Citation Nr: 1337305 Decision Date: 11/15/13 Archive Date: 11/26/13 DOCKET NO. 12-16 910 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Buffalo, New York THE ISSUE Entitlement to service connection for a psychiatric disorder. REPRESENTATION Appellant represented by: New York State Division of Veterans' Affairs ATTORNEY FOR THE BOARD Y. Curtis, Associate Counsel INTRODUCTION The Veteran served on active duty from August 1969 to April 1973. This matter is before the Board of Veterans' Appeals (Board) on appeal of a January 2012 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO) in Buffalo, New York that denied service connection for a psychiatric disorder. The scope of the claim includes any disability that may reasonably be encompassed by the claimant's description of the claim, reported symptoms, and other information of record. Clemons v. Shinseki, 23 Vet. App. 1 (2009). The appellant filed a claim seeking service connection for posttraumatic stress disorder (PTSD); however, various other psychiatric disorders have been diagnosed. The issue has been recharacterized to comport with the evidence of record. FINDING OF FACT A psychiatric disorder was not manifest in active service or to a compensable degree within one year of service discharge; any current psychiatric disorder is not caused or aggravated by such service. CONCLUSION OF LAW The criteria for service connection of psychiatric disorder, to include posttraumatic disorder have not been met. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. § 3.303. 3.304(f) (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veterans Claim Assistance Act of 2000 (VCAA) Upon receipt of a complete or substantially complete application, VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. VA must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. A December 2011 letter satisfied the duty to notify provisions. 38 U.S.C.A. § 5103(a) (West 2002); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002); 38 C.F.R. § 3.159(b)(1) (2012). This letter also notified the Veteran of regulations pertinent to the establishment of an effective date and of the disability rating. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The Veteran was informed of the need to show the impact of disabilities on daily life and occupational functioning. Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), rev'd in part sub nom. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The claim was subsequently readjudicated, most recently in a July 2012 supplemental statement of the case. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). In any event, the Veteran has neither alleged nor demonstrated any prejudice with regard to the content or timing of the notice. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination). See also Mayfield v. Nicholson, 444 F.3d 1328, 1333-34 (Fed. Cir. 2006). The Veteran's service treatment records, service personnel records, and VA treatment records have been obtained; he did not identify any private treatment records pertinent to the appeal 38 U.S.C.A. § 5103A (West 2002), 38 C.F.R. § 3.159 (2012). The Veteran has not indicated, and the record does not contain evidence, that he is in receipt of disability benefits from the Social Security Administration. 38 C.F.R. § 3.159(c)(2) (2012). A VA examination was provided in December 2011. The VA examiner conducted a thorough interview and described the current severity of the Veteran's mental health in sufficient detail so that the Board's decision is an informed one. Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). Principles of Service Connection Service connection may be established for a disability resulting from personal injury suffered or disease contracted during active military service. In order to prevail on the issue of service connection there must be competent evidence of a current disability; medical evidence, or in certain circumstances, lay evidence of in-service occurrence or aggravation of a disease or injury; and competent evidence of a nexus between an in-service injury or disease and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). Service connection for PTSD, in particular, requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a); a link, established by competent 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). The diagnosis of PTSD must comply with the criteria set forth in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM- IV). 38 C.F.R. § 4.125. 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; See also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Facts The Veteran's service treatment records do not indicate treatment for, or diagnosis related to, any type of psychiatric disability or mental problem. A March 1973 separation examination noted the Veteran's psychiatric condition as normal. VA treatment records indicate the Veteran complained of feelings of depression and anxiety in June 2000. He reported a longstanding, fluctuating history of social anxiety and mood disruption. He was diagnosed with depression with social anxiety and Paxil was prescribed. Additional therapy treatments were scheduled in August, September, and October 2000, however, he failed to report for the scheduled appointments. The Veteran reestablished mental health treatment with the VA in May 2011. He complained of depressed mood, but denied suicidal ideation. His depression diagnosis was continued