Citation Nr: 18144673 Decision Date: 10/25/18 Archive Date: 10/24/18 DOCKET NO. 15-04 364 DATE: October 25, 2018 ORDER Service connection for posttraumatic stress disorder (PTSD) is denied. REMANDED Entitlement to service connection for an acquired psychiatric disorder other than PTSD, to include depressive disorder not otherwise specified (NOS) and anxiety disorder NOS, is remanded. VETERAN’S CONTENTIONS The Veteran contends that he has PTSD as a result of in-service stressors related to fear of hostile military, or terrorist activity. FINDING OF FACT The competent evidence of record fails to show that the Veteran has a current diagnosis of PTSD. CONCLUSION OF LAW The criteria for service connection for PTSD have not been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R §§ 3.102, 3.30, 3.304. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from December 1968 to August 1971. These matters come to the Board of Veterans' Appeals (Board) on appeal from a March 2014 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Louisville, Kentucky. The Board has expanded the claim of entitlement to service connection for PTSD to one for service connection for an acquired psychiatric disorder, to include PTSD. See Clemons v. Shinseki, 23 Vet. App. 1 (2009) (the scope of a mental health disability claim includes any mental disability that may reasonably be encompassed by the claimant's reported symptoms and other information of record.) As explained below, the Board is denying service connection for PTSD, but finds that additional development is required regarding the issue of entitlement to service connection for an alternative acquired psychiatric disorder. Entitlement to service connection for posttraumatic stress disorder (PTSD) Generally, service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active military service. This means that the facts establish that a particular injury or disease resulting in disability was incurred coincident with service in the Armed Forces, or if preexisting such service, was aggravated therein. 38 U.S.C. § 1110; 38 C.F.R. § 3.303 (a). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an 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 Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Service connection for PTSD in particular requires medical evidence diagnosing the condition under the criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), or by findings supported in an examination report; 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), 4.125(a) (2017). VA implemented DSM-5, effective August 4, 2014, and the Secretary of VA determined that DSM-5 applies to claims certified to the Board on and after August 4, 2014. 79 Fed. Reg. 45,093, 45,094 (Aug. 4, 2014). The RO certified the Veteran's appeal to the Board in February 2015. Hence, the DSM-5 is the governing directive for the Veteran's claim. A Veteran's lay testimony alone may establish the occurrence of a claimed in-service stressor if: (1) the claimed stressor is related to his fear of hostile military or terrorist activity; (2) a VA psychiatrist or psychologist, or contract equivalent, confirms that the claimed stressor is adequate to support a diagnosis of PTSD and the Veteran's symptoms are related to the claimed stressor, and (3) the claimed stressor is consistent with the places, types, and circumstances of the Veteran's service. See 38 C.F.R. § 3.304 (f)(3). Determinations as to service connection will be based on review of the entire evidence of record, to include all pertinent medical evidence. VA must also consider all favorable lay evidence of record. See 38 U.S.C. § 5107 (b); see also Layno v. Brown, 6 Vet. App. 465, 469-70 (1994) (a Veteran is competent to report on that of which he or she has actually observed and is within the realm of his or her personal knowledge). The threshold question that must be addressed is whether the Veteran actually has the disability for which service connection is sought; PTSD. In the absence of proof of a present disability, there is no valid claim of entitlement to service connection. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). As will be discussed, the Board finds that the Veteran has not met the criteria for a diagnosis of PTSD during the course of the appeal. During a December 2013 VA examination, the Veteran’s described stressors included exposure to enemy fire and fearing for his life. After reviewing the claims file and administering a variety of psychological tests to determine whether a diagnosis of PTSD was appropriate, the examiner indicated that while the Veteran was exposed to the horrors of war, the evidence did not support a presence of PTSD. The examiner reasoned that there was an absence of any of the listed symptoms at a clinically significant level of impairment. The examiner further reasoned that the Veteran’s service treatment records (STRs) contain no indication of a mental health problem from screenings provided by medical providers. The Board finds the December 2013 VA examiner opinion, which concluded that the Veteran does not meet the criteria for a diagnosis of PTSD, to be highly probative. The opinion was provided after examining the Veteran and considering relevant facts. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) (holding that it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value of a medical opinion). The opinion also contains a sufficient rationale. The medical evidence of record otherwise includes VA treatment records from the Lexington VAMC which document negative PTSD screens in September 2013 and August 2018. In January 2015, a VA clinician diagnosed the Veteran with depressive disorder NOS and anxiety disorder NOS, but ruled out a diagnosis of PTSD. Concerning the Veteran's self-diagnosis of PTSD, as a lay person, he has not shown that he has specialized training sufficient to render an opinion as to the cause of his psychiatric disorder. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). In this regard, the diagnosis and etiology of psychiatric disorders is a matter not capable of lay observation, and requires medical expertise to determine. Accordingly, his opinion as to the diagnosis and etiology of his PTSD is not competent medical evidence. Thus, the Board finds the opinion of the December 2013 VA examiner to be significantly more probative than the Veteran's lay assertions. As a condition precedent for establishing service connection for a claimed disability is the diagnosis of the disability at any time during the pendency of the appeal and this Veteran does not have such a diagnosis, the Board must conclude that entitlement to service connection for PTSD must be denied because the weight of the evidence is against the claim. See 38 U.S.C. § 1110; 38 C.F.R. §§ 3.303, 3.304. In reaching the above conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C. § 5107 (b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). REASONS FOR REMAND Entitlement to service connection for an acquired psychiatric disorder other than PTSD, to include depressive disorder NOS and anxiety disorder NOS is remanded. The evidence of record reflects that the Veteran has additional psychiatric diagnoses apart from PTSD. Specifically, January 2015 Lexington VAMC – Leestown records document diagnoses of depressive disorder NOS and anxiety disorder NOS. The depressive disorder NOS and anxiety disorder NOS diagnoses were not addressed by the December 2013 VA examiner, as the VA treatment records documenting these diagnoses were not associated with the Veteran’s claims file until after the December 2013 VA examination. Therefore, a remand is needed to clarify whether the Veteran has additional psychiatric diagnoses related to service. The matter is REMANDED for the following action: 1. Request that the Veteran provide or authorize VA to obtain records of his relevant treatment that have not yet been associated with the claims file, and associate with the claims file any outstanding VA treatment records. 2. Schedule the Veteran for a VA psychiatric exam to determine the nature, etiology, and date of onset of any psychiatric disorders other than PTSD that were diagnosed during the appeal period, to include depressive disorder NOS and anxiety disorder NOS. The claims file should be made available to the examiner and review of the file should be noted in the requested report. The examiner should record the full history of the identified disorders, including the Veteran's competent account of his symptoms. Following review of the claims file and examination of the Veteran, the examiner should respond to the following: (a.) Please identify all current psychiatric disorders. (b.) For each psychiatric disorder diagnosed during the period on appeal, no matter whether it is currently resolved or not, is it at least as likely as not (50 percent probability or more) that it had its onset in service, or within one year of his separation from service, or is otherwise related to service? (c.) In formulating the requested opinions, please specifically acknowledge and discuss the psychiatric diagnoses of record, including depressive disorder NOS and anxiety NOS. In determining whether the Veteran meets the criteria for a current psychiatric diagnosis, please consider medical and lay evidence dated both prior to and since the filing of the September 2013 claim for service connection. Please note that although the Veteran may not meet the criteria for a psychiatric diagnosis at the present time, diagnoses made prior to and since the September 2013 date of claim filing meet the criteria for a "current" diagnosis. Please also note that the Veteran is competent to report symptoms, treatment, and injuries, and that his reports must be taken into account in formulating the requested opinions. (Continued on the next page)   All findings and conclusions should be supported with a complete rationale and set forth in a legible report, which should reflect the examiner's consideration and analysis of both the medical and lay evidence of record. If it is not possible to provide an opinion without resort to speculation, the reason that is so should be explained, indicating whether there is additional evidence that could enable an opinion to be provided or whether the inability to provide an opinion is based on the limits of medical knowledge. S. C. KREMBS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD J. Smith-Jennings, Associate Counsel