Citation Nr: 1338487 Decision Date: 11/22/13 Archive Date: 12/06/13 DOCKET NO. 12-18 782 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Des Moines, Iowa THE ISSUE Entitlement to service connection for posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Iowa Department of Veterans Affairs ATTORNEY FOR THE BOARD William Skowronski, Associate Counsel INTRODUCTION The Veteran served on active duty from June 1969 to May 1972. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2011 rating decision by a Regional Office (RO) of the Department of Veterans Affairs (VA). The Veteran's notice of disagreement was received in December 2011. A statement of the case was issued in May 2012, and a substantive appeal was received in July 2012. The Board notes that the RO denied service connection for PTSD on prior occasions. However, certain service department records have been received in connection with the present claim that effectively corroborated the combat stressors claimed by the Veteran. The Board thus views this case as falling under the provisions of 38 C.F.R. § 3.156(c) (2013). As such, a new and material analysis is not required. A review of the Virtual VA paperless claims processing system (Virtual VA) reveals that it contains VA treatment records not found within the physical claims folder. The Veteran requested a Board hearing, but withdrew his request in an August 2012 correspondence in accordance with 38 C.F.R. § 20.704(e) (2013). Thus, the Board shall proceed with appellate review at this time. FINDINGS OF FACT 1. The Veteran served in the Republic of Vietnam. 2. There is credible evidence that a claimed in-service stressor occurred. 3. The positive evidence is in a state of equipoise with the negative evidence on the question of whether a diagnosis of PTSD related to the corroborated stressors is warranted. CONCLUSION OF LAW PTSD was incurred in the Veteran's active duty service. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSION Service connection for PTSD requires a medical diagnosis that conforms to the Diagnostic and Statistical Manual, Fourth Edition (DSM-IV); 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). If the evidence establishes that the veteran engaged in combat with the enemy and the claimed stressor is consistent with the circumstances, conditions, and hardships 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)(2). In February 2006, the Veteran sought treatment at a VA outpatient center for what he believed to be PTSD. A VA psychiatrist assessed the Veteran and concluded he appeared to be experiencing symptoms of probable PTSD. In March 2008, the VA afforded the Veteran a PTSD examination. The examiner, a licensed psychologist, reviewed the Veteran's claim file and service records and extensively interviewed the Veteran. The examiner diagnosed the Veteran with alcohol abuse, partial remission, and cluster B type personality traits, but opined the Veteran would meet the criteria for a PTSD diagnosis if the his claimed in-service stressors were regarded as verifiable and valid. The examiner found that the Veteran presented "a reasonably full spectrum of [PTSD] symptoms." He noted, however, that the Veteran did not appear to a completely reliable historian and questioned the Veteran's account of his symptoms only arising after his service in Vietnam, especially because the Veteran sought mental health treatment and abused alcohol before entering the service. In April 2009, a VA treatment center performed another mental health assessment of the Veteran. The examiner, a psychiatrist, diagnosed the Veteran with "PTSD (provisional)," noting the Veteran does meet the criteria for PTSD if the alleged combat stressors were verified. The Veteran's personnel records indicate that he served in the Republic of Vietnam from June 1970 to May 1971. The Veteran alleged he experienced a number of traumatic events there. In a 2008 statement, he asserted enemy combatants attacked and infiltrated a base just after he arrived there in June 1970. The U.S. Army and Joint Services Records Research Center (JSRRC) retrieved official military records that document repeated attacks on the base where the Veteran's unit was stationed in June 1970. As such, the Board acknowledges that credible evidence supports the Veteran's claimed in-service stressor. See Pentecost v. Principi, 16 Vet. App. 124 (2002). The VA examiner, a psychologist, and the VA psychiatrist, who assessed the Veteran in April 2009, both found the Veteran would meet the criteria of a PTSD diagnosis if credible evidence corroborated his claimed in-service stressors. Neither examiner specified that their diagnoses conformed to the DSM-IV, but mental health care professionals are presumed to know and take into account the DSM-IV criteria in diagnosing PTSD, and thus such diagnoses are presumed to conform to the DSM-IV. See Cohen v. Brown, 10 Vet. App. 128, 139-42 (1997). In August 2009, the VA afforded the Veteran another PTSD examination. The examiner, a clinical psychologist, reviewed the Veteran's claim file and service records and extensively interviewed the Veteran. The examiner found that the Veteran does not meet the criteria for a PTSD diagnosis. The examiner reasoned that the Veteran does not report avoidance symptoms in a sufficient number of categories to meet diagnostic criteria for PTSD. The examiner acknowledged the prior examiners' provisional diagnoses, but concluded the Veteran's symptoms that the prior examiners classified as the requisite avoidance symptoms instead seem to represent an arousal symptom, hypervigilance. Notably, the examiner found that the Veteran's verified in-service stressor meets the diagnostic criteria for PTSD. The examiner diagnosed the Veteran with alcohol abuse in sustained partial remission and cluster B personality traits. In March 2011, the Veteran again sought VA treatment for PTSD. In a June 2011 report located in VA's Virtual VA, a mental health nurse practitioner diagnosed the Veteran with PTSD, provisional pending verification of stressors. Whether the Veteran has PTSD is clearly a medical question. The evidence in this case does not show a clear consensus diagnosis of PTSD. A VA psychologist who performed a thorough examination of the Veteran and a VA psychiatrist both provisionally diagnosed him with PTSD. A mental health nurse practitioner also provisionally diagnosed the Veteran with PTSD in 2011. Another VA psychiatrist opined the Veteran appeared to be experiencing symptoms of probable PTSD in 2006. But a VA psychologist who also performed a thorough evaluation of the Veteran concluded he did not meet the criteria of a PTSD diagnosis. The evidence is certainly equivocal to some degree, but given the conflicting opinions by medical professionals, it appears that the evidence for and against the Veteran's claim is in a state of equipoise. 38 U.S.C.A. § 5107(b). Hence, the benefit of the doubt goes to the Veteran, and service connection for PTSD is warranted. Veterans Claims Assistance Act of 2000 (VCAA) There is no need to undertake any review of compliance with the Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations in this case since there is no detriment to the Veteran as a result of any VCAA deficiency in view of the fact that the full benefit sought by the Veteran is being granted by this decision of the Board. See generally 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2013). The Board notes that the RO informed the Veteran how disability ratings and effective dates are assigned in letters sent in December 2007, January 2009, and August 2010. The RO will take such actions in the course of implementing this grant of service connection, and the Veteran may always file a timely notice of disagreement if he wishes to appeal from those downstream determinations. ORDER Service connection for PTSD is warranted. The appeal is granted. ____________________________________________ ALAN S. PEEVY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs