Citation Nr: 21013720 Decision Date: 03/10/21 Archive Date: 03/10/21 DOCKET NO. 18-48 813 DATE: March 10, 2021 ORDER Entitlement to service connection for an acquired psychiatric disability, to include post-traumatic stress disorder (PTSD), is denied. FINDING OF FACT The preponderance of the evidence of record is against finding that the Veteran has had PTSD, or any other acquired psychiatric disability, other than alcohol dependence and abuse, at any time during or approximate to the pendency of the claim. CONCLUSION OF LAW The criteria for service connection for an acquired psychiatric disability, to include PTSD, are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from December 1965 to September 1967. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an April 2018 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). This appeal is advanced on the Board's docket pursuant to 38 C.F.R. § 20.902(c) (2019); 38 U.S.C. § 7107 (a)(2) (2012). Entitlement to service connection for PTSD The Veteran contends that he has PTSD that is related to service. Service connection may be granted for a 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 scope of a mental health disability claim includes any mental disability that may reasonably be encompassed by the claimant’s description of the claim, reported symptoms, and the other information of record. See Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). Thus the Board has recharacterized the claim as one for an acquired psychiatric disability, to include PTSD. Establishing service connection generally requires evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection for PTSD generally 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. See Cohen v. Brown, 10 Vet. App. 128, 139-43 (1997); 38 C.F.R. § 3.304(f). The Board must consider all the evidence of record and make appropriate determinations of competence, credibility and weight. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). When there is an approximate balance of positive and negative evidence regarding any material issue, reasonable doubt will be resolved in favor of the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Board concludes that the Veteran does not have a current diagnosis of PTSD, or a current diagnosis of any other acquired psychiatric disability (other than substance abuse which will be discussed below) 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). VA provided the Veteran an examination in April 2018. The examiner noted that the Veteran served in the Republic of Vietnam and reported exposure to direct gun fire, mortar attacks, witnessing friends killed in action, and carrying a deceased soldier. The examiner reported the Veteran’s experiences in Vietnam would be adequate as a PTSD stressor. The Board notes the Veteran’s description of his reported stressors is consistent with his receipt of a Combat Infantry Badge (CIB) for his combat service in Vietnam. Thus, an in-service stressor is conceded in this case. However, after conducting a thorough examination, the examiner determined the Veteran did not meet the full Diagnostic and Statistical Manual, fifth edition (DSM-5) criteria for PTSD because he did not have sufficient negative alterations in cognition and mood associated with the traumatic events, beginning or worsening after the traumatic event occurred; sufficient marked alterations in arousal and reactivity associated with the traumatic events, beginning or worsening after the traumatic event occurred; the disturbances noted in the DSM-5 criteria B, C, D, and E did not last more than one month in duration; and the disturbances did not cause clinically significant distress or impairment in social, occupation, or other important areas of functioning. During the April 2018 examination, the Veteran reported hypervigilance; being mistrustful and suspicious of others since his service in Vietnam; attempting to avoid thinking about Vietnam but experiencing strong emotional reactions and intrusive memories related to the war; experiencing nightmares related to his service when he first returned from Vietnam; and experiencing short term memory and concentration issues. The examiner, after reviewing the Veteran’s medical records and providing an in-person examination, concluded the Veteran did not meet the DSM-5 criteria for a PTSD diagnosis or any other acquired psychiatric disability. To support her conclusion, the examiner noted that the Veteran did not have an exaggerated startle response; has not experienced nightmares related to the war in recent years; did not believe he lost his temper quickly; did not report significant interpersonal difficulty; and indicated that he is “…pretty steady.” The Veteran denied feeling depressed; however, he did indicate that he reflects often on life, which can make him sad. Moreover, the Veteran reported that he did not experience significant anxiety, panic attacks, depression, or angry outbursts. He denied experiencing suicidal or homicidal ideations and did not report any mental health treatment before, during, or after his active duty service. The examiner reported that the Veteran's military service did not cause impairment in marital relations or social, occupational or other areas of functioning. In fact, the examiner reported the Veteran had a successful marriage, as well as a social and occupational life. The Veteran reported close relationships with his wife, children, grandchildren and friends and described a stable work history. Furthermore, despite the Veteran receiving consistent medical treatment from July 2010 to August 2018 for other conditions, the VA treatment records do not contain a diagnosis of PTSD. Moreover, the records consistently show VA medical providers screened the Veteran for PTSD, which yielded negative results. In a June 2020 Informal Hearing Presentation (IHP), the Veteran’s Representative asserted the April 2018 examination was inadequate because there are discrepancies between the information recorded by the examiner and information the Veteran submitted in both his July 2018 Notice of Disagreement (NOD) and October 2018 Substantive Appeal (VA Form 9). In the July 2018 NOD, the Veteran’s representative stated that the Veteran experiences anxieties related to Vietnam that cause him social impairment and the examiner “downplayed” his symptoms. Specifically, the Veteran reported he avoids people; does not like to go out in crowds, experiences concentration and short-term memory issues; and constantly thinks about Vietnam. In the October 2018 VA Form 9, the Veteran’s representative again indicated the Veteran experiences PTSD symptoms. Specifically, the Veteran thinks about Vietnam daily, his symptoms severely affect his way of life; and he experiences short term memory and concentration issues. The examiner reported the same symptoms that the Veteran included in his NOD and VA Form 9 in her examination. Specifically, the examiner noted that the Veteran reported experiencing social issues, concentration and short-term memory issues, difficulty in crowds, and avoids people. The examiner acknowledged the Veteran’s reported symptoms but concluded that the Veteran’s thoughts seemed logical and coherent, his concentration seemed good, and his recent and remote recall appeared adequate. Furthermore, the Veteran did not report panic attacks, anxiety or angry outbursts. In summary, the examiner acknowledged the Veteran’s reported symptoms but concluded they do not rise to the level of supporting a DSM-5 diagnosis for PTSD or any other acquired psychiatric disability. The Board acknowledges that the Veteran asserts that the April VA examination was inadequate. However, the examiner in this case provided an in-person examination, reviewed the Veteran's pertinent medical history, conducted clinical evaluations, and provided an adequate discussion to support her findings. See Stefl v. Nicholson, 21 Vet. App. 120, 123-24 (2007); Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007). As the Veteran has identified no clear evidence that the examination was not properly conducted, the Board finds the April 2018 VA examination was properly conducted and is probative evidence. In the June 2020 IHP, the Veteran’s representative noted that although the April 2018 VA examiner did not diagnose the Veteran with PTSD or any other acquired psychiatric disorder, VA medical records note a diagnosis of alcohol dependence and abuse. To the extent the Veteran’s representative is arguing the Veteran is entitled to service connection for an alcohol dependence disorder, the Board notes the Veteran’s medical records do contain a history of alcohol dependence and abuse. However, for claims filed after October 31, 1990, service connection may not be granted for a disability that resulted from the Veteran's abuse of alcohol or drugs, including drug or alcohol abuse itself, except for abuse that is secondary to a service-connected disability. 38 C.F.R. § 3.301(a); Allen v. Principi, 237 F.3d 1368, 1376 (Fed. Cir. 2001). Neither the Veteran nor his representative have asserted, nor does the record otherwise suggest, that the Veteran’s alcohol abuse is secondary to his service-connected diabetes mellitus disability, which is the Veteran’s only service-connected disability. Thus, entitlement to service connection for alcohol dependence is not warranted in this case. Lastly, in the June 2020 IHP, the Veteran’s representative noted the Veteran’s wife wished to provide additional evidence. To date, the Board has not received additional evidence from the Veteran’s spouse nor a request for an extension to allow her additional time to submit evidence. (Continued on the next page)   In sum, the April 2018 VA examination is the most competent and probative evidence of record regarding the nature and etiology of the Veteran's claimed psychiatric disabilities, to include PTSD, as the examiner performed a comprehensive mental status examination and considered all relevant facts in this case. There is no competent evidence of record which weighs against the April 2018 VA examiner’s finding that the Veteran does not meet the criteria for a diagnosis of PTSD or any other acquired psychiatric disability. Although the Veteran contends that he has a current diagnosis of PTSD, he is not competent to provide a diagnosis in this case as the issue is medically complex, and requires specialized medical education and knowledge to diagnose. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). As the preponderance of the evidence weighs in favor of finding that the Veteran does not have a current acquired psychiatric disability, to include PTSD, the benefit-of-the-doubt doctrine does not apply, and the Veteran's claim of entitlement to service connection for an acquired psychiatric disability, to include PTSD, must be denied. See Gilbert v. Derwinski, 1 Vet. App 49 (1990); 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. M. HYLAND Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Zachery S.C. Luce, 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.