Citation Nr: 21064600 Decision Date: 10/20/21 Archive Date: 10/20/21 DOCKET NO. 16-52 724 DATE: October 20, 2021 ORDER Entitlement to service connection for residuals of a traumatic brain injury, to include headaches and memory loss, is denied. Entitlement to service connection for unspecified depressive disorder, secondary to posttraumatic stress disorder (PTSD), is granted. Entitlement to service connection for alcohol use disorder, secondary to PTSD, is granted. FINDINGS OF FACT 1. There is no competent diagnosis of any residuals of a traumatic brain injury. 2. The evidence is at least in equipoise that unspecified depressive disorder is secondary to PTSD. 3. The evidence is at least in equipoise that alcohol use disorder is secondary to the Veteran's PTSD. CONCLUSIONS OF LAW 1. The criteria for service connection for residuals of traumatic brain injury, to include headaches and memory loss, have not been met. 38 U.S.C. §§ 1110, 5107; 38C.F.R. § 3.303. 2. The criteria for service connection for unspecified depressive disorder, secondary to PTSD, have been met. 38 U.S.C. §§ 1110, 5107; 38C.F.R. §§ 3.303, 3.310. 3. The criteria for service connection for alcohol use disorder have been met. 38 U.S.C. §§ 1110, 5107; 38C.F.R. §§ 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty with the United States Army from June 1968 to July 1971, to include service in the Republic of Vietnam. These matters come before the Board of Veterans' Appeals (Board) on appeal of a June 2016 rating decision. In November 2019, the Veteran testified at a hearing before the undersigned Veterans Law Judge. A transcript of the hearing is of record. The claims were remanded in February and December 2020 for further development. The Board finds that the remand directives from the December 2020 remand have been substantially complied with (current VA examinations with opinions have been obtained) and therefore will proceed with the claims. The Board had also remanded the issue of entitlement to service connection for tremors of the arms and hands which has been granted in an April 2021 rating decision and is no longer on appeal. Service Connection Service connection will be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303, 3.304. Service connection generally requires evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Walker v. Shinseki, 701 F.3d 1331 (Fed. Cir. 2013). Secondary service connection requires: (1) a service-connected disability; (2) a nonservice connected disability; and (3) evidence that the nonservice connected disability is either (a) proximately due to or the result of the service-connected disability or (b) aggravated (increased in severity) by the service-connected disability. 38 C.F.R. § 3.310. Proof of a current disability is a threshold to establishing service-connection for any claimed disability. In the absence of proof of a present disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). 1. Entitlement to service connection for residuals of traumatic brain injury, to include headaches and memory loss is denied. The Veteran served in Vietnam. He alleges that he was in close proximity to several explosions during service and that he has experienced headaches ever since. The Veteran was afforded a VA examination in February 2021 to evaluate his claim for residuals of a traumatic brain injury. Following the examination, the examiner determined that there was no evidence to support a diagnosis of traumatic brain injury. The Board finds this examination and opinion to be adequate (as it is based on a review of the Veteran's medical history, responded directly to the questions posed by the Board, and contained a sufficient rationale) and probative as to the question of whether the Veteran currently suffers from a disability. Based on the VA examiner's opinion, the Board finds that the Veteran does not have a current diagnosis of residuals of a traumatic brain injury. Although the Veteran is competent to report headaches and memory and an in-service head injury, he is not competent to attribute any current residuals to such in-service head injury or opine as to the etiology of his headaches and memory loss. Evidence must show that the Veteran currently has the disability for which benefits are being claimed. Here, however, as noted above, the evidence does not establish that the Veteran had a traumatic brain injury in service or that he currently experiences any residuals of a traumatic brain injury. Thus, service connection is denied. 2. Entitlement to service connection for unspecified depressive disorder and entitlement to service connection for alcohol use disorder are granted. The Veteran is currently service connected for PTSD. Additionally, VA treatment records show that the Veteran has been diagnosed with recurrent depressive disorder. Moreover, in a June 2016 VA examination report, the Veteran was diagnosed with alcohol use disorder. The claims were remanded in order to determine whether the Veteran had a separate diagnosis of a depressive disorder and to determine whether the Veteran had an alcohol use disorder secondary to a service-connected psychiatric disorder. In a January 2021 report, a VA examiner determined that the Veteran had unspecified depressive disorder and mild alcohol use disorder, in sustained remission and that both conditions were at least as likely as not proximately due to or the result of the Veteran's service-connected PTSD. The examiner explained that the Veteran began to drink heavily on a daily basis throughout his Vietnam service and continued to drink heavily for 40 years until he was treated for his PTSD and depression. He also described a history of depression symptoms that were comorbid with PTSD soon after returning from Vietnam. He alcohol use was a means of coping of with his PTSD symptoms and some of his PTSD and depression symptoms appeared to have been minimized or covered up his alcohol use for many years. The examiner noted that the evidence in the claims file is consistent with a depressive disorder and alcohol use disorder being comorbid with a secondary to his PTSD diagnosis. On the other hand, in an April 2021 report, a VA examiner determined that the Veteran did not have a separate depressive disorder. The examiner acknowledged that the claims file showed a diagnosis of major depressive disorder but explained that although the Veteran reported a depressed mood at times, other symptoms identified presented as more strongly associated with PTSD than a clear diagnosis of depressive disorder. Therefore, the symptom of depressed mood was considered subsumed under the PTSD diagnosis. In a separate April 2021 report, a VA examiner determined that the Veteran did not have an alcohol use disorder. The examiner noted that there is evidence that the Veteran used alcohol since being in service, and at times, used it excessively. However, treatment providers have not consistently diagnosed him with an alcohol use disorder and there are more than one alcohol screens which were negative based on reported usage at that time. The examiner noted that the Veteran had not identified clear symptomatology which would meet criteria for an alcohol use disorder, as he identified being able to reduce or stop drinking when he wished and had not experienced ongoing or repeated negative consequences associated with his drinking aside from one DUI. (Continued on next page) For these reasons, the Board finds that the most probative evidence for and against the grant service connection for an unspecified depressive disorder and alcohol use disorder is, at least, in equipoise. Resolving any benefit of the doubt in favor of the Veteran, the Board will grant his claims for service for an unspecified depressive disorder and for alcohol use disorder, both secondary to PTSD. Evan M. Deichert Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Henriquez, 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.