Citation Nr: 1801268 Decision Date: 01/09/18 Archive Date: 01/19/18 DOCKET NO. 16-40 658 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUE Entitlement to service connection for posttraumatic stress disorder ("PTSD"). ATTORNEY FOR THE BOARD K. Anderson, Counsel INTRODUCTION The Veteran had active military service from September 1950 to June 1952. This appeal comes to the Board of Veterans' Appeals (Board) from a March 2015 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2017). 38 U.S.C. § 7107(a)(2) (2012). FINDING OF FACT The competent probative evidence of record does not indicate that the Veteran has been diagnosed with PTSD at this time. CONCLUSION OF LAW The criteria for service connection for PTSD have not been met. 38 U.S.C. §§ 1110, 5107(b) (2012); 38 C.F.R. §§ 3.303, 3.304(f) (2017). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran has asserted entitlement to service connection for PTSD. Specifically, he believes that his combat service in Korea has caused him to develop PTSD. After a careful and thorough review of the evidence of record, the Board finds that service connection for PTSD is not warranted. Under 38 U.S.C. § 7104, Board decisions must be based on the entire record, with consideration of all the evidence. In Timberlake v. Gober, 14 Vet. App. 122 (2000), the Court held, in pertinent part, that the law requires only that the Board address its reasons for rejecting evidence favorable to the claimant. The Federal Circuit has also held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty in the active military, naval, or air service. 38 U.S.C. §§ 1110, 1131. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303 (b). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303 (d). In order to establish service connection for the claimed disorder, there must be competent and credible evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999); see also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). Service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125 (a) (conforming to the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (4th or 5th ed.)) (DSM-IV or 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). A review of the Veteran's medical records fails to indicate that he has been diagnosed with PTSD at any point during the appeal period. The March 2015 VA examination report specifically finds that the Veteran "does not meet criteria for a diagnosis of PTSD." Further, the Veteran was not diagnosed with any other mental disorder. The Veteran asserts that the examiner did not believe him and that is why he was not diagnosed with PTSD at the VA examination. However, a review of the examiner's report notes that she does acknowledge that the Veteran's combat experiences in Korea were severe enough to meet the PTSD criterion A. However, the Veteran did meet any other criteria. Specifically, the examiner noted that the Veteran reported irritability at the examination; however, it was noted that he "was a bully" as a child, suggesting this was a longer term trait not related to military trauma. The examiner commented that the Veteran's irritability and anger did not lead to any social or occupational problems. The Veteran reported nightmares once per week; however, he did not remember any of them and reported that these nightmares did not cause any distress. He did not report any avoidance behaviors or alterations in cognitions. He did indicate having a startle reflex. He denied experience of depression, and although he reported "anxiety," he could not describe any symptoms other than that he will sometimes stay awake or wake early if he has something important to do the next day. Lastly, the examiner noted that the Veteran has lived his life in a stable and responsible manner. He is in a long term marriage of 62 years, has raised children and grandchildren, maintained steady employment of over 33 years with the same company, and was socially engaged and involved with friends, family, and church. The examiner opined that this is certainly a testament of the Veteran's emotional fortitude and resiliency. After reviewing the examination, the Board finds that the examination is adequate. The examiner went over all of the criteria with the Veteran. She discussed his contentions and found the Veteran to be credible; she acknowledged his in-service combat as well as traumatic experiences. The Board finds that the examiner as a VA psychologist is competent to provide an opinion on the Veteran's current mental state. The Board reviewed the Veteran's VA treatment notes to see if there was a suggestion or indication that the Veteran had treatment or diagnosis of a mental health disability. This review did not show any type of mental health diagnosis or treatment. Specifically, in March 2013, the Veteran had a PTSD screening that was negative. In November 2005 as well as in March and December 2007, the Veteran had negative PTSD screenings. In January 2014, the Veteran reported for a VA mental health screening because one of his Korean War buddies told him that he should apply for PTSD disability. He reported that he spoke to woman at the American Legion who gave him a form with symptoms of PTSD and the Veteran thought that he had some of those symptoms. He reported during this screening that he's "got some aggression," and only sleeps 3-4 hours. However, he did not report a depressed mood and did not endorse suicidal or homicidal ideations. At the end of the conversation, it is noted that the Veteran did not request treatment of symptoms, either pharmacological or psychotherapeutic interventions. Finally, the Veteran indicated that he is only seeking a disability evaluation, not clinical assessment or treatment. To prevail on the issue service connection, there must be medical evidence of a current disability at some point during the pendency of the claim. See Degmetich v. Brown, 104 F.3d 1328 (Fed. Cir. 1997). Absent a medical diagnosis of a disability, service connection must be denied. See 38 U.S.C. § 5107 (2012); Brammer v. Derwinski, 3 Vet. App. 223 (1992). The only evidence suggesting that the Veteran has a diagnosis of PTSD is from the Veteran's lay statements. While the Veteran is certainly competent to describe the his symptoms, he is not competent to render such a diagnosis of PTSD, as the evidence does not demonstrate that he possesses the ability, knowledge, or experience to provide such a diagnosis in this case. Unlike some disorders, diagnosis of mental health disabilities goes beyond a simple and immediately observable cause-and-effect relationship and would require medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125 (a) (conforming to the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (4th or 5th ed.)) (DSM-IV or DSM-V). See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n. 4 (Fed. Cir. 2007) ("Sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer."). Accordingly, the Board concludes that the preponderance of the evidence is against the claim for service connection for PTSD or any other acquired psychiatric disorder, and the benefit of the doubt rule does not apply. See 38 U.S.C. § 5107 (2012). Duties to Notify and Assist When VA receives a complete or substantially complete application for benefits, it must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). See also Quartuccio v. Principi, 16 Vet. App. 183 (2002); Pelegrini v. Principi, 18 Vet. App. 112 (2004). VA's duty to notify has been satisfied through a notice letter that fully addressed all notice elements. This letter informed the Veteran of what evidence was required to substantiate his claim and of the Veteran's and VA's respective duties for obtaining evidence. The Veteran was requested to submit any evidence in his possession and has been afforded a meaningful opportunity to participate effectively in the processing of his claim and given ample time to respond. In light of the above, the Board finds that all notices required by VCAA and implementing regulations were furnished to the Veteran and that no useful purpose would be served by delaying appellate review to send out additional VCAA notice letters. VA must also make reasonable efforts to assist the appellant in obtaining evidence necessary to substantiate the claim for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159 (2014). The Veteran was informed that the VA has not been able to obtain his complete original service treatment records. The National Personnel Records Center (NPRC) has indicated that these records could not be found and were likely destroyed in a 1973 fire at NPRC. An effort to reconstruct records from alternative sources included inpatient clinical records was unsuccessful. On January 7, 2014, the VA formally found that the Veteran's complete service treatment records are unavailable for review. Therefore, VA's duty to further assist the Veteran in locating additional records has been satisfied. See 38 U.S.C. § 5103A (d); see also 38 C.F.R. § 3.159 (c)(4) (2017). All post-service VA and private treatment records identified by the Veteran have also been obtained. The Veteran has not identified any additional records that should be obtained prior to a Board decision. Therefore, VA's duty to further assist the Veteran in locating additional records has been satisfied. See 38 U.S.C. § 5103A(d); see also 38 C.F.R. § 3.159 (c)(4) (2017). The Veteran was provided a VA examination in March 2015, which is adequate for the purposes of determining service connection, as it involved a review of the Veteran's pertinent medical history, as well as a clinical evaluation of the Veteran, and provided an opinion with supporting rationale. See generally Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). In light of the foregoing, the Board is satisfied that all relevant facts have been adequately developed to the extent possible; no further assistance to the appellant in developing the facts pertinent to the issue on appeal is required to comply with the duty to assist. 38 U.S.C. §§ 5103 and 5103A; 38 C.F.R. § 3.159. ORDER Service connection for posttraumatic stress disorder is denied. ____________________________________________ JENNIFER HWA Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs