Citation Nr: 21006380 Decision Date: 02/04/21 Archive Date: 02/04/21 DOCKET NO. 17-16 384 DATE: February 4, 2021 ORDER Entitlement to service connection for an acquired psychiatric disorder, diagnosed as a chronic adjustment disorder with disturbance of mood and conduct and unspecified delusional disorder, is granted. FINDING OF FACT The Veteran’s acquired psychiatric disorder, diagnosed as a chronic adjustment disorder with disturbance of mood and conduct and unspecified delusional disorder, is related to his active service. CONCLUSION OF LAW The criteria for entitlement to service connection for an acquired psychiatric disorder, diagnosed as a chronic adjustment disorder with disturbance of mood and conduct and unspecified delusional disorder, have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from May 1969 to January 1972. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a May 2016 rating decision. In September 2019, the Veteran and a witness testified before the undersigned Veterans Law Judge (VLJ) at a hearing. A transcript of that hearing is of record 1. Entitlement to service connection for acquired psychiatric disorder, diagnosed as a chronic adjustment disorder with disturbance of mood and conduct and unspecified delusional disorder, is granted. For the reasons discussed below, the Board finds that service connection is warranted for an acquired psychiatric disorder, diagnosed as a chronic adjustment disorder with disturbance of mood and conduct and unspecified delusional disorder. Service connection means that a veteran has a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge when the evidence shows that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110. Establishing service connection generally requires competent medical or lay 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. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence on any issue material to the claim. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102 (providing, in pertinent part, that reasonable doubt will be resolved in favor of the claimant). When the evidence supports the claim, or is in relative equipoise, the claim will be granted. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990); see also Wise v. Shinseki, 26 Vet. App. 517, 532 (2014). If the preponderance of the evidence weighs against the claim, it must be denied. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). An October 2019 psychological evaluation completed by a private licensed psychologist shows that the Veteran has current diagnoses of adjustment disorder with disturbance of mood and conduct and unspecified delusional disorder. The evaluation states that during the Veteran’s active service he stated that he sometimes had to act as a driver. In one particular instance, he had to transport a service member accused of threatening a Sergeant with an axe to a stockade. The accused service member sat in the backseat of the vehicle and did not threaten the Veteran. The Veteran reported it was a frightening situation for him and was far outside his experiences. An October 2015 VA Psychiatry Consult demonstrates that the Veteran reported having nightmares, flashbacks, hypervigilance, isolation, and crow-avoidance since his separation from active service that relate to a specific trauma that occurred during his active service in which he witnessed another member of the Army attack his Sergeant with a fire axe. He was subsequently tasked with driving the attacker from their base to a stockade in Germany approximately 100 miles away without protection from accused. The Veteran described constantly looking in his rear-view mirror while transporting the attacker and being fearful that he would be attacked. The Veteran is competent to report events of which he has personal knowledge of facts and circumstances that can be observed and described by a lay person. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). Thus, the Board finds that the Veteran is competent to report the above-noted driving incident during his active service as he is capable of describing an event that he states he personally experienced. The Veteran’s statements concerning the driving event have been essentially internally consistent, facially plausible, and consistent with other evidence submitted on his behalf. Caluza v. Brown, 7 Vet. App. 498 (1995). In support, the Veteran’s statements concerning the above incident have been internally similar throughout his appeal. See October 2015 VA Form 21-0781, Statement in Support of Claim for Service Connection for Post-Traumatic Stress Disorder (PTSD); see also September 2019 Hearing Transcript. His service treatment records, and service personnel records demonstrate that he was stationed in Germany during this time period. The Veteran has also provided the same general facts concerning the in-service driving event to his VA treatment providers. See White v. Illinois, 502 U.S. 346, 356, 112 S. Ct. 736 (1992) (statements made for the purpose of medical diagnosis or treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive a proper diagnosis or treatment); Rucker, 10 Vet. App. at 73 (observing that, although formal rules of evidence do not apply before the Board, recourse to the Federal Rules of Evidence may be appropriate if it assists in the articulation of the reasons for the Board’s decision). Thus, the Board finds the Veteran’s statements concerning the in-service driving event to be credible, as they are consistent with the evidence of record and the circumstances of his service. See 38 U.S.C. § 1154(a); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The October 2019 psychological evaluation provides that the Veteran reports chronic symptoms of difficulties with adjustment, including depression, isolation, irritability, mistrust in authority, and difficulties with responsibilities that began after the above-described driving event during his active service. Therefore, his chronic adjustment disorder with disturbance of mood and conduct is related to his military service events. The psychological evaluation further states that since witnessing the distressing incident, the Veteran has had high levels of paranoia, along with some grandiosity, that at this time have become entrenched and severe enough to warrant a diagnosis of delusional disorder. Thus, the Veteran’s delusional disorder is more likely than not related to his military service events and began during his military service. The Board finds the October 2019 private medical opinion to be especially probative as it represents as it represents the informed conclusion of a medical professional supported by a thorough explanation and based on an interview with the Veteran, a review of his medical history, and the symptomatology reflected in the medical and lay evidence of record. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (the probative value of a medical opinion comes from its reasoning); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (“[A] medical opinion must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions.”) Of note, the examiner advised that he spent 10 hours preparing the evaluation, including the interview, record review, and writing the report. The Board notes that the Veteran’s claims folder does not contain medical opinion disassociating his adjustment disorder with disturbance of mood and conduct or his unspecified delusional disorder with his active service. The Board notes that the Veteran’s VA treatment records indicate that he has a diagnosis of PTSD under the DSM-5. However, these diagnoses were provided after the Veteran reported that he witnessed the above-referenced axe attack on his Sergeant. The Veteran later clarified that he did not witness the event. See October 2019 Psychological Evaluation. Therefore, these diagnoses of PTSD are afforded no probative value as they were based upon an inaccurate factual history. Further, the October 2019 psychological examiner concluded that the Veteran did not meet the criteria for a diagnosis of PTSD as the stressful event he experienced in service does not rise to the level of a criterion A stressor and because he did not report current symptoms that meet the criteria for PTSD. See 38 U.S.C. §§ 3.304(f); 4.125(a). Thus, the preponderance of the evidence weighs against a diagnosis of PTSD. In sum, the preponderance of the evidence weighs in favor of service connection for an acquired psychiatric disorder, diagnosed as an adjustment disorder with disturbance of mood and conduct and unspecified delusional disorder. In the absence of any probative evidence to the contrary, entitlement to service connection is granted. Consequently, the benefit-of-the-doubt rule does not apply. See 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102; Gilbert, 1 Vet. App. at 55. P.M. DILORENZO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Sean Mussey, 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.