Citation Nr: 21024647 Decision Date: 04/23/21 Archive Date: 04/23/21 DOCKET NO. 17-40 688 DATE: April 23, 2021 ORDER Entitlement to service connection for trauma and stressor related disorder and generalized anxiety disorder is granted. FINDING OF FACT Trauma and stressor related disorder and generalized anxiety disorder are attributable to service. CONCLUSION OF LAW Trauma and stressor related disorder and generalized anxiety disorder were incurred in service. 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 September 1966 to May 1969. He had service in the Republic of Vietnam. In January 2020, the Veteran testified at a Board travel hearing before the undersigned Veterans Law Judge (VLJ). A copy of the transcript is of record. During the hearing, the VLJ clarified the issue on appeal, received additional evidence from the Veteran, and elicited relevant testimony from the Veteran. These actions complied with the duties owed during a hearing set forth in 38 C.F.R. § 3.103. 1. Service connection for an acquired psychiatric disorder. The Veteran seeks service connection for an acquired psychiatric disorder. After reviewing the evidence, the Board concludes that service connection is warranted for trauma and stressor related disorder and generalized anxiety disorder. Service connection may be established for disability resulting from personal injury or disease contracted in the line of duty in the active military, naval, or air service. 38 U.S.C. §§ 1110. To establish service connection a Veteran must generally show: “(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service.” Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). 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 or injury was incurred in service. 38 C.F.R. § 3.303 (d). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary 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 evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). Here, VA treatment records reflect the Veteran is currently diagnosed with “trauma/stressor related disorder, unspecified – reaction to severe stress, unspecified” and generalized anxiety disorder. The March 2018 VA examination report shows a diagnosis of an unspecified anxiety disorder. The issue is whether a psychiatric disorder is due to service. Service treatment records are silent regarding any complaints, treatment, symptoms, or diagnoses relating to a panic disorder. The May 1969 separation examination shows a clinically normal psychiatric evaluation. The Veteran denied any trouble sleeping, frequent or terrifying nightmares, depression or excessive worry, or nervous trouble in the May 1969 report of medical history. We note that a December 2016 letter notified the Veteran that his service treatment records could not be located and were therefore unavailable for review. However, service treatment records were associated with the Veteran’s claims file in April 2012. VA treatment records show the Veteran began mental health treatments in July 2014. At a primary care appointment, he reported that he had realized he has symptoms of being easily startled, always on guard, checking to make sure doors are locked in house, irritability, and that he was self-isolating and avoiding crowds. He reported that he always thought this was just his personality. A PTSD screen was positive. At a July 2014 psychotherapy session, the Veteran reported symptoms indicative of PTSD that have been present for decades and that he had always assumed the symptoms were normal and never pursued treatment. He stated that memories of Vietnam had increased since he began decreasing his workload, and that he had increases startle response, hypervigilance, irritability, nightmares, increased physical reactions when thinking or talking about Vietnam, and visual hallucinations when anxious. The treating psychiatrist diagnosed an unspecified anxiety disorder. The Veteran had a full mental health evaluation in September 2014 with a VA psychiatrist. He had experienced some symptoms such as nightmares since returning from Vietnam, and that he had developed increased anxiety in crowds since the 1980’s. he had increased irritability, problems with sleep, and hypervigilance for the past 1.5 years and was unsure how much was related to Vietnam, but felt that when he talked with friends who were combat veterans he has similar symptoms and had been thinking about Vietnam more. Regarding service, the Veteran reported that during the first Tet Offensive his base was almost overrun, and he felt fear that the enemy was targeting his position because he worked with cryptography equipment in communications. During the second Tet Offensive he reported that he came under friendly fire while returning to his compound, and that he was always fearful of this occurring. During the third Tet Offensive, a rocket landed in a building and killed a cook while the Veteran was on the base perimeter and he was one of the1st people to reach the building. Regarding PTSD symptoms, the psychiatrist noted recurrent involuntary intrusive memories of traumatic events, intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event, irritable behavior and angry outbursts, hypervigilance, exaggerated startle response, and sleep disturbance. The Veteran reported insomnia and feelings of worthlessness or excessive or inappropriate guilt. Regarding panic attacks, he reported palpitations, pounding heart, or accelerated heart rate, sweating, and trembling or shaking. The psychiatrist diagnosed unspecified anxiety disorder. In September 2018 the Veteran had a followup appointment with Dr. H, a VA psychiatrist. He reported an episode in which he physically harmed his wife during sleep and episodes of yelling in his sleep about 3-4 nights per week. Dr. Hahn continued the diagnosis of generalized anxiety disorder. At a January 2019 followup, the Veteran reported worsening nightmares and visual hallucinations when waking up. Dr. H diagnosed “trauma/stressor-related disorder NED – other reactions to severe stress” and generalized anxiety disorder. July 2019 treatment records show complaints of ongoing nightmares, hypnogogic hallucinations, and talking in his sleep, and the Veteran reported increased helicopter activity that was a trigger for him. The diagnoses included “trauma/stressor-related disorder, unspec – reaction to severe stress, unspecified” and generalized anxiety disorder. More recent VA treatment records show he continues to be diagnosed with these disorders. The Veteran has submitted lay statements in support of his claim. In a March 2016 statement, the Veteran reported that he was on a constant state of alert during enemy attacks with rockets and mortars with casualties, and that certain sounds and explosions triggered anxiety attacks. In a May 2017 statement, he reported anxiety from fear of being captured due to his position as a security NCO. In a March 2018 correspondence, he reported that he had jumped out of his car due to a loud explosion soon after returning from Vietnam, and that symptoms had worsened or returned since he semi-retired. He was provided a VA examination for PTSD in March 2018. The Veteran reported that, while in Vietnam, he provided security to the communications center and went into the field to deliver messages. The Veteran reported engaging in small arms fire fights and witnessing others being injured. He denied providing medical care or picking up human remains. He reports IDF with rounds hitting within 500 yards of his positions and denied seeing others injured. He reports travelling by air at times and reports mortars incoming while they were taking off once. He denied having to move bodies or body bags around or being on convoy duty. The examiner noted the Veteran reported witnessing another soldier hit and be medevacked out and experiencing incoming rockets in a separate statement to VA. The Veteran also reported being shot at while coming back to base and being called racial slurs. The examiner noted that the Veteran was initially seen for mental health at VA in July 2014. Notes indicated he reported their base was attacked and nearly overrun in Vietnam and that he worked in cryptography. Treatment notes also indicated increased anxiety in crowds since the 1980’s with increased irritability and sleep problems in the past year and a half, and that the Veteran reported thinking about Vietnam more recently with treatment increasing memory frequency. The examiner noted that September 2014 treatment notes indicate that symptoms began around the time he started working less and that the Veteran was not sure if they were related to Vietnam experiences. The examiner diagnosed unspecified anxiety disorder and noted the Veteran did not meet the DSM-5 criteria for PTSD. The examiner concluded that unspecified anxiety disorder was less likely than not caused by or to have begun during military service. the examiner explained the Veteran does not meet the DSM diagnostic criteria and his symptoms were noted to have begun around the time he retired from work. The Veteran testified at a Board travel hearing in January 2020. He reported that the nature of his duties with cryptology gear and classified messages caused constant fear of being captured by the enemy in Vietnam, and that he had ongoing fear for his life and fear of capture, death, or torture. He also reported experiencing rocket attacks and a cook that had been hit by shrapnel. He stated that he had anxiety since service and that at first, he did not know what it was. Helicopters, jets, and explosions such as fireworks triggered memories. He stated he had difficulties sleeping and nightmares after returning from Vietnam. The Veteran also reported that Dr. Hahn had diagnosed PTSD. Initially, the record establishes the Veteran does not have posttraumatic stress disorder. While the Veteran and his representative have contended that Dr. H diagnosed PTSD, review of the record shows Dr. H diagnosed “trauma/stressor related disorder, unspecified – reaction to severe stress, unspecified” and generalized anxiety disorder. Service connection for PTSD requires medical evidence diagnosing the condition in accordance with the DSM-5. See 38 C.F.R. §§ 3.304 (f); 4.125 (a). The 2018 VA examiner also determined the Veteran did not meet the criteria for PTSD under the DSM-5. As PTSD has not been diagnosed, service connection for PTSD cannot be granted. Although service connection may not be granted for PTSD, the evidence is in favor of granting service connection for the Veteran’s trauma and stressor related disorder and generalized anxiety disorder. For a medical opinion to be given weight, it must be based upon sufficient facts or data, the product of reliable principles and methods; and the result of principles and methods reliably applied to the facts. Nieves-Rodriquez v. Peake, 22 Vet. App. 295, 302 (2008). “It is the factually accurate, fully articulated, sound reasoning for the conclusion . . . that contributes probative value to a medical opinion.” Id. at 304. The Board finds the March 2018 VA medical opinion is of little probative value. The opinion was based on a review of the record and interview of the Veteran. However, the evidence does not support the examiner’s conclusion that the Veteran’s symptoms began in 2014 when he started working less. The Veteran has routinely reported that his symptoms merely worsened when he began working less. He has provided statements and testimony that he had symptoms during and after service that have continued since, and that he assumed his symptoms were normal until learning about PTSD. See Reonal v. Brown, 5 Vet. App. 458 (1993) (stating that “[a]n opinion based upon an inaccurate factual premise has no probative value”). The Board has considered the Veteran’s lay statements. In adjudicating a claim, the Board must fully assess the competence and credibility of the Veteran. Buchanan v. Nicholson, 451 F.3d 1331, 1335 (2006). Washington v. Nicholson, 19 Vet. App. 362 (2005). Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159 (a); Layno v. Brown, 6 Vet. App. 465, 470 (1994). Here, the Veteran is competent to report that he experiences psychiatric symptoms due to his service in Vietnam, that he has experienced certain symptoms continuously for many years, and that his symptoms recently worsened. He is also competent to report his observations and relate what he was told by medical professionals. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). His lay statements concerning his symptoms and their relation to in-service events have been consistent since he began receiving mental health treatments at VA. We also note that his psychiatric diagnoses, in particular the diagnosis for the trauma and stressor related disorder, were made in the context of the Veteran’s reports of in-service events and stressors. The Veteran’s lay statements regarding the nature and cause of his symptoms to be credible and highly probative. In sum, a psychiatric disorder was not diagnosed during service. The Veteran has credibly reported that he began noticing symptoms soon after he was discharged from service, including anxiety, irritability, and nightmares. He has consistently reported that he considered these symptoms normal and did not actively seek out psychiatric treatment until 2014 when his symptoms worsened. The generalized anxiety disorder was diagnosed when the Veteran began treatment, at which time he had reported that some symptoms had existed since he separated from service while others had progressively worsened. Pertinently, the Veteran’s current VA psychiatrist diagnosed an unspecified trauma and stressor related disorder. The diagnosis appears to have been rendered entirely based on the Veteran’s reported experiences during his service in Vietnam, and the Veteran’s reaction to severe stress he encountered during that service. Put another way, there is no indication in the record that other relevant trauma or stressors exist. While the only nexus opinion of record is negative, it is of lessened probative weight. The record supports finding that the Veteran’s trauma and stressor related disorder and generalized anxiety disorder are related to his service in Vietnam. Although we have considered the negative VA nexus opinion, the Veteran’s lay statements and the VA psychiatric treatment records are more probative. The Board is impressed with the testimony and the presentation prepared by his representative. Service connection for trauma and stressor related disorder and generalized anxiety disorder is granted. H. N. SCHWARTZ Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Morse 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.