Citation Nr: 21008127 Decision Date: 02/11/21 Archive Date: 02/11/21 DOCKET NO. 14-36 651 DATE: February 11, 2021 ORDER Entitlement to service connection for posttraumatic stress disorder (PTSD) is denied. REMANDED Entitlement to service connection for a psychiatric disorder other than PTSD, to include Major Depressive Disorder (MDD), to include as secondary to the service-connected right knee disability, is remanded. FINDING OF FACT The preponderance of the evidence of record is against finding that the Veteran has a diagnosis of PTSD at any time during or approximate to the pendency of the claim. CONCLUSION OF LAW The criteria for entitlement to service connection for PTSD have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Navy from April 1976 through November 1976. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a December 2012 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). This issue was originally before the Board in April 2018, when it was remanded for a VA examination and nexus opinion. When the issue was returned to the Board, it was again remanded in a December 2019 opinion because the Veteran did not receive notice of the scheduled VA examination and therefore the remand instructions were not satisfied. The Board finds there was substantial compliance with the December 2019 remand instructions. Stegall v. West, 11 Vet. App. 268, 271 (1998). Entitlement to service connection for PTSD is denied. The Veteran contends that he is entitled to service connection for a psychiatric disorder, to include PTSD, due to a right knee injury sustained in service. In particular, during service, while carrying a floor buffer up a flight of stairs with another servicemember, the equipment fell and pinned the Veteran’s right knee causing damage. This incident eventually led to a medical discharge. The Veteran claims he has PTSD from this incident specifically, and from his fear of treatment by the Navy doctors subsequent to his injury. As will be shown below, the Veteran has never been diagnosed with PTSD and, therefore, service connection for PTSD is not warranted. Service connection may be granted for a disability resulting from personal injury suffered or disease contracted in the line of duty, or for the aggravation of a pre-existing injury or disease in the line of duty. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Establishing a service connection generally requires (1) evidence of a current disability, (2) an in-service incurrence or aggravation of an injury or disease, and (3) a causal connection or “nexus” between the claimed in-service injury or disease and the current disability. Shedden v. Principi, 381 F.3d. 1163, 1166-67 (Fed. Cir. 2004). With respect to psychiatric disabilities, VA has expressly limited compensation to disabilities conforming to a Diagnostic and Statistic Manual of Mental Disorders, Fifth Edition (DSM-5) diagnosis. 38 C.F.R. § 4.125(a); see also Martinez-Bodon v. Wilkie, 32 Vet. App. 393 (2020) (holding the Court lacked jurisdiction to review or otherwise disturb the Secretary’s decision to require a DSM-5 diagnosis for psychiatric disabilities as set out in the schedule of ratings). Service connection for PTSD specifically requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a) (i.e., in accordance with DSM-5); 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). In addition to direct service connection, a Veteran may claim secondary service connection for a disability that is proximately caused by, or aggravated by, a service-connected disease or injury. 38 C.F.R. § 3.310(a). To establish entitlement on a secondary basis, the claimant must show that (1) there is evidence of a current disability; (2) there is a different service connected disability; and (3) there is a causal connection, or “nexus” between the service-connected disability and the current disability, showing either a causation or an aggravation of the current disability. See Allen v. Brown, 7 Vet. App, 439 (1995). The Veteran has no diagnosis of PTSD included in the claims file. As part of his mental health treatment, the Veteran received negative PTSD screens in February 2012, November 2016, November 2017, August 2018 and November 2018. The July 2020 VA examination also provided a negative diagnosis for PTSD. The Veteran claims he has nightmares about the accident in service, but when asked about the nightmares in the July 2020 VA examination, the Veteran reported that he could not remember the nightmares or what they were about. The Veteran also stated that he was afraid of the Navy doctors performing surgery on his knee and preferred to have treatment by a private physician with whom he was already familiar. The Veteran did not receive other medical treatment during service to show if this fear was isolated to his knee or the Navy doctors more generally, but he has continued to receive treatment since discharge at VA medical centers. Again, service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a) (i.e. in accordance with DSM-5). In this case, the Veteran has been provided with multiple PTSD screenings and a VA examination and he has not been found to meet the PTSD criteria at any time during the appeal. Thus, service connection for PTSD is denied. See id.; see also Martinez-Bodon, 32 Vet.App. 393. REASONS FOR REMAND With regards to the Veteran’s other acquired psychiatric claim, aside from PTSD, although the Board regrets to further delay adjudication of the Veteran’s claim, it appears there may be outstanding records relevant to this claim and, therefore, a decision cannot be made at this time. Unlike the PTSD claim, the record does reflect a current diagnosis of MDD in 2018, 2019, and again in the VA examination in January 2020. Previous medical records list depression as well as MDD, back to roughly 2011. Although none of these records associate the Veteran’s diagnosis to service or his service-connected right knee disability, the negative nexus opinions rendered were largely based on the lack of in-service mental health symptomatology or ongoing mental health problems since service. In contrast, there are records that suggest the Veteran had two hospital stays for suicidal ideation in or around 1980, a few years after active duty. Those specific hospitalization records are not included in the claims file. Therefore, a remand is necessary to make efforts to obtain these identified records. The matters are REMANDED for the following action: 1. Ask the Veteran to identify the hospital facility or facilities where he had two hospital stays for suicidal ideation in or around 1980. If they are VA facilities, obtain the VA records and any subsequent treatments as indicated by the Veteran. If they are private facilities, ask the Veteran to complete a VA Form 21-4142 for the identified facilities. Make two requests for the authorized records from the identified facilities, unless it is clear after the first request that a second request would be futile. 2. After the above development, and any additionally indicated development, has been completed, readjudicate the issue on appeal. Shereen M. Marcus Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Boivin, 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.