Citation Nr: 21042435 Decision Date: 07/13/21 Archive Date: 07/13/21 DOCKET NO. 15-18 349 DATE: July 13, 2021 ORDER Entitlement to service connection for an acquired psychiatric disorder, to include post-traumatic stress disorder (PTSD) is granted. FINDING OF FACT The most probative evidence of record shows that the Veteran has been diagnosed with PTSD based on an established in-service stressor. CONCLUSION OF LAW The criteria for service connection for an acquired psychiatric disorder, to include PTSD have been met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.303(a), 3.304(f). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active military service from January 1965 to March 1968. This matter comes before the Board of Veterans' Appeals (Board) from the September 2014 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). In January 2019, the Board remanded the claim of entitlement to service connection for an acquired psychiatric disorder, to include PTSD, for further development. Specifically, on remand, the Board directed that the RO obtain outstanding VA treatment records and schedule a VA examination to determine the nature and etiology of the Veteran's acquired psychiatric disorder. Pursuant to the Board's remand directives, outstanding VA treatment records and corroborating evidence were obtained, and a VA examination was conducted to determine the nature and etiology of the Veteran's acquired psychiatric disorder. For the reasons discussed below, the Board finds that the VA examination conducted in December 2019 was inadequate. However, because the Board is granting service connection for an acquired psychiatric disorder, this is harmless error with regard to this issue and results in no prejudice to the Veteran. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred or aggravated during active military service. 38 U.S.C. § 1110. Generally, service connection requires (1) the existence of a present disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Consistent with this framework, service connection is warranted for a disease first diagnosed after service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. § 3.303(d). Service connection for PTSD additionally requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a) (i.e., under the criteria of DSM-IV or DSM-5); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred (unless the evidence shows that the Veteran engaged in combat and the claimed stressor is related to combat). See 38 C.F.R. § 3.304(f). Entitlement to service connection for an acquired psychiatric disorder, to include PTSD The Veteran contends that his PTSD is related to his military service. Specifically, the Veteran has asserted that while he was stationed in Germany, his father suffered severe and life-threatening burns covering the majority of his body. The Veteran further reports that he attempted to obtain leave to take care of his father and assist his mother, but the leave request was denied. Based on the evidence of record, the Veteran's claim of entitlement to service connection for an acquired psychiatric disorder, to specifically include PTSD is granted. Initially, the Board will address the Veteran's reported in-service stressors. The first identified stressor was that he was denied leave to see his father (who sustained life-threatening injuries) and was subsequently treated harshly by his commanders. The Veteran also identified that he sustained a motorcycle accident while in service. In an August 2014 memorandum, VA issued a Formal Finding of a Lack of Evidence to Verify Stressors. The memorandum noted that the information required to verify the stressful events described by the Veteran was insufficient to send to the U.S. Army and Joint Services Records Research Center (JSRRC) and/or insufficient to research the case for an Army record. Consistently throughout the record, the Veteran has asserted that during his period of active service, he was denied leave to see his father, who again suffered a life-threatening injury resulting in burns over 80 percent of his body. In credible buddy statements, dated August 2013, October 2019, December 2019, the Veteran's spouse and two brothers noted that the Veteran's father suffered burns on his body. The Veteran's brothers were home with their father at the time of the accident and were aware that their brother (the Veteran) was notified of the accident and was denied leave. An August 1966 Special Court Martial Orders show that the Veteran received military punishment resulting in multiple restrictions after he impermissibly left his assigned military facility in a UASREUR-licensed privately owned vehicle without a license. In a May 2015 statement, the Veteran stated that following his leave request denial, he began to "feel the officials were against him." He also reported that he received an Article 15 for not cleaning a firearm that did not belong to him and was assigned to do hard labor. He also stated that he then began experiencing reckless and self-destructive behavior. Not knowing whether his father was alive, the Veteran left his post and the guard on duty reported him to his company commander and which resulted in military non-judicial punishment. Given this lay evidence and the service treatment records, the Board finds that there is sufficient corroboration of the Veteran's reported stressors in service. As such, the other stressor will not be discussed further. As an initial matter, the Board notes that an August 2014 VA treatment record reveals diagnoses, under the DSM-5, of dysthymia; generalized anxiety disorder, nicotine use disorder; and personality disorder NOS with Cluster B traits. VA treatment records, dated April 2016 and August 2016, revealed a diagnosis of Major Depressive Disorder, recurrent, chronic. The treatment record also included the following notation: RTC one month continued psychotherapy for PTSD. In a July 2016 VA treatment record, an examining clinician noted that the Veteran "continues to experience ptsd issues as well as depressive problems." An August 2018 VA treatment record revealed that the Veteran had a positive screening test for PTSD. Turning to the issue of a diagnosis of a psychiatric condition related to this stressor, the Board finds the evidence is in equipoise. The evidence in support of the claim includes several private treatment records. In July 2013, October 2014, April 2015, August 2016, and July 2020 private treatment records, Dr. D.L. stated that the Veteran had diagnoses of PTSD, severe and chronic secondary to military service; major depression; and panic disorder. In the July 2013 record, the clinician noted that the Veteran had been experiencing PTSD ever since his military service, but he was unaware of this disorder until the recent wars in Iraq and Afghanistan. Dr. D.L. also noted that the Veteran's stress episode was due to being denied personal leave to visit his father before his possible death. In the October 2014 and April 2015 private treatment notes, Dr. D.L. stated that the Veteran met all diagnostic criteria for PTSD under DSM-V and that it was his firm clinical opinion that the Veteran's current, severe psychological distress is the direct result of his military service. In an August 2016 private treatment record, authored by Dr. D.L., reveals that the Veteran had diagnoses of PTSD, severe and chronic secondary to military experience; major depression; and generalized anxiety disorder. Dr. D.L. also stated that the Veteran's trauma symptom inventory (TSI) is consistent with severe military-related PTSD. In a July 2020 private treatment note, Dr. D.L. again stated that the military traumas that the Veteran experienced during his time in the military (1965 to 1968) were sufficient for the diagnosis of PTSD, resulting from the Veteran's military service. Dr. D.L. also noted that the Veteran's PTSD directly resulted from military service traumas. The evidence against the claim includes a PTSD Disabilities Benefits Questionnaire (DBQ). The Veteran was afforded an Initial PTSD DBQ in December 2019. The examiner noted diagnoses of major depressive disorder, recurrent, mild and alcohol use disorder in sustained remission. The examiner also noted that the Veteran did not meet the diagnostic criteria for PTSD under the DSM-5 criteria, noting that the Veteran met Criterion A-D, but he did not meet Criterion E-I. In the remarks section of the report, the examiner stated that although the Veteran's father's injury may meet Criteria A for PTSD, the Veteran's response did not. The examiner noted that the Veteran's major depressive disorder was not due to, nor first incurred during active service. The examiner reasoned that there was no indication of these symptoms during his military service or shortly after. The examiner also reported that the Veteran described a number of life stressors subsequent to military service that could cause depression, to include two divorces due to infidelity, alcohol abuse, job loss, drug use, and theft. Upon review of this December 2019 opinion, the Board does not find that it provides much probative value. The examiner appeared to disregard the numerous notations of PTSD prior to the examination. And, here, the Board may presume that the diagnoses provided by these mental health care professionals were made in accordance with the appropriate DSM criteria. See Cohen v. Brown, 10 Vet. App. 128, 140 (1997). In addition, even in finding that the Veteran did not have a diagnosis of PTSD, the examiner failed to provide an opinion with adequate supporting rationale as to the non-PTSD diagnoses. Instead, the examiner impermissibly relied solely on the absence of symptoms during military service and thereafter as his supporting rationale. In summary, the Veteran has received several PTSD diagnoses during the appeal period that appear to be based on his established stressor. The Board notes that the diagnosis in July 2013 did not specify whether the DSM-IV or the DSM-V was used. However, as this diagnosis was provided after the release of the DSM-V in May 2013, the Board finds that that it was made in accordance with the DSM-V diagnostic criteria. See Cohen, 10 Vet. App. at 140. Further, the private clinician clarified that the diagnosis was made under the DSM-V in his subsequent report, which followed VA-issued treatment records indicating a PTSD diagnosis. In considering these PTSD diagnoses alongside the determinations of the VA examiner in 2019, the Board finds that the evidence establishes a current diagnosis of an acquired psychiatric disorder, including major depression and PTSD; and with regard to the etiology of the diagnosed PTSD, the Board finds that the most probative evidence shows that it was due to an in-service stressor. Thus, the claim of entitlement to service connection for an acquired psychiatric disorder, to include PTSD is granted. GAYLE STROMMEN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Hanson 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.