Citation Nr: 21042127 Decision Date: 07/12/21 Archive Date: 07/12/21 DOCKET NO. 17-38 943 DATE: July 12, 2021 ORDER Entitlement to service connection for an acquired psychiatric disability, diagnosed as posttraumatic stress disorder (PTSD), generalized anxiety disorder (GAD), and depression, is granted. FINDING OF FACT Resolving reasonable doubt in the Veteran's favor, the medical evidence shows diagnoses of PTSD, GAD, and depression based on a claimed in-service stressor. CONCLUSION OF LAW The criteria for service connection for an acquired psychiatric disability, diagnosed as PTSD, GAD, and depression have been met. 38 U.S.C. §§ 1110, 1131, 5103, 5013A, 5107 (2019); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2020). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from February 1968 to August 1971. He honorably served in Vietnam and received the Purple Heart Medal, among other decorations, for his service. See DD Form 214. The Veteran appeals an August 2016 rating decision by the Department of Veterans Affairs (VA) Agency of Original Jurisdiction (AOJ) denying entitlement to service connection for PTSD, depression, and anxiety. A Board of Veterans' Appeals (Board) hearing was held in July 2021. The transcript from the hearing has not yet been associated with the file, as the appeal is being granted under the Board's "One Touch" program. However, the hearing transcript will be added to the claims file in the ordinary course of business. 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, anxiety, and depression. A veteran is entitled to VA disability compensation if there is a current disability resulting from personal injury suffered in active service, or for aggravation of a preexisting injury suffered in active service. 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 for PTSD requires medical evidence establishing a diagnosis of the condition, credible supporting evidence that the claimed in-service stressor actually occurred, and a link, established by medical evidence, between the current symptomatology and the claimed in-service stressor. See 38 C.F.R. § 3.304(f). Within the legal framework, the sufficiency of a stressor is a medical determination, while the occurrence of the stressor is a legal determination. Sizemore v. Principi, 18 Vet. App. 264 (2004). 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). 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). The Veteran was afforded a VA examination in July 2016 to assess the nature and etiology of his reported psychological symptoms. Although the VA examiner noted the Veteran's in-service events met Criterion A for a PTSD diagnosis, he ultimately concluded the Veteran did not have PTSD or any acquired psychiatric disorder under the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). See July 2016 VA examination report. The VA examiner reviewed the Veteran's record and interviewed the Veteran prior to providing a detailed examination report; thus, the Board finds the VA examination report somewhat probative. However, overall, the Board finds this opinion inadequate. For example, on the examination report, the VA examiner noted the Veteran "did not endorse any clinical symptoms of PTSD, anxiety, or depression in the interview" but contrarily checked that the Veteran experienced symptoms of anxiety. Id. Further, the VA examiner noted the Veteran did not meet Criteria B-E but inexplicably met Criterion F, which requires his psychiatric disturbance, through meeting Criteria B, C, D, and E, to have a duration of more than one month. Id. Finally, the Veteran noted he "tried to talk about what went on [in Vietnam, but] the examiner did not want to hear it." See July 2017 Veteran statement. While the Veteran is not competent to opine on the etiology or diagnosis of his psychiatric symptoms, he is competent to testify to his experience in Vietnam combat and various psychiatric symptoms. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). Thus, the Board finds the July 2016 VA examiner's opinion inadequate as he did not address the Veteran's competent lay statements and his report is internally inconsistent. However, the Veteran has a clinical diagnosis of PTSD and GAD; thus, the first element for service connection is met. See December 2016 Dr. S.L. examination report. The Veteran's military occupational specialty (MOS) in the Army was a light weapons specialist. See DD Form 214. The Veteran reported enemy attacks and an air strike that "dropped a bomb...that blew [him] and a Vietnamese soldier off the side of a hill." See July 2016 VA examination report. As noted above, the Veteran's DD Form 214 shows that he was awarded the Purple Heart Medal, Vietnam Service Medal, and the Combat Infantry Badge, among other decorations. March 1971 service treatment records reflect the Veteran suffered a gunshot wound to his left arm during an enemy ambush in the Republic of Vietnam. In the case of any veteran who engaged in combat, lay testimony, alone, may be sufficient to establish the occurrence an in-service stressor related to combat with the enemy. See 38 C.F.R. § 3.304(f)(2). Thus, the evidence of record clearly establishes the second element for service connection, an in-service event or stressor. Although the July 2016 VA examiner did not diagnose the Veteran with any psychiatric disorder, he did note the Veteran's in-service stressors were sufficient to meet the Criteria A element for PTSD and were based on fear of hostile military or terrorist activity. The sufficiency of his in-service stressors was also confirmed by Dr. S.L. In December 2016, Dr. S.L. conducted an initial assessment interview of the Veteran in addition to followup questioning before clinically diagnosing him with PTSD and GAD due to his combat service in Vietnam. Dr. S.L. also noted the Veteran's depression and essentially found that and his other symptoms "relate to his military experience. Dr. S.L. noted the Veteran was a "good survivor" after his experiences in Vietnam, but he still reflected symptoms of "survival guilt, hypervigilance, sleep problems, and concentration problems" in addition to "feelings of isolation, strong emotional responses to 'normal' situations and significant triggers." See December 2016 Dr. S.L. examination report. Dr. S.L. noted the Veteran was resilient and "managed to function fairly well after his experiences" in Vietnam, but concluded the Veteran had "no more than the normal and typical stress and crisis that most individuals" experience after his separation from service; therefore, he concluded the Veteran's in-service stressors were the primary factor in his current psychiatric disorders. Id. Dr. S.L., a licensed clinical social worker, is recognized by the Minnesota Board of Behavioral health to diagnose and treat patients under the DSM-5. The Board finds Dr. S.L.'s opinion probative as the Veteran's August 1967 pre-induction examination noted no psychiatric symptoms prior to service, Dr. S.L. provided detailed rationale, and he considered the Veteran's credible lay statements. In summation, Dr. S.L. diagnosed the Veteran with PTSD and GAD and noted depression, and found a medical link between the Veteran's current psychiatric symptoms and his in-service combat. The Veteran's probative lay statements regarding his combat in the Republic of Vietnam, corroborated by military personnel and treatment records, establish the occurrence of his in-service stressor. Thus, affording the Veteran the benefit of the doubt, the Board grants service connection for an acquired psychiatric disability, characterized by PTSD, GAD, and depression. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 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.