Citation Nr: 1325413 Decision Date: 08/12/13 Archive Date: 08/16/13 DOCKET NO. 11-05 523 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Augusta, Maine. THE ISSUE Entitlement to service connection for an acquired psychiatric disorder to include Post-Traumatic Stress Disorder (PTSD). REPRESENTATION Appellant represented by: Teena Petro, Agent ATTORNEY FOR THE BOARD O. Lopez, Associate Counsel INTRODUCTION The Veteran served on active duty from July 1968 to July 1970. This case comes to the Board of Veterans' Appeals (Board) on appeal from a March 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Indianapolis, Indiana. FINDING OF FACT The evidence of record shows that the Veteran has PTSD that is likely related to his combat experience in Vietnam. CONCLUSION OF LAW The criteria for service connection for PTSD have been met. 38 U.S.C.A. §§ 1101, 1110, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.304 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION I. Duties to Notify and to Assist Upon its receipt of a claim for veterans' benefits, VA, under the Veteran's Claims Assistance Act (VCAA), must: (1) notify the claimant of the information and evidence not of record necessary to substantiate the claim; and (2) assist the claimant in substantiating the claim. 38 U.S.C.A. §§ 5100, 5102-5103A, 5106, 5107, 5126 (West 2002 & Supp. 2012). In this case, the Board is granting the Veteran's claim in full. Therefore, if VA committed any errors regarding its duties to notify or to assist, those errors were harmless and did not prejudice the Veteran. II. Merits of the Claim The Veteran seeks service connection for an acquired psychiatric disorder to include PTSD, which, he states, is related to traumatic events that he experienced in Vietnam. For the reasons stated below, the Veteran's claim is granted. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303(a) (2012). Generally, "[t]o establish a right to compensation for a present disability, a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service"-the so-called "nexus" requirement." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection for PTSD requires: (1) medical evidence of a diagnosis of PTSD that conforms to the Diagnostic Statistical Manual, Fourth Edition (DSM-IV); (2) medical evidence of a link between the current symptoms and an in-service stressor; and (3) credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. §§ 3.304(f), 4.125(a) (2012). The Board must consider all information and lay and medical evidence of record. When there is an approximate balance of positive and negative evidence, i.e., when the evidence is in a state of "equipoise," regarding any issue material to the determination of a matter, the Board must give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b) (West 2002 & Supp. 2012). In support of his claim for PTSD, the Veteran submitted the following statement in which he indentified the claimed in-service stressor: "I served as a combat soldier on a fire support base called Bastone [sic] from 1969-1970 in North Vietnam. During the time I was serving on this fire base we were under mortar, sniper, and ground assault. This was constant, all day and all night." The Veteran also described to a VA psychiatrist a mortar attack that resulted in the death or injury of an entire gun crew and that he witnessed a "175MM Howitzer blow up and kill one of the gunners and another guy." The Veteran's discharge certificate (DD-214) identifies the Veteran's occupational specialty as "13A10 FA Basic," field artilleryman. The Veteran's service personnel record documents that he served in Vietnam from October 1969 to July 1970 with Battery A, First Battalion, 83rd Artillery. The Defense Personnel Record Image Retrieval System (DPRIS) confirms that in April 1970 Battery A received two enemy mortar rounds that killed one and wounded eight. It also confirms that, in February 1970, Fire Support Base Bastgone received a rocket attack and a mortar attack. The Board finds that the DPRIS provides credible supporting evidence that the Veteran's claimed in-service stressors occurred. As to the other two elements needed to establish service connection for PTSD, the Board has reviewed the Veteran's psychiatric records, which date from December 2007 to January 2011. These records indicate that, in that time, the Veteran underwent at least seven mental health examinations, six of which were by VA examiners and the seventh by two private examiners. The Board notes that the Veteran's diagnoses include PTSD, depression, an adjustment disorder with depression, an adjustment disorder with depressed mood, and an anxiety disorder. Below, the Board summarizes the examinations and discusses the evidence that it finds most probative. In January 2008, a VA psychiatrist diagnosed the Veteran with an adjustment disorder with depression and referred him for PTSD screening. Later that month, a licensed clinical social worker diagnosed the Veteran with PTSD and depression. In February 2008, the Veteran filed his claim for PTSD with VA. In June 2008, a VA psychiatrist diagnosed an anxiety disorder. In October 2008, VA provided the Veteran a compensation and pension examination to substantiate his claim. That examiner found that the Veteran did not report psychological symptoms that met the DSM-IV PTSD symptom criteria. The examiner, however, diagnosed the Veteran with an adjustment disorder with depressed mood and anxiety, "which is seen to result in large part from his adjustment to retirement life." In December 2009, the Veteran underwent a private mental health examination by a licensed mental health counselor and a licensed psychologist. The examiners produced a detailed report, concluding that the Veteran's symptoms met the criteria for a diagnosis of PTSD and that the PTSD was "caused by the Veteran's war experience in Vietnam." In September 2010, a VA psychiatrist noted that the Veteran had a history of bipolar spectrum disorder and PTSD. To resolve these differences in diagnoses, VA ordered a "reconciliation of diagnosis" and emphasized that that Veteran be examined by "a board of two psychiatrists." The Veteran underwent that examination in January 2011. While the report of the examination notes that the Veteran was interviewed by two examiners, only one examiner, a psychologist, signed the report. The report states that the Veteran endorsed some symptoms of PTSD, but that he did not the meet the full criteria for PTSD "due to insufficient number or symptoms/lack of impairment due to symptoms." The report, however, includes a summary conclusion that "a diagnosis of Anxiety Disorder ... [is] most appropriate at this time." Of the evidence noted above, the Board finds the report of the private mental health examination to be the most probative on whether the Veteran's symptoms meet the criteria for PTSD under the DSM-IV and whether there is a link between the Veteran's symptoms and the claimed in-service stressor. The report is comprehensive and provides a well-reasoned, detailed explanation as to why the Veteran's symptoms meet the criteria for PTSD under the DSM-IV and how the PTSD is related to the Veteran's combat experience in Vietnam. Conversely, the Board finds the January 2011 VA examination defective because it failed to adhere to the request that the Veteran be examined "by a board of two psychiatrists." As noted above, one examiner, a psychologist, signed the examination report. It is unclear if the other examiner, who did not sign the report, is a psychiatrist. Moreover, as to the anxiety disorder diagnosed at that time, the examiner (or examiners) summarily concluded that the symptoms of that disorder are not related to Vietnam, but did not explain why that is the case. Weighing the evidence of record, the Board concludes that the evidence supporting a grant of service connection for PTSD is at least in equipoise. In this regard, there is sufficient evidence of a current diagnosis of PTSD, a corroborated in-service stressor, and medical evidence linking the diagnosis of PTSD to the in-service stressor. Under such circumstances, the Board finds that reasonable doubt should be resolved in the Veteran's favor and that entitlement to service connection for PTSD is warranted. Even though there are separate diagnoses, given that the various mental health professionals were not all in agreement, the Board considers that all current symptoms and diagnoses are part and parcel to his PTSD and, therefore, grants service connection for an acquired psychiatric disorder to include PTSD. Cf. Clemons v. Shinseki, 23 Vet. App. 1 (2009). ORDER Entitlement to service connection for acquired psychiatric disorder to include Post-Traumatic Stress Disorder (PTSD) is granted. ____________________________________________ JONATHAN B. KRAMER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs