Citation Nr: 1735792 Decision Date: 08/29/17 Archive Date: 09/06/17 DOCKET NO. 15-10 817 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUE Entitlement to service connection for an acquired psychiatric disorder, to include major depressive disorder, mood disorder and posttraumatic stress disorder (PTSD). REPRESENTATION Veteran represented by: J. Travis Studdard, Attorney WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD Polly Johnson, Associate Counsel INTRODUCTION The Veteran had active service from June 1968 to January 1971 and from June 1977 to August 1980. He is the recipient of an Air Medal with "V" device, and an Army Commendation Medal. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2013 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Decatur, Georgia. The RO in Atlanta, Georgia retains jurisdiction of the case. In February 2016, the Veteran testified at a Travel Board hearing. A transcript of the hearing is associated with the claims file. The United States Court of Appeals for Veterans Claims (Court) held that a claim for service connection for PTSD encompasses claims for service connection for all psychiatric disabilities. Clemons v. Shinseki, 23 Vet. App. 1 (2009). Here, the Veteran has been diagnosed with PTSD, mood disorder, and major depressive disorder. Thus, the Board has redefined the Veteran's psychiatric appeal, as is listed on the title page of this decision. The Veteran has perfected an appeal as to the issues of entitlement to service connection for chronic obstructive pulmonary disease, sleep apnea, bilateral flatfoot, and blocked carotid arteries. The Veteran has requested a hearing on these matters but has not yet been afforded one. As such, the Board will defer consideration of these issues at this time. FINDING OF FACT The Veteran has PTSD related to combat service in Vietnam, and his major depressive disorder as a result of PTSD. CONCLUSIONS OF LAW 1. The criteria for service connection for PTSD are met. 38 U.S.C.A. §§ 1101, 1110, 5107 (West 2014); 38 C.F.R. §§3.303, 3.304, 4.125 (2016). 2. The criteria for service connection for major depressive disorder are met. 38 U.S.C.A. §§ 1101, 1110, 5107 (West 2014); 38 C.F.R. §§ 3.303, 3.304, 3.310, 4.125 (2016). REASONS AND BASES FOR FINDING AND CONCLUSIONS Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Establishing service connection generally requires (1) evidence of a current disability; (2) evidence of in-service incurrence or aggravation of a disease or injury; and (3) 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). If a Veteran participated in combat and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, the Veteran's lay testimony alone may establish the occurrence of the claimed stressor. 38 C.F.R. § 3.304(f)(2) (2016) A determination that a veteran engaged in combat with the enemy may be supported by any evidence which is probative of that fact, and there is no specific limitation of the type or form of evidence that may be used to support such a finding. VAOPGCPREC 12-99 (1999). Evidence submitted to support a claim that a veteran engaged in combat may include the veteran's own statements and an "almost unlimited" variety of other types of evidence. Gaines v. West, 11 Vet. App. 353, 359 (1998). Analysis The Veteran contends that he has a psychiatric disability relate to his experiences during combat service in Vietnam. It is not in dispute that the Veteran has current diagnoses of PTSD and major depressive disorder. See, e.g., February 2016 Psychological Evaluation from Dr. J.K; April 2015 VA Psychotherapy Treatment Notes. The Veteran's DD Form 214 reflects his military occupational specialty (MOS) was as an aircraft and engine mechanic. His personnel records show service in Vietnam. His statements reflect that in his role as a helicopter repairman, he did missions during which his helicopters came under attack and he witnessed death. Moreover, the RO has conceded the Veteran's combat service in Vietnam. See, March 2015 Statement of the Case. Thus, the issue turns on whether there is a link, established by medical evidence, between current symptoms and an in-service stressor. There are two opinions of record on that point. In March 2013, the Veteran underwent a VA examination wherein the examiner noted that the Veteran participated in combat activity, but said that the Veteran did not meet the DSM-5 criteria for PTSD. The examiner diagnosed mood disorder, not otherwise specified. A February 2016 psychological evaluation from a private provider reflects diagnoses of PTSD, major depressive disorder, and alcohol abuse. The psychologist who authored the evaluation elicited a detailed history from the Veteran during an in-person examination and administered a mental status examination, psychosocial pain inventory, Minnesota Multiphasic Personality Inventory-2, Beck Depression Inventory-II, Beck Hopelessness Scale, Beck Anxiety Inventory, and Trauma Symptoms Inventory-2. The Veteran recounted details from his military experience, discussed his current medication regimen, and described his current symptoms, which included fitful sleep, erratic appetite, crying spells, irritability, anger, impaired concentration and memory, anxiety, and social isolation. Based on testing and interview, the psychologist noted extreme emotional distress, characterized by dysphoria, apathy, fearfulness, hopelessness, and anxiety, and stated that the Veteran's sense of futility and hopelessness would increase the probability of suicidal behavior, though he denied suicidal ideation during the interview. Ultimately, the examiner determined that the Veteran met the diagnostic criteria under the DSM-5 for PTSD, as well as the diagnostic criteria for major depressive disorder. Moreover, the examiner opined that PTSD was directly related to the Veteran's combat experiences in Vietnam. In a March 2016 addendum to her report, the psychologist clarified that PTSD and major depressive disorder were two separate diagnoses, and that the major depressive disorder developed secondary to the uncontrolled PTSD. After a review of the record, the Board finds that the evidence is at least in equipoise as to whether the Veteran's PTSD and major depressive disorder are related to an in-service combat stressor. In this regard, the Board accords greater probative value to the February 2016 report, and March 2016 addendum, proffered by the private psychologist, who took a detailed history from the Veteran and authored an extensive report, taking into account the Veteran's symptoms, functioning, occupational difficulties, and emotional control, to make a finding that the Veteran suffers from PTSD and consequently, major depressive disorder, resulting from his Vietnam combat service. Conversely, the Board accords little probative value to the March 2013 VA examination, in which the examiner essentially checked boxes without offering comments, remarks, or rationale for the opinion that the Veteran did not meet the PTSD criteria. The private opinion satisfies the criteria for service connection for PTSD and major depression. It includes a medical diagnosis, and an opinion linking the diagnosis to the in-service combat stressor. Because the Veteran participated in combat; and the stressors are consistent with that service, no further evidence is needed to establish their occurrence. The opinion also serves to link the diagnosed major depression to the PTSD. While a mood disorder was separately diagnosed in the past, major depression is recognized as a form of mood disorder and is part of the service connected disability. DSM-IV (the term "mood disorder" is not used in the DSM-V). Accordingly, resolving reasonable doubt in favor of the Veteran, the Board finds that service connection for PTSD and for major depressive disorder is warranted. 38 U.S.C.A. § 5107 (b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Service connection for a psychiatric disability to include PTSD and major depressive disorder, is granted. ____________________________________________ Mark D. Hindin Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs