Citation Nr: 21040127 Decision Date: 07/02/21 Archive Date: 07/02/21 DOCKET NO. 15-22 413 DATE: July 2, 2021 ORDER Service connection for a psychiatric disability, to include posttraumatic stress disorder (PTSD) and major depressive disorder (MDD) is denied. FINDING OF FACT The preponderance of the evidence is against a finding that the Veteran's psychiatric disability began during active service or is otherwise related to service. CONCLUSION OF LAW The criteria for service connection for a psychiatric disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from April 1969 to January 1971 and from January 1991 to June 1991. This matter is before the Board of Veterans' Appeals (Board) on appeal from a May 2013 rating decision. The Veteran testified before the undersigned at a February 2020 hearing. A transcript of that hearing is of record. The Veteran contends that he has a psychiatric disability related to service. Specifically, the Veteran has testified that he experienced events during service in the Republic of Vietnam that caused him to have PTSD. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. To establish a service connection for a disability, a Veteran must 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. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303; Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). That determination requires a finding of current disability that is related to an injury or disease in service. Watson v. Brown, 4 Vet. App. 309 (1993). Service connection may be granted for a disability diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability is due to disease or injury that was incurred or aggravated in service. 38 C.F.R. § 3.303(d). A Veteran need only demonstrate that there is an approximate balance of positive and negative evidence to prevail. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). To deny a claim on its merits, the preponderance of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 519 (1996). There are particular requirements for establishing entitlement to service connection for PTSD in 38 C.F.R. § 3.304(f) that are in ways similar, but also nonetheless separate, from those for establishing entitlement to service connection generally. Arzio v. Shinseki, 602 F.3d 1343, 1347 (Fed. Cir. 2010). Entitlement to service connection for PTSD requires (1) medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a); (2) credible supporting evidence that a claimed in-service stressor occurred; and (3) a link, established by medical evidence, between current symptoms and the in-service stressor. 38 C.F.R. §§ 3.304(f) and 4.125. Where an alleged stressor involves "fear of hostile military or terrorist activity," a Veteran's lay testimony alone may establish the occurrence of the stressor if a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of PTSD and that the Veteran's symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of the Veteran's service. 38 C.F.R. § 3.304(f)(3). At a February 1969 entrance examination for service, the Veteran marked history of "nervous trouble," and indicated he had been told by the family doctor that he has trouble with his nerves. In March 1991 during his second term of service, the Veteran indicated he had frequent trouble sleeping. All other service treatment records (STRs) were negative for psychiatric symptoms. In VA medical records from September 2005 through December 2012, the Veteran denied psychiatric symptoms and scored negative on PTSD and depression screenings. At a March 2013 VA examination, the Veteran reported experiencing trauma during service in the form of being on a fire base while deployed that was frequently attacked, witnessing soldiers die in mortar attacks, being a part of convoys in which a truck hit a landmine, and being exposed to rounds or hitting the deck due to missiles shooting overhead. The examiner found that the experienced events met the criteria for a stressor for PTSD, however, that the Veteran's symptoms generally did not meet the criteria for PTSD. The Veteran endorsed sleeping problems, "crazy dreams" not specifically related to the military, having crying spells and feelings of punishment. The examiner found that these symptoms were possibly mild symptoms of depression, however, that the Veteran did not endorse sufficient breadth, severity or frequency of symptoms to support a formal diagnosis. In February 2019, VA and private medical records indicate that the Veteran experienced an altered state episode, in which he had auditory hallucinations, rambling speech and anxiety. The Veteran was admitted to the hospital for approximately two weeks. Records during that period noted that the Veteran was confused, anxious, had panic attacks, felt hopeless, had paranoia and heard voices. Providers noted multiple times that the Veteran experienced a stroke in November 2018. Neither the Veteran nor any providers referenced military service during this time. The discharge diagnosis was dementia with delusions and depression, status post stroke. After the Veteran's hospitalization, he received treatment for depression. In November 2019, the Veteran denied flashbacks, hypervigilance, startle response, anger, impulsivity, sleep problems or nightmares. Diagnosis was noted as history of altered mental state and major depression disorder with psychotic features. At a February 2020 hearing, the Veteran testified that he did not discuss his symptoms because they were "private problems." The Veteran testified at that time that he had flashbacks and thoughts of Vietnam. The Veteran's wife testified that the Veteran was irritable, depressed and tended to isolate. At a March 2021 VA examination, the Veteran reported symptoms including depressed mood, anxiety, chronic sleep impairment, mild memory loss, and disturbances of motivation and mood. The Veteran denied flashbacks, nightmares, and significant anger or conflict. The examiner diagnosed major depressive disorder, single episode, in partial remission, referencing the February 2019 hospitalization. The examiner noted that although the Veteran indicated he had seen combat in Vietnam and Saudi Arabia, the Veteran did not report any current or history of PTSD symptoms. Therefore, the Veteran did not have a PTSD diagnosis. The examiner also noted that the Veteran had not exhibited any mood disturbance or psychiatric disorder prior to the 2019 hospitalization and that there was no evidence to suggest psychiatric symptoms were related to his military experience. Therefore, the examiner opined that the Veteran's current psychiatric diagnosis was less likely than not related to service. The examiner stated that the current psychiatric issues may be related to the 2018 stroke, but ultimately found it too speculative to say. After review of the record, the Board finds that the preponderance of the evidence is against a finding that the Veteran has a psychiatric disability that was incurred in service or is otherwise related to service. Both VA examiners found that the Veteran did not meet the criteria for a PTSD diagnosis. While some medical records reference a history of PTSD, these were based on reports of a PTSD diagnosis by the Veteran. There is no evidence of evaluation and actual diagnosis of PTSD. Regarding other psychiatric disabilities diagnosed, the record indicates that in November 2018 the Veteran experienced a stroke. Subsequently, in February 2019 he experienced an episode of altered mental state with psychiatric manifestations. The discharge diagnosis of delusions with depression and psychotic features included "status post stroke," indicating that the episode resulted from or was related to the stroke. The March 2021 VA examiner also indicated that the symptoms may be related to the history of stroke. The March 2013 VA examiner did not find sufficient evidence in the record or at examination to make a formal diagnosis of a psychiatric disability. The March 2021 VA examiner opined that the Veteran's current psychiatric disability was not related to service, as there was no evidence prior to the February 2019 hospitalization of a psychiatric symptoms. The Board is sympathetic to the Veteran's testimony and reports of experiencing psychiatric symptoms related to his experiences in Vietnam and Saudi Arabia and finds these reports credible. Indeed, laypersons are competent to report on matters observed or within their personal knowledge. Layno v. Brown, 6 Vet. App. 465, 470 (1994). Further, the Board acknowledges the fact that the Veteran testified he had difficulty reporting his symptoms in a clinical setting. However, the Board must weigh such reports against the medical and other evidence of record. Buchanan v. Nicholson, 451 F. 3d 1331 (Fed. Cir. 2006). Here, although the Veteran contends he has a psychiatric disability related to service, the medical evidence of record does not show a diagnosed psychiatric disability prior to February 2019. The Veteran simply did not report psychiatric symptoms sufficient to make a formal diagnosis at the March 2013 VA examination, nor in any VA or private visits prior to February 2019. Indeed, prior to February 2019, the Veteran screened negative for PTSD and depression and denied having symptoms of PTSD, anxiety and depression. In the absence of such evidence, the Board cannot grant the claim for service connection. Accordingly, the Board finds that the preponderance of the evidence is against a finding that service connection for a psychiatric disability is warranted. Therefore, the claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). JOHN Z. JONES Veterans Law Judge Board of Veterans' Appeals Attorney for the Board H. Ahmad 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.