Citation Nr: 1213167 Decision Date: 04/11/12 Archive Date: 04/19/12 DOCKET NO. 10-07 900 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Boise, Idaho THE ISSUE Entitlement to service connection for an acquired psychiatric disability, claimed as to include posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD J. M. Macierowski, Counsel INTRODUCTION The Veteran served on active duty from September 1965 to August 1968. This matter comes before the Board of Veterans' Appeals (Board) on appeal from June 2007, January 2008, and August 2008 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Boise, Idaho. In his February 2010 VA Form 9, the Veteran requested a hearing before the Board in conjunction with his appeal. However, in July 2011, he did not report for his scheduled hearing, and there is a notation in the file that he had cancelled his request. In any event, since he did not report the request is deemed withdrawn. 38 C.F.R. § 20.704 (2011). The Veteran's claim for service connection for PTSD has been recharacterized as a claim for service connection for an acquired psychiatric disorder, to include PTSD. See Clemons v. Shinseki, 23 Vet. App. 1 (2009) (finding that a claim for benefits for one psychiatric disability also encompassed benefits based on other psychiatric diagnoses and should be considered to be within the scope of the filed claim). FINDING OF FACT The record does not reflect a diagnosed psychiatric disability, to include PTSD. CONCLUSION OF LAW An acquired psychiatric disability, to include PTSD, was not incurred in, or aggravated by, active military service. 38 U.S.C.A. §§ 1110, 5103A, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.303, 3.304 (2011). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2011). October 2006 and March 2007 letters satisfied the duty to notify provisions. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b) (1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The Veteran was notified of regulations pertinent to the establishment of an effective date and of the disability rating in the October 2006 letter. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The Veteran's service treatment records, VA medical treatment records, and identified private medical records have been obtained. 38 U.S.C.A. § 5103A, 38 C.F.R. § 3.159. The record does not reflect that the Veteran is in receipt of disability benefits from the Social Security Administration. 38 C.F.R. § 3.159 (c) (2). A VA PTSD examination was conducted in July 2008, and an addendum opinion obtained in August 2008; the VA examination conducted a complete social and industrial survey, and mental status examination, of the Veteran; the addendum provided a multi-axial diagnosis with a complete rationale. 38 C.F.R. § 3.159(c) (4); Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). There is no indication in the record that any additional evidence, relevant to the issue decided herein, is available and not part of the claims file. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of the case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); see also Dingess/Hartman, 19 Vet. App. at 486; Shinseki v. Sanders 129 S. Ct. 1696 (2009). Service connection may be established for a disability resulting from diseases or injuries which are clearly present in service or for a disease diagnosed after discharge from service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Additional specific regulations apply to claims for PTSD. Service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a) (2011); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f). Effective July 13, 2010, 38 C.F.R. § 3.304 (f) was amended to eliminate the requirement for corroborating evidence of a claimed in-service stressor if it is related to a veteran's fear of hostile military or terrorist activity. 75 Fed. Reg. 39,843 (2010). The regulatory revision is applicable to a claim for service connection for PTSD that was received on or after July 13, 2010; received before July 13, 2010, but has not been decided by a regional office as of that date; appealed to the Board on or after July 13, 2010; appealed to the Board before July 13, 2010, but not decided by the Board as of that date; or pending before VA on or after July 13, 2010, because the Court of Appeals for Veterans Claims (Veterans Court) vacated a Board decision on the application and remanded it for adjudication. Id. The Veteran's claim is affected by the amended regulation. However, service connection for PTSD is not warranted because the competent evidence of record does not reflect that the stressors identified by the Veteran in his November 2006 statements resulted in PTSD. In his September 2006 claim, the Veteran indicated that he had not yet sought treatment for PTSD. A VA outpatient treatment record dated in September 2007 noted that the Veteran had attended a PTSD clinical team group therapy meeting, but no diagnosis of PTSD was noted in that record. Similarly, PTSD was also not diagnosed at the July 2008 VA PTSD examination, or in the consequent addendum opinion. While the July 2008 VA examiner found that the Veteran received a score of 130 on the Mississippi Scale for Combat Related PTSD, an average score for those who take the questionnaire and are ultimately diagnosed with PTSD, the Veteran only endorsed four of 10 common indices for the PTSD diagnosis on the Personality Assessment Inventory. Thus, while the results of these tests showed evidence of symptoms usually associated with PTSD, but did not support a formal diagnosis. On the multi-axial diagnosis, no Axis I or Axis II psychiatric disability was noted. While some evidence suggesting the existence of PTSD symptoms is of record, it does not establish a current diagnosis of PTSD. As noted above, the Veteran participated in a September 2007 PTSD clinical team group therapy meeting, but this in and of itself is not evidence that the Veteran has a PTSD diagnosis, and the September 2007 record does not reflect that a PTSD diagnosis is a prerequisite in order to attend this type of group meeting. Further, although a May 2007 VA outpatient visit noted a positive PTSD screen, based on four basic questions, this is also not a PTSD diagnosis, which would require mental status testing as well as a multi-axial assessment. Finally, although the Veteran indicated in his July 2009 notice of disagreement that he would obtain and submit a separate medical opinion, the record does not reflect that a private medical professional, or another VA clinician, ever made a formal diagnosis of PTSD. To that end, service connection for non-PTSD acquired psychiatric disabilities has also been considered. Clemons v. Shinseki, 23 Vet. App. 1 (2009). However, as noted above, the July 2008 VA PTSD examination report does not reflect that any non-PTSD psychiatric disabilities were diagnosed on Axis I or Axis II in the multi-axial evaluation. The remaining evidence of record, to include the May 2007 and September 2007 VA outpatient treatment records discussed above, also do not reflect a diagnosed non-PTSD psychiatric disability. In the absence of proof of a present disability, there can be no valid claim for service connection. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Because record does not reflect a diagnosed psychiatric disability, to include PTSD, the preponderance of the evidence is against the Veteran's claim for service connection. Thus, the benefit of the doubt doctrine is inapplicable, and the Veteran's claim must be denied. See 38 C.F.R. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Entitlement to service connection for an acquired psychiatric disability to include PTSD is denied. ____________________________________________ ROBERT C. SCHARNBERGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs