Citation Nr: 18153200 Decision Date: 11/27/18 Archive Date: 11/27/18 DOCKET NO. 16-43 193 DATE: November 27, 2018 ORDER Entitlement to service connection for bilateral hearing loss is granted. Entitlement to service connection for tinnitus is granted. Entitlement to service connection for testicular cancer is granted. Entitlement to service connection for posttraumatic stress disorder (PTSD) is granted. Entitlement to service connection for gastroesophageal reflux disease (GERD) as secondary to service-connected PTSD is granted. Entitlement to service connection for migraine headaches as secondary to service-connected PTSD is granted. FINDINGS OF FACT 1. The Veteran currently has a bilateral hearing loss disability for VA compensation purposes. 2. The Veteran's bilateral hearing loss is at least as likely as not related to active service. 3. The Veteran’s tinnitus is at least as likely as not incurred during active service. 4. The Veteran's testicular cancer is at least as likely as not related to the Veteran’s presumed exposure to herbicide agents during active service. 5. The Veteran has been diagnosed with PTSD based on an established, in-service stressor. 6. The Veteran’s GERD is attributable to his service-connected PTSD. 7. The Veteran’s migraine headaches are attributable to his service-connected PTSD. CONCLUSIONS OF LAW 1. The criteria to establish entitlement to service connection for bilateral hearing loss have been met. 38 U.S.C. § 1101, 1110, 1154, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria to establish entitlement to service connection for tinnitus have been met. 38 U.S.C. § 1101, 1110, 1154, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 3. The criteria to establish entitlement to service connection for testicular cancer have been met. 38 U.S.C. § 1101, 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307. 4. The criteria to establish entitlement to service connection for PTSD have been met. 38 U.S.C. §§ 1101, 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304. 5. The Veteran's GERD is proximately due to, or the result of, his service-connected PTSD. 38 U.S.C. §§ 1101, 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 6. The Veteran's migraine headaches are proximately due to, or the result of, his service-connected PTSD. 38 U.S.C. §§ 1101, 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service in the United States Army from July 1969 to February 1971. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a June 2013 rating decision. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service-the so-called "nexus" requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 38 F.3d 1163, 1167 (Fed. Cir. 2004)). The absence of any one element will result in denial of service connection. Service connection may also be granted for any disease initially diagnosed after service when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In addition, for Veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, including tinnitus and sensorineural hearing loss, are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.307, 3.309. For the showing of a chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. 38 C.F.R. §§ 3.303(b), 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. If a veteran was exposed to an herbicide agent during active military, naval, or air service, certain diseases shall be service-connected if the requirements of section 3.307(a)(6) are met even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of section 3.307(d) are also satisfied. 38 C.F.R. § 3.309(e). Section 3.307(d)(6) provides that the term "herbicide agent" means a chemical in an herbicide used in support of the United States and allied military operations in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975. 38 C.F.R. § 3.307 (d)(6)(i). Section 3.307(d)(6) also provides that a veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service. 38 C.F.R. § 3.307(d)(6)(iii). Service in the Republic of Vietnam includes service in the waters offshore and service in other locations if the conditions of service involved duty or visitation in the Republic of Vietnam. Id. The diseases presumed to be associated with herbicide exposure include: chloracne or other acneform diseases consistent with chloracne, type 2 diabetes (also known as type II diabetes or adult-onset diabetes), Hodgkin's disease, ischemic heart disease (including, but not limited to, acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm) and coronary bypass surgery; and stable, unstable and Prinzmetal's angina), all chronic B-cell leukemias (including, but not limited to, hairy-cell leukemia and chronic lymphocytic leukemia), multiple myeloma, non-Hodgkin's lymphoma, Parkinson's disease, acute and subacute peripheral neuropathy, porphyria cutanea tarda, prostate cancer, respiratory cancers (cancer of the lung, bronchus, larynx, or trachea), and soft-tissue sarcomas (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma). 38 C.F.R. § 3.309(e). For the purposes of § 3.307, the term herbicide agent means a chemical in an herbicide used in support of the United States and allied military operations in the Republic of Vietnam during the Vietnam era. 38 C.F.R. § 3.307(a)(6)(i). Agent Orange is generally considered an herbicide agent and will be so considered in this decision. Notwithstanding the foregoing, regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d); see also Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). In other words, a presumption of service connection provided by law is not the sole method for showing causation in establishing a claim for service connection for disability due to herbicide exposure. See Stefl v. Nicholson, 21 Vet. App. 120 (2007) (holding that the availability of presumptive service connection for some conditions based on exposure to Agent Orange does not preclude direct service connection for other conditions based on exposure to Agent Orange). Service connection for PTSD requires medical evidence diagnosing the condition; 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 diagnosis of PTSD must be established in accordance with 38 C.F.R. § 4.125(a), which provides that all psychiatric diagnoses must conform to the fifth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-V). 38 C.F.R. § 3.304(f). Effective August 4, 2014, VA amended the portion of its Schedule for Rating Disabilities dealing with mental disorders and its adjudication regulations that define the term "psychosis" to remove outdated references to the DSM IV and replace them with references to the recently updated DSM-V. See 79 Fed. Reg. 45, 094 (August 4, 2014). VA adopted as final, without change, this interim rule and clarified that the provisions of this interim final rule do not apply to claims that have been certified for appeal to the Board or are pending before the Board on or before August 4, 2014. See Schedule for Rating Disabilities - Mental Disorders and Definition of Psychosis for VA Purposes, 80 Fed. Ref. 14,308 (March 19, 2015). In the present case, the RO certified the Veteran's appeal to the Board in September 2016, which is after August 4, 2014. Thus, the DSM-V is applicable in the present case. The pertinent regulation provides that, if the evidence establishes that the Veteran engaged in combat with the enemy and that the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the Veteran's service, the Veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. See 38 U.S.C. § 1154(b); 38 C.F.R. § 3.304(f)(1). For stressors unrelated to combat that are not based on fear of hostile military or terrorist activity, credible supporting evidence is necessary in order to grant service connection. Such evidence may be obtained from service records or other sources. See Moreau v. Brown, 9 Vet. App. 389 (1996). The United States Court of Appeals for Veterans Claims (Court) has held that the regulatory requirement for "credible supporting evidence" means that "the appellant's testimony, by itself, cannot, as a matter of law, establish the occurrence of a non-combat stressor." Dizoglio v. Brown, 9 Vet. App. 163, 166 (1996). Therefore, the Veteran's lay testimony, is insufficient, standing alone, to establish service connection. Cohen v. Brown, 10 Vet. App. 128, 147 (1997). Effective July 13, 2010, if a stressor claimed by a veteran is related to the Veteran's fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of PTSD and that the Veteran's symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the places, types, and circumstances of the veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. For purposes of this paragraph, "fear of hostile military or terrorist activity" means that a veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the veteran or others, such as from an actual or potential improvised explosive device (IED); vehicle-imbedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon friendly military aircraft, and the veteran's response to the event or circumstance involved a psychological or physiological state of fear, helplessness, or horror. See 75 Fed. Reg. 39843, 39852 (July 13, 2010) (now codified at 38 C.F.R. § 3.304(f)(3). Service connection may also be granted where a disability is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 48 (1995) (en banc). 1. Entitlement to service connection for bilateral hearing loss. The Veteran contends that he has bilateral hearing loss as a result of noise exposure during active service. The Veteran has reported that his noise exposure during service consisted of gunfire, artillery, machine guns, bulldozers, and explosions. See October 2012 VA examination. The Veteran stated that he did not wear hearing protection during these events. The Veteran’s DD 214 shows that he had active service in the Republic of Vietnam, and his military occupational specialty (MOS) was carpenter. The Department of Defense's Noise Exposure Listing reflects that this MOS has a high probability of noise exposure. Given the circumstances of the Veteran's service, the Board acknowledges the Veteran's assertion of in-service noise exposure as credible and consistent with his service. 38 U.S.C. § 1154(a). A review of the Veteran’s STRs shows that his ears were found to be normal in the clinical evaluation of the April 1969 enlistment examination. Regarding the reported audiometric findings, the Board notes that because it is unclear whether such thresholds were recorded in using American Standards Association (ASA) units or International Standards Organization-American National Standards Institute (ISO-ANSI) units, the Board will consider the recorded metrics under both standards, relying on the unit measurements most favorable to the Veteran’s appeal. As it relates to VA examinations and VA records, audiological reports were routinely converted from ISO-ANSI results to ASA units until the end of 1975 because the regulatory standard for evaluating hearing loss was not changed to require ISO-ANSI units until September 9, 1975. In light of the above, and where necessary to facilitate data comparison for VA purposes in the decision below, including under 38 C.F.R. § 3.385, audiometric data originally recorded using ASA standards will be converted to ISO-ANSI standard by adding between 5 and 15 decibels to the recorded data as follows: HERTZ 500 1000 2000 3000 4000 Add 15 10 10 10 5 The ASA figures are on the left in each column and not in parentheses. HERTZ 500 1000 2000 3000 4000 RIGHT 0 (15) 0 (10) -10 (0) -10 (0) 0 (5) LEFT 5 (20) 0 (10) 0 (10) 0 (10) 20 (25) Although the Veteran reported having ear, nose, or throat trouble in the April 1969 Report of Medical History, he denied having a history of hearing loss. The physician’s summary also indicated that this report was related to epistaxis rather than hearing loss. No audiological findings were reported in the Veteran’s February 1971 separation examination, and no associated Report of Medical History is included in the record. The Veteran’s post-service occupational and recreational noise exposure included working for 40 years as a crane operator. See October 2012 VA examination. However, the Veteran reported that he wore hearing protection in this occupation. The Veteran was provided with a VA examination related to his service connection claim for bilateral hearing loss in October 2012. Although an audiological evaluation was conducted, the results were not reported. The examiner stated that the test results were not reliable despite repeated attempts and reinstruction. The examiner added that the test results were strongly suggestive of a possible non-organic hearing loss/hearing loss component. As the results were unreliable and unsuitable for rating purposes, the examiner did not provide a medical opinion. Although no results from the October 2012 VA examination were reportable, the record also includes the results of a VA audiological evaluation from the earlier portion of the appeal period in April 2012. This evaluation documented that the Veteran’s pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 45 45 55 / 65 LEFT 40 40 60 / 65 Speech recognition scores were also reported, but they were not the result of testing using the Maryland CNC word list. The Board notes that these results demonstrate the presence of a current bilateral hearing loss disability for VA compensation purposes. See 38 C.F.R. § 3.385. Regarding the question of nexus, G.U., ARNP, opined in July 2015 that it was at least as likely as not that the Veteran’s bilateral hearing loss was related to his active service. G.U. noted that the Veteran's lay statement, service records, and his MOS as a combat engineer established that he was frequently exposed to significant noise exposure and acoustic trauma throughout his military service. G.U. also found it significant that the Veteran never wore hearing protection during active service. G.U. noted that the Veteran was initially diagnosed with hearing loss and tinnitus after service in 2000 by a private provider, but he reported that his hearing loss and tinnitus began during his military service. In this regard, G.U. pointed to the fact that the Veteran was not provided with an audiological evaluation prior to his separation from active service. Although G.U. acknowledged the October 2012 VA examiner's finding that the Veteran's audiological test results were too unreliable to report, she found the examiner's rationale to be insufficient to justify this conclusion. She also highlighted the April 2012 audiological findings and the Veteran's receipt of bilateral hearing aids in 2012 as evidence that the Veteran currently had bilateral hearing loss. G.U. additionally reported that the findings from current medical literature revealed that it was not only possible for hearing loss to develop after environmental exposures, but it was more likely than not that this sequence of events would occur. One study found that "noise-induced damage to the ear has progressive consequences that are considerably more widespread than are revealed by conventional testing." Another study found that animals exposed to loud noises at a young age exhibited accelerated age-related hearing loss later, despite "recovering" their hearing initially. From her review of the medical literature, G.U. concluded that an audiogram could be normal for months or years following an acoustic trauma before showing hearing loss related to the prior trauma. The Board finds that G.U.’s opinion should be afforded great probative weight as G.U. gave a comprehensive rationale that reflects her review of the record as well as the pertinent medical literature. As noted above, the October 2012 VA examiner did not provide a medical opinion to weigh against G.U.’s positive conclusion. G.U.’s opinion also explained that the April 2012 findings demonstrating bilateral hearing loss are more consistent with the other evidence of record than the findings from the October 2012 VA examination. Although G.U. partially relied on her understanding that the Veteran's MOS was combat engineer as evidence of noise exposure, the Board does not find that this misconception diminishes the opinion's probative value as the Veteran's documented MOS of carpenter provides similar evidence of noise exposure. Consequently, the Board finds that the most probative evidence establishes that the Veteran currently has bilateral hearing loss for VA compensation purposes that is at least as likely as not related to his conceded noise exposure during active service. Entitlement to service connection for bilateral hearing loss is therefore granted. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 2. Entitlement to service connection for tinnitus. The Veteran contends that he has tinnitus that is related to noise exposure during active service. The Board notes that the Veteran’s STRs do not include any complaints, treatment, or diagnoses related to tinnitus. However, the Veteran has stated that his current symptoms of bilateral, constant tinnitus manifested during his service in Vietnam. See October 2012 VA examination. In an August 2011 VA treatment record, the Veteran also indicated that his tinnitus symptoms had been present since his Vietnam service. Although lay persons are generally not competent to offer evidence which requires medical knowledge, they may provide competent testimony as to visible symptoms and manifestations of a disorder. Jones v. Brown, 7 Vet. App. 134, 137 (1994); Layno v. Brown, 6 Vet. App. 465, 469 (1994); Barr v. Nicholson, 21 Vet. App. 303 (2007); Buchanan v. Nicolson, 451 F.3d 1331 (Fed. Cir. 2006). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition; (2) the layperson is reporting a contemporaneous medical diagnosis; or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 137677 (Fed. Cir. 2007). The Veteran is competent to report symptoms such as ringing or buzzing in his ears as this requires only personal knowledge as it comes to him through his senses. See Layno v. Brown, 6 Vet. App. 465, 470 (1994); Barr v. Nicholson, 21 Vet. App. 303, 309 (2007). In addition, the Veteran is competent to identify a disorder such as tinnitus for diagnostic purposes. 38 C.F.R. § 3.159(a)(2); Barr, 21 Vet. App. at 310; Charles v. Principi, 16 Vet. App. 370, 374 (2002); Falzone v. Brown, 8 Vet. App. 398, 405 (1995). The Board also finds the Veteran’s reported history of continuous tinnitus symptoms since service to be credible as it has been consistent throughout the record. During an October 2012 VA examination related to the Veteran’s claim, the examiner noted the Veteran’s report of tinnitus symptoms, but stated that he was not providing a medical opinion in light of the unreliable results from the audiological testing for hearing loss. However, the examiner did not include any rationale to explain why the nature of the audiological test results would affect a determination regarding the etiology of the Veteran’s tinnitus. Thus, the Board does not find that the examiner’s statement provides any probative weight. Resolving all doubt in the Veteran's favor, the Board finds that the Veteran meets the requirements for a presumption of service connection. Service connection for tinnitus is therefore granted. 38 C.F.R. §§ 3.102, 3.303, 3.303(b), 3.307, 3.309. 3. Entitlement to service connection for testicular cancer, to include as due to exposure to herbicide agents. The Veteran has contended that his testicular cancer was related to his exposure to herbicide agents during active service. The record shows that the Veteran served in the Republic of Vietnam from December 1969 to February 1971. See DD Form 214. Thus, his exposure to herbicide agents is presumed. 38 C.F.R. § 3.307(a)(6)(iii). The Veteran's service treatment records are silent for any complaints, treatment, or diagnoses related to testicular cancer. The record indicates that the Veteran was diagnosed with left testicular cancer after service in 1981, and he is status post three months of radiation. See November 2005 Private treatment record. Although the Veteran provided a February 2012 VA Form 21-4142 to obtain records regarding his 1981 treatment for testicular cancer from the Memorial of Hospital of Jacksonville, this provider responded in May 2012 that the records were no longer available as they only kept copies of records for 8 years. However, the Veteran is competent to report incidences of treatment and competent to relay what a physician has told him. See Layno v. Brown, 6 Vet. App. 465 (1994). The Board also finds his reported history of testicular cancer to be credible as the current treatment records that have noted the Veteran’s reported history have not suggested that his report is inaccurate or questionable. In addition, several of the Veteran’s family members have submitted statements reporting that he was diagnosed with testicular cancer in 1981 and received treatment at that time. Although testicular cancer is not one of the diseases that is presumptively due to exposure to herbicide agents, the Board notes that service connection may still be established on a direct basis. See Stefl v. Nicholson, 21 Vet. App. 120 (2007); Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). Regarding this theory of entitlement, G.U., ARNP, provided a medical opinion in July 2015. G.U. noted that her medical opinion was based on a review of the Veteran's claims file. G.U. stated that based on the Veteran's credible report, he was diagnosed with a left testicular seminoma in March 1981 before his left testicle was removed. The Veteran then underwent three months of radiation. G.U. explained that the current medical literature substantiated a link between testicular atrophy from Agent Orange exposure and the subsequent development of testicular cancer. One study stated that "the evidence that testicular atrophy was a precursor of malignancy may explain why testis cancer has increased while normal sperm count has fallen over the past 50 years and why there is an association between exposure during service in Vietnam to agents that damage spermatogenesis and development of testis cancer." G.U. also observed that several studies have correlated Agent Orange exposure with the increased development of seminomas (testicular cancer) in military working dogs that were deployed to Vietnam. Despite the paucity of human cohort studies regarding testicular cancer and Agent Orange exposure, the high prevalence of canine seminomas from Vietnam service dogs provided convincing evidence in favor of a connection. This conclusion was supported by one study's finding that dioxin exposure specifically increased the risk of reproductive cancers, including testicular cancers, in humans. In support of her opinion, Dr. L. attached excerpts from the referenced studies. The Board finds that G.U.’s opinion is highly probative as it was based on a review of the claims file and G.U. provided a thorough rationale that was supported by citations to medical literature. There is also no contrary medical opinion of record. In light of the above discussion, the most probative evidence of record supports the conclusion that the Veteran's testicular cancer was related to his presumed exposure to herbicide agents during active service. Accordingly, service connection is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 4. Entitlement to service connection for PTSD. The Veteran contends that he has PTSD as a result of active service. The Board notes that the Veteran’s STRs are silent for any complaints, diagnoses, or treatment for PTSD or any other psychiatric disorder. However, The Veteran has identified several in-service stressors as the basis for his current PTSD. One such stressor occurred during the Veteran’s active service in Vietnam. See October 2012 VA Examination. The Veteran reported that in his MOS as a carpenter, he also worked as a combat engineer and swept roads for land mines. During an October 2012 VA examination related to the Veteran’s claim, the examiner, a psychologist, noted that the Veteran’s reported stressor satisfied criterion A, i.e., it was adequate to support a diagnosis of PTSD. In addition, the examiner determined that the stressor was related to the Veteran’s fear of hostile military or terrorist activity. However, the October 2012 VA examiner found that the Veteran did not satisfy the remaining criteria necessary to establish a PTSD diagnosis under the DSM-IV. Test results indicated that the Veteran's trauma-related symptoms were subclinical, and the examiner noted that prior VA screenings for PTSD in December 2011 and December 2012 were negative. The Veteran had also experienced intercurrent stressors of testicular cancer and the death of a grandson. The examiner instead documented an Axis I diagnosis of mood disorder not otherwise specified (NOS). Despite the October 2012 VA examiner's conclusion that the Veteran did not meet the full diagnostic criteria for PTSD, the examination findings reflect that the Veteran's symptoms are related to the claimed stressor. The examiner noted that he had symptoms of reexperiencing and increased arousal. Thus, and resolving any reasonable doubt in favor of the Veteran, the Board finds that the criteria set forth in 38 C.F.R. § 3.304(f)(3) regarding confirmation from a VA psychologist are met. In addition, this stressor is consistent with the places, types, and circumstances of the Veteran's service. As previously stated, the Veteran’s DD 214 shows that he had active service in Vietnam and an MOS of carpenter. The Board notes that one of the job duties of the MOS of carpenter and masonry specialist is to assist in the performance of combat engineer missions. See Careers and Jobs: Carpenter and Masonry Specialist (12W), U.S. Army, https://www.goarmy.com/careers-and-jobs/browse-career-and-job-categories/construction-engineering/carpentry-and-masonry-specialist.html. Consequently, the Veteran’s stressor has been established. Later in August 2015, Dr. L., MD, completed a Disability Benefits Questionnaire (DBQ) concerning psychiatric disorders. Dr. L. determined that the Veteran had a diagnosis of PTSD. Dr. L. noted in an associated August 2015 opinion that the Veteran’s PTSD symptoms began during his active service. In the section of the report regarding stressors, Dr. L. listed two stressors that were different from the Veteran's established stressor related to fear of hostile or terrorist activity. However, it appears from the abrupt end of this section that the entire list of stressors was not included in the report. Dr. L. also noted in the remarks section that the Veteran had been exposed to multiple traumatic experiences during service. Affording the Veteran the benefit of the doubt, the Board finds that this PTSD diagnosis was based on the Veteran's established stressor regarding land mines. In reviewing the evidence from this period, the Board finds that the October 2012 VA examiner’s determination that the Veteran did not have a current diagnosis of PTSD has diminished probative value as the examiner indicated that it was based on the DSM-IV rather than the DSM-5 criteria applicable in this case. The Board acknowledges that the DBQ form used by Dr. L. in August 2015 reflects that her PTSD diagnosis was also based on the DSM-IV criteria. However, a February 2015 VA treatment record appeared to confirm that the Veteran had diagnosis of PTSD as well as major depressive disorder that was recurrent and in partial remission. The Board notes that the record did indicate which version of the DSM was used for the diagnosis. Nevertheless, as this diagnosis was provided after the May 2013 release of the DSM-V, the Board presumes that it was made in accordance with the DSM-5 criteria. See Cohen v. Brown, 10 Vet. App. 128, 140 (1997). Based on the foregoing, the weight of the evidence supports finding that the Veteran has a PTSD diagnosis under the DSM-5 based on his established stressor. Consequently, entitlement to service connection for PTSD is granted. 38 U.S.C. §§ 101, 1110; 38 C.F.R. §§ 3.6, 3.102, 3.303, 3.304(f), 4.125(a). The Board notes that during this period, the Veteran has also received diagnoses for mood disorder NOS and major depressive disorder. However, the records from this period have not distinguished the symptoms associated with the Veteran's PTSD from those associated with his other psychiatric disorders. With resolution of the benefit of the doubt in the Veteran's favor, the Board considers all manifested psychiatric symptoms as being due to his PTSD. See Mittleider v. West, 11 Vet. App. 181 (1998). 5. Entitlement to service connection for GERD, to include as secondary to service-connected PTSD. The Veteran contends that he has GERD that is secondary to his service-connected PTSD. The record reflects that the Veteran has a current diagnosis of GERD. See December 2012 VA treatment record. In July 2015, G.U., ARNP, opined that the Veteran’s GERD was at least as likely as not secondary to, or related to, his service-connected PTSD. G.U. stated highlighted the report from one study that there was large body of evidence supporting the link between psychological distress and several functional gastrointestinal diseases, including GERD. Another study reported that "certain stressful life events have been associated with the onset or symptom exacerbation in some of the most common chronic disorders of the digestive system, including GERD." Therefore, stressful events, such as the Veteran's PTSD stressor could cause or at least aggravate GERD. The Board finds that this opinion offers substantial probative value as G.U. reviewed the record before reaching a conclusion, and she specifically explained why her conclusion was supported by the findings of current medical literature. In addition, there is no other medical opinion of record that has addressed this theory of entitlement. Although the Veteran has reported suffering from symptoms of GERD since service, Dr. L.’s August 2015 opinion indicates that the Veteran’s PTSD symptoms have also been present since service. Thus, this reported history does not affect the probative weight of G.U.’s conclusion. In light of the above discussion, the weight of the evidence is in favor of finding that the Veteran's GERD is due to, or the result of, his PTSD. Service connection for GERD is therefore granted as secondary to service-connected PTSD. 38 C.F.R. § 3.310. In light of this grant of secondary service connection, the Board need not consider whether the Veteran's GERD is directly related to service. 6. Entitlement to service connection for migraine headaches, to include as due to exposure to herbicide agents. The Veteran contends that he has migraine headaches that are secondary to his service-connected PTSD. The record demonstrates that the Veteran has a current diagnosis of migraine headaches. See December 2012 VA treatment record. In a July 2015 opinion, G.U., ARNP, stated that the Veteran's migraine headaches were secondary to, or related to, his service-connected PTSD. G.U. noted that the current medical literature supported a nexus between PTSD and the development of migraines. One study found that PTSD was more commonly found in people who had suffered from a headache than it was in the general population. The same study stated that PTSD was more frequently seen in those with chronic migraines versus episodic, concluding that PTSD was a risk factor for headache continuation. In addition, multiple research studies concluded that PTSD was more likely to be diagnosed in headache and migraine sufferers versus those who did not report such symptomatology. Thus, these studies supported a nexus between PTSD and headache/migraine sufferers. The Board finds that G.U.’s opinion provides great probative value as she offered a complete rationale and used information from the record as well as relevant medical literature to substantiate her conclusion. The record does not include a negative medical opinion to counter G.U.’s determination. The Board acknowledges that the Veteran has reported experiencing problems with headaches since service. See March 2013 VA treatment record. However, the August 2015 opinion from Dr. L. indicates that the Veteran’s PTSD symptoms have also been present service. Thus, the Veteran’s reported history of symptoms does not reduce the probative value of G.U.’s conclusion. In summary, the most probative evidence supports finding that the Veteran's migraine headaches are due to, or the result of, his PTSD. Service connection for migraine headaches is therefore granted as secondary to service-connected PTSD. 38 C.F.R. § 3.310. In light of this grant of secondary service connection, the Board need not consider whether the Veteran's migraine headaches are directly related to service. GAYLE STROMMEN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD K.C. Spragins, Associate Counsel