Citation Nr: 21010499 Decision Date: 02/25/21 Archive Date: 02/25/21 DOCKET NO. 16-29 080 DATE: February 25, 2021 ORDER Entitlement to service connection for posttraumatic stress disorder (PTSD) is denied. FINDING OF FACT The preponderance of the evidence of record is against finding that the Veteran has, or has had at any time during the appeal, a current diagnosis of PTSD. CONCLUSION OF LAW The criteria for service connection PTSD are not met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), 3.304. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from February 1970 to December 1973. The Board of Veterans’ Appeals (Board) remanded the claim in November 2019 to the Department of Veterans Affairs (VA) Agency of Original Jurisdiction (AOJ). On remand, the AOJ granted service connection for bipolar disorder. See September 2020 AOJ rating decision. As such, that issue is no longer on appeal and before the Board for appellate review. Further, as the actions specified in the remand have been completed, the remaining matter has been properly returned to the Board for appellate consideration. See Stegall v. West, 11 Vet. App. 268 (1998). Service Connection Service connection will be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 1153; 38 C.F.R. §§ 3.303, 3.304, 3.306. 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). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection for PTSD specifically requires that the record show: (1) a current medical diagnosis of PTSD in accordance with 38 C.F.R. § 4.125 (a) (requiring mental disorder diagnoses to conform with the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)); (2) combat status or credible supporting evidence that the claimed in-service stressor actually occurred; (3) medical evidence of a causal nexus between diagnosed PTSD and the claimed in-service stressor. 38 C.F.R. § 3.304 (f). Reasonable doubt concerning any matter material to the determination is resolved in the Veteran’s favor. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. Entitlement to service connection for an acquired psychiatric disorder The Veteran contends that he has PTSD related to his military service. The question for the Board is whether the Veteran has a current psychiatric disability (other than bipolar disorder) and specifically, PTSD, that began during service or is at least as likely as not related to an in-service injury, event, or disease. As noted above, service connection has been established for bipolar disorder, effective June 3, 2013. The Board concludes that the Veteran does not have a current diagnosis of PTSD, and has not had one at any time during the pendency of the claim or recent to the filing of the claim. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Insomuch as the Veteran has attempted to establish a diagnosis of PTSD through his own lay assertions, the Board finds that the Veteran is not competent to provide a current diagnosis of such due to the medical complexity of the matter. See Jandreau v. Nicholson, 492 F.3d 1372, 1377, n.4 (Fed. Cir. 2007) (“sometimes the layperson will be competent to identify the disability where the disability is simple, for example a broken leg, and sometimes not, for example, a form of cancer”). Thus, the Veteran is not competent to render such a diagnosis. The Veteran’s service treatment records are silent of complaints, a diagnosis, or treatment of any psychiatric disorder. Notably, his January 1970 and October 1973 Reports of Medical History revealed no depression or excessive worry, nervous trouble, loss of memory, suicide attempts, or frequent trouble sleeping. In August 2017, the Veteran was diagnosed with PTSD and bipolar disorder by a private psychologist. The psychologist noted that the Veteran was relatively stable on medication with occasional bouts of sleepiness that appear to present as manic episodes. His insights appeared intact and his thought processes were linear. No rationale was provided for the diagnoses, nor were any tests referred to in the psychologist’s letter. Therefore, the Board finds this opinion of little probative value. At his August 2019 Board hearing, the Veteran testified that while serving in Vietnam, rockets and mortars were fired at him. He reported drug and alcohol abuse since his service. The Veteran had not had many friends and noted irritability with others. He reported being recently diagnosed with PTSD after talking to a private psychologist and noted that he had been treated for bipolar disorder for years. In December 2019, the Veteran underwent a VA examination for PTSD. The examiner indicated that the Veteran did not have a diagnosis of PTSD that conformed to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5). He was diagnosed with bipolar disorder with alcohol use disorder in sustained remission. The examiner noted that the August 2017 private examination and opinion was “very brief, superficial, and lacked proper medical documentation supporting either diagnosis.” The Veteran’s symptoms included depressed mood, anxiety, suspiciousness, chronic sleep impairment, impaired judgement, impaired abstract thinking, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, and an inability to establish effective relationships. The examiner opined that based on the Veteran’s psychiatric history and symptoms that his condition does not meet the DSM-5 criteria for a diagnosis of PTSD. He explained that the Veteran’s reported stressors met the PTSD criterion A; however, the Veteran does not have symptoms attributable to the stressors. Therefore, he did not criteria B, C, D, E, F, G, which all must be met for a diagnosis of PTSD to be made. In July 2020 and August 2020, the Veteran reported, during VA primary care calls, that he was taking medication to treat his bipolar disorder, but that he felt that he needed to treat his PTSD. The psychiatrist informed the Veteran that bipolar disorder is a serious mental illness and could effectively be treated with medication. Importantly, service connection may only be granted for a current disability; when a claimed disability is not shown, there may be no grant of service connection. See 38 U.S.C. §§ 1110, 1131; Rabideau v. Derwinski, 2 Vet. App. 141 (1992) (Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability). “In the absence of proof of a present disability there can be no valid claim.” See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Here, the record contains no current diagnosis of an acquired psychiatric disorder, other than his service-connected bipolar disorder, and as the Veteran is not currently diagnosed with PTSD per DSM-5, his service connection claim must be denied. As there is no current disability, a discussion of any in-service incurrence or aggravation of a disease or injury, or nexus, is unnecessary. Entitlement to service connection for PTSD is denied. In reaching the above conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C. § 5107 (b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). S. L. Kennedy Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Costello, 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.