Citation Nr: 18143717 Decision Date: 10/23/18 Archive Date: 10/19/18 DOCKET NO. 15-10 130A DATE: October 23, 2018 ORDER Entitlement to service connection for posttraumatic stress disorder (PTSD) is granted. REMANDED Entitlement to service connection for multiple joint arthritis, including of the back, bilateral hips, and bilateral knees (also claimed as rheumatoid arthritis), is remanded. Entitlement to service connection for bilateral hearing loss is remanded. Entitlement to service connection for sleep apnea is remanded. Entitlement to service connection for diabetes mellitus type II, to include as due to herbicide exposure, is remanded. Entitlement to service connection for peripheral neuropathy of the bilateral upper extremities, to include as secondary to diabetes mellitus type II, is remanded. Entitlement to service connection for peripheral neuropathy of the bilateral lower extremities (also claimed as diabetic feet), to include as secondary to diabetes mellitus type II, is remanded. Entitlement to service connection for organic impotence (claimed as erectile dysfunction), to include as secondary to diabetes mellitus type II, is remanded. FINDING OF FACT The Veteran’s PTSD is related to a verified in-service stressor. CONCLUSION OF LAW An acquired psychiatric disorder, diagnosed as PTSD, was incurred in active service. 38 U.S.C. § 1110 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 4.125 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from May 1970 to December 1971. He also had subsequent service in the United States Army Reserve. This case comes before the Board of Veterans’ Appeals (Board) on appeal from a February 2014 rating decision of the Department of Veterans Affairs (VA). A hearing was held before the undersigned Veterans Law Judge in June 2018. A transcript of the hearing is of record. Following the hearing, the Veteran submitted copies of an internet article already of record for which there is an automatic waiver of initial agency of original jurisdiction (AOJ) review, along with a waiver of such review. Initially, the Board notes that the AOJ originally denied the Veteran’s claims for service connection for bilateral hearing loss, diabetes mellitus type II, diabetic feet, and erectile dysfunction in a September 2012 rating decision. The AOJ accepted the Veteran’s February 2013 written submissions as a request for reconsideration of those claims, as well as claims for service connection for most of the remaining issues above. See also December 2013 written statement (adding peripheral neuropathy). The AOJ reconsidered and continued to deny those claims in the February 2014 rating decision. The issues have been characterized as stated above to more accurately reflect the nature of the claims based on the Veteran’s contentions and the other evidence of record. The Board also notes that, in response to the AOJ’s request for clarification as to the specific location of his arthritis, the Veteran responded he has arthritis from his “back down to [his] knee[s].” See February 2013 AOJ letter; March 2013 written statement. During the Board hearing, he testified that his private doctor told him that he has rheumatoid arthritis, rather than arthritis from injury affecting individual joints. See June 2018 Bd. Hrg. Tr. at 16-18. The treatment records from that provider appear to show diagnoses of degenerative joint disease of the lumbosacral spine, hips, and knees, but do not suggest that the Veteran has been diagnosed with rheumatoid arthritis or another systemic arthritic disorder. See, e.g., December 2003 and October 2004 private treatment records from Dr. R.B. Based on the foregoing, the issue on appeal has been recharacterized as stated above. Law and Analysis 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. 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). Service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f). A mental disorder diagnosis must conform to the Fourth Edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), or, for claims received by or pending before the AOJ on or after August 4, 2014, the DSM-5 (Fifth Edition). See 38 C.F.R. §§ 4.125, 4.130; 79 Fed. Reg. 45093 (Aug. 4, 2014). Because this case was certified to the Board after that time, the regulations pertaining to the DSM-5 are for application. Nevertheless, the Board finds that the Veteran may still establish service connection based on a DSM-IV diagnosis, as he had initiated an appeal for this issue prior to that time. In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that service connection is warranted for PTSD. The Veteran has contended that his PTSD is related to an in-service incident in which he witnessed his friend (J.D., a fellow service member) become badly injured from being attacked by another service member with a straight razor when they were stationed in Korea. He has recalled that an argument started, ultimately resulting in the other service member jumping on J.D. with the straight razor. The Veteran has also recalled trying to stop the fight. He clarified during the Board hearing that he was unsure if J.D. had lived or died at that time. See, e.g., Bd. Hrg. Tr. at 22-28; March 2013, April 2013, and December 2013 written stressor statements; June 18, 2013, and July 2013 VA treatment records. Regarding the claimed stressor, the Veteran’s service personnel records confirm that he was stationed in Korea from October 1970 to December 1971. In a January 2014 response to a stressor verification request from the AOJ, the Joint Services Records Research Center (JSRRC) indicated that, after researching the U.S. Army historical records available to the office and coordinating research with the National Archives and Records Administration, it was able to document that a service member with the same first and last name provided by the Veteran (no organization provided) was seriously injured in October 1971 in Korea. The AOJ did not receive any additional information as to the incident after a request to the U.S. Army Crime Records Center later that same month. The Board finds the Veteran’s reports as to his recollection of the in-service incident competent and credible. The JSRRC response confirms the nature of J.D.’s injuries, and the Veteran’s recollection of the severity of the injuries is consistent with that report. Resolving reasonable doubt in favor of the Veteran, the Board finds there is credible evidence that the claimed in-service stressor occurred. The Board also finds that the Veteran’s PTSD is related to the verified in-service stressor. In this regard, the Veteran was referred for VA mental health treatment in February 2013 due to concerns of unresolved grief following the death of his spouse four years prior. At that time, Dr. R.V. diagnosed him with depression, not otherwise specified (NOS). In a follow-up appointment with Dr. R.V. several months later, the Veteran again discussed his spouse’s death, as well as recurrent intrusive thoughts about the in-service incident where his friend was attacked with the straight razor. Dr. R.V. reminded the Veteran that his feeling of helplessness may have been similar to how he felt when his wife died, and the Veteran agreed. The Veteran was diagnosed with noncombat-related PTSD, major depression without psychotic features, and a sleep disorder, NOS. It was noted that he would be referred for a sleep study to rule out sleep apnea (a diagnosis of which is now of record and the subject of a separate claim). See June 2013 VA treatment records. In an initial VA psychotherapy intake appointment the following month, another VA treatment provider (Dr. J.K.) noted that the consultation request stated that the Veteran’s symptoms were too severe for short-term treatment in primary care. Following evaluation, Dr. J.K. provided a summary of the Veteran’s history, noting that he seemed well adjusted in the Army and did not report any combat experience or disciplinary action, and that his most traumatic event was witnessing a friend die in the military after being stabbed multiple times. In addition, she determined that, overall, given the Veteran’s military trauma history of witnessing the death of his friend, he met the criteria for PTSD, chronic. She also determined that he met the criteria for major depressive disorder, recurrent, moderate, given his recurrent symptoms of depression, and it appeared that his symptoms of depression were secondary to his symptoms of PTSD. See July 2013 VA treatment record; see also, e.g., September 2013 VA treatment record (appointment to discuss treatment recommendations with licensed clinical social worker). In other words, Dr. J.K. considered the Veteran’s complete history and reported in-service stressor and determined that the stressor was adequate to support a diagnosis of PTSD. She also determined that he had depression symptoms that were related to his PTSD. In addition, the February 2013 and June 2013 depression-related diagnoses appear to relate that diagnosis to the unprocessed grief related to the Veteran’s spouse’s death. In reviewing Dr. J.K.’s opinion in the context of the other evidence of record, the Board finds that her determination was based on her consideration of the Veteran’s mental health history as a patient, as well as current medical understanding, and is therefore entitled to probative weight. See Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012) (providing that an examination is not rendered inadequate where rationale provided by examiner “did not explicitly lay out the examiner’s journey from the facts to a conclusion”); Acevedo v. Shinseki, 25 Vet. App. 286, 294 (2012) (stating that medical reports must be read as a whole and in context of evidence of record). There is no medical opinion to the contrary, and the remainder of the VA mental health treatment records supports such a determination. Based on the foregoing, the Board concludes that service connection is warranted for PTSD. REASONS FOR REMAND On review, the Board finds that additional development is necessary prior to final adjudication of the Veteran’s remaining claims. Specifically, it appears that there may be outstanding, relevant VA and private treatment records, as well as Social Security Administration (SSA) records, as detailed in the directives below. The Agency of Original Jurisdiction (AOJ) should also make an attempt to secure the Veteran’s complete service personnel records and any Reserve records, as they may be relevant to the claims. In addition, because the outcome of the diabetes mellitus claim could affect the outcome of the claims of related complications, the claims are inextricably intertwined, and a remand is required. The case is REMANDED for the following actions: 1. The AOJ should obtain and associate the Veteran’s complete service personnel records from his active duty service, as well as any service treatment records and service personnel records from his Reserve service with the claims file. The AOJ should also verify any relevant period of service if necessary. It is noted that the claims file contains copies of service personnel records from the Veteran’s period of active duty service; however, it is unclear if these records constitute the entire service personnel file. See April 2012 3101 printout. In addition, the Veteran has indicated that he had Reserve service for six years after his active duty service, and the record of assignments in the service personnel records shows the organization and stations for his Ready Reserve service in the 1970s. All attempts and responses should be documented in the claims file. 1. 2. The AOJ should request that the Veteran provide the names and addresses of any and all health care providers who have provided treatment for arthritis, bilateral hearing loss, sleep apnea, and diabetes mellitus and claimed complications. After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate these records with the claims file. A specific request should be made for any non-VA treatment, including: (1) audiological testing from his post-service construction work with the Tennessee Valley Authority and (2) records from any non-VA pain management provider. See, e.g., October 2014 VA treatment record (noted Veteran elected to continue with private pain management); June 2018 Bd. Hrg. Tr. at 13-15 (Veteran testified that he received annual audiological testing at his work). The AOJ should also secure any outstanding VA treatment records, including: (1) any treatment from prior to April 2011 and (2) any scanned/uploaded non-VA reports for the claimed disorders, including the May 2013 sleep study from RoTech/Sleep Central and the October 2014 MRI report from Premier Radiology. The non-VA consultation reports appear to be located in the Vista Imaging System. 3. The AOJ should obtain a copy of any decision to grant or deny SSA disability benefits to the Veteran and the records upon which that decision was based and associate them with the claims file. If the search for such records has negative results, the claims file should be properly documented as to the unavailability of those records. See, e.g., February 2013 VA treatment record (Veteran reported being in receipt of SSA disability income). 4. After completing the above actions, the AOJ should conduct any other indicated development. Further development may include obtaining an additional VA medical opinion for the bilateral hearing loss claim or providing VA examinations or obtaining VA medical opinions for the remaining claims. J.W. ZISSIMOS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M. Postek, Counsel