Citation Nr: 18148058 Decision Date: 11/06/18 Archive Date: 11/06/18 DOCKET NO. 13-31 270 DATE: November 6, 2018 ORDER Entitlement to service connection for posttraumatic stress disorder (PTSD) is denied. FINDING OF FACT The competent and credible evidence of record does not show that the Veteran has a current diagnosis of PTSD. CONCLUSION OF LAW The criteria for entitlement to service connection for PTSD are not met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107(b); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 4.125. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from September 2002 to July 2005. The Board notes that, generally, the scope of a claim of service connection for a specific psychiatric disability (here, PTSD) encompasses all psychiatric diagnoses shown. Clemons v. Shinseki, 23 Vet. App. 1, 4-6 (2009). However, prior final rating decisions separately denied service connection for psychiatric disabilities other than PTSD, and such other psychiatric disabilities are not the subject of the instant claim. In that regard, a December 2008 rating decision denied service connection for adjustment disorder claimed as anxiety, depression, and insomnia, and a November 2009 rating decision denied service connection for bipolar disorder. The Veteran did not appeal these rating decisions and has not submitted additional evidence pertinent to the bases of denial for these claims. Accordingly, the appeal in the instant case is limited to the specific diagnosis of PTSD (filed as a new claim). VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326. A letter dated in October 2010 satisfied the duty to notify provisions. 38 U.S.C. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002); Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006); Prickett v. Nicholson, 20 Vet. App. 370, 377-78 (2006). Further, the purpose behind the notice requirement has been satisfied because the Veteran has been afforded a meaningful opportunity to participate effectively in the processing of his claim, to include the opportunity to present pertinent evidence. Simmons v. Nicholson, 487 F.3d 892, 896 (Fed. Cir. 2007); Sanders v. Nicholson, 487 F.3d. 881, 887 (Fed. Circ. 2007), rev’d on other grounds, Sanders v. Shinseki, 556 U.S. 396 (2009). Thus, the Board finds that the content requirements of the notice VA is to provide have been met. See Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004). The duty to assist the Veteran has also been satisfied in this case. The Veteran’s service treatment records, VA medical treatment records, and identified private treatment records have been obtained. 38 U.S.C. § 5103A, 38 C.F.R. § 3.159. The record does not reflect that the Veteran is in receipt of disability benefits from the Social Security Administration. 38 C.F.R. § 3.159(c)(2); Golz v. Shinseki, 590 F.3d 1317, 1320-21 (Fed. Cir. 2010). The RO obtained VA examinations and opinions addressing the Veteran’s claim in November 2012 and June 2016. The examinations are adequate in this case as they were based on a complete review of the evidence in the claims file, an interview of the Veteran, and a psychiatric evaluation of the Veteran. Although the November 2012 VA opinion does not provide an explanation for the lack of a PTSD diagnosis, the June 2016 VA examiner provided a thorough discussion in support of the conclusion that the Veteran does not meet the diagnostic criteria for a diagnosis of PTSD. Accordingly, the Board finds the June 2016 VA examination to be adequate. 38 C.F.R. § 3.159(c)(4); Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). Finally, there is no indication in the record that additional evidence relevant to the issue being decided herein is available and not part of the record. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev’d on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Entitlement to service connection for posttraumatic stress disorder (PTSD) The Veteran contends that service connection is warranted for PTSD. He has reported various in-service stressors, including: (1) being harassed by his supervisors during service resulting in an involuntary discharge; (2) being prevented by superiors from completing treatment at the life skills support center; and (3) severe occupational problems during service. Service connection may be established for a disability resulting from disease or injury which was clearly present in service or for a disease diagnosed after discharge from service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. 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 present disability. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Service connection for PTSD requires (1) medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a); (2) a link, established by medical evidence, between current symptoms and an in-service stressor; and (3) credible supporting evidence that the claimed in-service stressor occurred. See 38 C.F.R. § 3.304(f). For cases certified to the Board before August 4, 2014, such as this case, the diagnosis of PTSD must be in accordance with the American Psychiatric Association’s Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-IV). 38 C.F.R. § 4.125(a) (2014); Schedule for Rating Disabilities-Mental Disorders and Definition of Psychosis for Certain VA Purposes, 79 Fed. Reg. 45,093 (Aug, 4, 2014) (Applicability Date) (updating 38 C.F.R. § 4.125 to reference DSM-V). The existence of a current disability is the cornerstone of a claim for VA disability compensation. 