Citation Nr: 1800023 Decision Date: 01/02/18 Archive Date: 01/19/18 DOCKET NO. 13-07 113 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Newark, New Jersey THE ISSUE Entitlement to service connection for a psychiatric disability, to include depressive disorder, adjustment disorder, and posttraumatic stress disorder. REPRESENTATION Appellant represented by: Joseph Moore, Attorney ATTORNEY FOR THE BOARD T. Davis, Associate Counsel INTRODUCTION The Veteran served on active duty from July 1964 to July 1968. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2011 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Newark, New Jersey. In April 2016, the Board denied entitlement to service connection for a psychiatric disability. The Veteran filed a timely appeal to the United States Court of Appeals for Veterans Claims (Court). In an August 2016 Joint Motion for Remand (JMR) and August 2016 Court Order, the Board's decision was vacated and remanded for action consistent with the JMR. Consistent with the JMR the Board has received a new medical opinion. The Veteran's private physician provided the new medical opinion. The opinion takes into consideration the Veteran's reported stressors and provides an etiological opinion in reference to the Veteran's depression. FINDINGS OF FACT 1. The Veteran did not engage in combat with the enemy during service. 2. The Veteran has PTSD. 3. The claims file contains credible supporting evidence of an in-service stressor that is related to the Veteran's PTSD. He served on active duty during Vietnam was present during a base attack at Tan son Nhut air base in December 1966; he feared for his life during the engagement. CONCLUSION OF LAW The criteria for entitlement to service connection for PTSD have been met. 38 U.S.C.A. §§ 1110, 1131, 1154(b) (West 2014); 38 C.F.R. § 3.304(f) (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSION As the Board's decision to grant service connection for PTSD is completely favorable, no further action is required to comply with VA's duties to notify and assist. Service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a) (i.e., in accordance with DSM-IV and DSM-V); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f). With exceptions not here applicable, if VA determines that a veteran did not engage in combat with the enemy, or that the Veteran did engage in combat with the enemy but the claimed stressor is unrelated to such combat, the Veteran's lay testimony, by itself, will not be enough to establish the occurrence of the reported stressor. Dizoglio v. Brown, 9 Vet. App. 163, 166 (1996). Instead, the record must contain credible supporting evidence that corroborates a veteran's testimony or statements. Cohen v. Brown, 10 Vet. App. 128, 146-47 (1997). This credible supporting evidence cannot consist solely of after-the-fact medical nexus evidence. Moreau v. Brown, 9 Vet. App. 389, 394-95 (1996). The available sources for corroboration of a claimed stressor are not necessarily limited to service records (as previously required prior to the adoption of 38 C.F.R. § 3.304(f)), but may also include other sources of evidence. See Cohen, 10 Vet. App. at 143 (citing to M21-1, Part VI, para 7.46(f) (Sept. 21, 1992)); M21-1, Subch. XII, para 50.45(d) (1989). Moreover, corroboration does not require there be verification of every detail. Suozzi v. Brown, 10 Vet. App. 307, 311 (1997); Pentecost v. Principi, 16 Vet. App. 124 (2002). In the present case, the Board finds that the Veteran has PTSD. A February 2013 VA examination report found that the Veteran did not have PTSD and instead provided a diagnosis of unspecified depressive and personality disorder. Notwithstanding the foregoing, in July 2017, and after the case was remanded back to the Board from the Court, a competent and credible private psychiatrist diagnosed the Veteran with PTSD under both DSM-IV and DSM-V criteria. The private examiner reviewed the entire claims file, including VA examination reports and opinions. He reported that the Veteran was misdiagnosed with depression and a personality disorder and that it is very clear that identifying the Veteran's proper diagnosis had been an issue in this case. Therefore, he interviewed and examined the Veteran several times in order to obtain a proper diagnosis. See correspondence received 11/10/2017 at 14. Indeed, the examiner diagnosed PTSD utilizing both DSM- IV and DSM-V criteria. He provided a full analysis and rationale for his findings. He concluded that based on the DSM-V, that Veteran met the diagnostic criteria for PTSD, specifically PTSD, with dissociative symptoms and delayed expression. He further provided that based on the DSM-IV, the Veteran met the diagnostic criteria for PTSD, specifically, chronic PTSD with delayed onset. See correspondence received 11/10/2017 at 14-17. The examiner further explained that the Veteran's misdiagnosis is the reason why he was not responsive to pharmacological intervention. See correspondence received 11/10/2017 at 9-10. The Board also finds that, while the evidence does not show the Veteran engaged in combat during service, the record contains credible supporting evidence that a reported in-service stressor occurred. In a November 2011 written statement, the Veteran described an incident in which he was present during a mortar attack while serving on temporary duty at the Tan Son Nhut Air Base in South Vietnam. He recalled experiencing feelings of fear and abandonment during the attack. The Veteran's statements are competent evidence as to matters within the realm of his personal knowledge. 38 C.F.R. § 3.159 (a)(2); Layno v. Brown, 6 Vet. App. 465, 469-70 (1994). Service records showing that the Veteran was in Vietnam on a temporary duty assignment from November 1966 to January 1967 and a chronology of base attacks from the Office of Air Force History showing that on December 4, 1966, Tan Son Nhut received 33 rounds of enemy fire, both corroborate the Veteran's account. See correspondence received 11/10/2017 at 21. Finally, the evidence establishes a link between current symptoms and the verified in-service stressor. The July 2017 private psychiatric examiner concluded that, "after review of the claims file and interview with the Veteran, there is absolutely no question that the diagnosis is, and always has been, PTSD." He further provided that the etiology of the Veteran's PTSD is unequivocal and casually related to his active- duty service. The examiner reasoned that the Veteran was present during a base attack and feared for his life during the engagement, and then began suffering from sleepless nights shortly afterward. The Veteran also exhibited an escalated startle response, to include an incident following his return from Southeast Asia where he and his bunk mate mistook firing practice nearby for incoming mortar rounds. See correspondence received 11/10/2017 at 17. The private examiner further provided that the Veteran had once been very driven and high achieving, but after his service discharge, he displayed a negativistic attitude, was resentful of others, felt worthless, and withdrew from other people, becoming increasingly isolated. "This was a significant departure from his attitude and behaviors before he entered the Air Force." The psychiatrist concluded that outside of active military service, there is no evidence that the Veteran experienced trauma or any other events that would contribute to the development of a PTSD diagnosis. Id. Overall, the examiner provided a link between the Veteran's current symptoms and his in-service stressors. Because the requirements of 38 C.F.R. § 3.304(f) have been met, service connection for PTSD is warranted. ORDER Service connection for PTSD is granted. ____________________________________________ MARJORIE A. AUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs