Citation Nr: 21027851 Decision Date: 05/07/21 Archive Date: 05/07/21 DOCKET NO. 15-46 741 DATE: May 7, 2021 ORDER Entitlement to service connection for an acquired psychiatric disability, to include posttraumatic stress disorder (PTSD), is granted. REMANDED Entitlement to total disability rating based upon individual unemployability (TDIU) is remanded. FINDING OF FACT Resolving reasonable doubt in the Veteran's favor, his acquired psychiatric disability, to include PTSD, is at least as likely as not related to service. CONCLUSION OF LAW The criteria for service connection for an acquired psychiatric disability, to include PTSD, are 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 in the United States Navy from January 1969 to October 1970. During his period of service, he earned the Navy Unit Commendation, Armed Forces Expeditionary Medal, Vietnam Service Medal, Vietnam Campaign Medal, and National Defense Service Medal. Entitlement to service connection for an acquired psychiatric disability Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. In order to prevail on a claim of service connection, generally, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service occurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). In certain cases, competent lay evidence may demonstrate the presence of any of these elements. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). A diagnosis of PTSD must be established in accordance with 38 C.F.R. § 4.125(a), which provides that all psychiatric diagnoses must conform to the American Psychiatric Association's DSM. 38 C.F.R. § 3.304(f). The Veteran appeared for a VA PTSD examination in September 2014, at which time the VA examiner diagnosed PTSD. Thus, the current-disability criterion for service connection is met. See Shedden, supra. Next, the Board must consider whether the Veteran sustained a disease or injury in service. A review of the Veteran's service treatment records does not reveal any complaints or diagnosis of an acquired psychiatric disability during his military service. With regard to an in-service event or stressor, the Veteran reported several stressor events. Specifically, in a February 2020 lay statement, the Veteran reported being selected to carry out numerous unrecorded rescue missions with the 1st Marines while serving in Vietnam. During these missions, the Veteran has reported being exposed to direct combat activity, to include hand-to-hand combat, and rescuing injured servicemembers. The Veteran also reported being held captive by Vietnamese soldiers for four days. In support of his claim, the Veteran also provided buddy statements to corroborate his contentions. Although the Veteran's claimed stressors have not been verified, the Board finds his claimed in-service stressors to consistent with the places, types, and circumstances of his service in Vietnam. Further, pursuant to the examination reports of record, the examiners determined the Veteran's claimed stressors were adequate to support a diagnosis of PTSD. 38 C.F.R. § 3.304(f)(3). The remaining question is whether there is a medical nexus between the Veteran's acquired psychiatric disability and service. An addendum opinion was obtained in September 2014. The VA examiner noted that she felt the Veteran was exaggerating; however, she did not believe the stressors were entirely fabricated. Instead, the examiner noted her belief that the Veteran was inflating his role in the operation. Based on this, the VA examiner determined the PTSD diagnosis was not appropriate and instead diagnosed unspecified trauma related to rule out PTSD, as the Veteran had been given the Vietnam Service Medal and Vietnam Campaign Medal along with medication that was intended to target a mood disorder. The Veteran most recently appeared for a VA PTSD examination in March 2021. The examiner opined that the Veteran's PTSD was at least as likely as not incurred in or caused by service. In support of the opinion, the examiner explained that a lay statement from a fellow servicemember corroborated the Veteran's original statement, which indicated the Veteran showed up with bandages; however, the bandages were dismissed as being associated with bar fights. The Veteran also often disappeared and reappeared with bandages. Lastly, the fellow servicemember corroborated that an individual by the name of "Catfish" had come to the berthing space to speak with the Veteran. The examiner noted that the medical evidence of record included various mental health diagnoses, to include a January 2014 mental health emergency department note that indicated a diagnosis of depression, PTSD and insomnia; a May 2014 mental health treatment note that revealed a rule out diagnosis of PTSD; a July 2014 mental health outpatient note that revealed a diagnosis of PTSD, persistent depressive disorder and a rule out diagnosis of personality disorder; and a January 2019 private PTSD disability benefits questionnaire (DBQ) provided by Dr. K.D. that revealed a diagnosis of PTSD. The examiner further noted that the Veteran's DD-214 showed he was earned the Armed Forces Expeditionary Medal, which is awarded to military personnel for their deployment to a foreign country and active participation in a conflict. Accordingly, the examiner opined that the Veteran's claimed acquired psychiatric disability was at least as likely as not incurred in or caused by service. In light of the foregoing, the Board finds the evidence is at least in equipoise regarding the question of whether the Veteran's acquired psychiatric disability, to include PTSD, is related to his military service. As such, reasonable doubt will be resolved in favor of the Veteran and service connection for acquired psychiatric disability, to include PTSD, is granted. 38 U.S.C. § 5107(b) (2012); 38 C.F.R. § 3.102 (2020); Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). REASONS FOR REMAND Entitlement to a TDIU Entitlement to a TDIU has been raised during the period on appeal. The TDIU claim is inextricably intertwined with the Board's grant of service connection for an acquired psychiatric disability and the pending assignment of its corresponding rating percentage by the Agency of Original Jurisdiction (AOJ). Consideration of the TDIU must be deferred pending implementation of the award granted herein. The matters are REMANDED for the following action: 1. Implement the Board's grant of service connection for an acquired psychiatric disability, to include PTSD. 2. Arrange for any additional development deemed necessary. 3. Thereafter, adjudicate the TDIU claim. A. S. CARACCIOLO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Tracy O. Joseph, 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.