Citation Nr: 19145489 Decision Date: 06/12/19 Archive Date: 06/11/19 DOCKET NO. 18-12 069 DATE: June 12, 2019 ORDER Entitlement to service connection for post-traumatic stress disorder (PTSD) is granted. FINDING OF FACT The Veteran has PTSD caused by his active military service stressors. CONCLUSION OF LAW The criteria for PTSD have all been met. 38 U.S.C. §§ 1110, 1154, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.309, 4.125. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active duty service from February 2008 to February 2012, including service in Afghanistan. The Veteran’s awards and decorations include the Combat Action Ribbon for his service in Afghanistan. This matter comes before the Board of Veteran’s Appeals (Board) on appeal from the May 2017 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO), which denied service connection for the Veteran’s PTSD. Entitlement to service connection for PTSD is granted. Generally, service connection for a disability requires evidence of: (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 in or aggravated by service. See Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009). Service connection for PTSD requires medical evidence establishing a diagnosis of the condition, credible supporting evidence that the claimed in-service stressor actually occurred, and a link, established by medical evidence, between the current symptomatology and the claimed in-service stressor. 38 C.F.R. § 3.304(f). Given the Veteran’s record of combat, the provisions of 38 U.S.C. § 1154(b) are applicable. These provisions create a presumption that a combat Veteran’s reports of injuries sustained in combat are correct. Turning to the evidence of record, the Veteran contends that the claimed PTSD is related to active military service. Specifically, the Veteran describes intrusive memories of fire fights as well as witnessing the death of a corporal by an improvised explosive device (IED) explosion in January of 2011 while in Afghanistan. See May 2017 VA medical examination, October 2018 San Diego Veterans Affairs Medical Center (VAMC) treatment records. The Veteran’s in-service treatment records reflect no complaints of PTSD. Post service, the VA Disability Benefits Questionnaire dated August 2012 reflects the Veteran does not have a psychiatric condition to include PTSD. The Veteran was screened for PTSD. February 2013 VA medical treatment record indicates that although the Veteran’s diagnostic impression was PTSD, he screened negative for PTSD. The July 2016 VA medical treatment record also reflects the Veteran screened negative for PTSD. VA medical treatment record dated April 2017 reflects that the Veteran was referred to a VA Mental Health Clinic by primary care for evaluation and treatment of anxiety and irritability. During the evaluation, a Ph.D., VA Staff Psychologist conducted a 90-minute intake interview of the Veteran using DSM-5 testing. Following the interview, the Veteran was diagnosed with PTSD. Each criterion for PTSD was addressed and found to be present. In the VA medical treatment record, the Veteran indicated that his symptoms of anxiety and irritability were first noted following his combat deployments, which was 5 to 6 years prior to the intake interview. The VA medical treatment record noted that the Veteran had two combat deployments in Iraq and Afghanistan in 2009 and 2010 to 2011. Further in the VA medical treatment record, the Veteran reported being attacked and ambushed, firing weapons at the enemy, caring for the wounded, receiving rocket mortar fire, seeing dead bodies, clearing or searching buildings and ships, receiving small arms fire, handling human remains, and experiencing someone killed nearby. The medical treatment record noted the Veteran’s symptoms were consistent with PTSD. The VA medical treatment record further noted that the Veteran’s index trauma was his observing a pressure plate incident in which a comrade was killed while in Afghanistan. The Veteran was afforded a VA medical examination, which was conducted on May 2017, after a review of the claims file. The VA examination states that the Veteran does not have a PTSD diagnosis that conforms to DSM-5 criteria. The diagnostic summary in the VA examination notes that the Veteran’s symptoms do not meet the diagnostic criteria for PTSD under DSM-5 and he does not have a mental disorder that conforms with DSM-5. The VA examiner noted that the Veteran’s stressor would fit criteria A, but the Veteran screened negative for PTSD until 2017. The VA examiner further noted that the Veteran’s present recollection of his psychiatric symptoms during his military service is not consistent with the records reviewed. The VA examiner also noted that there are no indications of functional impairment which would suggest any clinically significant anxiety, or other psychiatric disorder. In October 2018, the Veteran was seen in a 40-minute outpatient psychotherapy appointment by a VA Ph.D., licensed clinical psychologist. The VA psychologist diagnosed the Veteran with PTSD in accordance with DSM-5. The VA psychologist also noted that the Veteran reported he experienced a combat trauma event that happened 6 to 10 years prior and that he suffers from quite a bit of repeated, disturbing, and unwanted memories and dreams of the stressful experience. The Veteran has also reported that he frequently feels upset and has strong physical reactions when something reminds him of the stressful experience. The VA psychologist has also indicated that the Veteran reported that he avoids memories, thoughts, or feelings related to the stressful experience and that there are some instances where he avoids external reminders of the stressful experience. The Veteran provided a private physician letter from a Ph.D., licensed clinical psychologist dated February 2018 indicating that the Veteran has a diagnosis of PTSD in accordance with DSM-5. The private physician letter stated that a full intake was completed as part of the initial session. The letter further states that the Veteran’s symptoms have been present for the greater part of the past 5 years since his return to civilian life after leaving the USMC. As an initial matter, the Board finds that the Veteran in this case engaged in combat with the enemy. In the April 2017 VA treatment record, the examiner noted that the Veteran reported his stressors as being attacked, ambushed, and firing weapons at the enemy. In the May 2017 VA medical examination and October 2018 VA medical treatment records, the Veteran reported that he witnessed the death of a corporal by an IED explosion while on combat duty in Afghanistan. Additionally, the Veteran received a Combat Action Ribbon; sufficient evidence to conclude that he engaged in combat with the enemy. The combat provisions of 38 U.S.C. § 1154(b) are applicable in this case. As such, the in-service incurrence element of an in-service stressor is met in this case. After a review of all lay and medical evidence of record, the Board finds that the Veteran has current diagnosed PTSD consistent with DSM-5. While the record includes VA psychiatric treatment records demonstrating the Veteran does not have a current diagnosis of PTSD consistent with DSM-5, the Veteran’s private Ph.D., licensed clinical psychologist, the VA Ph.D., licensed clinical psychologist, and the VA staff psychologist diagnosed the Veteran with PTSD. The Board acknowledges the private psychologist’s medical opinion diagnosing the Veteran with PTSD. The evidence is approximately balanced as to whether the Veteran has PTSD. Resolving reasonable doubt in his favor, the Board concludes that the current disability element is met. The same favorable records attribute his PTSD to service. Thus, the Board finds that service connection for PTSD is warranted and the appeal is granted. JAMES G. REINHART Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD R. Williams, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.