Citation Nr: 1753383 Decision Date: 11/21/17 Archive Date: 12/01/17 DOCKET NO. 14-09 543 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Detroit, Michigan THE ISSUE Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD). REPRESENTATION Veteran represented by: Joseph R. Moore, Attorney-at-Law ATTORNEY FOR THE BOARD T. Henry, Associate Counsel INTRODUCTION The Veteran served on active duty from November 1983 to November 1987. This matter comes before the Board of Veterans' Appeals (Board) from a March 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) Detroit, Michigan. In January 2015, the claim was remanded for further development. FINDINGS OF FACT Resolving all doubt in Veteran's favor, PTSD is related to his military service, to include in-service sexual trauma/personal assault. CONCLUSION OF LAW The Veteran's acquired psychiatric disorder was incurred in active duty military service. 38 U.S.C. §§ 1110, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSION A claimant is entitled to VA disability compensation if there is a disability resulting from personal injury suffered or disease contracted in the line of duty in active service, or for aggravation of a preexisting injury suffered or disease contracted in the line of duty in active service. 38 U.S.C.A. §§ 1110, 1131. Generally, to establish a right to compensation for a present disability, a claimant must show: (1) a present disability; (2) an 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 or aggravated during service, the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Entitlement to service connection for PTSD in particular requires: (1) medical evidence diagnosing PTSD in accordance with the Diagnostic and Statistical Manual of Mental Disorders, (DSM); (2) a link between current symptoms and an in-service stressor, as established by medical evidence; and (3) credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. §§ 3.304(f), 4.125(a). In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the United States Court of Appeals for Veterans Claims (Court) stated that "a veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." To deny a claim on its merits, the preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996) (citing Gilbert, 1 Vet. App. at 54). Here, the Board finds the criteria for service connection for an acquired psychiatric disorder have been met. The medical evidence of record contains diagnoses of PTSD in accordance with the DSM, as well as diagnoses of depressive disorder, and generalized anxiety disorder. See, e.g., October 2015 VA Examination, Correspondence entered in VBMS in September 2017. The Veteran contends his current acquired psychiatric disorder is related to exposure to near-fatal pneumonia as well as military sexual trauma (MST). See Correspondence entered in VBMS in November 2009. The Veteran stated that he was hospitalized for pneumonia and during this time, he had a near death experience. The Veteran stated that his family visited him in the hospital as they thought he was going to die. See id. Along with the hospitalization trauma, the Veteran stated that he was sexually assault by four men. See id. In March 1987, the Veteran's service treatment records (STR) confirmed the Veteran's hospitalization for pneumonia. See STRs entered in VBMS in December 2015 pages 6-7. Regarding the Veteran's MST, there are no complaints of MST in the Veteran STRs. However, in January 2015, the Veteran submitted a buddy statement documenting the changes the Veteran underwent, to include drinking and isolation, since leaving the service. Accordingly, the Board finds the occurrence of his claimed in-service stressor regarding both exposures to near-fatal pneumonia as well as military sexual trauma has been established. Finally, the Board finds there is medical evidence establishing a link between the Veteran's current acquired psychiatric disorder and his in-service stressors. In July 2013, the Veteran was afforded a VA examination to determine the nature and etiology of his acquired psychiatric disorder. The Veteran stated that prior to his discharge from the Navy in 1987, he experienced almost fatal pneumonia followed by a MST experience. The Veteran reported that he was on life support. He stated that he saw the white light. Regarding his MST, the Veteran stated that four men raped him with a mop handle." He indicated that he did not report the assault because "I didn't even know it was possible to" and did not mention the incident until he was asked about MST at GROPC. He noted "I went and threw my clothes away and took a shower and presumed it didn't happen." See C&P Examination in Legacy in June 2013. The examiner confirmed the Veteran's PTSD diagnosis. The examiner opinion that it is at least as likely as not that veteran meets criteria for a diagnosis of PTSD that is caused by or the result of his reported MST experiences during his military service. In January 2015, the Board noted that there were some inconsistencies in the Veteran's statement. The Board further noted that the July 2013 examiner did not rectify the inconsistencies; therefore, the claim was remanded for further development. In October 2015, the Veteran underwent a VA examination to determine the nature and etiology of his acquired psychiatric disorder. The examiner reviewed the claims file and performed an in-person examination. The Veteran stated that he was ill and passed out. He was transported to the ICU. He then reportedly felt a sharp pain in his chest. A nurse "shoved" a carpet needle into his penis with a pair of pliers in order to awaken him. The Veteran stated he awoke "pissed off" and suicidal because he hated being in the Navy, adding he wanted them to let him die. The examiner confirmed the Veteran PTSD diagnosis. The examiner opined that the condition claimed was at least as likely as not (50% or greater probability) incurred in or caused by the claimed in-service injury, event or illness. Regarding the MST, the examiner noted that it happened toward the end of the Veteran's career; therefore, there are no in-service markers present in his records to substantiate the stressor. However, his post-service behavior (e.g., alcohol abuse, inability to maintain close relationships/social isolation; involvement in the mental health system) are all consistent with someone with a history of personal assault as described by Veteran. The examiner concluded that the Veteran's PTSD is caused by or the result of his exposure to a near-fatal case of pneumonia, as well as military sexual trauma, experienced while serving in the Navy. In September 2017, the Veteran submitted an evaluation from a private doctor. See Correspondence entered in VBMS in September 2017, pages 28, 41. The examiner reviewed the Veteran's medical information and lay statements and performed an in-person examination. The examiner noted that the Veteran did not report his MST for some time because victims of sexual assault, especially male on male assaults, are not forthcoming about details and are often not discussed. The examiner confirmed the Veteran's PTSD diagnosis. The examiner noted that the Veteran was free of psychiatric disease before being sexually assaulted. Subsequent to the assault, the Veteran developed classic signs and symptoms of PTSD, a substance use disorder, and concomitant psychiatric illnesses causally related to the initial diagnosis of PTSD leading to severe social and occupational impairments. The examiner noted that the Veteran's brain injury had nothing to do with the initial military sexual trauma and the development of disabling psychiatric illness, but only exacerbated his mental illness. The examiner concluded that the Veteran's physical and sexual assault caused the Veteran's PTSD. Accordingly, the Board finds the medical evidence establishes a link between the Veteran's current acquired psychiatric disorder and his in-service stressors. For these reasons, the Board finds a grant of service connection is warranted for an acquired psychiatric disorder. 38 C.F.R. §§ 3.303, 3.304(f). ORDER Entitlement to service connection for an acquired psychiatric disorder is granted. ____________________________________________ MICHAEL LANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs