Citation Nr: 21065903 Decision Date: 10/27/21 Archive Date: 10/27/21 DOCKET NO. 17-44 260 DATE: October 27, 2021 ORDER Service connection for an acquired psychiatric disorder to include posttraumatic stress disorder (PTSD), an anxiety disorder and a major depressive disorder is granted. REMANDED The issue of service connection for sinusitis is remanded. The issue of service connection for allergic rhinitis is remanded. The issue of service connection for hypertension is remanded. The issue of service connection for a heart disease (claimed residual of a heart attack) is remanded. FINDING OF FACT The Veteran has an acquired psychiatric disorder, to include PTSD, generalized anxiety disorder and major depressive disorder is the result of active service. CONCLUSION OF LAW The criteria to establish service connection for an acquired psychiatric disorder to include PTSD, an anxiety disorder and a major depressive disorder have been met. 38 U.S.C. §§ 1110, 1154 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from February 1990 to February 1993. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2015 rating decision issued by the RO. 1. Service connection for an acquired psychiatric disorder to include PTSD, an anxiety disorder and a major depressive disorder Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty in the active military, naval, or air service. 38 U.S.C. §§ 1110, 1131. Establishing service connection generally requires (1) evidence of a current disability; (2) evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table); 38 C.F.R. § 3.303. Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b). There are particular requirements for establishing entitlement to service connection for PTSD in 38 C.F.R. § 3.304(f) that are separate from those for establishing service connection generally. Arzio v. Shinseki, 602 F.3d 1343, 1347 (Fed. Cir. 2010). Those requirements are: (1) a diagnosis of PTSD in accordance with 38 C.F.R. § 4.125; (2) credible supporting evidence that the claimed in-service stressor occurred; and (3) medical evidence of a causal nexus between current symptomatology and the specific claimed in- service stressor. 38 C.F.R. § 3.304(f). If a stressor claimed by a veteran is related to the veteran's fear of hostile military or terrorist activity and a VA psychiatrist or psychologist confirms that the claimed stressor is adequate to support a diagnosis of PTSD and that the 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 the veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. 38 C.F.R. § 3.304(f)(3). "Fear of hostile military 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, and the veteran's response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror. Id. The list of examples of such an event or circumstance specifically includes incoming mortar, rocket, and sniper fire. Id. Service personnel records show that the Veteran was stationed aboard the USS Detroit. He contends that while on watch aboard the vessel during maneuvers, he saw a missile fired from the USS Saratoga that hit a Turkish ship. This incident has been confirmed. Various news reports indicate the Turkish vessel was struck and several of its crew were killed, including its commanding officer. Others aboard the allied vessel were injured. The Veteran reported that they were instructed to man their battle stations on his ship and he thought they were under attack. After an hour they were ordered to "stand-down" but his ship participated in the search and rescue operations. An October 2015 VA PTSD examination report reflects a diagnosis of anxiety. The Veteran reported that he had distressing memories of the incident. His reported symptoms included poor sleep, night sweats, nightmares, distressing memories, avoidant behavior, emotional stress, social isolation, and diminished interest in activities. However, the Veteran did not have a diagnosis of PTSD that conformed to the DSM-5 criteria. The psychiatrist reported in part that the Veteran did not meet the criteria for PTSD based on the reported stressor because there was insufficient evidence to substantiate its occurrence. The psychiatrist also reported that several of the criteria necessary to establish a diagnosis of PTSD were not met. A July 2017 VA treatment record documents diagnoses of PTSD and an anxiety disorder. An April 2018 VA mental health treatment note reflects that the Veteran received follow-up treatment for his PTSD/anxiety and insomnia. The Veteran reported that he felt fine and denied experiencing any problems. He had no problems falling asleep but woke during the night. He had no other complaints. The November 2018 VA mental health treatment note reflects that the Veteran received follow-up treatment for his PTSD, anxiety, and insomnia. He reported that his anxiety was exacerbated lately. He reported that he slept well throughout the night and awoke feeling well rested. He had no other complaints. The January 2019 VA PTSD examination report documents diagnoses of PTSD and insomnia disorder with other medical comorbidity (PTSD and chronic pain). The Veteran reiterated his service stressors. The psychologist indicated that this stressor met Criterion A (i.e., it was adequate to support the diagnosis of PTSD). The psychologist indicated there was exposure to actual or threatened death or serious injury (Criterion A); intrusion symptoms associated with the traumatic event (Criterion B); persistent avoidance of stimuli associated with the traumatic event (Criterion C); negative alterations in cognitions and mood associated with the traumatic event (Criterion D); and, marked alterations in arousal and reactivity associated with the traumatic event (Criterion E). The duration of the disturbance was more than 1 month (Criterion F); the disturbance caused clinically significant distress or impairment in social, occupational, or other important areas of functioning (Criterion G); and, the disturbance was not attributable to the physiological effects of a substance (Criterion H). The psychologist explained that the Veteran's insomnia symptoms were related to the PTSD which was related to the identifiable exposure event experienced by the Veteran during his period of service in Southwest Asia. A March 2019 mental disorders disability benefits questionnaire (DBQ) completed by the Veteran's treating psychologist documents diagnoses of generalized anxiety disorder and major depressive disorder. The Veteran reiterated his stressor account. On examination, the psychologist concluded that the Veteran had anxiety and depressive symptoms that were attributable to his period of service. The psychologist explained that the Veteran's symptoms were impairing and interfering with his ability to cope with normal stressors and maintain healthy relationships. The Board has considered the opinion of the VA psychiatrist in the October 2015 VA examination report. The VA psychiatrist found that that the Veteran did not have a diagnosis of PTSD that conformed to the DSM-5 criteria because there was insufficient evidence to substantiate that the Veteran had experienced the stressor claimed. However, the psychiatrist did not offer opinion as to whether the Veteran's diagnosed anxiety was attributable to an event or incident incurred during the Veteran's period of service. The January 2019 VA PTSD examination report documents diagnoses of PTSD and insomnia disorder. The Veteran reiterated his stressor account, as he did in the March 2019 mental disorders examination. The latter examiner also diagnosed PTSD. In sum, the Veteran has been diagnosed with PTSD, an anxiety disorder and a depressive disorder related to a confirmed in-service stressor. The claim will be granted. The Board expresses no opinion regarding the severity of the disorder. The RO will assign an appropriate disability rating on receipt of this decision. Ferenc v. Nicholson, 20 Vet. App. 58 (2006) (discussing the distinction in the terms "compensation," "rating," and "service connection" as although related, each having a distinct meaning as specified by Congress). REASONS FOR REMAND 1. The issue of service connection for sinusitis is remanded. 2. The issue of service connection for allergic rhinitis is remanded. 3. The issue of service connection for hypertension is remanded. 4. The issue of service connection for a heart disease (claimed residual of a heart attack) is remanded. The matters are REMANDED for the following action: 1. BACKGROUND FOR THE RO ADJUDICATOR: The Veteran contends that he has current sinusitis, allergic rhinitis, hypertension, and a heart disease that had their onset due to event, incident, disease, or injury incurred during his period of service. A March 2012 VA treatment record reflects that the Veteran has hypertension that requires medication for control. A September 2012 VA treatment record reflects the Veteran has allergic rhinitis and presented for treatment for sinusitis/bronchitis. A December 2012 VA treatment record reflects the dosage of Flonase was increased to treat his allergic rhinitis and the Veteran was restarted on sinus rinses for his chronic sinusitis. A July 2013 VA treatment record reflects that the Veteran's dosage of Flonase for treatment for his allergic rhinitis was continued and he continued with the sinus rinses for treatment of his chronic sinusitis. The July 2013 VA treatment record also documented active problems, including in pertinent part, hypertension and minor heart attack noted from ECG. The February 2017 VA treatment record documents diagnoses, in pertinent part, of essential hypertension and allergic rhinitis. An April 2020 VA telephone treatment record documents that the Veteran's chief complaint was nasal congestion. The evidence of record is insufficient for determining whether service connection may be granted. Remand is required to afford the Veteran a VA examination to determine whether he has current sinusitis, allergic rhinitis, hypertension, and a heart disorder that had their onset due to event, incident, disease, or injury incurred during his period of service. See McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006); see also Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). THE REMAND DIRECTIVES FOLLOW. 2. Schedule the Veteran for a VA examination to determine the nature and likely etiology of the claimed sinusitis and allergic rhinitis. The VBMS file must be reviewed by the examiner. All indicated tests and studies must be performed and the clinical findings must be reported in detail. A comprehensive clinical history must be obtained, to include a discussion of the Veteran's documented medical history and assertions - he asserts that he has sinusitis and allergic rhinitis that had onset due to event, incident, disease, or injury incurred during his period of service. After reviewing the entire record, the examiner must provide an opinion with supporting explanations as to the following: Does the Veteran have current sinusitis and allergic rhinitis that had their onset due to event, incident, disease, or injury incurred during his period of service? As indicated above, the examiner must review the record in conjunction with rendering the requested opinion; however, his/her attention is drawn to the following: *A September 2012 VA treatment record reflects the Veteran has allergic rhinitis and presented for treatment for sinusitis/bronchitis. He was prescribed Flonase and Certerize for his allergic rhinitis and a 7-day course of Augmentim for his sinusitis/bronchitis. *A December 2012 VA treatment record reflects that there was no radiographic evidence for sinusitis. The dosage for Flonase (used to treat the allergic rhinitis) was increased and the Veteran was restarted on sinus rinses for his chronic sinusitis. *A July 2013 VA treatment record reflects that the Veteran's continued to use Flonase for treatment for his allergic rhinitis and sinus rinses for treatment for his chronic sinusitis. *The February 2017 VA treatment record documents diagnosis, in pertinent part, of allergic rhinitis. *An April 2020 VA telephone treatment record documents that the Veteran's chief complaint was nasal congestion. A thorough explanation must be provided for the opinion rendered. If the examiner cannot provide the requested opinion without resorting to speculation, he or she must expressly indicate this and provide a supporting rationale as to why an opinion cannot be made without resorting to speculation. THE EXAMINER IS ADVISED THAT BY LAW, THE MERE STATEMENT THAT THE CLAIMS FOLDER WAS REVIEWED AND/OR THE EXAMINER HAS EXPERTISE IS NOT SUFFICIENT TO FIND THAT THE EXAMINATION IS SUFFICIENT. 3. Schedule the Veteran for a VA examination to determine the nature and likely etiology of the claimed hypertension. The VBMS file must be reviewed by the examiner. All indicated tests and studies must be performed and the clinical findings must be reported in detail. A comprehensive clinical history must be obtained, to include a discussion of the Veteran's documented medical history and assertions - he asserts that he has hypertension that had onset due to event, incident, disease, or injury incurred during his period of service. After reviewing the entire record, the examiner must provide an opinion with supporting explanations as to the following: Does the Veteran have current hypertension that had its onset due to event, incident, disease, or injury incurred during his period of service? As indicated above, the examiner must review the record in conjunction with rendering the requested opinion; however, his/her attention is drawn to the following: *The January 1993 separation examination report reflects that the Veteran's blood pressure reading was 120/72. *A March 2012 VA treatment record reflects that the Veteran has hypertension that requires medication (Lisinopril) for control. *A July 2013 VA treatment record documented active problems, including in pertinent part, hypertension. *A February 2017 VA treatment record documents diagnosis, in pertinent part, of essential hypertension. *June 2019 and March 2020 VA treatment records confirm diagnosis, in pertinent part, of essential hypertension. A thorough explanation must be provided for the opinion rendered. If the examiner cannot provide the requested opinion without resorting to speculation, he or she must expressly indicate this and provide a supporting rationale as to why an opinion cannot be made without resorting to speculation. THE EXAMINER IS ADVISED THAT BY LAW, THE MERE STATEMENT THAT THE CLAIMS FOLDER WAS REVIEWED AND/OR THE EXAMINER HAS EXPERTISE IS NOT SUFFICIENT TO FIND THAT THE EXAMINATION IS SUFFICIENT. 4. Schedule the Veteran for a VA examination to determine the nature and likely etiology of the claimed heart disease. The VBMS file must be reviewed by the examiner. All indicated tests and studies must be performed and the clinical findings must be reported in detail. A comprehensive clinical history must be obtained, to include a discussion of the Veteran's documented medical history and assertions - he asserts that he has a current heart disease that had onset due to event, incident, disease, or injury incurred during his period of service. After reviewing the entire record, the examiner must provide an opinion with supporting explanations as to the following: Does the Veteran have a current heart disease that had its onset due to event, incident, disease, or injury incurred during his period of service? As indicated above, the examiner must review the record in conjunction with rendering the requested opinion; however, his/her attention is drawn to the following: *An August 2011 VA treatment record reflects that the Veteran had an abnormal EKG. *An October 2011 VA treatment record reflects that the Veteran has cardiovascular risk factors like hypertension, hypercholesterolemia, coronary artery disease (CAD) and overweight. *A July 2013 VA treatment record documented active problems, including in pertinent part, minor heart attack noted from ECG. *An August 2017 VA treatment record reflects no ischemic heart disease. A thorough explanation must be provided for the opinion rendered. If the examiner cannot provide the requested opinion without resorting to speculation, he or she must expressly indicate this and provide a supporting rationale as to why an opinion cannot be made without resorting to speculation. THE EXAMINER IS ADVISED THAT BY LAW, THE MERE STATEMENT THAT THE CLAIMS FOLDER WAS REVIEWED AND/OR THE EXAMINER HAS EXPERTISE IS NOT SUFFICIENT TO FIND THAT THE EXAMINATION IS SUFFICIENT. Vito A. Clementi Veterans Law Judge Board of Veterans' Appeals Attorney for the Board G. Jackson The Board's action is binding only in this case. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.