Citation Nr: 21010389 Decision Date: 02/24/21 Archive Date: 02/24/21 DOCKET NO. 15-39 076 DATE: February 24, 2021 ORDER Entitlement to service connection for an acquired psychiatric disorder, diagnosed as posttraumatic stress disorder (PTSD), is granted. FINDING OF FACT The Veteran’s PTSD is related to a verified in-service stressor. CONCLUSION OF LAW An acquired psychiatric disorder, diagnosed as PTSD, was incurred in active service. 38 U.S.C. § 1110; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 4.125. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from September 1966 to September 1969. This case comes before the Board of Veterans’ Appeals (Board) on appeal from a September 2014 rating decision by the Department of Veterans Affairs (VA). A hearing was held before the undersigned Veterans Law Judge in May 2019. A transcript of the hearing is of record. In an August 2019 decision, the Board denied the above claim, as well as another claim that was on appeal. The Veteran appealed the Board’s decision to the United States Court of Appeals for Veterans Claims (Court). In May 2020, the Court granted an April 2020 Joint Motion for Partial Remand (Joint Motion) filed by the parties and remanded the above claim to the Board. The Board remanded the case for further development in October 2020. The requested development has been completed, and the case has since been returned to the Board for appellate review. Law and Analysis Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty in the active military, naval, or air service. 38 U.S.C. §§ 1110, 1131. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection for PTSD 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 evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits. VA shall consider all information and lay and medical evidence of record in a case and when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the weight of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that service connection is warranted for an acquired psychiatric disorder, diagnosed as PTSD. The Veteran has contended that he developed a psychiatric disorder as a result of his military service, including fearing for his life due to being on full alert battle mode and constantly monitoring military forces of the Soviet Union, whom he feared may attack him. See, e.g., January 2014 written statement; October 2014 notice of disagreement; and October 2015 substantive appeal. The agency of original jurisdiction (AOJ) conceded this in-service stressor related to fear of hostile military activity, a finding that was confirmed by the Board for detailed reasons in its August 2019 decision that remain applicable for this decision. See also September 2015 statement of the case; March 2015 and December 2020 VA examination reports and 38 C.F.R. § 3.304(f)(3). The Veteran’s service treatment records show that he was found to be psychiatrically normal at the time of the September 1966 entrance examination and the April 1969 separation examination, and he denied a history of relevant symptoms on the corresponding reports of medical history. The post-service evidence indicates that he has received current mental health diagnoses. See, e.g., VA treatment records from June 2013 (initial VA treatment evaluation several months before claim; noted demonstrated depressive disorder, anxiety disorder, and mild residual PTSD symptoms with diagnoses of first two disorders), August 2013 (continued diagnoses from same provider), and April 2016 (anesthesia pre-evaluation note with active problem list including PTSD); VA examination and private evaluation reports detailed below. In addition, the Board finds that the Veteran has PTSD that is related to the verified in-service stressor. In this regard, the March 2015 VA examiner determined that the Veteran’s reported stressor was related to fear of hostile military activity, but he did not meet the full criteria required for a PTSD diagnosis, considering both the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) and the DSM-5 (Fifth Edition). The examiner also determined that the Veteran had a diagnosis of other specified trauma- [and stressor-] related disorder but did not provide an etiology opinion related to that diagnosis. In a December 2018 private evaluation, Dr. K.D. diagnosed the Veteran with depressive disorder that he determined was either caused or aggravated by unspecified physical and emotional trauma during military service. In so doing, he referenced the March 2015 VA examination report, noting that it supported the Veteran’s disability claim, but he did not discuss any established in-service events to support his determination of a nexus in providing the opinion. The Board notes that the Veteran’s May 2019 hearing testimony that he had an in-service head injury as a possible event to relate his current mental health diagnoses to (also noted in the history portion of this report) is inconsistent with the contemporaneous record showing that he was treated in October 1966 for a skin laceration after a report of being hit on the nose, including an x-ray to rule out a possible nose fracture that was negative. In the April 1969 separation report of medical history, he denied a history of head injury, and he specifically reported incurring no head injuries in service during the June 2013 VA mental health appointment several months prior to filing his claim. Based on the foregoing, the Board finds that this medical opinion has limited, if any, probative value. See Curry v. Brown, 7 Vet. App. 59, 68 (1994) (holding that contemporaneous evidence has greater probative value than history as reported by a claimant); see also Reonal v. Brown, 5 Vet. App. 458, 460-61 (1993); Swann v. Brown, 5 Vet. App. 229, 233 (1993); Black v. Brown, 5 Vet. App. 177, 180 (1993) (an opinion based on an inaccurate (or unsubstantiated) factual premise has limited, if any, probative value) and Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning). In a July 2020 private evaluation, Dr. B.V. noted agreement with the March 2015 VA examiner that the Veteran met the DSM-5 criteria for a diagnosis of other specified trauma- and stressor-related disorder and determined that it was more likely than not that the disorder was the result of the Veteran’s reported stressor. In so finding, he indicated that there were no post-military traumatic incidents to account for this disorder. The Board requested a new VA examination and medical opinion on review of the record and in light of the Joint Motion. The December 2020 VA examiner determined that the Veteran’s reported stressor was related to his fear of hostile military activity and adequate to support the diagnosis of PTSD, and that he did meet the full criteria required for a PTSD diagnosis. The examiner determined that it was at least as likely as not that the Veteran’s PTSD was incurred in or caused by the claimed in-service injury, event, or illness. In so finding, he noted consideration of the Veteran’s in-service circumstances and post-service mental health problems and indicated that his PTSD was clearly related to the reported stressor. The examiner’s determination, which addresses the central medical issues in this case, was based on an analysis of the evidence and current medical understanding, and it is therefore entitled to probative weight. See Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012) (an examination is not rendered inadequate where the rationale provided by an examiner “did not explicitly lay out the examiner's journey from the facts to a conclusion”); Acevedo v. Shinseki, 25 Vet. App. 286, 294 (2012) (medical reports must be read as a whole and in the context of the evidence of record). The content of the March 2015 VA examination and July 2020 private evaluation reports also supports such a determination as to this relationship. Based on the foregoing, the Board concludes that service connection is warranted for PTSD. In reaching this decision, the Board acknowledges that the Veteran’s diagnosis has been variously identified. However, the benefit sought on appeal is granted in a manner consistent with the fact that the most probative evidence shows that the PTSD diagnosis is the proper diagnosis for the service-related mental health disorder. The other specified trauma- and stressor-related disorder was provided in the context of the Veteran not meeting the full criteria required for a PTSD diagnosis (i.e., as a subthreshold PTSD diagnosis); however, the December 2020 VA examiner determined that the Veteran did, in fact, meet the complete criteria based on his presentation. The December 2018 private evaluation in which Dr. K.D. diagnosed depressive disorder lacks probative value on the question of etiology, as discussed above. The VA treatment records indicating that the Veteran may have depressive disorder and anxiety disorder do not provide a nexus to his service. In fact, the August 2013 VA treatment record indicates that the Veteran and his wife were able to attribute his current mood to his fear of an approaching medical exam and their financial difficulty in travel expenses incurred with his medical appointments, which are nonservice-related factors. Moreover, the March 2015 and December 2020 VA examiners determined that the Veteran’s symptoms included a depressed mood and anxiety, for which Dr. B.V. agreed in the July 2020 private evaluation report. The single evaluation assigned for the psychiatric disability contemplating this symptomatology would be assigned under the same rating criteria. Finally, the request to consider entitlement to a total disability rating based on individual unemployability (TDIU) from the Veteran’s representative in the June 2019 written appellate brief remains an issue not before the Board; the issue may be addressed by the AOJ if indicated after effectuating the grant of service connection in this decision. MICHELLE L. KANE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Postek, 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.