Citation Nr: 21030711 Decision Date: 05/19/21 Archive Date: 05/19/21 DOCKET NO. 20-26 894 DATE: May 19, 2021 ORDER Entitlement to service connection for posttraumatic stress disorder (PTSD) is granted. FINDINGS OF FACT 1. The Veteran had active duty from April 1966 to January 1970 2. A treating VA psychologist attributes diagnosed PTSD to a documented claimed stressor during service. CONCLUSION OF LAW The acquired psychiatric disorder of PTSD was incurred in service. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran initially filed four separate claims for service connection for insomnia, anxiety, claustrophobia, and depression. During the appeal period, he filed another claim for PTSD. The Regional Office (RO) then construed each of the initial psychiatric claims as claims for service connection for PTSD. The current appeal incorporates each of those claims into a single, broadened issue. The grant of the appeal thus encompasses the symptomatology of all psychiatric disorders claimed during the appeal period. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). Turning to the relevant laws and regulations, service connection may be granted on a direct basis as a result of disease or injury incurred in service based on nexus using a three-element test: (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 in or aggravated by service. See 38 C.F.R. § 3.303(a), (d); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009). With specific regard to PTSD claims, three elements must be present: (1) a current medical diagnosis of PTSD in accordance with 38 C.F.R. § 4.125(a); (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); Cohen v. Brown, 10 Vet. App. 128 (1997). There are several lay evidence exceptions in which depending on the nature of the in-service stressor, the Veteran's testimony alone may be sufficient for verification. However, here, none of the 38 C.F.R. § 3.304(f)(1-5) exceptions apply to the Veteran's claim. Turning to the evidence, the first element of service connection a current disability is met. In October 2017, VA medical personnel diagnosed the Veteran with an unspecified trauma or stressor related disorder, rule out PTSD, and chronic insomnia. The Veteran was treated for multiple psychiatric disorders until a June 2018 VA PTSD consult, in which he was assessed with a diagnosis of PTSD under the DSM-V. Thereafter, he was continually treated at VA medical facilities for PTSD. As such, the first element of service connection is met. Next, the second element a verified in-service stressor is also met, as the Veteran was able to find supporting documentation from the National Archives that matched many of the stressors he claimed influenced his psychiatric disorders. As one in particular has been associated with his PTSD diagnosis, it will be the focus here. Specifically, he submitted multiple lay statements describing an incident where he witnessed another sailor's foot caught between the rear of the gun the Veteran manned and the "pit," which caused an injury where he could see the bones of his toes out of his boots, and led to the other sailor having his toe amputated. The Veteran stated it was overwhelming to see his blood and hear his screams. After contacting the National Archives, he was able to digitally search deck logs for the ships he served on. He then submitted relevant deck logs, most notably some that detailed that the incident in which the fellow sailor suffered amputation of his left great big toe and a contusion to the second toe as described in the Veteran's submitted correspondences. Thus, given the supporting evidence, the Veteran's claimed stressor is verified, and the second element is met. (Continued on the next page) Finally, the third element a medical nexus is also met, as a VA medical professional found that the Veteran had a DSM-V diagnosis of PTSD caused by the verified stressor. The VA medical professional noted a single Criterion A stressor, which was the stressor described above, and that the PTSD was related to military trauma. The Regional Office (RO) did not schedule a VA examination to determine the etiology of any psychiatric disorder. Here, although not a formal medical nexus opinion, a VA medical professional has given a DSM-V diagnosis of PTSD with a single, verified military stressor of note. There is no negative medical nexus opinion of record, and given the sufficient evidence of a positive nexus, remand for one would be of no benefit to the Veteran. As such, the medical nexus element is met, and service connection is granted. C. J. McEntee Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Brendan A. Evans, 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.