and Citalopram was prescribed. On VA examination in December 2011, the Veteran reported that he retrieved dead bodies and was exposed to artillery fire while serving in Vietnam. His stressor statements were later confirmed by the Joint Services Records Research Center (JSSRC). He denied witnessing soldiers being killed, wounded, or mutilated. He reported feelings of fear associated with the artillery fire, but could not identify any thing that haunted him about his military service in Vietnam. He denied a family psychiatric history of mental health problems, but noted that his father was quiet, sad, and socially reserved. Although he endorsed occasional suicidal thoughts, he denied a history of suicide attempts or psychiatric hospitalizations. He stated that he was fired from his last job in June 2011 for putting the wrong prices on items. The VA psychologist noted that the Veteran does not meet the full criteria for PTSD because he does not persistently re-experience the trauma or experience symptoms of increased arousal. The psychologist noted symptoms of depressed mood, anxiety, flattened affect, and suicidal ideation. Depressive disorder was diagnosed and a GAF score of 60 was assigned. He concluded that the Veteran was psychologically traumatized by his service in Vietnam. Specifically, the Veteran was exposed to persistent artillery fire which triggered significant fear. However, the VA psychologist concluded that the Veteran's depressive disorder was unrelated to his military service. To support his opinion, the psychologist noted that, although the Veteran denied a family history of depression, he stated that his father was a lot like himself in that he was very quiet, looked sad, and stayed to himself. In support of his claim, the Veteran submitted a statement from Cassandra Kimler, the Veteran's daughter. She reported that she believed the Veteran was affected by his time in Vietnam. She noted that he had an inconsistent job history and was emotionally unavailable during her childhood. In May 2012, the Veteran requested and received an evaluation for posttraumatic stress disorder. He reported that he needed a diagnosis of PTSD in order to obtain service-connected benefits. He stated that he had bad experiences in Vietnam that result in occasional nightmares, but he denied having persistent memories or reliving the situations. He also admitted to occasional feelings of hopelessness, but primarily reported that his low mood is due to lack of money. The VA physician noted that the Veteran was very guarded with a flat affect. PTSD was not diagnosed; depression and anxiety were. A GAF score of 60 was assigned. She continued his prescription for Citalopram and referred the Veteran for vocational rehabilitation. Analysis The Veteran contends that he has PTSD that is due to his exposure to rocket attacks and dead bodies while serving in Tan Son Nhut, Vietnam. The Joint Services Records Research Center (JSSRC) reviewed the Veteran's stressor statement and found that it was at least as likely as not that he was exposed to rocket attacks during service. Thus, the Veteran's exposure to an in-service stressor is conceded. A review of the Veteran's post-service treatment records, however, does not reveal a diagnosis of PTSD. In fact, two VA psychologists specifically found that he did not meet the diagnostic criteria for PTSD. During the December 2011 VA exam, the psychologist noted that he does not persistently re-experience the trauma or experience symptoms of increased arousal. Similarly, when the Veteran received an evaluation for PTSD in May 2012 he denied having persistent memories or reliving situations from Vietnam. With respect to diagnoses of other psychiatric disabilities; specifically depressive and anxiety disorders, there is no competent evidence linking any diagnosed psychiatric disability to service. In December 2011, the VA psychologist opined that the Veteran's depressive disorder was unrelated to service and noted that the Veteran exhibited symptoms similar to those of his father. In May 2012, the Veteran reported that his low mood was primarily due to lack of funds and he denied having persistent memories or reliving the situations from Vietnam. Both the Veteran and his daughter maintain that he suffers from a psychiatric disability due to his experiences in Vietnam. However, as laypersons, lacking in medical training and expertise, they cannot provide a competent opinion on a matter as complex as the etiology of a psychiatric disability. There are multiple potential etiologies of the Veteran's current psychiatric disability. Significantly, nearly three decades passed before the Veteran's first diagnosis and intervening factors must be considered when determining the etiology of the Veteran's psychiatric disability. The normal clinical findings at the time of separation from service, as well as the negative nexus opinion with respect to linking the Veteran's current psychiatric disabilities to service, is probative evidence against the claim for service connection. The preponderance of the evidence is against the claim for service connection for a psychiatric disorder; there is no doubt to be resolved; and service connection is not warranted. ORDER Entitlement to service connection for a psychiatric disorder is denied. ____________________________________________ RONALD W. SCHOLZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs