Citation Nr: 19166375 Decision Date: 08/27/19 Archive Date: 08/27/19 DOCKET NO. 16-60 544 DATE: August 27, 2019 ORDER The claim for entitlement to service connection for posttraumatic stress disorder (PTSD) is denied. FINDING OF FACT The Veteran does not have PTSD. CONCLUSION OF LAW PTSD was not incurred in or aggravated by active duty service. 38 U.S.C. § 1110; 38 C.F.R. §§ 3.303, 3.304. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from October 2009 to October 2013. This case comes before the Board of Veterans’ Appeals (Board) on appeal from a June 2015 rating decision issued by Department of Veterans Affairs (VA) Regional Office (RO). Referred Claim In a December 2016 rating decision, service connection was awarded for an unspecified depressive disorder. The Veteran disagreed with the initial rating assigned to the depressive disorder and initiated an appeal in December 2016. The RO responded to the Veteran’s notice of disagreement (NOD) with a December 2017 rating decision awarding a higher 50 percent evaluation for the depressive disorder effective January 3, 2017. This 50 percent evaluation was continued in a July 2019 rating decision, which also recharacterized the service-connected psychiatric disability as major depressive disorder with unspecified trauma-and stressor-related disorder. However, the Veteran has not been provided a statement of the case (SOC) in response to his NOD. The Board does not have jurisdiction over this matter and refers the claim for a higher initial rating for major depressive disorder with unspecified trauma-and stressor-related disorder to the agency of original jurisdiction (AOJ) for the appropriate action. Service Connection 1. Entitlement to service connection for PTSD. The Veteran contends that service connection is warranted for the specific condition of PTSD as it was incurred due to a traumatic experience during active duty service. In statements dated throughout the claims period, the Veteran describes experiencing nightmares and intrusive thoughts related to an April 2014 incident when he was hospitalized for several days due to acute alcohol intoxication. After review of the evidence, the Board finds that service connection is not appropriate for PTSD as the weight of the evidence is against the finding of a current disability. Service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a) (DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, (5th ed.) (2016) (DSM V)); 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 (unless the evidence shows that the Veteran engaged in combat and the claimed stressor is related to combat). 38 C.F.R. § 3.304(f). The record establishes that the Veteran does not have PTSD. Three VA psychiatric examinations were conducted in May 2015, January 2017, and December 2018. None of the examiners identified the presence of PTSD; rather, the Veteran was diagnosed with a depressive disorder and unspecified trauma-stressor-related disorder. The later diagnosis was associated with the Veteran’s April 2013 in-patient treatment for an alcohol-induced coma. Service connection is already in effect for the Veteran’s major depressive disorder and unspecified trauma-stressor-related disorder, and the assigned disability rating includes the Veteran’s reports of anxiety, sleep impairment, and disturbances of motivation of mood. Therefore, the Veteran is already service-connected for the symptoms he describes as due to PTSD. Service and post-service treatment records also do not establish a current diagnosis of PTSD. The Veteran’s mental health records from the VA Medical Center (VAMC) document treatment for depression, an adjustment disorder, and bipolar disorder. In December 2016, the Veteran’s VA primary care doctor noted that the Veteran was followed in the mental health clinic for “bipolar/depression/PTSD,” but this finding was based on the Veteran’s own reports of his diagnoses. The primary care doctor did not perform any psychiatric evaluations to confirm or deny the reported diagnoses and merely advised the Veteran to continue his treatment with the mental health department. Medical records from the Veteran’s VA social workers do not contain a diagnosis or finding of PTSD. Instead, the Veteran’s mental health treatment is focused on his depressive and bipolar disorders. The Board has considered the statements of the Veteran that he has PTSD. Lay testimony is competent to establish the presence of observable symptomatology and “may provide sufficient support for a claim of service connection.” Layno v. Brown, 6 Vet. App. 465, 469 (1994). However, where the determinative issue involves medical causation or a medical diagnosis, there must be competent medical evidence to the effect that the claim is plausible. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). Whether lay evidence is competent and sufficient to establish a diagnosis in a particular case is a fact issue to be addressed by the Board. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). In this case, the Board finds that the Veteran is not competent to diagnose the presence of PTSD. He is competent to identify and explain the symptoms that he observes and experiences, but psychiatric disorders require more than a simple observation of symptoms. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). Psychiatric disorders are by their very nature complex disabilities that require specialized training to properly diagnose. The United States Court of Appeals for the Federal Circuit (Federal Circuit) has also explicitly stated that PTSD is not capable of a lay diagnosis. Young v. McDonald, 766 F.3d 1348, 1352 (Fed. Cir. 2014) (“PTSD is not the type of medical condition that lay evidence... is competent and sufficient to identify”). The Board therefore finds that the Veteran is not competent to diagnose himself with PTSD. As such, the diagnosis of PTSD in the Veteran’s December 2016 VAMC record based purely on his own statement is also of no probative value. In sum, the weight of the competent evidence establishes that the Veteran does not have PTSD. None of the three VA examiners identified PTSD and the Veteran’s mental health records from the VAMC are negative for probative diagnoses of PTSD. The Board has considered the statements of the Veteran that he has PTSD, but finds that he is not competent to render a medical opinion in this instance. In addition, the Veteran is service-connected for other psychiatric diagnoses that contemplate the symptoms he has reported as due to PTSD. Thus, the weight of the competent evidence of record establishes that the Veteran does not have PTSD in accordance with 38 C.F.R. § 4.125(a) and the claim is denied. M. H. HAWLEY Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Riley, 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.