Citation Nr: 1330266 Decision Date: 09/20/13 Archive Date: 09/25/13 DOCKET NO. 03-31 350 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Hartford, Connecticut THE ISSUES 1. Entitlement to service connection for posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for psychiatric disability other than PTSD, to include anxiety disorder, not other otherwise specified (NOS), and major depressive disorder in partial remission. REPRESENTATION Appellant represented by: Robert V. Chisholm, Attorney ATTORNEY FOR THE BOARD John Francis, Counsel INTRODUCTION The Veteran served on active duty from February 1966 to February 1968. This appeal to the Board of Veterans' Appeals (Board) arose from a September 2003 rating decision in which the RO denied service connection for PTSD. In October 2003, the Veteran filed a notice of disagreement (NOD). In January 2004, the Veteran testified during a hearing before a Decision Review Officer (DRO) at the RO; a transcript of that hearing is of record. A statement of the case (SOC) was issued in December 2004, and the Veteran filed a substantive appeal (via a VA Form 9, Appeal to the Board of Veterans' Appeals) in December 2004. In his December 2004 substantive appeal, the Veteran requested a hearing before a Veterans Law Judge at the RO. In correspondence received in December 2006, the Veteran cancelled his hearing request. In January 2007, the Veteran's representative requested a Board video-conference hearing. In correspondence in February 2007, the Veteran withdrew his request for a Board hearing. In July 2007, the Board remanded, inter alia, the claim for service connection for PTSD, to the RO, via the Appeals Management Center (AMC) in Washington, DC, for further action, to include additional development of the evidence. After accomplishing further action, the AMC continued to deny the claim (as reflected in a June 2010 supplemental SOC (SSOC)) and returned this matter to the Board. In January 2011, the Board, again, remanded the claim on appeal to the RO, via the AMC, for further action, to include additional development of the evidence. In the remand, the Board pointed out that the RO originally adjudicated the matter on appeal as service connection for PTSD. However, in light of the diagnoses of psychiatric disorders other than PTSD of record-specifically, anxiety disorder, not otherwise specified (NOS), and major depressive disorder in partial remission-and the decision of the United States Court of Appeals for Veterans Claims (Court) in Clemons v. Shinseki, 23 Vet. App. 1 (2009), the Board recharacterized the claim on appeal as one for service connection for an acquired psychiatric disorder to include PTSD. After completing the requested development, the AMC continued to deny the claim on appeal (as reflected in the January 2012 SSOC) and returned the matter to the Board for further appellate consideration. In June 2012, the Board denied service connection for PTSD. Because the Board determined that a separate adjudication was warranted with respect to the matter service connection for psychiatric disability other than PTSD, the Board remanded the separate claim for additional development. The Veteran appealed the denial of service connection for PTSD to the United .States Court of Appeals for Veterans Claims (Court). In a September 2012 Order, the Court vacated that portion of the June 2012 decision in which the Board denied service connection for PTSD. and remanded the matter for compliance with the instructions in a June 2012 Joint Motion for Partial Remand. The Board acknowledges that only the matter of service connection for PTSD was remanded by the Court, and that, technically, only that matter is currently before the Board. As noted, the Board remanded the matter of service connection for psychiatric disability other than PTSD to the RO, via the AMC, in June 2012. Giving the timing of the remand, the appeal, and the Court Order, the RO/AMC has taken no action on the remand. However, as explained below, upon review of all the evidence of record, including additional relevant evidence received since June 2012, and for the reasons expressed , the Board is re-assuming jurisdiction over the matter of service connection for psychiatric disability other than PTSD, as the record presents sufficient basis to allow both claims. FINDINGS OF FACT 1. All notification and development actions needed to fairly adjudicate each claim on appeal have been accomplished. 3. There is credible evidence confirming the occurrence of in-service stressors, to include those associated with fear of hostile military activity. 3. Competent, probative medical opinion evidence on the questions of whether the Veteran meets the diagnostic criteria for PTSD and major depressive disorder, and whether the disorders are etiologically related to traumatic events in service, is in relative equipoise. CONCLUSION OF LAW Resolving all reasonable doubt in the Veteran's favor, the criteria for service connection for PTSD, and for major depressive disorder in partial remission, are met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1137 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.384, 4.125 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002 & Supp. 2012) includes enhanced duties to notify and assist claimants for VA benefits. VA regulations implementing the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2012). Given the favorable disposition of the both claims on appeal, the Board finds that all notification and development actions needed to fairly adjudicate these claims have been accomplished. Wensch v. Principi, 15 Vet App 362, 367-68 (2001). II. Analysis Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. 38 U.S.C.A. § 1112; 38 C.F.R. § 3.304. See also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996) [(table)]. The requirement of a current disability is satisfied when the claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim and that a claimant may be granted service connection even though the disability resolves prior to the Secretary's adjudication of the claim. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). When a claimant makes a claim, he is seeking service connection for symptoms regardless of how those symptoms are diagnosed or labeled. Clemons v. Shinseki, 23 Vet. App. 1 (2009) Additionally, for Veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, to include psychoses, are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. The definition of psychoses for this purpose does not include any of the several diagnoses of the Veteran's mental health illness in the record. See 38 C.F.R. § 3.384. Alternatively, service connection may be established under 38 C.F.R. § 3.303(b) by (a) evidence of (i) the existence of a chronic disease in service or during an applicable presumption period under 38 C.F.R. § 3.307 and (ii) present manifestations of the same chronic disease, or (b) when a chronic disease is not present during service, evidence of continuity of symptomatology. However, absent a diagnosis of a chronic disease as defined in 38 C.F.R. § 3.309(a), service connection may not be awarded based on continuity of symptomatology. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In this case, the acquired psychiatric diagnoses of record are not recognized as chronic diseases. Service connection for PTSD requires medical evidence establishing a diagnosis of the condition in accordance with 38 C.F.R. § 4.125(a) (i.e., the diagnosis must comply with the Fourth Edition of the Diagnostic and Statistical Manual of Mental Disorders, 1994 (DSM-IV)); in certain circumstances, credible supporting evidence that the claimed in-service stressor occurred; and a link, established by medical evidence, between current symptomatology and the claimed in-service stressor. See 38 C.F.R. §§ 3.304(f), 4.125; see also Cohen v. Brown, 10 Vet. App. 128, 140 (1997). Under DSM-IV, a stressor is a traumatic event in which both of the following were present: (1) the person experienced, witnessed, or was confronted with an event or event that involved actual or threatened death or serious injury, or threat to the physical integrity of self or others; and (2) the person's response involved intense fear, helplessness, or horror. A stressor must consist of an event during such service that is outside the range of usual human experience and such that would be markedly distressing to almost anyone, such as experiencing an immediate threat to one's life or witnessing another person being seriously injured or killed. It is the distressing event, not mere presence that constitutes a valid stressor. Zarycki v. Brown, 6 Vet. App. 91, 99 (1994). Service in a combat zone is stressful to some degree to all who are there, whatever their duties or experiences. Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). For claims that were appealed to the Board but not decided as of July 13, 2010, changes to the applicable regulations are in effect as follows. If a stressor claimed by a Veteran is related to the Veteran's fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of PTSD and that the Veteran's symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of the Veteran's service, the Veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. 38 C.F.R. § 3.304 (f) (3); 75 Fed. Reg. 39,843 (Jul. 13, 2010) "Fear of hostile military or terrorist activity" means that a Veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the Veteran or others, such as from an actual or potential improvised explosive device; vehicle-imbedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon friendly military aircraft, and the Veteran's response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror. Diagnoses of acquired psychiatric disorders including PTSD must be rendered in accordance with the diagnostic criteria for the condition set forth in the Fourth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). See 38 C.F.R. § 4.125 (noting that VA has adopted the nomenclature of the DSM-IV). Lay evidence is competent to establish the presence of observable symptomatology and "may provide sufficient support for a claim of service connection." Layno v. Brown, 6 Vet. App. 465, 469 (1994). When a condition is capable of lay observation and may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature." Lay evidence can be competent and sufficient to establish a diagnosis when a layperson (1) is competent to identify the medical condition; or, (2) is reporting a contemporaneous medical diagnosis; or, (3) describes symptoms at the time which supports a later diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Although a lay person is competent in certain situations to provide a diagnosis of a simple condition, a lay person is not competent to provide evidence as to more complex medical questions. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Likewise, mere conclusory or generalized lay statements that a service event or illness caused a current disability are insufficient. Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). The Board must weigh any competent lay evidence and to make a credibility determination as to whether it supports a finding of service incurrence; or, if applicable, continuity of symptomatology; or both, sufficient to establish service connection. See Barr v. Nicholson, 21 Vet. App. 303 (2007); see also Layno, supra. The credibility of lay evidence may not be refuted solely by the absence of corroborating contemporaneous medical evidence, but it is a factor. Davidson v. Shinseki, 581 F.3d at 1313, 1316 (Fed.Cir. 2009). Other credibility factors are the lapse of time in recollecting events attested to, prior conflicting statements as opposed to consistency with other statements and evidence, internal consistency, facial plausibility, bias, interest, the length of time between alleged incurrence of disability and the earliest or first corroborating medical or lay evidence thereof, and statements given during treatment (which are usually given greater probative weight, particularly if close in time to the onset thereof). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107(West 2002); 38 C.F.R. § 3.102 (2012); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Given the totality of the evidence, to particularly include the Veteran's statements of his experiences, the VA outpatient treatment records, and the various private, VA, and VA contract medical examination and opinions, and resolving all reasonable doubt on the question of diagnosis and medical nexus in the Veteran's favor (see 38 U.S.C.A. § 5107(b), 38 C.F.R. § 3.102, and Gilbert, 1 Vet. App. at 53-56), the Board finds that the criteria for service connection for PTSD and for major depressive disorder in partial remission are met. The Veteran served as a U.S. Army cook, to include during service in the Republic of Vietnam from July 1966 to July 1967. During this service in Vietnam, the Veteran was assigned to the 85th Evacuation Hospital. On many occasions during the pendency of this appeal, the Veteran reported that in addition to food service duties, he carried meals through patient wards and witnessed seriously injured and deceased soldiers. He also reported assisting the transport of injured and deceased men from helicopters. He reported occasionally performing guard duty on the base perimeter and in a prisoner ward, responding as a rifleman during an attack on the base, and coming under attack while driving off base to obtain supplies. He reported that the aircraft transporting him home came under small arms fire. The Joint Services Record Research Center confirmed that at least one attack occurred at the Veteran's base during his tour of duty. The Board concludes that the Veteran's reported experiences are credible, as they are consistent with the nature of his duties as a junior soldier in a evaluation hospital, his presence and participation in a verified attack on his base, and expressed fear of hostile attack while on duty as a guard, while driving outside the base, and while a passenger in an aircraft receiving incoming fire. Thus, there is sufficient, credible evidence confirming the occurrence of in-service stressors, to include those associated with fear of hostile military activity. Service treatment records are silent for any symptoms or diagnoses of a psychiatric disorder. Following active service, the Veteran worked in maintenance positions in an industrial facility and for the U.S. Postal Service until regular retirement in December 2006. Records of private medical care dated from 1983 to 1997 are also silent for any mental health symptoms. The RO received the Veteran's claims for service connection for PTSD in March 2003. In October 2003, the RO denied service connection for PTSD, in part, because there was no evidence of a diagnosis or medical treatment for PTSD. In a January 2004 RO hearing, the Veteran acknowledged that he had never been diagnosed or treated for PTSD or any psychiatric disorder. The Veteran first sought counseling in March 2005 at a VA Vet Center. In an intake interview, the Veteran reported his experiences with injured and deceased soldiers in the hospital and having adjustment issues following his tour in Vietnam. The Veteran's memories and intrusive thoughts were the only PTSD symptoms reported at that time. He also reported that his wartime memories were revived upon the death of his spouse in 2000. The Veteran participated in only three counseling sessions, and the counselor noted no diagnosis. In May 2005, following a positive PTSD screening by his primary care clinicians, the Veteran initially sought mental health treatment at a VA clinic. During the intake consultation, he reported increased anxiety and re-experiencing events in service. The Veteran also reported seeing shadows and hearing shouting or the sound of equipment. Nightmares impaired his sleep. The Veteran reported avoiding crowds and news. The examiner diagnosed chronic PTSD. A June 2005 clinical note shows that the Veteran was prescribed medication for anxiety and depression. Further VA outpatient records note PTSD as an ongoing diagnosis, but do not discuss the basis for the diagnosis. A January 2006 note suggests that the medication was prescribed for treatment of anxiety and depression. In November 2005, a private psychologist noted that he started treating the Veteran in May 2005. The physician diagnosed PTSD meeting the criteria of DSM-IV because of the intrusive recollections, frequent nightmares, and flashbacks. The Veteran avoided war-related material and was hypervigilant. Employment records from the Postal Service showed that the Veteran was granted leave from work from November 2005 to at least April 2006. Although the psychologist never provided clinical notes as requested, he submitted a follow-up statement in April 2007 again noting that he had been providing on-going mental health care since May 2005 for chronic PTSD and anxiety arising from the Veteran's wartime experiences. The psychologist also diagnosed alcohol abuse that he found to be a means for the Veteran to cope with the memories. In July 2007, the Board remanded the claim on appeal to facilitate additional research on the occurrence of the Veteran's traumatic events and to obtain a VA examination. In March 2010, the Veteran underwent a VA examination to assess the appropriateness of a PTSD diagnosis. A VA physician reviewed the claims file and medical records and conducted a lengthy interview. The examiner confirmed that the Veteran did experience qualifying traumatic events and endorsed some avoiding in numbing symptoms, including avoiding thoughts or feelings with moderate impact and detachment from others. The physician concluded that the avoidance symptoms did not rise to the level of that required to meet the full diagnostic criteria for PTSD. Further, the physician noted that the Veteran adapted well to the transition to civilian life after service despite the traumatic events. The physician did conclude that the diagnostic criteria were met for major depressive disorder, which was noted years earlier in 2000 during treatment for a serious gastrointestinal disorder, but did not clearly associate the origin of the disorder to events in service. VA outpatient mental health clinic records show that the Veteran received on-going medication for symptoms of PTSD, anxiety, and depression. The treatment was monitored by a VA Advanced Practice Registered Nurse who noted symptoms such as sleep disturbance, anxiety, depression, hyperarousal, avoidant behaviors, and recurrent thoughts of Vietnam. The nurse did not indicate that the symptoms represented separate disorders arising from separate causes. In January 2011, the Board again remanded the matter on appeal for re-examination, taking into consideration the new regulation pertaining to PTSD. Pursuant to the remand, the Veteran underwent VA examination in February 2011 by a VA neuropsychologist. The examiner noted the Veteran's reports of daily intrusive thoughts and nightmares, and hyperarousal associated with memories of his service in Vietnam. The examiner also noted the March 2010 examiner's characterization of his avoidance symptoms as not meeting the DSM-IV criteria. The neuropsychologist also noted that the reports of avoidance in her examination were also vague. The Veteran reported that he did not discuss his experience with buddies and that he avoided crowded places. The examiner also noted, however, that the Veteran did not report avoidance to the level that the Veteran was solitary or isolated. The Veteran reported that he saw some friends twice weekly. There was also no evidence of anhedonia, in that even though the Veteran stopped working, he continued to work on cars as a hobby. He also reported to the examiner that while he generally kept to himself, he behaved in that way prior to going to Vietnam. Testing at the time of this examination was not useful in rendering a diagnosis, because the Veteran displayed concentration difficulty and provided responses to various forms of the same question with quite different answers. The VA neuropsychologist concluded that the Veteran did not meet the diagnostic criteria for PTSD. The examiner did note the previous diagnoses of depression and alcohol abuse and that the Veteran continued to express symptoms of depression and anxiety, but evaluated these symptoms as not clearly connected with wartime experiences. The neuropsychologist also found that the "trajectory" of being asymptomatic at the time of return from Vietnam to a sudden complaint of symptoms to the private psychologist in 2005 was not supported in the record and that the VA outpatient treatment appeared to have improved his symptoms. Moreover, the neuropsychologist found no clear explanation of why his symptoms degraded since the 2010 examination. The neuropsychologist noted that her conclusion was based on review of the outpatient treatment notes, which she evaluated as not meeting the full criteria of PTSD, the results of the two VA examinations, and her own clinical observations and analysis. The psychologist assessed the Veteran as having met the criteria for anxiety disorder, not otherwise specified (NOS), and major depressive disorder in partial remission, and confirmed that the criteria are not met for PTSD under the DSM-IV. The neuropsychologist also concluded that the anxiety and depression symptoms were "...not all thought to be clearly connected to the in-service stressors..." and that the alcohol use "...was difficult to quantify, and it is unclear whether he is drinking in response to other or more general anxiety symptoms." The Veteran submitted the report of a psychological test and evaluation performed by a private clinical psychologist who noted that he formerly held positions at VA including at a VA PTSD clinic and as a compensation and pension examiner. He further noted experience as a medical school professor and as a published author on topics associated with PTSD. The psychologist noted that he examined the Veteran by telephone over three hours on two occasions and reviewed the entire claims file. He provided a very detailed summary of the Veteran's personal, military, and medical history. The psychologist administered four tests and concluded that the anxiety and depression test results showed moderate to serious problems with the Veteran's emotional state. He diagnosed PTSD but not a mood disorder. The psychologist noted that the Veteran's symptoms of nightmares, flashbacks, and psychological distress were a response to traumatic events in service that involved fear and helplessness. Contrary to the VA examiners, the psychologist found that the Veteran did display persistent avoidance of stimuli, citing the use of alcohol to mask his feelings, avoiding certain activities and places that gave rise to recollections of the trauma. He also displayed diminished interest in activities and was estranged from others following the death of his wife. Another indicator of avoidance was the Veteran's statement that he did not seek treatment at an earlier date because he was never briefed on PTSD symptoms although the facts have been well publicized in the media. The psychologist disagreed with the VA psychologist's comment regarding the "trajectory" of the Veteran's history, noting that in his experience there were numerous cases of PTSD with delayed onset of symptoms. The private psychologist concluded that the Veteran had diagnosis of PTSD in accordance with the DSM-IV criteria and that the disorder arose from the traumatic experiences in Vietnam. He further concluded that the symptoms of a major depressive disorder overlap and it is not possible to separate them from each other. The Veteran also submitted a November 2012 statement from an acquaintance who noted that she had known the Veteran since 1968, and that he was having "a lot of psychological problems, phobias, and paranoids (sic). He was unable to sleep or eat and he was dependent on alcohol a lot." The acquaintance also noted that the Veteran had difficulty being around a crowd of people. The Board concludes that service connection for PTSD and a major depressive disorder is warranted because the competent, credible lay and medical evidence both for and against the questions or diagnosis and medical etiology are of relatively equal probative weight. It is the responsibility of the Board to assess the credibility and weight to be given the evidence. See Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993) (citing Wood v. Derwinski, 1 Vet. App. 190, 192-93 (1992)). When reviewing medical opinions, the Board may appropriately favor the opinion of one competent medical authority over another. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). However, the Board may not reject medical opinions based on its own medical judgment. Obert v. Brown, 5 Vet. App. 30 (1993); see also Colvin v. Derwinski, 1 Vet. App. 171 (1991). First addressing the lay evidence of record, the Board finds that the Veteran is both competent and credible in his reports of his experiences in Vietnam as well as his observable symptoms. The events are consistent with the nature and circumstances of his service and his symptom reports were accepted by all examiners without challenge as imaginary or manipulative. The VA psychologist in 2011 questioned the "trajectory" of symptoms noting their absence in the medical record for many decades prior to 2005. However, this observation contrary to lay assertions by the Veteran and his acquaintance of behaviors that existed since service but for which the Veteran did not seek medical help and attempted to suppress with alcohol abuse. The private psychologist in 2013 attributed the long history of alcohol abuse to self-treatment for the PTSD symptoms. Although the RO received the Veteran's claim in March 2003, the only evidence of any mental symptoms prior to March 2005 are reflected in the observations of the Veteran's acquaintance and the Veteran's report that he did not seek treatment because he was not informed of the nature of PTSD. The Board assigns some probative weight to these observations, even though they are not entirely consistent with the Veteran's long history of successful domestic and occupational life. Nevertheless, as noted above, there is offsetting lay evidence that the Veteran experienced some mental health symptoms, although not severe, prior to 2005. The private psychologist in 2013 also concluded that a delayed onset of symptoms is often seen and did not arise in this Veteran's case until after the death of his spouse in 2000. The medical opinion and other evidence includes evidence both for and against a diagnosis of PTSD arising from the events in service. The Board assigns some probative weight to the body of VA outpatient clinical reports of treatment for PTSD, although the reports do not provide an in-depth assessment of the symptoms or their relationship to the events and are primarily notations of medication management. The Board places greater probative weight on the two letter reports of the private psychologist in 2005 and 2007. Even though he never provided his clinical notes, the psychologist reported that he had been providing on-going mental health care since May 2005 for chronic PTSD and anxiety arising from the Veteran's wartime experiences. Of note is that he included the anxiety symptoms together with PTSD arising from the same wartime events. The Board places greatest probative weight on the evaluations of the VA physician in 2010, the VA psychologist in 2011, and the private psychologist in 2013. All examiners provided a detailed evaluation with full explanation of their opinions which clearly contain disagreements regarding whether the Veteran's symptoms met certain DSM-IV criteria, as well as whether separate depression and anxiety disorders were present and whether any separate disorder(s) arose from wartime experiences. As these reports constitute competent evidence of relatively equal probative weight both for and against the claim, the Board concludes that, with resolution of all reasonable doubt in the Veteran's favor, service connection for PTSD and for major depressive disorder in partial remission is warranted.. All examiners diagnosed anxiety and depression, but disagreed on their etiology. Regarding depression, the Board places greatest probative weight on the conclusion of the private psychologist who noted, in 2013, that any symptoms of depression arising from the death of the Veteran's spouse or his serious medical treatment in 2000 could not be separated from the symptoms of PTSD. VA examiners in 2010 and 2011 diagnosed depression and anxiety not associated with events in service but rather with the post-service events. Again, as there is competent medical evidence of relatively equal probative weight for and against this etiology, the Board resolves all doubt in favor of the Veteran and grants service connection for major depressive disorder in partial remission. Finally, the Board notes that the record reflects that symptoms of anxiety did arise, at least in part, from events in service, but were included in the diagnosis of PTSD by the private psychologist in 2005 and 2007. The private psychologist in 2013 did not diagnose a separate anxiety disorder. Moreover, the DSM-IV lists PTSD as a subset in the general category of anxiety disorders. Therefore, based on the totality of the pertinent medical evidence, the Board finds that the Veteran's anxiety is not a separate, distinct disorder subject to service connection, but, rather, that anxiety symptoms have been best assessed by examiners as a component of his PTSD. ORDER Service connection for PTSD is granted. Service connection for major depressive disorder in partial remission is granted. ____________________________________________ JACQUELINE E. MONROE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs