Citation Nr: 21067607 Decision Date: 11/04/21 Archive Date: 11/04/21 DOCKET NO. 15-25 621 DATE: November 4, 2021 ORDER Service connection for posttraumatic stress disorder (PTSD) is denied. FINDING OF FACT The preponderance of the evidence of record is against finding that the Veteran has, or has had at any time during the appeal, a current diagnosis of PTSD. CONCLUSION OF LAW The criteria for service connection for PTSD are not met. 38 U.S.C. §§1110, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a), 3.304 (2021). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from July 1975 to October 1976. This matter is before the Board of Veterans' Appeals (Board) on appeal from a March 2016 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). A Board hearing was held before the undersigned in August 2018. A transcript of the hearing is of record. This matter was previously before the Board in June 2019 and August 2020 when it was remanded for further development. A May 2021 rating decision granted service connection for migraine headaches, major depressive disorder (an acquired psychiatric disorder other than PTSD), and mild neurocognitive disorder due to traumatic brain injury (TBI). As the decision constitutes a full grant of the claims previously before the Board, the matters are no longer before the Board and will not be discussed further. Service connection for PTSD is denied. The Veteran and his attorney generally contend that the Veteran is entitled to service connection for PTSD. 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 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). Under 38 C.F.R. § 4.125, diagnoses of mental disorders are to conform to DSM-5. 38 C.F.R. § 4.125 [incorporating by reference VA's adoption of the American Psychiatric Association: DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, Fifth Edition (DSM-5), for rating purposes]. However, the applicability date of the rulemaking requiring diagnosis of psychiatric disorders under DSM-5 indicated that the revision is not applicable where a case was pending before the Board on or before August 4, 2014. See 80 Fed. Reg. 14,308 (Mar. 19, 2015). The Veteran's appeal was certified on July 9, 2018. Therefore, the DSM-5 is applicable to his case. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that the Veteran does not have a current PTSD diagnosis and has not had a PTSD diagnosis at any time during the pendency of the claim. 38 U.S.C. §§ 1131, 5107(b); 38 C.F.R. § 3.303(a), (d); Holton v. Shinseki, 557 F.3d 1363, 1366 (2009); Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013), 26 Vet. App. at 294; McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). The Board notes that the record reflects that the Veteran reported psychiatric symptoms, including excessive worry, depression, and being uncomfortable around strangers and in large crowds, as noted in a November 1977 VA examination report. In addition, during the August 2018 Board hearing, the Veteran reported avoiding conflicts, feeling depressed, difficulty with social and romantic interactions, and checking his home three to four times before leaving. However, there is no evidence PTSD is currently present or diagnosed. The Veteran's VA treatment records are silent for any diagnosis or treatment for PTSD and contain negative screening tests for PTSD, including in October 2013 and November 2019. In addition, the Veteran's private psychologist, Dr. G.R., submitted a January 2014 psychiatric evaluation which noted diagnoses of Asperger's Syndrome and Major Depression, but did not diagnose PTSD. Furthermore, medical records furnished by the Social Security Administration (SSA) reflect diagnoses of depression and Asperger's Syndrome but also do not contain a diagnosis of PTSD. In November 1977, the Veteran underwent a VA examination in which he reported worrying, depression, and being uncomfortable around strangers and in large crowds, as noted above. However, following clinical interview, the examiner diagnosed hysterical neurosis, conversion type with some secondary symptoms of psychophysiological musculoskeletal disorder in the form of tension headaches and backache; there was no mention of PTSD. Lastly, a March 2021 VA examiner concluded that the Veteran did not meet DSM-5 criteria for a PTSD diagnosis; rather, he was diagnosed with Major Depressive Disorder and Mild Neurocognitive Disorder due to TBI. The examiner indicated that the Veteran reported intense and stressful events related to his superiors and medical personnel not believing that he had a headache condition but noted that the Veteran did not report any stressors that would qualify for a PTSD diagnosis. The examiner also indicated that the Veteran was not exposed to actual or threatened death, serious injury, or sexual violation and did not report any intrusion symptoms, persistent avoidance of stimuli, negative alterations in cognitions and mood, or marked alterations in arousal and reactivity associated with the traumatic event which last more than one month; cause clinically significant distress or impairment in social, occupational, or other important areas of functioning; and is not attributable to the physiological effects of a substance or another medical condition. The Board places great probative weight on the medical evidence of record, notably the January 2014 psychiatric evaluation completed by Dr. G.R. and the March 2021 VA examination report, as the diagnoses were made following full interview and evaluation of the Veteran and adequately consider the Veteran's lay statements, including reported stressors and associated symptoms. The existence of a current disability is the cornerstone of a claim for service connection and VA disability compensation. 38 U.S.C. § 1131; Degmetich v. Brown, 104 F.3d 1328, 1332 (1997). Evidence must show that the Veteran currently has the disability for which benefits are being claimed. Here, the medical evidence does not reflect that the Veteran has had a PTSD diagnosis at any point during the appeal period. While the Veteran's application for service connection for PTSD illustrates that the Veteran believes he has a current disability of PTSD for VA purposes, he is not competent to provide a diagnosis in this case. The Veteran acknowledged this at the August 2018 Board hearing, when he indicated that he is unsure which psychiatric diagnosis is appropriate and can only report his symptoms and behaviors. Although the Veteran is competent to identify and explain the symptoms that he observes and experiences, psychiatric disorders require more than a simple observation of symptoms. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). Psychiatric disorders are by their very nature complex disabilities that require specialized training to properly diagnose. The United States Court of Appeals for the Federal Circuit has also explicitly stated that PTSD is not capable of a lay diagnosis. Young v. McDonald, 766 F.3d 1348, 1352 (Fed. Cir. 2014) ("PTSD is not the type of medical condition that lay evidence . . . is competent and sufficient to identify"). Therefore, the Board finds that the Veteran is not competent to diagnose himself with PTSD. The Board does not question the Veteran's sincerity in his belief that service connection is warranted for PTSD. However, without evidence of a current PTSD diagnosis, a preponderance of the evidence is against the claim. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Therefore, service connection for PTSD is denied. M. SORISIO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Jiggetts 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.