Citation Nr: 18159226 Decision Date: 12/18/18 Archive Date: 12/18/18 DOCKET NO. 16-60 076 DATE: December 18, 2018 ORDER Entitlement to service connection for an acquired psychiatric disorder, to include post traumatic stress disorder, is denied. FINDING OF FACT 1. The Veteran does not have a current diagnosis of post traumatic stress disorder (PTSD). 2. The evidence of record does not establish that a psychiatric disorder other than PTSD is causally related to the Veteran's active service. CONCLUSION OF LAW The criteria for service connection for an acquired psychiatric disorder, to include PTSD, have not been met. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. §§ 3.303, 3.304(f), 4.125(a). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from March 1968 to March 1970. This case comes before the Board of Veterans’ Appeals (Board) on appeal from an August 2016 rating decision of the Department of Veterans Affairs Regional Office. 1. Entitlement to service connection for post traumatic stress disorder The Board has recharacterized the claim as one for service connection for an acquired psychiatric disorder, to include PTSD, in accordance with Clemons v. Shinseki, 23 Vet. App. 1(2009). Service connection may be established for disability due to a disease or injury that was incurred in or aggravated by active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may also be granted for any disease initially diagnosed after service, 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: (1) medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125 (a); (2) credible supporting evidence that the claimed in-service stressor actually occurred; and (3) medical evidence of a nexus between current symptomatology and the claimed in-service stressor. 38 C.F.R. § 3.304 (f). In the absence of proof of a current disability, there can be no valid claim for service connection. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (finding service connection presupposes a current diagnosis of the condition claimed). The requirement that a current disability be present is satisfied “when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim... even though the disability resolves prior to the Secretary’s adjudication of the claim.” McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under laws administered by the Secretary. The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107 (2012); 38 C.F.R. § 3.102 (2017); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Although all the evidence has been reviewed, the Board is not required to discuss each piece of evidence in detail. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board’s analysis herein will focus on what the most relevant and salient evidence shows, or fails to show, with respect to the Veteran’s claim. The Board notes that VA is now required to apply concepts and principles set forth in DSM-5 to all applications for benefits that are received by VA or that are pending before the agency of original jurisdiction on or after August 4, 2014. 79 Fed. Reg. 45094. As the Veteran filed his claim in June 2016, the DSM-5 criteria are applicable. The Veteran has asserted that he is entitled to a service connection for PTSD stemming from a stressor during service in Vietnam in which he took incoming 85mm rocket fire. The Veteran’s DD-214 confirms that he served in Vietnam where he worked as a Light Air Defense Weapons Crewman, which would corroborate the account of his in- service stressor. The Veteran underwent a VA examination in July 2016. The examination was conducted by a VA psychologist using the DSM-5 criteria. The examiner noted that while the in-service stressor the Veteran experienced was adequate to support a diagnosis of PTSD the only symptom he exhibited was a depressed mood. The Veteran also stated he has nightmares about Vietnam, has mood swings, stares off into space and forgets things. The examiner noted a number of inconsistencies in the symptoms and events the Veteran described. Specifically, she asserted that the Veteran stated that during the past two weeks he has slept “a lot more than usual” and “a lot less than usual.” While the Veteran has asserted he was exposed to incoming rocket fire during Vietnam he claimed that the worst event he ever experienced was the passing of his father who died in 1985. As the Veteran’s father died of natural causes that would not meet Criterion A for PTSD under DSM-5. The examiner further noted that the Veteran’s treatment records did not support a diagnosis of PTSD and he has never been officially diagnosed by a psychologist or psychiatrist. Moreover, he has not been compliant with any prescribed mental health treatment. Thus, the examiner concluded that the Veteran did not have a current diagnosis of PTSD. The examiner noted diagnoses of cocaine use disorder in remission (per Veteran’s report) and unspecified depressive disorder, most likely related to a combination of his current stressors (homelessness, lack of income) and chronic history of substance dependence which altered his mood. The examiner in this case is competent to provide the above analysis given her background, she is credible given that her analysis has not been questioned, and it has significant probative value given the detail and rationale provided. In addition to the above examination, a January 2017 treatment records indicated that the Veteran did not have a current diagnosis of PTSD. A VA examination dated May 2015 indicated that at PTSD diagnosis for the Veteran was “suggested.” In this examination the examiner noted that the Veteran was experiencing symptoms such as disturbing memories and dreams, getting upset over a stressful event, sleep difficulty, and angry outbursts. However, as referenced above, the examiner only suggested that the Veteran was suffering with PTSD, she did not give an definitive diagnosis. Additionally, the examination was performed under the DSM-4 criteria as opposed to DSM-5. Thus, this examination has little probative value. The examiner in this instance is competent to provide the above analysis given her background. However, it has less credibility given that is directly contradicted by the more recent and detailed July 2016 examination. Further, given that the examination was conducted under the DSM-4 criteria as opposed to DSM-5 and it only suggests a diagnosis of PTSD, it has little probative value. The Board finds that the weight of the competent and probative evidence does not demonstrate that the Veteran has an acquired psychiatric disorder other than PTSD that is related to service. As discussed above, the probative July 2016 VA examination report indicated that the diagnosed depressive disorder was more likely than not related to current post-service stressor and did related that diagnosis to service. To the extent that there was a diagnosis of substance abuse, service connection for that disorder is not permitted. Based on a review of the evidence of record and with consideration of the Veteran’s statements, the Board finds that the weight of the evidence demonstrates that service connection for an acquired psychiatric disorder, to include PTSD, is not warranted. K. J. Alibrando Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M. Luby, Associate Counsel