Citation Nr: 21041106 Decision Date: 07/08/21 Archive Date: 07/08/21 DOCKET NO. 17-13 484 DATE: July 8, 2021 ORDER Entitlement to service connection for an acquired psychiatric disorder is denied. FINDING OF FACT The preponderance of the competent and credible evidence weighs against a finding that any acquired psychiatric disorder is attributable to service. CONCLUSION OF LAW The criteria for service connection for an acquired psychiatric condition have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2018); 38 C.F.R. §§ 3.102, 3.303 (2020). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from November 1966 to October 1970. He appeals a December 2016 rating decision by the Department of Veterans Affairs (VA) Agency of Original Jurisdiction (AOJ) denying entitlement to service connection for posttraumatic stress disorder (PTSD). A Board of Veterans' Appeals (Board) hearing was held in May 2021. A transcript is of record. The scope of a mental health disability claim includes any mental disability that may reasonably be encompassed by the Veteran's description of the claim, reported symptoms, and the other information of record. See Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). Thus, the Board has recharacterized the claim on appeal to entitlement to service connection for an acquired psychiatric disorder, to include PTSD. A veteran is entitled to VA disability compensation if there is a disability resulting from personal injury suffered or disease contracted in the line of duty in active service, or for aggravation of a preexisting injury suffered or disease contracted in the line of duty in active service. See 38 U.S.C. § 1110. Generally, to establish a right to compensation for a present disability, a veteran must show: (1) a present disability; (2) an 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, the so-called "nexus" requirement. See Shedden v. Principi, 381 F.3d 1163, 1167 (2004). Service connection may be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that a disease was incurred in service. 38 C.F.R. § 3.303(d). The determination of whether the requirements of service connection have been met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). A veteran need only demonstrate an approximate balance of positive and negative evidence in order to prevail. See Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). For a claim to be denied on the merits, a preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996). Originally, as noted above, the Veteran filed a claim for PTSD. The Veteran claims he was "diagnosed with PTSD at the Bedford VAMC;" however, the records reflect this is not the case. See January 2017 notice of disagreement (NOD). August 2016 VA treatment records reflect the Veteran's psychiatric symptoms "suggested" a diagnosis PTSD as he appeared to meet Criteria B, C, and D under a PTSD diagnosis in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV); however, this was only a suggestion and does not constitute an actual diagnosis. Furthermore, the DSM-IV was replaced by the DSM-5, effective August 4, 2014, and applies to all applications for benefits received by VA or pending before the AOJ on or after August 4, 2014. See 80 Fed. Reg. 14,308 (Mar. 19, 2015). As such, only the DSM-5 applies to this Veteran's current claim. The Veteran contends he has been treated for PTSD "on a monthly basis for several years now" and his VA psychologist suggested he "attend PTSD groups for more treatment." See March 2017 VA Form 9. This is also not reflected by VA treatment records. Rather, the record reflects the Veteran sought psychiatric treatment in August 2016 and ended treatment in December 2016 after travelling to Arizona for the winter. See December 2016 VA treatment records ("Veteran will call me when he returns from Arizona in March 2017"). The Veteran's records do not reflect any other psychiatric treatment. Additionally, December 2016 VA treatment records note the Veteran's VA psychologist suggested he join a "peer group for stress management" and when no groups were available at the VA facility, his psychologist recommended "coffee socials to connect with other veterans," which the Veteran declined. Overwhelmingly, the evidence of record does not reflect an actual diagnosis of PTSD under the DSM-5. For example, the Veteran responded that he did not have PTSD or depressive symptoms at any medical screenings. See, e.g., June 2017 VA treatment records; September 2018, September 2019, and December 2020 VA treatment records. The Veteran "denied experiencing PTSD symptoms for all of his life" with the exception of a "recent meltdown" in July 2016 where he experienced "extreme anxiousness" after a phone call regarding identity theft. See August 2016 VA treatment records. Importantly, an October 2016 VA examiner and two VA psychologists found the Veteran did not meet the criteria for PTSD and instead diagnosed the Veteran with adjustment disorder. See August 2016 and October 2016 VA treatment records. As such, although the Veteran does not have a clinical diagnosis of PTSD, the Board finds the evidence reflects the Veteran has adjustment disorder and the first element for service connection is met. As for the second element for service connection, the Veteran contends he witnessed several traumatic events while serving in Guam, mainly that "he observed injured and deceased servicemen" while fueling planes "between 3 and 4:30am" when men brought back "the most severely injured soldiers from Vietnam." See August 2016 VA treatment records; October 2016 VA Form 21-0781; October 2016 VA examination report. The claimed stressors are consistent with the places, types, and circumstances of the Veteran's service as his DD Form 214 corroborates that the Veteran served as a fuel specialist and service treatment records note treatment at Andersen Air Force Base, Guam from April 1968 to September 1969. 38 C.F.R. § 3.304(f)(3). Additionally, the October 2016 VA examiner found his claimed in-service stressors met the Criteria A element for a PTSD diagnosis. As such, an in-service event or stressor, the second element necessary for service connection, is conceded. Id. Thus, the crux of this case centers on whether the Veteran's adjustment disorder is related to service. In October 2016, the Veteran received a VA examination to assess any acquired psychiatric disorder the Veteran may have. As stated above, the VA examiner, a clinical psychologist, diagnosed the Veteran with adjustment disorder. After a thorough review of the record and Veteran assessment, she concluded the Veteran's adjustment disorder was less likely than not due to his claimed in-service events. Instead, the VA examiner noted the Veteran's adjustment disorder was "directly caused by his experience of identity theft" and "no other mental conditions were apparent." The Board finds the VA examiner's opinion probative. Her examination report reflects a thorough review of the record as she noted "no history of mental health treatment prior to the Veteran's 'meltdown' this past summer as a result of his experience of identity theft." She correctly noted the Veteran's service treatment records and July 1970 separation examination contain no evidence of a psychiatric condition. Also, as noted above, the Veteran consistently denied any PTSD or depressive symptoms at medical appointments. Of note, are October and November 2016 VA treatment records where the Veteran discussed a "relapse" and "'flashback' to his time in Guam" after visiting wheelchair-bound veterans. As of the May 2021 Board hearing, the Veteran ran a nonprofit for the last 10 years. The nonprofit raises money to provide electronics to severely wounded veterans, who the Veteran regularly visits in hospitals around the nation. The Veteran reported he enjoyed his nonprofit but was understandably upset by some injuries. See November 2016 VA treatment records; see also May 2021 Board hearing transcript at 9 ("I've been to Walter Reed 23 times in the last 10 years to the most severely injured soldiers...it's very difficult to see...."). These flashbacks and nightmares regarding his time in Guam were addressed by the October 2016 VA examiner in her examination report. Additionally, the Veteran's VA psychologist noted the Veteran denied any physiological sensations associated with his claimed "flashback" and "denied that meeting with wounded veterans was triggering for him." See November 2016 VA treatment records. Further, the Veteran denied any functional impairment, noted "he sleeps well, and his mood is 'pretty good.'" See October 2016 VA treatment records. Finally, at the May 2021 Board hearing, the Veteran testified he did not feel his symptoms affected his ability to function in any area of his life and he did not suffer from flashbacks or intrusive thoughts of in-service events until "just the last year." See May 2021 Board hearing transcript at 8-9. As such, all of the competent and credible evidence, including the Veteran's VA psychologists and October 2016 VA examiner, reflect the Veteran's psychiatric symptoms do not stem from his in-service event in Guam. Accordingly, the Board finds the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for an acquired psychiatric disorder. The benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53. DONNIE R. HACHEY Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Bona, 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.