Citation Nr: 21010212 Decision Date: 02/24/21 Archive Date: 02/24/21 DOCKET NO. 16-47 412 DATE: February 24, 2021 ORDER The claim of entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) and major depressive disorder (MDD), is granted. FINDING OF FACT The Veteran’s acquired psychiatric disorder, to include PTSD and MDD, is related to his active duty service. CONCLUSION OF LAW The criteria for entitlement to service connection for an acquired psychiatric disorder have been met. 38 U.S.C. §§ 1110, 1154; 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2019). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had honorable active duty service in the United States Army from January 1988, to April 1991 and in the Army Reserves from February 2003 to April 2004, from June 2006 to November 2006 (Active Duty for Training), from June 2009 to June 2010 and from May 4, 2015, to May 15, 2015. He received the Global War on Terrorism Service Medal and Army Service Ribbon, among other notable commendations. This matter comes before the Board of Veterans’ Appeals (Board) from rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). In June 2013, the RO denied the Veteran’s initial claim of entitlement to service connection for PTSD. In November 2014 the RO denied the Veteran’s separate claim of entitlement to service connection for anxiety and depression, and again denied entitlement to service connection for PTSD. While the Veteran’s claim has previously been listed as two separate claims for psychiatric conditions, the Court of Appeals for Veterans Claims (Court) has held that a claim of service connection encompasses all pertinent symptomatology, regardless of how that symptomatology is diagnosed. Clemons v. Shinseki, 23 Vet. App. 1 (2009). As such, in light of Clemons and the current evidence of record, the issue on appeal has been expanded and recharacterized as reflected above. The Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge (VLJ) in December 2020. A written transcript of the hearing has yet to be associated with the claims file, however, there is no prejudice in proceeding without the transcript because the Board is granting the claim in full. 1. The claim of entitlement to service connection for an acquired psychiatric disorder, to include PTSD and MDD. The Veteran contends his psychiatric conditions are causally related to his active duty service. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Service connection for PTSD, specifically, requires: (1) medical evidence establishing a clear diagnosis of PTSD; (2) credible supporting evidence that the claimed in-service stressor actually occurred; and (3) a link, established by medical evidence, between current symptoms and the in-service stressor. 38 C.F.R. § 3.304(f). In PTSD claims, the Board is required to evaluate evidence based on places, types, and circumstances of service, as shown by military records and all pertinent medical and lay evidence. See Hayes v. Brown, 5 Vet. App. 60, 66 (1993); see also 38 U.S.C. § 1154(a); 38 C.F.R. § 3.304(f). As to claims made by combat veterans, such as the Veteran in this case, VA shall accept as sufficient proof of service-connection of any disease or injury alleged to have been incurred in or aggravated by such service satisfactory lay or other evidence of service incurrence or aggravation of such injury or disease, if consistent with the circumstances, conditions, or hardships of such service, notwithstanding the fact that there is no official record of such incurrence or aggravation in such service and, to that end, shall resolve every reasonable doubt 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). The combat presumption must be applied to two questions: (1) whether the claimed in-service injurious event occurred and (2) whether the claimed disability itself occurred while in service. See Reeves v. Shinseki, 682 F.3d 988, 999 (Fed. Cir. 2012). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive and provide the reasons for its rejection of any material evidence favorable to the veteran. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Board determinations with respect to the weight and credibility of evidence are factual determinations going to the probative value of the evidence. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. In the present matter, the Board concludes that the Veteran has a current psychiatric disability, to include PTSD and a depressive disorder, related to his active duty service, specifically, due to his combat exposure. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). First, the Board notes that the credible and probative evidence of record shows that the Veteran has a current diagnosis of PTSD, and a history of diagnoses of mood disorders including depression and anxiety. See e.g., April 2018 PTSD Disability Benefits Questionnaire (DBQ); August 2016 PTSD Residential Rehabilitation Treatment Program Referral. Next, the Board notes that there is credible supporting evidence that the Veteran’s claimed in-service stressor actually occurred. The Veteran’s November 1987 Report of Medical Examination shows that he did not have an identified psychiatric condition at his enlistment. The Veteran’s lay statements of record competently and credibly establish that he was exposed to combat during his active service in that he experienced “direct mortar attacks, exposure to individuals who were injured” or killed, as well as daily chaos and regular sniper attacks. See e.g., August 2016 PTSD Residential Rehabilitation Treatment Program Referral. The Veteran’s descriptions of in-service events are consistent with the circumstances, conditions, and hardships of such service in the Gulf War. In February 2004, during a period of his foreign service and a day before he was scheduled to travel to Kuwait, the Veteran was seen for complaints of confusion, lack of concentration, and lack of patience; he further reported having trouble sleeping and experiencing anxiety and depression. On this and other occasions throughout and between his years of active service, the Veteran complained of psychiatric symptoms. As such, the Board concludes that an in-service event occurred, and specifically that the combat presumption applies. Finally, the Board finds that the Veteran’s claimed psychiatric condition is etiologically related to his active duty service. The evidence of record reflects that the Veteran received ongoing mental health treatment since approximately 2006, to include inpatient psychiatric treatment. The Veteran’s treatment records show that he was diagnosed with PTSD and depression at least as early as 2007. See October 2007 Mental Health Communication Note. By June 2011, the Veteran reported feelings of despair and extreme irritability, which led to physical altercations. He was assessed with depressive disorder, not otherwise specified. As part of the development for the instant claims, the Veteran was provided a VA examination in April 2018, at which time he was diagnosed with PTSD, and no other psychiatric conditions. The examining psychologist persuasively opined that it was at least as likely as not that the Veteran’s PTSD “could be traced back to the noted traumatic events during the deployment to Iraq than to any other traumatic events claimant has identified in the medical records.” The Board finds this examination report and accompanying opinion to be probative evidence in support of the Veteran’s service connection claim. This examiner conducted a thorough review of the Veteran’s psychiatric treatment history, of his service record, and of lay statements regarding the Veteran’s symptoms and combat exposure, and then the examiner provided a reasoned rationale for his medical conclusions. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). The Board acknowledges that the evidence of record contains some conflicting medical evidence that does not specifically attribute the Veteran’s mental health symptoms to his active service, such as a June 2009 pre-deployment examination, which concluded that the Veteran did not have “a mental health condition which would warrant suspending the mobilization process,” and a March 2013, VA examination report that stated that the Veteran did not meet diagnostic criteria for PTSD, however, the Board finds these conclusions less probative as the examiners did not conduct full review of the Veteran’s pertinent psychiatric treatment history or adequately acknowledge his post-deployment complaints of psychiatric symptoms. (Continued on the following page.) Upon review of the record, the Board finds the preponderance of the evidence establishes that the Veteran’s current acquired psychiatric disorder is related to his active service. Accordingly, the Board finds that service connection for an acquired psychiatric disorder, to include PTSD and MDD is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. B. MULLINS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Hart, 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.