Citation Nr: 21076335 Decision Date: 12/23/21 Archive Date: 12/23/21 DOCKET NO. 16-26 488 DATE: December 23, 2021 ORDER Entitlement to service connection for posttraumatic stress disorder (PTSD) is granted. FINDING OF FACT The Veteran's PTSD is at least as likely as not related to his in-service stressor. CONCLUSION OF LAW The criteria for entitlement to service connection for PTSD have been met. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.304(f), 4.125(a). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served honorably in the United States Army from October 1990 to February 1995. This matter comes before the Board of Veterans' Appeals (Board) from a rating decision issued in August 2015 by the Department of Veterans Affairs (VA) Regional Office (RO). In September 2020, the Veteran had a hearing before the undersigned Veterans Law Judge. A copy of the hearing transcript has been associated with the claims file. In a June 2021 decision, the Board determined that the evidence received since the last final May 2000 rating decision was new and material, and the claim for service connection for PTSD was reopened. 38 U.S.C. § 5108; 38 C.F.R. §§ 3.156, 20.1103. The Board ultimately remanded the claim for further development and a new VA examination. The Board is now satisfied that there was substantial compliance with its remand orders and is prepared to fully adjudicate the issue at hand. See Dyment v. West, 13 Vet. App. 141, 146-147 (1999); Stegall v. West, 11 Vet. App. 268, 271 (1998). 1. Entitlement to service connection for PTSD The Veteran contends that he is due entitlement to service connection for PTSD. Specifically, the Veteran claims that his statements regarding in-service stressors are sufficient to show a link between his current diagnosis and an event that occurred while on active duty. Under the relevant laws and regulations, service connection for PTSD requires three elements. First, the medical evidence diagnosing the condition must be in accordance with 38 C.F.R. § 4.125(a). Second, there must be credible supporting evidence that a claimed in-service stressor occurred. And third, there must be a link, established by medical evidence, between current symptoms and the in-service stressor. 38 C.F.R. § 3.304(f). The Veteran submitted VA treatment records that contain notes from Dr. M.S. at the Maui VA Clinic in which he diagnoses the Veteran with PTSD. The notes from Dr. M.S. state that the diagnosis is being made under the requirements of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Therefore, the condition is found to be diagnosed in accordance with 38 C.F.R. § 4.125(a). The VA treatment record shows another assessment of PTSD in accordance with the DSM-5 in February 2015. In March 2015 Dr. M.S. again assessed the Veteran with PTSD under the DSM-5. The Veteran reports that his family tells him they see a "before and after" regarding his personality before joining the military and then after separating from the military. VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. 38 U.S.C. § 1154(a). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Here, the lay statements of record all describe symptoms of PTSD. The claims file contains a diagnosis of PTSD before these lay statements and continues to confirm a diagnosis of PTSD after the lay statements. Therefore, the Board finds these to be competent and probative statements. In August 2015, the Veteran was afforded a VA examination. The examiner found that the Veteran did not have a diagnosis of PTSD that conformed with the DSM-5 criteria. The examiner diagnosed the Veteran with an unspecified sleep disorder and adjustment disorder with anxiety and depressed mood due to the Veteran's separation with his long-time girlfriend and his children. As noted above, the Board found this examination inadequate, as the Veteran's VA treatment provider assigned him a diagnosis of PTSD per the DSM-5 on multiple occasions. The August 2015 VA examiner did not provide an adequate explanation as to why these diagnoses were improper. Further, in rendering his opinion that the Veteran's anxiety disorder and sleeping disorder were less likely than not caused by service, the examiner opined only that there was a 15-year gap between his service and his diagnosis, indicating that he was functioning well in the intervening years. In addition, the Veteran made lay statements in the examination about stressful events he experienced during service including his drill sergeant injuring a soldier, the death of a man during training exercises, and intense training where he claims to have posed as a terrorist for the purpose of training special forces which put him in uncomfortable and dangerous situations. The August 2015 examiner did concede exposure to stressors. The Veteran returned to the Maui VA Clinic after the VA examination. Again, the Veteran's physician noted a diagnosis of PTSD under the DSM-5. The Veteran also reported an in-service stressor where he was nearly burned due to an explosion that occurred while he was hiding under a house. In September 2020, the Veteran presented for a Board hearing in front of the undersigned VLJ. Much of the testimony presented was to show why the August 2015 VA examination was inadequate. The Veteran reported that the examination was silent as to his PTSD diagnoses from the VA Clinic and that many of the statements were contradictory. The Veteran also claimed that the examiner did not review all of the pertinent and relevant information within the claims file. The Veteran also testified to the stressors he experienced in service, including that he experienced a bomb go off when he was stuck underneath a building during a training exercise. Ever since then, the Veteran states he has had nightmares and things get chaotic for him in his sleep. Further, the Veteran reported how the symptoms have continued since service. The Veteran received a new VA examination in September 2021. The examiner noted that the Veteran has a diagnosis of PTSD that conforms to DSM-5 criteria. It was noted that the Veteran identified his stressor as occurring in 1993 and he began to show symptoms in 1995. He reported he was triggered by seeing military vehicles or hearing military news. The examiner reported the Veteran's in-service stressor to be an explosion that went off while he was hiding under a building. He was in fear of his own safety and he now is hypervigilant. The examiner found this stressor to be credible and sufficient due to the fact that the Veteran had a fear of imminent death or injury. The examiner opined that the Veteran's PTSD was at least as likely as not incurred in or caused by the claimed in-service stressor. By way of rationale, the examiner stated that the Veteran is currently diagnosed with PTSD with no history of mental health issues prior to his stressor in 1993. His symptoms of anxiety and sleeping issues are likely subsumed in his PTSD diagnosis (1995 separation exam indicating sleep disorder, talking in sleep, symptoms of insomnia). The August 2015 examination indicated the Veteran's anxiety and sleep issues. In addition, the Veteran also described hypervigilance and feeling triggered by seeing military vehicles, being in airplanes, and hearing military news. Therefore, it is at least as likely as not his PTSD incurred in service. The Board agrees with the finding in the September 2021 VA examination and grants the Veteran service connection for his PTSD. Throughout the record the Veteran is consistently found to have a diagnosis of PTSD as reported in the VA treatment records. The Veteran also submitted lay statements from family and friends that corroborated the symptoms of PTSD that were noted by his VA physicians. The Board also finds the Veteran's lay statements to be credible and sufficient to support his in-service stressor. Additionally, the VA examiner found the Veteran's in-service stressor report of an explosion occurring while he was trapped under a building to be sufficient to establish criterion A of DSM-5 and found that the Veteran had a fear of imminent death or injury due to the incident. The Veteran's in-service stressor clearly led to his issues with insomnia, sleep issues, and restlessness in his sleep that manifested itself into the symptoms that led to the Veteran's PTSD diagnosis. VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Here, the Board determines that the evidence of record supports the Veteran's claim, and he is therefore entitled to a grant of service connection for his PTSD. Caroline B. Fleming Veterans Law Judge Board of Veterans' Appeals Attorney for the Board E.L. Aumiller, 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.