Citation Nr: 21009154 Decision Date: 02/19/21 Archive Date: 02/19/21 DOCKET NO. 17-48 421 DATE: February 19, 2021 ORDER Service connection for persistent depressive disorder is granted. FINDING OF FACT Resolving all doubt in favor of the Veteran, his currently diagnosed persistent depressive disorder is related to his military service. CONCLUSION OF LAW The criteria for service connection for persistent depressive 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 October 1965 to October 1968. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a rating decision issued in March 2016 by a Department of Veterans Affairs (VA) Regional Office (RO). In October 2020, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the record. At such time, the Veteran waived Agency of Original Jurisdiction (AOJ) consideration of the evidence associated with the record since the issuance of the July 2017 statement of the case. 38 C.F.R. § 20.1305(c). The undersigned also held the record open for 60 days for the submission of additional evidence, which was received in November 2020. 38 U.S.C. § 7105(e)(1). Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. Id. ; see also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff’d, 78 F.3d 604 (Fed. Cir. 1996) [(table)]. For PTSD, service connection requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a), 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). However, if a claimed stressor is related to the veteran’s 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). At his October 2020 Board hearing and in documents of record, the Veteran contends he has an acquired psychiatric disorder, to include PTSD, as a result of his service in the Republic of Vietnam. In this regard, the record reflects that he was stationed there from September 1966 to April 1967, and he alleges experiencing two particularly stressful events: (1) in October 1966, he was in the process of retrieving and transporting a deceased Army of the Republic of Vietnam (ARVN) service member’s coffin when he felt threatened when was surrounded by local villagers holding machetes, hoes, and tools, and (2) in February 1967, he assisted in unloading severely wounded fellow Marines from helicopters. VA treatment records dated in November 2015 reflect a notation by a nurse that the Veteran’s “current symptoms presented are consistent with PTSD” and, following a consultation with a social worker, a diagnostic impression of PTSD was rendered. However, following a review of the record, an interview with the Veteran, and a mental status examination, a January 2016 VA examiner determined that the Veteran did not meet the DSM-5 criteria for a diagnosis an acquired psychiatric disorder, to include PTSD. In this regard, while he found that the Veteran’s aforementioned reported in-service stressors were related to his fear of hostile military or terrorist activity and adequate to support a diagnosis of PTSD, the remaining criteria for such a diagnosis were not met. Subsequent VA treatment records dated through October 2019 continue to reflect a diagnosis of PTSD due to the Veteran’s service in Vietnam endorsed by a physician, but there was no discussion of the specific stressors that supported such diagnosis, as well as a diagnosis of depression. Furthermore, in November 2020, the Veteran underwent a psychological evaluation with a private psychologist, Dr. A-S. At such time, Dr. A-S conducted a review of the record, an interview with the Veteran, and a mental status examination with diagnostic testing. He also included an in-depth discussion of the Veteran’s experiences in Vietnam, and subsequent symptoms and functional impairment, and concluded that the Veteran met the diagnostic criteria for diagnoses of PTSD and persistent depressive disorder, which he found were more likely than not related to his military experiences in Vietnam. Based on the foregoing, the Board finds that service connection for PTSD is not warranted. Specifically, as the Veteran’s stressors are related to his fear of hostile military or terrorist activity coincident with his service in Vietnam, a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, must confirm that the claimed stressor is adequate to support a diagnosis of PTSD and that the veteran’s symptoms are related to the claimed stressor. 38 C.F.R. § 3.304(f)(3). However, as noted previously, the initial PTSD diagnosis in the Veteran’s VA treatment records was provided by a social worker and, while a physician subsequently endorsed such diagnosis due to his service in Vietnam, he did not identify the specific stressors that supported such diagnosis. Moreover, Dr. A-S is not a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted. Thus, the Board finds that the diagnoses of PTSD of record do not meet the regulatory criteria for the award of service connection for such disorder. However, as to the diagnosis of persistent depressive disorder, which was rendered subsequent to the January 2016 VA examination, the record reflects that the Veteran has been diagnosed with such disorder as evidenced by his VA treatment records beginning in October 2019 and Dr. A-S’s November 2020 evaluation. Furthermore, his service in the Republic of Vietnam has been confirmed, and Dr. A-S has opined that such disorder is related to such aspect of the Veteran’s military service. Notably, there is no medical opinion to the contrary. Thus, the Board resolves all doubt in favor of the Veteran and finds that his currently diagnosed persistent depressive disorder is related to his military service. Consequently, service connection for such disorder is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). A. JAEGER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. M. Kelly, 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.