Citation Nr: 21003688 Decision Date: 01/22/21 Archive Date: 01/22/21 DOCKET NO. 17-31 467 DATE: January 22, 2021 ORDER Entitlement to service connection for post-traumatic stress disorder (PTSD) is granted. FINDING OF FACT Resolving all reasonable doubt in the Veteran’s favor, his PTSD is at least as likely as not related to his active duty service. CONCLUSION OF LAW The criteria for entitlement to service connection for PTSD have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Army from July 2003 to November 2003 and from April 2005 to July 2006. In January 2020, the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the claims file. Service Connection Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service, or if preexisting service, was aggravated therein. 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). To establish service connection for a disability, there must be competent evidence of the following: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship or nexus between the present disability and the disease or injury incurred or aggravated during service. Horn v. Shinseki, 25 Vet. App. 231, 236 (2010); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Gutierrez v. Principi, 19 Vet. App. 1, 5 (2004) (citing Hickson v. West, 12 Vet. App. 247, 253 (1999)). In many cases, medical evidence is required to meet the requirement that the evidence be “competent”. However, when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination “medical in nature” and is capable of lay observation. Barr v. Nicholson, 21 Vet. App. 303, 309 (2007). Entitlement to service connection for PTSD The Veteran contends that his acquired psychiatric disorder, to include PTSD, is related to military stressors that occurred during his active service Afghanistan. Service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a); 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). If a stressor claimed by a veteran is related to a 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 a veteran’s symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of a veteran’s service, a veteran’s lay testimony alone may establish the occurrence of the claimed in-service stressor. 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; 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 psycho-physiological state of fear, helplessness, or horror. 38 C.F.R. § 3.304(f)(3). If VA determines that the veteran engaged in combat with the enemy and that the alleged stressor is related to combat, then the veteran’s lay testimony or statements are accepted as conclusive evidence of the occurrence of the claimed stressor. 38 U.S.C. § 1154(b); 38 C.F.R. § 3.304(f). No further development or corroborative evidence is required, provided that the claimed stressor is “consistent with the circumstances, conditions, or hardships of the veteran’s service.” Id. If, however, VA determines that the veteran did not engage in combat with the enemy or that the alleged stressor is not related to combat, the veteran’s lay testimony by itself is not sufficient to establish the occurrence of the alleged stressor. Instead, the record must contain service records or other evidence to corroborate the veteran’s testimony or statements. See Moreau v. Brown, 9 Vet. App. 389, 394 (1996). At the outset, the Board notes that the Veteran’s in-service stressor has been conceded. The Veteran has consistently alleged that he was deployed to Afghanistan during which he witnessed live weapons fire and feared for his life. Service treatment records show that the Veteran was an infantryman and was deployed to Afghanistan from June 2005 to June 2006. The Board also finds that the Veteran has a current diagnosis for PTSD under DSM-V with diagnosis. VA treatment records show that multiple positive Veteran’s screen test for PTSD. VA treatment records note the Veteran’s symptoms of PTSD and PTSD diagnosis as well as his participation in group counseling for the same. A VA examiner in March 2013 found that the Veteran did not meet the DSM-V criteria for PTSD and instead diagnosed the Veteran with adjustment disorder and alcohol use disorder. The Board finds the March 2013 examiner’s opinion to be of low probative value. Noted symptoms at the examination included depressed mood, anxiety, chronic sleep impairment, disturbances of motivation and mood and difficulty in establishing and maintaining effective work and social relationships. The examiner stated that “although [the Veteran] has been diagnosed with PTSD and he is in PTSD group, the counselors mostly address the PTSD symptoms and they do not have access to STR to review the accuracy of the stressor.” However, as noted above, the Veteran’s in-service stressor has been conceded. The Veteran’s spouse has also submitted a statement in which she relates observing symptoms of the Veteran’s PTSD, to include sleep disturbances, irritability, and threats of self-harm. The Board thus finds that the record evidence is at least in relative equipoise as to whether the Veteran’s PTSD is related to military service. The Board notes that when the evidence is in relative equipoise, by law; the Board must resolve all reasonable doubt in favor of the claimant. See U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Therefore, considering the totality of the evidence, the Board finds that service connection for an acquired psychiatric disorder, to include PTSD, is warranted. The extent of the problem is not before the Board at this time. John J. Crowley Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board V. Woehlke 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.