Citation Nr: 21001225 Decision Date: 01/07/21 Archive Date: 01/07/21 DOCKET NO. 17-57 820 DATE: January 7, 2021 ORDER Entitlement to service connection for an acquired psychiatric disability, to include posttraumatic stress disorder, is granted. FINDING OF FACT Resolving reasonable doubt in the Veteran’s favor, his posttraumatic stress disorder is etiologically related to his service-connected traumatic brain injury. CONCLUSION OF LAW The criteria for service connection for an acquired psychiatric disability, to include posttraumatic stress disorder, have been met. 38 U.S.C. § 1110; 38 C.F.R. §§ 3.303, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Marine Corps from June 1983 to November 1983, from November 1984 to November 1987 and from February 1991 to April 1991. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a May 2013 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO) in Phoenix, Arizona. In November 2020, the Veteran testified before the undersigned Veterans law Judge. A transcript of the hearing is associated with the claims file. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Service connection may also be granted for disabilities that are caused or aggravated by service-connected disabilities. 38 C.F.R. § 3.310. Entitlement to service connection for posttraumatic stress disorder. The Veteran contends that he suffers from posttraumatic stress disorder (PTSD) which is related to service, to include as secondary to or associated with service-connected traumatic brain injury (TBI). The Court of Appeals for Veteran Claims (Court) has held that a claim for service connection for a psychiatric disorder encompasses all pertinent symptomatology, regardless of how that symptomatology is diagnosed. Clemons v. Shinseki, 23 Vet. App. 1 (2009). The Board will broaden the claim under Clemons, and consider whether a broader claim for service connection is warranted for an acquired psychiatric disorder to include PTSD. The Veteran is service-connected for a TBI (claimed as a concussion). The Veteran’s TBI is evaluated under Diagnostic Code 8045. Under Diagnostic Code 8045, there are three main areas of dysfunction that may result from a TBI: cognitive (which is common in varying degrees after a traumatic brain injury), emotional/behavioral, and physical. Each of these areas of dysfunction may require evaluation. 38 C.F.R. § 4.124a. The Board finds that the Veteran’s psychiatric symptoms are associated with his TBI yet are characterized by separate manifestations, which warrant a separate evaluation and service-connection. He testified that his PTSD had its onset while he was in service and, alternatively, that it is secondary to his service-connected traumatic brain injury (TBI), which had its onset in September 1983. He reported that while in service, during a football game, he was injured and became unconscious for over 12 hours and was hospitalized. He further testified that after being told he has a very passive aggressive personality, he sought treatment at his workplace EAP for anxiety and PTSD. Subsequently, he stated, he has been under psychological evaluation and underwent neurological testing. See November 2020 Hearing Transcript. After a review of his service treatment records by the private psychologists, the Board finds that they relate his PTSD to his TBI. In a March 2014 Disability and Benefits Questionnaire, the Veteran’s private psychologist, Dr. N. K., diagnosed him with PTSD, mood disorder due to TBI, and TBI (concussion injury while in the service in September 1983). DSM-5 criterion A-F were used to determine diagnoses. Dr. N. K. also stated that the Veteran suffered from other issues including depression, obsessive compulsive behavior, and had 28 years in recovery from alcohol abuse. September 2017 VA examination did not find a mental health diagnosis that meets the DSM-5 criteria. September 2018 private neuropsychology assessment utilized twenty tests/procedures to find diagnoses of posttraumatic stress disorder and postconcussional syndrome by Dr. B.A. In a November 2019 private treatment record, Dr. N. K. stated that as per 1983 service records, the Veteran suffered from a prolonged concussion while playing football. Dr. N. K. stated that this led to psychosocial and behavioral impairment. Further, the physician stated, tests showed atrophic brain on MRI and likely posttraumatic injuries with TBI, and a neuropsychological evaluation consistent with PTSD/post-concussion syndrome. The physician concluded that the Veteran is left with cognitive and behavioral impairments from his previous TBI/PTSD/concussion type injuries. Dr. N. K. opined that the Veteran’s PTSD should be recognized as an important consequence of his TBI. In the above evaluations, a psychologist diagnosed the Veteran as having posttraumatic stress disorder. The psychologist summarized relevant history. The psychologist opined that the PTSD was caused by the service-connected TBI. The psychologist provided adequate rationale for this opinion. The Board affords the private examinations with opinion significant probative weight as they properly considered the Veteran’s lay statements regarding his medical history and in-service injury. Additionally, they were based on an accurate factual premise, and provided adequate rationale with supporting explanation. Moreover, the Board finds the Veteran’s testimony to be credible and the record corroborates his reports of in-service TBI. As the record contains a current diagnosis of an acquired psychiatric disability that has been linked to a service-connected disability, the Board grants secondary service connection. 38 U.S.C. § 1110; 38 C.F.R. §§ 3.303, 3.310. As this grant is based on the evidence submitted by the Veteran and his testimony, the Board finds that this is a full grant of the benefit sought based on the argument presently provided on appeal.   In sum, the Board finds that the evidence is at least in equipoise as to whether the Veteran’s PTSD is related to his service-connected TBI. Accordingly, the Board resolves reasonable doubt in the Veteran’s favor and finds that service connection for PTSD is warranted. 38 U.S.C. § 5107(b); 39 C.F.R § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Nathaniel J. Doan Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. Wilson, 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.