Citation Nr: 21006474 Decision Date: 02/04/21 Archive Date: 02/04/21 DOCKET NO. 15-16 319 DATE: February 4, 2021 ORDER Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), is granted. FINDING OF FACT The Veteran has a current diagnosis of PTSD; medical evidence links his current PTSD symptoms to an in-service stressor related to fear of hostile military or terrorist activity; and a VA-contracted psychiatrist and VA psychologists have confirmed that the claimed stressor is adequate to support a diagnosis of PTSD and that the Veteran’s symptoms are related to the claimed stressor. CONCLUSION OF LAW The criteria for entitlement to service connection for an acquired psychiatric disorder, to include PTSD, are met. 38 U.S.C. §§ 1110, 1154, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304(f)(3). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty with the United States Army from March 2003 to May 2004 and from February 2007 to February 2010, including service in Southwest Asia (Iraq), with subsequent Reserve service. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a December 2013 rating decision of an Agency of Original Jurisdiction (AOJ) of the Department of Veterans Affairs (VA). In June 2018, the Board broadened the Veteran’s claim to consider all psychiatric diagnoses of record and remanded this matter for additional development. In October 2020, the AOJ issued a rating decision that granted entitlement to service connection for a left knee disability. Thus, that issue is no longer before the Board, as the appeal as to that issue has been resolved in a manner that is fully favorable to the Veteran. If the Veteran disagrees with the effective date of service connection or initial rating assigned by the AOJ, he should seek review of that decision by filing the appropriate VA-promulgated form. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Service connection for PTSD requires (1) medical evidence diagnosing PTSD; (2) a link, established by medical evidence, between a Veteran’s present symptoms and an in-service stressor; and (3) credible supporting evidence that the claimed in-service stressor occurred. See 38 C.F.R. § 3.304(f). If a stressor claimed by the Veteran is related to his fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, 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). The Veteran asserts that his PTSD is related to military stressors during his service in Iraq. See, e.g., April 2019 VA Forms 21-0781 (Statements in Support of Claim for PTSD). The Board agrees. Initially, the Board observes that there has not been substantial compliance with the June 2018 remand directives, as the record does not show that the AOJ verified the Veteran’s specific dates of ACDUTRA and INACDUTRA. See June 2018 Board Remand at 4. Moreover, the AOJ did not attempt to verify the Veteran’s reported stressors. See id. at 4-5. However, remand to achieve substantial compliance is not warranted, as the present record supports a full grant of the benefit sought on appeal. In September 2019, the Veteran presented for an examination with a VA-contracted psychiatrist. The examiner diagnosed the Veteran with unspecified depressive disorder and explained that a PTSD diagnosis was not appropriate because, although the Veteran’s stressors were adequate to support a diagnosis of PTSD, his symptoms were not. See September 2019 Psychiatric Examination Report at 1 (Current Diagnoses), 5 (Remarks). The examiner noted that the Veteran had no history of hospitalization or emotional crisis. See id. at 3. The examiner opined that the Veteran’s unspecified depressive disorder was less likely than not due to his military service because there was no evidence of psychiatric complaints, treatment, or findings prior to military service, during military service, or within one year of military service. See September 2019 Psychiatric Opinion. Review of the record shows the Veteran was hospitalized for psychiatric symptoms for a week in July 2016. See July 18, 2016 VA Psychiatric Admission Evaluation Note; July 25, 2016 VA Psychiatry Note. The Board also notes a February 2008 Health Questionnaire during active duty where the Veteran reported feeling down, depressed, and hopeless with little interest or pleasure in doing things “nearly every day.” See February 2008 Health Questionnaire. The examiner’s report and opinion do not discuss this evidence. Here, the VA-contracted examiner’s medical opinion is entitled to no probative weight, as it is based on an inaccurate factual basis. Moreover, the Board observes that even if the examiner’s opinion was based on an accurate factual basis, the examiner mechanically applied rules without providing any rationale. However, as the examiner’s opinion that the Veteran’s stressors are adequate to support a diagnosis of PTSD does not relate to these deficiencies, the Board finds that this aspect of the examiner’s opinion is probative. Notwithstanding the examiner’s inadequate opinion, remand is unnecessary, as there is other evidence of record (discussed below) that supports a grant of the benefit sought on appeal. In this regard, a VA psychologist diagnosed the Veteran with co-morbid major depressive disorder (MDD) and PTSD with delayed expression. See April 3, 2019 VA Mental Health Note. Moreover, a VA psychologist previously diagnosed PTSD based on the Veteran’s report of mental health symptoms in 2004 following his return from duty in Iraq, with a significant factor noted as “exposure to war.” See August 16, 2016 Mental Health Note. Here, the evidence shows that all the criteria for service connection for PTSD pursuant to 38 C.F.R. § 3.304(f)(3) are met. There is a current diagnosis of PTSD by a VA psychologist. There is no reason to doubt the VA psychologist’s diagnosis was not in accord with the Diagnostic and Statistical Manual Version 5 (DSM-5) as required by 38 C.F.R. § 4.125(a). VA psychologists attribute the Veteran’s mental health symptoms to his military service in Iraq. The September 2019 VA-contracted psychiatrist confirmed that the Veteran’s claimed stressors were adequate to support a diagnosis of PTSD. The August 2016 VA psychologist noted that the Veteran’s symptoms are related to “exposure to war,” which demonstrates that the stressors are related to fear of hostile military or terrorist activity. The reported stressors are consistent with the places, types, and circumstances of the Veteran’s service in Iraq. Finally, there is no clear and convincing evidence that the Veteran’s stressors did not occur.   Thus, all the criteria for service connection for PTSD pursuant to 38 C.F.R. § 3.304(f)(3) are met. Accordingly, the appeal is granted. S. BUSH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D.M. Badaczewski, 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.