Citation Nr: 21004123 Decision Date: 01/26/21 Archive Date: 01/26/21 DOCKET NO. 13-28 147 DATE: January 26, 2021 ORDER Entitlement to service connection for an unspecified anxiety disorder is granted. FINDING OF FACT Resolving reasonable doubt in the Veteran’s favor, his unspecified anxiety disorder is at least as likely as not related to stressors he experienced during military service. CONCLUSION OF LAW The criteria for service connection for an unspecified anxiety disorder are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from September 1972 to September 1975. This matter is before the Board of Veterans’ Appeals (Board) on appeal from a December 2012 rating decision of a Department of Veteran Affairs (VA) Regional Office (RO). The Veteran testified before the undersigned during a December 2013 hearing. This matter was most recently before the Board in January 2020, when it was remanded for additional development. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) and anxiety The Veteran contends that he has a psychiatric disorder, claimed as PTSD, due to personal verbal and physical assaults experienced during military service. The Board concludes that the Veteran has a current anxiety disorder that is at least as likely as not related to stressors experienced during military service. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). VA treatment records from March 2011 contain a positive PTSD screening test, but no evidence of a diagnosis based on the full Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), which was current at the time. See 38 C.F.R. § 4.125(a) (2011). A subsequent screening test the same month was negative. These reports were followed by two intake assessments performed by VA psychiatric nurses in May 2011 and July 2012, each showing a diagnosis of PTSD based on military and childhood stressors, but without discussion of the specific stressors involved or the Veteran’s symptoms under DSM-IV criteria for PTSD. After an initial Board remand in May 2015, the Veteran was assessed by a VA contract examiner in July 2015. Though this examiner diagnosed the Veteran with PTSD, the examiner’s assessment misidentifies the Veteran’s claimed stressor as one involving fear of hostile military or terrorist activity rather than a personal assault, as consistent with his account as described in the noted medical history. See 38 C.F.R. § 3.304(f). The examiner also failed to provide a nexus opinion, as directed by the Board’s remand. Noting these inadequacies, the Agency of Original Jurisdiction (AOJ) provided a new VA examination in February 2016. This examiner found that the Veteran did not meet the diagnostic criteria for PTSD, instead diagnosing an unspecified anxiety disorder. The examiner noted a history of abuse during the Veteran’s childhood in addition to reports of violent assaults during military service. The examiner indicated the Veteran had experienced adequate stressors to meet criterion A for a PTSD diagnosis under the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), however he did not report current symptoms at the time of the examination adequate to support a diagnosis of PTSD. Noting the reports of nightmares and other PTSD symptoms in the treatment records and earlier contract examination, the examiner indicated the Veteran’s symptoms were greatly reduced from these earlier reports, with the only remaining reported symptom being anxiety. In the accompanying nexus opinion, the examiner stated that the Veteran’s disability was less likely than not related to service due to the lack of documentation of claimed assaults in the Veteran’s service records. In January 2020, the Board addressed the July 2015 and February 2016 examinations, finding each to be inadequate. The July 2015 examination was found inadequate based on the examiner’s misidentification of the Veteran’s claimed stressor as involving fear of hostile military or terrorist activity, a finding not supported by the Veteran’s history as documented in the record. See Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). The February 2016 examiner likewise failed to provide a complete assessment of the Veteran’s condition during the appeal period, neglecting to address the earlier PTSD diagnoses and focusing only on the symptoms as they presented on the date of the examination. Id. Following the January 2020 remand, the AOJ obtained a new medical opinion from a VA clinical psychologist who had not previously examined the Veteran. In this April 2020 medical opinion, the VA psychologist supported the findings of the February 2016 examiner, indicating that symptoms as reported on that examination were subclinical for a diagnosis of PTSD based on the Veteran’s emphasis on sleep and nightmare problems while denying many other symptoms typical of PTSD. Based on this assessment, the January 2020 VA psychologist opined that the diagnosis of an unspecified anxiety disorder was accurate and the Veteran’s anxiety with associated sleep and nightmare difficulties were partially attributable to military stressors. Based on these reports, the Board finds that the evidence shows the Veteran at least as likely as not has a current diagnosis of an anxiety disorder, though the record lacks adequate medical evidence to support finding a current diagnosis of PTSD. Regarding the claimed in-service stressors related to personal assaults the Veteran asserts he experienced during military service, there are no specific reports of these assaults in the Veteran’s service records. The Board notes, however, that statements reporting an in-service personal assault may be corroborated based on sources other than service records. See 38 C.F.R. § 3.304(f)(5). The Veteran testified at his December 2013 Board hearing that he avoided reporting several incidents of harassment and assault while stationed at Fort Riley before requesting a transfer. The Veteran has repeatedly stated in submission to VA that he feared for his life due to these assaults, which he has consistently reported occurred between March and September 1972. His service records confirm that he was stationed at Fort Riley for this period and was transferred to Fort Carson in October 1972, where he completed three additional years of service. The Veteran testified that he did not receive similar harassment following this transfer. The Veteran’s wife, whom the Veteran was dating at the time of the claimed assaults, confirmed in a July 2012 statement that the Veteran told her about threats he was receiving from other soldiers during the time he was stationed at Fort Riley. Based on this evidence, the Board finds the Veteran’s reports of the assaults he experienced during service to be credible. His consistent reports are generally supported by the timeline of his service documented in his service personnel records and the statement provided by his wife, and there is no evidence contradicting his accounts of these events. Based on this review of the record, the evidence shows the Veteran at least as likely as not has a current diagnosis of an unspecified anxiety disorder, he experienced stressors in the form of verbal and physical personal assaults during active service, and a January 2020 opinion from a VA psychiatrist indicates his current disorder is at least partially due to these military stressors. Therefore, the Board finds the evidence to at least be in equipoise as to whether the Veteran’s current unspecified anxiety disorder is related to service. Accordingly, after resolving the benefit of reasonable doubt in favor of the Veteran, the Board finds that service connection for an unspecified anxiety disorder is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. M. HYLAND Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Pitman, 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.