38 U.S.C. § 1110; see Degmetich v. Brown, 104 F.3d 1328, 1332 (1997) (holding that interpretation of section 1131 of the statute as requiring the existence of a present disability for VA compensation purposes cannot be considered arbitrary). In the absence of proof of a present disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). VA treatment records from 2008 through 2016 are negative for a fully substantiated diagnosis of PTSD. In July 2010, the Veteran reported that he thought he had PTSD, and that he wanted to be referred to that program. A September 2010 VA treatment record notes that the Veteran reported his belief that he had PTSD from being “harassed” during service. He endorsed symptoms including suicidal ideation, difficulty falling asleep, constant anxiety, unsettling thoughts, anger issues, and depression. The neuropsychologist indicated that the Veteran did not wish to undergo neuropsychological evaluation at that time. A December 2010 record reflects a diagnosis of bipolar affective disorder. An August 2012 record notes the Veteran’s complaints of anxiety and depression. The diagnosis was “depression/anxiety” without suicidal or homicidal ideation. The physician noted that the Veteran was seen earlier that month with a diagnosis of mood disorder. A February 2013 treatment record notes a diagnosis of anxiety disorder and depression. Records dated from 2015 through 2018 reflect diagnoses of bipolar I disorder, borderline personality disorder, adjustment disorder, insomnia, anxiety, and homelessness. In November 2012, the Veteran underwent a VA mental disorders examination. The Veteran endorsed symptoms including explosive behavior, lack of motivation, feelings of detachment, being argumentative, strained marital relationship, and trouble sleeping. The examiner noted that the Veteran’s first encounter with a mental health professional was during active duty. He noted that the Veteran was enrolled in the Life Skills training, but did not complete the course and that he was arrested due to threatening and homicidal ideation against his supervisor. The Veteran reported a history of two psychiatric hospitalizations and two episodes of parasuicidal behavior. The Veteran noted that he had been accused of domestic violence “many, many times.” The diagnoses were cannabis dependence and cannabis induced anxiety disorder. In June 2016, the Veteran underwent a VA PTSD examination. The Veteran reported stressors including: (1) witnessing a friend die after being shot and seeing another friend stabbed (prior to military service); and (2) being confronted by a superior during military service resulting in being “taken down by police with guns.” With regard to the Veteran’s reported in-service stressor, the examiner remarked that “[t]his would be a type of assault if not justified as [a] means to restrain someone to prevent further harm, but there is no evidence or markers to support that he was injured in any way or was bothered at the time or shortly there after by this alleged event.” He noted symptoms of anxiety, suspiciousness, chronic sleep impairment, disturbances of motivation and mood, difficulty establishing and maintaining effective work and social relationships, suicidal ideation, and impaired impulse control. The diagnoses were bipolar disorder and borderline personality disorder. The examiner concluded that the Veteran did not have a diagnosis of PTSD that conforms to DSM-IV or DSM-V. The examiner explained that the Veteran’s service treatment records were silent as to any complaints of or treatment for a mental disorder during service aside from a few sessions for “occupational problems” in 2005. The examiner noted that, although the Veteran reported PTSD-like symptoms during the VA examination, the Veteran’s treatment records and military records do not support complaints or symptoms of PTSD. Thus, after reviewing the treatment records and the diagnostic interview, the examiner did “not see enough evidence to support a diagnosis of PTSD” and that the examiner agreed with the diagnoses of bipolar disorder and borderline personality disorder complicated by a history of alcohol and cannabis abuse. After thorough review of the evidence of record, the Board concludes that service connection for PTSD is not warranted, as the weight of the probative evidence reflects that the Veteran does not have a current diagnosis of PTSD. There is no medical evidence of record which confirms that the Veteran’s symptoms meet the full diagnostic criteria for a diagnosis of PTSD under either the DSM-IV or the DSM-V. The VA treatment records and the November 2012 VA examination are generally silent as to any findings of PTSD. The Board has noted that a March 2015 VA treatment record indicated that he had “PTSD like” symptoms, however, this is not an actual diagnosis. Although it is indicated in an August 2015 treatment record that he had elevated scores on a PTSD screening test, this reportedly only showed that the presence of PTSD was possible. Additionally, the June 2016 VA examiner concluded that the Veteran’s symptoms do not meet the diagnostic criteria for a diagnosis of PTSD. The June 2016 VA examiner’s opinion was based on a thorough review of the claims file as well as a clinical interview of the Veteran, and provides supporting explanation and rationale for the conclusion. Thus, the Board finds the June 2016 VA examination to be sufficiently thorough and complete, and therefore entitled to significant probative value. The Board acknowledges the Veteran’s reports that he suffers from PTSD. Although lay persons are competent to provide opinions on some medical issues, the specific issue under discussion here falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Establishing PTSD as a disability for VA purposes requires diagnostic testing and a diagnosis conforming to the criteria as set forth in the Diagnostic and Statistical Manual for Mental Disorders. 38 C.F.R. §§ 4.125, 4.130. The Veteran has not been shown to possess the medical expertise or knowledge required to diagnose a disability such as PTSD. Therefore, because the Veteran is a lay witness, his statements do not constitute competent evidence of a diagnosis for PTSD conforming to the DSM-IV or DSM-V. Accordingly, the probative evidence of record shows that the Veteran does not have a diagnosis for PTSD under the criteria set forth in DSM-IV or the DSM-V during the appeal period or in proximity to the claim for service connection. See McClain v. Nicholson, 21 Vet. App. 319 (2007) (holding that the requirement of a current disability is met when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim); see also Romanowsky v. Shinseki, 26 Vet. App. 289 (2013). In the absence of proof of a present disability, there can be no valid claim. Brammer, 3 Vet. App. at 225. In view of the foregoing, the Board concludes that the preponderance of the evidence is against the claim for service connection for PTSD. Because the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not for application, and the claim must be denied. 38 U.S.C. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). MICHAEL MARTIN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M. Katz, Counsel