Citation Nr: 1606475 Decision Date: 02/22/16 Archive Date: 03/01/16 DOCKET NO. 12-27 587 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to service connection for posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Penelope E. Gronbeck, Attorney WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD D.S. Lee, Counsel INTRODUCTION The Veteran served on active duty from October 1974 through March 1979. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2010 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. The Veteran perfected a timely appeal of that denial. The Veteran's testimony was received during a September 2015 video conference hearing. A transcript of that testimony is associated with the claims file. At the Veteran's request, the record was held in abeyance for 60 days from the date of the hearing to allow the Veteran the opportunity to submit additional evidence. Additional evidence, in the form of October 2015 arguments from the Veteran's representative and a September 2015 private opinion from O.A.S., was received with the Veteran's waiver of review by the agency of original jurisdiction (AOJ). The newly submitted evidence is associated with the claims file and has been reviewed as part of the record by the Board. FINDINGS OF FACT 1. The stressors alleged by the Veteran are corroborated by credible evidence in the record. 2. The Veteran has current PTSD that resulted from his in-service stressors. CONCLUSION OF LAW The criteria for service connection for PTSD are met. 38 U.S.C.A. §§ 1131, 1153, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.159, 3.303, 3.304 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Board is cognizant of VA's notification and assistance requirements under 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 and 38 C.F.R. § 3.159. Nonetheless, given the favorable action taken below as to the issue on appeal, no further notification or assistance in developing the facts pertinent to that limited matter is required at this time. Indeed, such action would result only in delay. II. Analysis Generally, service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). Service connection may also be granted for a disease first 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). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C.A. § 5107(b). Service connection for PTSD specifically requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the in-service stressor occurred. 38 C.F.R. § 3.304(f). In support of his claim for service connection for PTSD, the Veteran has alleged in his claims submissions and hearing testimony that he served in a Medivac unit while he was stationed at Fort Hood, Texas. He states that, although his specialty was helicopter mechanics, he served as a maintenance crew chief, and in that capacity, was required to accompany Medivac teams to military and civilian rescue operations and provide necessary support. For his stressors, he alleges that he witnessed the aftermath of numerous fatal and grisly accidents and that he was often tasked with participating in clean-up activities. In particular, he alleges that he responded to a military accident in which a military vehicle had flipped and killed a soldier on board. The Veteran recalled that he witnessed the accident's aftermath and the victim's body and took special note of the fact that the victim resembled him. The Veteran also reports a separate stressor incident in which his team provided emergency support for a civilian motor vehicle accident in which a victim was decapitated and killed. According to the Veteran, he also witnessed the immediate aftermath of that accident, and in fact, was tasked with placing the victim's body and severed head in a body bag. Essentially consistent with the Veteran's assertions, the service department records in the claims file corroborate that he did serve at Fort Hood, Texas from April 1976 through August 1978. The Veteran's Enlisted Qualification Record notes that he was attached to a transportation unit and performed duties as a vehicle and utility helicopter mechanic during that time. The service department records do not contain any express reference to the Veteran's specific duties or assignments. In that regard, there is no evidence that directly corroborates the Veteran's claimed stressor events. Still, in some instances (most commonly in cases where the claimed stressor is a personal assault) evidence from sources other than the veteran's service records may be considered to corroborate the veteran's reported stressor. 38 C.F.R. § 3.304(f)(5); see also Patton v. West, 12 Vet. App. 272, 277 (1999). Such evidence can include evidence of behavioral changes after the alleged stressor. Examples of behavior changes that may constitute credible evidence of the stressor include, but are not limited to: a request for a transfer to another military duty assignment; deterioration in work performance; substance abuse; episodes of depression, panic attacks, or anxiety without an identifiable cause; or unexplained economic or social behavior changes. 38 C.F.R. § 3.304(f)(5). Here, the service personnel records show that the Veteran received an overall favorable performance review in March 1976 prior to his assignment to Fort Hood. In that review, his superior officer noted that the Veteran required little supervision in performing his tasks and demonstrated an outstanding attitude toward his duties. In contrast, performance reviews conducted in October 1977 and August 1978, after the Veteran's transfer to Fort Hood, are both negative and indicate overall deterioration in the Veteran's work performance. In the October 1977 performance review, the Veteran's superior officer expressed that the Veteran was unable to handle "personal problems," was frequently tardy for duty, and demonstrated a lax attitude. The August 1978 review notes that the Veteran was requiring constant supervision and counseling, had difficulties due to personal problems and issues with temper, and was having altercations with his peers and superiors. The supervising officer stated overall that the Veteran was a marginal soldier who had difficulty setting aside his "personal problems" and performing his day to day duties. Although the Board recognizes again that resorting to alternative sources of information such as records pertaining to declining duty performance and personality changes is more commonly reserved for instances involving personal assault, the declining performance and personality changes shown here in the Veteran's service department records do suggest an in-service change in mental status. In that regard, facts regarding the Veteran's assigned duties, the apparent deterioration in the Veteran's performance, and apparent personality changes are all consistent with the chronology, location, and nature of the Veteran's claimed duties and stressors. Indeed, the apparent deterioration in the Veteran's work performance from 1977 and moving forward would appear to suggest in-service changes in the Veteran's mental status that are consistent with a reaction to his stressors. In view of the foregoing, the Board finds that the service department records in the claims file do corroborate the Veteran's reported stressors. Subject to the above, the post-service treatment records document ongoing mental health treatment received by the Veteran since March 2003. Early VA treatment records through April 2004 indicate an initial diagnosis of bipolar disorder. A May 2004 depression screen, however, was positive for depression. In February 2009, the Veteran was evaluated by a VA psychiatrist for suspected PTSD. At that time, the Veteran reported having a history of symptoms such as: suicide attempts; nightmares; isolative behavior; irritability; hypervigilance; avoiding crowds; difficulty with concentration, attention, and memory; being startled easily; foreshortened sense of future; detachment from other people; and avoiding reminders of traumatic experiences. A mental status examination revealed dysthymic mood with congruent affect. The treating VA psychiatrist opined that the Veteran's history and symptoms were consistent with a PTSD diagnosis that was related directly to his claimed in-service stressors. Subsequent VA treatment records note concurring diagnoses of chronic PTSD and bipolar disorder. The PTSD diagnoses expressed in the VA treatment records are corroborated by a private opinion submitted by O.A.S., Ph.D. During the private examination, the Veteran continued to report having few friends and having difficulty getting along with others. He reported ongoing nightmares, hypervigilance, emotional reactivity such as becoming verbally loud and intense over trivial matters, difficulty feeling close to others, recurrent memories of his traumatic events, avoiding situations that triggered such memories, and anxiety. In terms of occupation, he reported that he worked as a trucker after service, which allowed him to work by himself. He continued to report a history of suicide attempts, most recently in 2008, when he attempted to overdose on insulin. O.A.S. noted that the Veteran had been diagnosed previously during VA treatment with PTSD. A battery of psychiatric tests was interpreted by O.A.S. as being consistent with PTSD. A mental status examination revealed mercurial affect that ranged from being affable to irritable to tearful without any recognition or insight into that variability. Mood was also variable throughout the interview and was marked by reactivity. O.A.S. opined overall that the Veteran's history is consistent with concurring diagnoses of PTSD and bipolar disorder and stated that the Veteran's PTSD is attributable directly to the traumatic events during service. The foregoing PTSD diagnoses are contradicted by the findings and opinions expressed in a January 2010 VA examination. During that examination, the examiner diagnosed dysthymic disorder and borderline personality disorder; however, provided no explanation as to the bases for those differing diagnoses. Similarly, the examiner did not acknowledge the PTSD diagnoses expressed during earlier VA treatment, nor did he offer any discussion as to the significance of or any reasons as to why he did not concur with the earlier diagnoses. In a May 2012 addendum, the examiner attempted to explain that the Veteran's disorder during service appeared to have been triggered by emotional and situational stress, and apparently on that basis, determined that the Veteran's psychiatric problems were likely attributable to borderline personality disorder. Once again, however, the examiner did not address the previous PTSD diagnoses in the record. In the absence of any discussion addressing the PTSD diagnoses in the record, the rationale and bases provided by the VA examiner are incomplete and are therefore not entitled to significant probative weight. Prejean v. West, 13 Vet. App. 444, 448-49 (2000) (factors for assessing the probative value of a medical opinion may include the physician's access to the claims file and the thoroughness and detail of the opinion); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998) (the failure of the physician to provide a basis for his opinion goes to the weight or credibility of the evidence in the adjudication of the merits); Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993) (the probative value of medical evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches; as true with any piece of evidence, the credibility and weight to be assigned to these opinions are within the province of the Board as adjudicators). By contrast, the private opinion from O.A.S. appears to be based upon a review of the Veteran's relevant medical history and a complete psychiatric and social history that was reported credibly by the Veteran and is consistent with the facts shown in the record. Moreover, the Board notes, the PTSD diagnoses rendered in O.A.S.'s opinion and in the VA treatment records appear to be supported fully by the noted symptomatology and history. For these reasons, the Board assigns far greater probative weight to O.A.S.'s opinion and the PTSD diagnoses shown in the VA treatment records than it does to the VA examiner's January 2010 and May 2012 opinions. Owens v. Brown, 7 Vet. App. 429, 433 (1995) (the Board's duty is to assess the credibility and probative value of evidence, and, provided that it offers an adequate statement of reasons or bases, the Board may favor one medical opinion over another). Based upon the foregoing evidence and analysis, the Board finds that the Veteran is entitled to service connection for PTSD. This appeal is granted. ORDER Service connection for PTSD is granted. ____________________________________________ DAVID L. WIGHT Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs