Citation Nr: 21029609 Decision Date: 05/14/21 Archive Date: 05/14/21 DOCKET NO. 18-04 838 DATE: May 14, 2021 ORDER Entitlement to service connection for a mental health disorder, diagnosed as posttraumatic stress disorder (PTSD), is granted. REMANDED Entitlement to service connection for an anal fissure is remanded. FINDING OF FACT The Veteran's PTSD is related to verified in-service stressors. CONCLUSION OF LAW The criteria for service connection for a mental health disorder, diagnosed as PTSD, have been met. 38 U.S.C. § 1110; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 4.125. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from August 2001 to August 2005. This case comes before the Board of Veterans' Appeals (Board) on appeal from a May 2017 rating decision by the Department of Veterans Affairs (VA). A hearing was held before the undersigned Veterans Law Judge in June 2020. A transcript of the hearing is of record. The Veterans Law Judge held the record open for a 30-day period following the hearing to allow for the submission of additional evidence. Thereafter, the Veteran submitted evidence for which there is an automatic waiver of initial agency of original jurisdiction (AOJ) review. Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty in the active military, naval, or air service. 38 U.S.C. §§ 1110, 1131. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. 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). Service connection for PTSD 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 evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits. VA shall consider all information and lay and medical evidence of record in a case and when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that service connection is warranted for PTSD. The Veteran has contended that he developed a mental health disorder as a result of his military service while stationed in Iraq from 2004 to 2005, including fearing for his life due to receiving constant mortar attacks and going on convoys with his unit one of which required them to remove armor from a Humvee after two service members had been killed in it. He indicated that those experiences ultimately affected his confidence and ability to be an effective police officer after service, rather than that post-service work itself being the initial cause of his current problems. See, e.g., November 2016 written statement; November 2017 VA treatment record; January 2018 substantive appeal. The AOJ conceded these in-service stressors related to fear of hostile military activity, and the Board finds that this determination is consistent with the evidence of record. See November 2017 statement of the case; March 2017 VA examination report, DD 214, January 2005 post-deployment health assessment, and 38 C.F.R. § 3.304(f)(3). The Veteran's service treatment records show that he was found to be psychiatrically normal at the time of the August 2001 entrance examination, and he denied a history of relevant symptoms on the corresponding reports of medical history. He also denied a history of relevant symptoms and no mental health referral was made on the December 2003 pre-deployment and January 2005 post-deployment health assessments. The post-service evidence shows that he has received a PTSD diagnosis. In addition, the Board finds that the Veteran has PTSD that is related to the verified in-service stressors. In March 2017, the Veteran attended one session with a private treatment provider in which it was noted that he chose not to seek in-service treatment for various problems because he felt that the general mentality of the military was to persist despite such problems, and he continued to attempt to manage impairment on his own after service until more recently. It was also noted that the Veteran had significant anxiety, irritability, and depressive symptoms he related to his military service, but an etiology opinion was not provided. The March 2017 VA examiner determined that the Veteran's reported stressors were related to his fear of hostile military activity and adequate to support the diagnosis of PTSD, but he did not meet the full criteria required for a PTSD diagnosis under the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). The examiner explained that the Veteran only met the diagnostic criteria for Criteria A (but not any of the complete diagnostic criteria for Criteria B through E), with his symptoms consistent with an unspecified depressive disorder. He determined that the depressive disorder was not related to the Veteran's in-service circumstances, but rather, surfaced following his resignation from the police department in 2015 (i.e., a post-service onset). In September 2017 and October 2017, other VA examiners provided medical opinions consistent with the March 2017 VA examiner's determination. The first of these examiners noted that the Veteran had not reported in-service or ongoing post-service mental health problems until after he was employed as a police officer. The second examiner noted that the Veteran also had a diagnosis of unspecified anxiety disorder, but neither diagnosis was related to his military service based on similar rationale. On the other hand, the Board notes that the Veteran has reported that he was not open to the March 2017 VA examiner, as he felt it was too difficult to discuss how he had been affected by his time in Iraq. Rather, he would present a picture of apparent competence instead of telling people how he was feeling, as noted by one of his prior treatment providers, social worker A.S. See November 2017 VA treatment record; June 2020 Bd. Hrg. Tr. The treatment provider further noted that the Veteran's difficulty sharing personal struggles outside of his family could also be partially cultural based on his reports that Hmong people tend to be more private in this regard, and that it took time for him to develop trust and open up to her. In addition, the records from treatment with A.S. show that the Veteran decided to initially focus on anger for treatment purposes, then they would later focus on symptoms of depression, anxiety, and PTSD. Thereafter, she noted that the Veteran was agreeable to a full PTSD diagnostic assessment, which resulted in a PTSD diagnosis related to fear of hostile military activity during his Iraq deployment. See VA treatment records from July 2017 and November 2017; see also June 2020 spouse written statement. In the June 2020 medical opinion, the Veteran's current VA treatment provider, Dr. N.W., noted that she had treated the Veteran since May 2019, also referencing his prior treatment with A.S. Dr. N.W. similarly indicated that the Veteran met DSM-5 criteria for PTSD related to his Iraq deployment traumatic combat environment experiences. In reviewing the VA treatment providers' findings in the context of the other evidence of record, the Board finds that their determinations are based on consideration of the Veteran's in-service history confirmed by the record and medical history as a patient, as well as current medical understanding. Therefore, the opinions are entitled to probative weight. Based on the foregoing, and resolving any reasonable doubt in favor of the Veteran, the Board concludes that service connection is warranted for PTSD. In reaching this decision, the Board acknowledges that the Veteran's diagnosis has been variously identified. However, the benefit sought on appeal is granted in a manner consistent with the fact that the most probative evidence outlined above shows that the PTSD diagnosis is the proper diagnosis for the service-related mental health disorder. REASONS FOR REMAND On review, the Board finds that additional development is necessary prior to final adjudication of the Veteran's remaining claim. Specifically, it appears that there may be outstanding non-VA treatment records, as detailed in the directives below. The Veteran has not been provided a VA examination for the anal fissure claim. He has contended that when he was on his Iraq deployment, he had been eating MREs (meal, ready-to-eat) that resulted in him having a really hard, painful stool that may have caused a tear and resulted in bleeding he observed at that time, although he did not seek treatment. See, e.g., November 2016 written statement; December 2017 VA treatment record; June 2020 Bd. Hrg. Tr. During VA treatment, he reported the history of bleeding, as well as problems with anal leakage and a recent diagnosis of hemorrhoids on a colonoscopy. Based on the foregoing, including the competent and credible reports of ongoing rectal bleeding, a VA examination and medical opinion are needed. The case is REMANDED for the following actions: 1. Request that the Veteran provide the names and addresses of any and all health care providers who have provided treatment for his anal fissure. This should specifically include the June 2017 colonoscopy report and any related treatment at Coon Rapids Endoscopy Center, as reported in a January 2018 VA treatment record. After acquiring this information and obtaining any necessary authorization, obtain and associate these records with the claims file. 2. After completing the foregoing development to the extent possible, schedule the Veteran for a VA examination to determine the nature and etiology of any current anal fissure or residuals thereof that may be present. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment and personnel records, post-service medical records, and statements. The examiner should state whether it is at least as likely as not that the Veteran has an anal fissure or residuals thereof that manifested in or are otherwise related to his military service, including any symptomatology therein. The Veteran has contended that when he was on his Iraq deployment, he had been eating MREs that resulted in him having a really hard, painful stool that may have caused a tear and resulted in bleeding he observed at that time that has been ongoing intermittently since. He has indicated that he did not seek in-service treatment because he would not go to sick call for something embarrassing like that, and that he would have been made fun of by other service members if he had sought treatment. See, e.g., November 2016 written statement; December 2017 VA treatment record; June 2020 Bd. Hrg. Tr. During VA treatment, he reported the history of bleeding, as well as problems with anal leakage and a recent diagnosis of hemorrhoids on a colonoscopy. On examination in a subsequent colon and rectal appointment, the assessment was suspect combination of perianal irritation/pruritis with intermittently symptomatic internal hemorrhoids. See VA treatment records from December 2017 to February 2018. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. MICHELLE L. KANE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Postek, 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.