Citation Nr: 1500581 Decision Date: 01/07/15 Archive Date: 01/13/15 DOCKET NO. 12-28 024 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Hartford, Connecticut THE ISSUE Entitlement to service connection for posttraumatic stress disorder (PTSD). REPRESENTATION Veteran represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL The Veteran (Appellant); Veteran's spouse ATTORNEY FOR THE BOARD Patricia Kingery, Associate Counsel INTRODUCTION The Veteran, who is the appellant in this case, served on active duty from February 1966 to December 1967. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2012 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Hartford, Connecticut. In June 2014, the Veteran testified at a hearing at the local RO before the undersigned Veterans Law Judge. A transcript of the hearing is of record. The most recent statement of the case, dated September 2012, does not include review of a June 2014 Vet Center treatment records and a July 2014 private psychiatric assessment report; however, as discussed below, the Board is granting service connection for PTSD. As such, the Veteran is not prejudiced by the Board promulgating a decision without agency of original jurisdiction (AOJ) consideration of this evidence in the first instance. In reviewing this case, the Board has not only reviewed the Veteran's physical claims file, but also the file on the "Virtual VA" system to insure a total review of the evidence. FINDINGS OF FACT 1. The Veteran has a current DSM-IV diagnosis of PTSD. 2. A VA psychologist has confirmed that the Veteran's claimed stressor is adequate to support a diagnosis of PTSD and related to his fear of hostile military or terrorist activity arising from his active service in the Republic of Vietnam. 3. There is credible supporting evidence that the Veteran's PTSD is related to the claimed stressor. CONCLUSION OF LAW Resolving reasonable doubt in the Veteran's favor, the criteria for service connection for PTSD have been met. 38 U.S.C.A. §§ 1101, 1110, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2014). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159 (2014). The Board grants service connection for PTSD, constituting a full grant of the benefit sought on appeal; therefore, no discussion of VA's duty to notify and to assist is necessary. Service Connection for PTSD Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Generally, service connection for a disability requires evidence of: (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 in or aggravated by service. See Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009). Service connection for PTSD requires medical evidence establishing a diagnosis of the condition, credible supporting evidence that the claimed in-service stressor actually occurred, and a link, established by medical evidence, between the current symptomatology and the claimed in-service stressor. 38 C.F.R. § 3.304(f) (2014). Additionally, the current version of § 3.304(f)(3) states that when the claimed in-service stressor is related to the veteran's "fear of hostile military or terrorist activity," the following shall be demonstrated to establish service connection for PTSD: (1) the claimed stressor is consistent with the places, types and circumstances of the veteran's service; (2) a VA psychiatrist or psychologist, or contract equivalent, confirms the claimed stressor is adequate to support a diagnosis of PTSD; and (3) the veteran's symptoms are related to the claimed stressor. For purposes of 38 C.F.R. § 3.304(f)(3), "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. The Veteran contends that he has PTSD due to stressors arising from his active service in the Republic of Vietnam. The Veteran contends that, while aboard the USS Hermitage, the ship was under fire and he saw a shell that landed 50 to 60 feet away in the water. The Veteran contends that, following the death of a fellow service member on board the ship, the body was kept in the freezer until the ship made port and he would see the body in the freezer. The Veteran also contended that, while in Da Nang, he was manning a 50-caliber machine gun and was given instructions that no small boats should be allowed to approach. The Veteran reported that, one night he trained his gun on a small boat that continued to approach and almost fired before the boat finally announced it was filled with friendly service members. The Veteran contends that he has PTSD due to these in-service stressors. See July 2011 VA examination report, May 2012 written statement, June 2014 Board hearing transcript. First, the Board finds that the weight of the evidence is at least in equipoise as to whether the Veteran has a current DSM-IV diagnosis of PTSD. An April 2011 private psychiatric evaluation report notes a provisional diagnosis of PTSD. The July 2011 VA examination report notes that the Veteran did not have a current DSM-IV diagnosis of PTSD because his symptomatology did not satisfy Criterion C (symptoms of avoidance) and re-experiencing symptoms were also believed to be mild. In a July 2014 private psychiatric assessment report, Dr. R.G. (the same doctor who prepared the April 2011 private psychiatric evaluation report) noted that the Veteran's symptoms had worsened since 2011. Dr. R.G. noted symptoms of emotional numbing, isolation, avoidance, irritability, and anger. Dr. R.G. diagnosed the Veteran with PTSD and also noted an Axis II diagnosis of avoidant traits. Based on the above, the Board finds that the Veteran has a current DSM-IV diagnosis of PTSD. Next, there is credible supporting evidence of a stressor stemming from fear of hostile military or terrorist activity. In this case, although the Veteran has reported several in-service stressors, described above, none has been specifically corroborated. During the July 2011 VA examination, the Veteran reported that, while on the USS Hermitage in Da Nang, he was manning a 50-caliber machine gun and was given instructions that no small boats should be allowed to approach. The Veteran reported that, one night he trained his gun on a small boat that continued to approach and almost fired before the boat finally announced it was filled with friendly service members. The Veteran reported that he was in great fear that it was an enemy boat. The VA psychologist, while not diagnosing the Veteran with PTSD, indicated that the reported stressor was adequate to support a diagnosis of PTSD and was related to the Veteran's fear of hostile military of terrorist activity. In a March 2012 written statement, Dr. R.G. noted that he seen the Veteran twice for psychiatric consultations and, based on these evaluations, opined that the Veteran suffers from PTSD associated with his service in Vietnam. The July 2014 private psychiatric evaluation report notes that the Veteran reported the same in-service stressors he related at the July 2011 VA examination. Based on the Veteran's reported stressors and psychiatric evaluation of the Veteran, Dr. R.G. opined that the Veteran had suffered from PTSD for many years and indicated that the currently diagnosed PTSD was related to the Veteran's service in Vietnam. Based on the above, the Board finds that the Veteran's claimed stressor is related to his fear of hostile military or terrorist activity. Here, the Veteran is competent to describe his in-service stressors, and his claimed stressors are consistent with the places, types, and circumstances of the Veteran's service. There is no clear and convincing evidence to the contrary; therefore, the Board finds that the Veteran's lay testimony alone is sufficient to establish the occurrence of his claimed in-service stressors. See 38 C.F.R. § 3.304(f)(3). Further, the Board finds the March 2012 letter from Dr. R.G. and July 2014 private psychiatric evaluation report to be competent and credible medical evidence that the Veteran's currently diagnosed PTSD is related to the claimed in-service stressor. For these reasons, and resolving reasonable doubt in favor of the Veteran, the Board finds that the criteria for service connection for PTSD have been met. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. ORDER Service connection for PTSD is granted. ____________________________________________ K.J. ALIBRANDO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs