Citation Nr: 1511923 Decision Date: 03/20/15 Archive Date: 04/01/15 DOCKET NO. 13-10 438 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUES 1. Entitlement to service connection for posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for adjustment disorder with depressed mood. REPRESENTATION Veteran represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD Laura E. Collins, Associate Counsel INTRODUCTION The Veteran served on active duty from January 1970 to September 1971, including service in the Republic of Vietnam. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2010 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. The Veteran claimed entitlement to service connection for PTSD. Claims of service connection for psychiatric disability encompass claims for all psychiatric disorders that are reasonably raised by the record. Clemons v. Shinseki, 23 Vet. App. 1 (2009). Therefore, the Veteran's claim encompasses his diagnosis of adjustment disorder with depressed mood during the appeal period. The Board has recharacterized the claim on appeal as reflected on the title page. FINDINGS OF FACT 1. The preponderance of the evidence does not show a diagnosis of PTSD. 2. Adjustment disorder with depressed mood had its onset in service. CONCLUSIONS OF LAW 1. The criteria for service connection for PTSD are not met. 38 U.S.C.A. §§ 1110, 1154(a), 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2014). 2. Adjustment disorder with depressed mood was incurred in service. 38 U.S.C.A. §§ 1110, 1154(a), 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2014). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist VA has a duty to provide notification to the Veteran with respect to establishing entitlement to benefits, and a duty to assist with development of evidence under 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. § 3.159(b). The duty to notify was satisfied prior to the decision on appeal by way of a letter sent to the Veteran in October 2009 that informed him of his duty and VA's duty for obtaining evidence. It also provided notice of the evidence and information necessary to establish a disability rating and an effective date in accordance with Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VA also has a duty to assist the Veteran in the development of the claim. This duty includes assisting the Veteran in the procurement of service treatment records (STRs) and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all relevant facts have been properly developed, and that all available evidence necessary for equitable resolution of the issue has been obtained. The Veteran's STRs have been obtained and no post-service treatment records were identified. He was afforded a VA psychiatric examination in May 2012. The examination report is adequate as it provides clear conclusions with supporting data and reasoned medical explanations connecting the two. Stefl v. Nicholson, 21 Vet. App. 120, 124-25 (2007); Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). II. PTSD Establishing service connection for PTSD requires: (1) medical evidence diagnosing PTSD; (2) credible supporting evidence that the claimed in-service stressor actually occurred; and (3) medical evidence of a link between current symptomatology and the claimed in-service stressor. 38 C.F.R. § 3.304(f) (2014). Here there is simply no medical evidence diagnosing PTSD, including VA treatment records and VA examination reports. When there is an approximate balance of evidence for and against the issue, all reasonable doubt will be resolved in the Veteran's favor. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and recurrence of his symptoms. Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Lay evidence can be competent and sufficient evidence of a diagnosis if the layperson is competent to identify the medical condition. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir.2009); Jandreau, 492 F.3d at 1376-77. However, "VA must consider lay evidence but may give it whatever weight it concludes the evidence is entitled to." Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). Here, the Veteran is not competent to identify the medical condition of PTSD, as it falls outside the realm of common knowledge of a lay person and is diagnosed by clinical testing pursuant to the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders. There is no evidence that the Veteran has the requisite medical knowledge to administer such a test or interpret the results. Jandreau, 492 F.3d at 1377 n.4. The Board thus finds that the Veteran's lay evidence is insufficient to establish a current diagnosis of PTSD. As there is no competent medical or lay evidence of a current diagnosis of PTSD, there is no basis to grant service connection. Brammer v. Derwinski, 3 Vet. App. 223 (1992). The Board finds that the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for PTSD and the claim must be denied. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert. III. Adjustment disorder with depressed mood Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Davidson, 581 F.3d 1313; Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995). Service connection may be granted when "the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service." 38 C.F.R. § 3.303(a). Determinations as to service connection will be based on review of the entire evidence of record, to include all pertinent medical and lay evidence, with due consideration to VA's policy to administer the law under a broad and liberal interpretation consistent with the facts in each individual case. 38 U.S.C.A. § 1154(a); 38 C.F.R. § 3.303(a). The May 2012 VA examiner diagnosed adjustment disorder with depressed mood and opined that it is at least as likely as not caused by the Veteran's exposure to combat in Vietnam. There is no medical opinion evidence to the contrary. Taken together with the Veteran's competent and credible reports of combat exposure, the Board finds that service connection is warranted. ORDER Service connection for PTSD is denied. Service connection for adjustment disorder with depressed mood is granted. ____________________________________________ STEVEN D. REISS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs