Citation Nr: 1619420 Decision Date: 05/13/16 Archive Date: 05/19/16 DOCKET NO. 10-47 808 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Baltimore, Maryland THE ISSUE Entitlement to service connection for an acquired psychiatric disability, to include posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD T. Sherrard, Counsel INTRODUCTION The Veteran, who is the Appellant in this case, had active service from June 1967 to June 1971. He received a Purple Heart for wounds received in combat in Vietnam. This matter comes before the Board of Veterans' Appeals (BVA or Board) from a March 2010 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. Jurisdiction over the Veteran's claims file was subsequently transferred to the Baltimore RO. The scope of a service connection claim for a mental disability is not restricted to the specific diagnosis alleged by the claimant, but includes any mental disability which may reasonably be encompassed by the claimant's description of the claim, the reported symptoms, and other information of record. Clemons v. Shinseki, 23 Vet. App. 1 (2009). In this case, the Veteran has been diagnosed with anxiety disorder and depression in addition to PTSD. Therefore, the issue on appeal has been recharacterized as it appears on the title page of this decision. FINDING OF FACT The Veteran has been diagnosed with a current psychiatric disability, to include PTSD, anxiety disorder, and major depressive disorder, that is related to his combat experiences in Vietnam. CONCLUSION OF LAW Resolving reasonable doubt in favor of the Veteran, the criteria for service connection for an acquired psychiatric disability have been met. 38 U.S.C.A. §§ 101, 1101, 1110, 5103(a), 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2015). REASONS AND BASES FOR FINDING AND CONCLUSION Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The United States Court of Appeals for Veterans Claims (Court) has held that "Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of a present disability there can be no valid claim." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). Initially, the Board finds that the evidence demonstrates that the Veteran engaged in direct combat with the enemy during active service. His service personnel records show that he received a Purple Heart for wounds received in action in Vietnam on December 1, 1967. Service treatment records also show that he suffered shrapnel wounds on this date. For this reason, the Board finds that the claimed in-service stressors are consistent with the places, types, and circumstances of the Veteran's service in Vietnam, and the Veteran's lay testimony alone may establish the occurrence of the claimed in-service stressors under the governing regulation. See 38 U.S.C.A. § 1154(b). Moreover, the Veteran has been diagnosed with a psychiatric disability caused by his experiences during active service. The evidence of record includes an August 2009 psychiatric evaluation conducted by a private psychiatrist, Dr. H., in which the doctor diagnoses PTSD, moderate to severe, manifested by recurrent distressing flashbacks, nightmares, bad memories, images, thoughts, and perceptions of traumatic combat-related events, increased arousal, difficulty failing or staying asleep, irritability, outbursts of anger, difficulty concentrating, hypervigilance, and increased startle response occurring at least 6 months after the traumatic event and causing psychosocial and occupational impairment. Dr. H. specifically diagnosed PTSD using DSM-IV criteria, and stated that the diagnosis, which was related to the Veteran's combat experiences, did not appear to exist prior to military service. Next, in November 2009, a private physician, Dr. S., diagnosed major depressive disorder and PTSD using DSM-IV criteria based on the Veteran's combat experiences. The claim has primarily been denied on the basis of the January 2010 VA examination report, in which the VA examiner, a nurse practitioner, concluded that the Veteran did not meet the criteria for a diagnosis of PTSD as he did not persistently re-experience his combat traumas, nor did he avoid stimuli associated with the traumas or have numbing of general responsiveness. However, she did diagnose anxiety disorder based on his military traumas and noted that his combat traumas involved risk of death and intense fear. In sum, regardless of the specific diagnosis (PTSD, anxiety disorder, major depressive disorder), the evidence of record overwhelmingly demonstrates that the Veteran has a current psychiatric disability that is related to his combat experiences in Vietnam. For these reasons, the Board finds that the criteria for service connection for an acquired psychiatric disability are met. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations imposes obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2015). Given the full grant of benefits sought on appeal, no conceivable prejudice to the Veteran could result from this decision; therefore, no discussion of compliance with the VCAA is necessary. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). [CONTINUED ON NEXT PAGE] ORDER Service connection for an acquired psychiatric disability, to include posttraumatic stress disorder, anxiety disorder, and major depressive disorder, is granted. ____________________________________________ JONATHAN B. KRAMER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs