Citation Nr: 21077466 Decision Date: 12/29/21 Archive Date: 12/29/21 DOCKET NO. 16-36 937 DATE: December 29, 2021 ORDER Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) and major depressive disorder, is granted. REMANDED Entitlement to service connection for hypertension, to include as due to toxic herbicide agent exposure, or as secondary to a service-connected acquired psychiatric disability, is remanded. FINDING OF FACT Resolving all reasonable doubt in the Veteran's favor, his acquired psychiatric disorders, to include PTSD and major depressive disorder, are at least as likely as not related to active duty service. CONCLUSION OF LAW The criteria for entitlement to service connection for an acquired psychiatric disorder, to include PTSD and major depressive disorder, have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.309. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Army from August 1967 to August 1969. The Veteran appeared and testified before the undersigned Veterans Law Judge during an August 2021 virtual teleconference hearing. A transcript is of record. The Board of Veterans' Appeals (Board) remanded these matters in November 2018 to obtain updated medical records and medical opinions. The requested development has been completed, and the appeal has returned to the Board for further appellate consideration. The Board is now satisfied there was substantial compliance with the remand, as updated medical records and medical opinions with thorough supporting rationale have been obtained. See Stegall v. West, 11 Vet. App. 268 (1998). However, additional relevant evidence was entered into the record after the VA examination was obtained and, as such, a remand for the matter of service connection for hypertension is necessary. Furthermore, the Board acknowledges that the Veteran filed a claim for entitlement to service connection for PTSD. However, a service connection claim which describes only one particular psychiatric disorder should not necessarily be limited to that disorder. Rather, as reflected herein, VA should consider the claim as one for any psychiatric disability that may be reasonably encompassed by the evidence of record. Clemons v. Shinseki, 32 Vet. App. 1, 5-6 (2009). Service Connection Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131. Generally, the evidence must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); Caluza v. Brown, 7 Vet. App. 498, 505 (1995). Service connection for PTSD requires medical evidence diagnosing the condition; 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). The applicable regulation requires that the in-service stressor or traumatic event involve actual or threatened death, serious injury, or a threat to the physical integrity of self or others and the person's response involve intense fear, helplessness, or horror. Regarding any disease or injury alleged to have been incurred in or aggravated by service, VA shall accept as sufficient proof of service connection satisfactory lay or other evidence if consistent with circumstances, conditions, or hardships of such service, notwithstanding the fact that there is no official records of incurrence or aggravation in service. All reasonable doubt in this regard shall be resolved in favor of the veteran. The combat presumption may be rebutted by clear and convincing evidence to the contrary. 38 U.S.C. § 1154(b); 38 C.F.R. § 3.304(d). 1. Entitlement to service connection for an acquired psychiatric disorder, to include PTSD and major depressive disorder The Veteran contends that his psychiatric disorders are related to active service. Specifically, he reports that he was a combat Veteran who regularly received and returned enemy small fire, was in close proximity to mortar attacks, and saw numerous dead bodies, some of whom were his friends, during his service in Vietnam. After a review of all the evidence of record, the Board concludes that the Veteran's current psychiatric disorders, to include PTSD and major depressive disorder, are related to active duty service. As an initial matter, the Regional Office (RO) conceded that the Veteran's credible lay testimony, military occupational specialty as a wheel vehicle mechanic, and Vietnam Service Medal with two bronze stars establishes occurrence of the claimed stressor, as the Veteran's service in Vietnam placed him in an area of hostile military activity. Next, the medical evidence of record demonstrates that the Veteran has current diagnoses of PTSD and major depressive disorder. Specifically, he had a positive PTSD screening in March 2019, and he submitted a private physician's disability benefits questionnaire in October 2021 confirming that the Veteran has a PTSD diagnosis in accordance with the DSM-V. Furthermore, an October 2019 VA examiner diagnosed the Veteran with major depressive disorder and noted that he has been receiving treatment with antidepressants from his primary care doctor. Next, in the October 2021 disability benefits questionnaire, the Veteran's private physician opined that it is more likely than not that the Veteran's PTSD is related to service because the Veteran reported that he began to experience intrusion symptoms, advance symptoms, negative alterations in cognitions and mood, and alterations in arousal and reactivity after experiencing the in-service stressors. The examiner found the Veteran's statements credible and consistent with the conditions of combat and noted that the DSM-V states that PTSD symptoms can be delayed years before criteria of the diagnosis are met. Furthermore, the Veteran's mental health treatment in the record, which requires treatment with medication, is consistent with a finding that his delayed onset PTSD is related to active service. Additionally, the private physician opined that it is more likely than not that the Veteran's major depressive disorder with anxious distress is proximately due to the Veteran's service-connected hearing loss. The physician noted that ample medical research has substantiated that hearing loss is associated with significant psychological and medical morbidity, including social isolation, frailty, and falls, and that hearing impairment is linked to cognitive decline in adults. Furthermore, the physician stated that the Veteran does not have other risk factors contributing to his current depression. As such, the preponderance of the evidence supports that the Veteran's acquired psychiatric disorders, including PTSD and major depressive disorder, are likely related to active service. In making this decision, the Board considered the negative evidence of record, including March 2013 and October 2019 VA examiners' opinions. However, the March 2013 VA examiner based their opinion that the Veteran does not have a diagnosis of PTSD on the DSM-IV, which is no longer applicable. Additionally, the October 2019 VA examiner did not discuss all of the Veteran's reported symptoms contained throughout the record or reported by the Veteran's wife. As such, these opinions lack probative value. Ultimately, affording the Veteran the benefits of the doubt, service connection for an acquired psychiatric disorder, to include PTSD and major depressive disorder, should be granted. 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. REASONS FOR REMAND 1. Entitlement to service connection for hypertension, to include as due to toxic herbicide agent exposure, or as secondary to a service-connected acquired psychiatric disability, is remanded. The Veteran claims he is entitled to service connection for hypertension due to either exposure to Agent Orange during service in Vietnam or secondary to his service-connected depression and/or PTSD. While the Board regrets further delay, a remand for an addendum opinion is necessary. The Veteran underwent an October 2019 VA examination, and the VA examiner provided a nexus opinion with thorough supporting rationale concerning whether the Veteran's hypertension is related to Agent Orange exposure. The examiner also provided an opinion as to whether the Veteran's hypertension is caused or aggravated by his service-connected acquired psychiatric disorders. However, the examiner supported their opinion, in part, by stating that medical literature does not show evidence of direct etiological or causational link between PTSD or other mental health disorders and the development of hypertension. After the October 2019 VA examination, the Veteran submitted a medical study in June 2020 indicating that hypertension rates were higher in individuals with either PTSD or PTSD and depression. As a result, an addendum opinion is required. The matters are REMANDED for the following action: 1. The RO should obtain any updated VA treatment records and associate them with the claims file. 2. Return the claims folder to the examiner who performed the October 2019 VA examination (or to another VA examiner if they are unavailable) for review, and obtain an addendum opinion as to the nature, extent, and etiology of the Veteran's hypertension. Based on a review of the record, the examiner should opine whether it is at least as likely as not (i.e. a 50 percent or greater probability) that the Veteran's hypertension is related to his active duty service, to include whether it is proximately due to or aggravated beyond its normal progression by his service-connected acquired psychiatric disorders, to include PTSD and/or major depressive disorder. It would be most helpful if the examiner considers and discusses the medical research articles and studies provided by the Veteran which suggest a connection between hypertension and psychiatric disorders, including PTSD and depression. A new examination is not necessary unless deemed so by the examiner. B.T. KNOPE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Veltri, Associate Counsel