Citation Nr: 21025412 Decision Date: 04/28/21 Archive Date: 04/28/21 DOCKET NO. 15-18 423A DATE: April 28, 2021 ORDER Entitlement to service connection for posttraumatic stressor disorder (PTSD) is denied. FINDING OF FACT The preponderance of the evidence is against finding that the Veteran has had a DSM-V compliant diagnosis of PTSD at any time during the appeal. CONCLUSION OF LAW The criteria for service connection for PTSD are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 4.125. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from August 28, 1980 to September 26, 1980. This app comes before the Board of Veterans’ Appeals (Board) on appeal from rating decisions in August 2014 and April 2015 by a Regional Office (RO) of the Department of Veterans Affairs (VA). In December 2018, the Veteran testified at a video conference hearing before the undersigned Veterans Law Judge. A transcript of that hearing is of record. In March 2019 the Board remanded claims for entitlement to service connection for a low back condition, left knee disability, and acquired psychiatric disorder, to include PTSD and major depressive disorder (MDD). While pending return to the Board, the RO granted service connection for left knee osteoarthritis and degenerative arthritis of the spine/intervertebral disc syndrome in September 2020. Service connection was also granted in January 2021 for MDD for the Veteran’s claimed depression. For the knee and low back issues, this represents a full grant of the benefits sought, and the issues are no longer in appellate status. See Grantham v. Brown, 114 F. 3d 1156, 1158 (Fed. Cir. 1997). However, the Veteran’s representative has essentially continued argument as to the issue of entitlement to service connection for separately claimed PTSD, which remains denied and was addressed in a January 2021 supplemental statement of the case. Adjudication of this remaining claim is addressed below. It is also noted that the representative presented arguments in his April 2021 Informal Hearing Presentation pertaining to the rating assigned for the Veteran’s major depressive disorder, to include the assignment of a total disability rating based upon individual unemployability. In that regard, the Veteran is reminded that he must file a notice of disagreement on the proper form. Entitlement to service connection for PTSD. Service connection has been established for MDD, with a 30 percent rating effective June 20, 2013 and a 50 percent rating from December 30, 2020. This appeal is therefore narrowly focused on the pursued claim for service connection for PTSD as a separate and distinct disability. Pertaining to claims of entitlement to service connection for PTSD the presence of three particular elements is required: (1) a current medical diagnosis of PTSD; (2) medical evidence of a causal nexus between current symptomatology and a claimed in-service stressor; and (3) credible supporting evidence that the claimed in-service stressor actually occurred. 38 C.F.R. § 3.304 (f). The medical evidence diagnosing PTSD must be in accordance with 38 C.F.R. § 4.125 (a), which refers to the American Psychiatric Association Diagnostic and Statistical Manual for Mental Disorders (DSM) as the source of criteria for the diagnosis of claimed psychiatric disorders. The Board notes that, effective March 19, 2015, VA amended the portion of the Rating Schedule dealing with mental disorders so as to replace outdated references to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), with references to the DSM-V. See 79 Fed. Reg. 149, 45,094 (Aug. 4, 2014). VA directed that the changes be applied only to applications for benefits received by VA or pending before the agency of original jurisdiction on or after August 4, 2014, but not to claims certified to, or pending before, the Board, the Court of Appeals for Veterans Claims, or the United States Court of Appeals for the Federal Circuit on or before August 4, 2014. As the Veteran’s original PTSD claim was made on June 20, 2013, but first certified to the Board after August 4, 2014, the DSM-V applies. As such, diagnoses must conform to the DSM-V. Service connection may also be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). The Veteran claims that he has PTSD related to the mentally abusive tactics of his drill instructor in service, and/or aggravated by his now service-connected MDD. Service treatment records are silent for a PTSD diagnosis. Additionally, post-service medical records are silent for a diagnosis of PTSD under the DSM-V and instead consistently noted MDD as the Veteran’s primary DSM-V diagnosis. Such findings mirror that of September 2019 and December 2020 VA examiners who diagnosed MDD (a service connected acquired psychiatric disability) but not PTSD. That said, the Board remanded the matter in March 2019 to obtain a VA examination with opinion as to the nature and etiology of the Veteran’s diagnosed acquired psychiatric disabilities. He underwent an examination in December 2020. The Veteran was solely diagnosed with MDD but not PTSD based on the examination results and review of the record. The examiner specified that a DSM-V diagnosis of PTSD was not established as the Veteran did not meet criterion A, F, G, H, and I. The examiner also considered the totality of the record and found that the Veteran’s most appropriate diagnosis has always been MDD. In so doing, the examiner stated that the PTSD diagnoses of record lacked full DSM-V diagnostic assessment needed to establish a formal mental health diagnosis. The Board finds this opinion to be adequate and highly probative as it is well rationalized against the evidence of record. Service connection may only be granted for a current disability; when a claimed condition is not shown, there may be no grant of service connection. See 38 U.S.C. § 1131; Rabideau v. Derwinski, 2 Vet. App. 141(1992). In the absence of proof of a present disability, there can be no valid claim for service connection. See Degmetich v. Brown, 104 F.3d 1328 (1997); Brammer v. Derwinski, 3 Vet. App. 223, 225(1992). The requirement that a current disability be present is satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim, even if the disability resolves prior to the adjudication of the claim. See McClain v. Nicholson, 21 Vet. App. 319(2007). The preponderance of the evidence is against finding that the Veteran has had a DSM-V diagnosis of PTSD at any time during the appeal. He has repeatedly been found not to have PTSD based on objective testing and examination. The 2020 examiner considered the examination results, the record, and the Veteran’s lay reports in finding that he has not had a diagnosis of PTSD. Positive diagnoses of PTSD of record are afforded no weight as, per the discussion above, they are not supported by appropriate findings necessary to establish a diagnosis. His actual psychiatric diagnosis, MDD, is already service connected. In the absence of evidence of a current disability, service connection for PTSD on a direct or secondary basis must be denied. Consideration is given to the Veteran’s assertion that he suffers from PTSD. He is not competent to diagnosis PTSD. Young v. McDonald, 766 F.3d 1348, 1353 (Fed. Cir. 2014). Moreover, as previously discussed, the Veteran has been repeatedly examined and found not to meet the full criteria for a diagnosis of PTSD. His medical history was specifically considered in the 2020 examination which confirmed the absence of a DSM-V diagnosis of PTSD. Notwithstanding the above, the Board emphasizes that the December 2020 examiner opined that all of the Veteran’s claimed PTSD symptoms are subsumed by his currently service-connected MDD. As the preponderance of the evidence is against a current diagnosis of PTSD, the benefit of the doubt doctrine is therefore not for application and the claim is denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. MICHAEL A. HERMAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. L. Burroughs, 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.