Citation Nr: 1634470 Decision Date: 09/01/16 Archive Date: 09/09/16 DOCKET NO. 07-26 020 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUE Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder, and including as secondary to service-connected duodenal ulcer disease. REPRESENTATION Appellant represented by: Kathy A. Lieberman, Attorney ATTORNEY FOR THE BOARD Shamil Patel, Counsel INTRODUCTION The Veteran had active service in the U.S. Army from August 1972 to July 1974. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in San Juan, the Commonwealth of Puerto Rico, which denied service connection for PTSD and declined to reopen a previously denied claim for service connection for an anxiety disorder. In May 2011, the Board reopened the previously denied claim for an anxiety disorder, and remanded that claim and the claim for PTSD for further development. The claims were again remanded in March 2013, August 2013, April 2014, November 2014, and August 2015. In light of the various psychiatric diagnoses evident in the claims file, the Board has since recharacterized the Veteran's claim as one of entitlement to service connection for an acquired psychiatric disorder. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). FINDING OF FACT The Veteran's anxiety disorder with PTSD is etiologically related to service. CONCLUSION OF LAW The criteria for service connection for anxiety disorder with PTSD have been met. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2014); 38 C.F.R. § 3.303 (2015). REASONS AND BASES FOR FINDING AND CONCLUSION Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110. 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) (2015). The Veteran has been diagnosed with an unspecified anxiety disorder and major depression during the appeal period. Therefore, element (1) of service connection has been satisfied. With respect to element (2), an in-service incurrence, the Veteran's service treatment records do not reflect any complaints, treatment, or a diagnosis specifically pertaining to an acquired psychiatric disorder, and his June 1974 separation examination was normal. Notably, he was treated for gastrointestinal issues, which have since been service-connected as duodenal ulcer disease, but are relevant to his current claim. Notwithstanding the lack of documented psychiatric findings in service, the Veteran has reported that he was under difficult and stressful circumstances while in the military. A July 2016 statement from his representative summarized the Veteran's reports, noting that he witnessed a soldier set fire to his own bed, witnessed the removal of a soldier from the barracks due to drug use, witnessed a knife fight, and was tasked with performing the duties of an E-5 while working as an E-4. His limited English proficiency was also a source of stress during service. Private treatment records from September 1982 show the Veteran reported doing well until he joined the Army and was assigned to Germany, where he had to live in an environment of drug abuse, frequent altercations, and poor unit morale. As a result, he began to feel increasingly anxious and tense, with difficulty sleeping and frequent stomach pains. At the time of his visit, he reported complaints of chronic anxiety, frequent nightmares, difficulty controlling himself when upset, and a tendency to anticipate the worst. The treating psychiatrist diagnosed him with anxiety neurosis, chronic, and a psychosomatic disorder of the gastrointestinal system. He stated that, because of the stress the Veteran was subjected to during his tour in Germany, he developed gastric illness. Earlier VA treatment records from October 1980 show the Veteran was seen for gastrointestinal issues, but also prescribed Ativan, which can be used to treat anxiety. A June 2011 private opinion also noted that the Veteran had gastrointestinal issues related to anxiety, and that same physician stated in May 2013 that the Veteran's ulcer disease was closely related to stress and chronic anxiety. A July 2016 private opinion also noted the correlation between stress and ulcers. In sum, there is evidence to support the conclusion that the gastrointestinal symptoms experienced by the Veteran during service were manifestations of anxiety he was experiencing at that time. Therefore, element (2) of service connection, an in-service incurrence, has been met. Finally, with respect to element (3), there are a number of opinions both supporting and refuting a link between the Veteran's current condition and his period of service. The September 1982 opinion, as well as private opinions from March 2009 and July 2016, support such a connection. VA opinions from April 2013, December 2013, April 2014, and February 2015 refute this connection. The probative value of all of the opinions is mixed, but the Board notes that the negative VA opinions generally rely on the lack of a temporal relationship between the first diagnosis of a psychiatric condition to service. That is, the Veteran was discharged in 1974, but not diagnosed with an anxiety disorder until 1982. While that is certainly a factor to be considered, it does not fully address the question of etiology, and the positive opinions do assert a link between the current anxiety disorder and service. Therefore, the evidence regarding etiology is at least in equipoise, and resolving all doubts in the Veteran's favor, element (3) has been established for anxiety disorder. The Veteran has also claimed service connection for PTSD, and the evidence includes diagnoses of PTSD during the appeal period. There are particular requirements for establishing entitlement to service connection for PTSD in 38 C.F.R. § 3.304(f) that are in ways similar, but also nonetheless separate, from those for establishing entitlement to service connection generally. Arzio v. Shinseki, 602 F.3d 1343, 1347 (Fed. Cir. 2010). However, as the evidence has not distinguished between the symptoms associated with PTSD versus those associated with his anxiety disorder, the Board finds it appropriate to grant service connection for an anxiety disorder with PTSD. ORDER Service connection for an anxiety disorder with PTSD is granted. ____________________________________________ M. TENNER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs