused or aggravated by such disability. The only competent (medical) evidence that addresses that medical question is the opinion offered by the March 2010 VA examiner, who essentially indicated that the Veteran's psychiatric medications appear to have been a factor. Accordingly, all the requirements for establishing secondary service connection are met, and service connection for sexual dysfunction (impotence/erectile dysfunction) as secondary to medication the Veteran takes for PTSD is warranted. ORDER Service connection for PTSD is granted. Secondary service connection for erectile dysfunction is granted. ____________________________________________ GEORGE R. SENYK Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs