Citation Nr: 22015352 Decision Date: 03/17/22 Archive Date: 03/17/22 DOCKET NO. 16-08 837 DATE: March 17, 2022 ORDER Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), depression, and anxiety is granted. FINDING OF FACT Resolving reasonable doubt in the Veteran's favor, his acquired psychiatric disorder to include PTSD, depression, and anxiety, is etiologically related to service. CONCLUSION OF LAW The criteria for service connection for and acquired psychiatric disorder to include PTSD, depression, and anxiety, have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from September 1989 to August 1993. In November 2018, the Veteran testified before the undersigned Veterans Law Judge (VLJ). A transcript of the hearing is of record. In May 2019, the Board denied the Veteran's claim for an acquired psychiatric disorder, to include PTSD, depression, and anxiety. The Veteran subsequently appealed the May 2019 Board decision to the United States Court of Appeals for Veterans Claims (Court). In a February 2020 Order, the Court granted the parties' Joint Motion for Partial Remand (JMPR), vacating the Board's May 2019 decision and remanded the appeal to the Board for readjudication consistent with the JMPR. In August 2020, and in response to the JMPR, the Board remanded the claim for further development. In February 2021, the Board remanded the claim for further development. Service connection for an acquired psychiatric disorder Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). To establish a right to compensation for a present 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." Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Analysis The Veteran contends that his acquired psychiatric disorder is related to his military service. The Veteran has current diagnoses of unspecified depressive disorder, adjustment disorder, anxiety, PTSD, and chronic sleep impairment. As such, element one under Shedden is met. The Veteran's service treatment records (STRs) do not document complaints, treatments, and diagnosis for an acquired psychiatric condition. During his April 1989 Report of Medical History, Enlistment Examination and his July 1993 Report of Medical History: Separation Examination, the Veteran noted that he did not have frequent trouble sleeping, depression or excessive worry, loss of memory or amnesia, or nervous trouble or any sort. Clinically, his psychiatric exam was noted to be normal. In March 2009, the Veteran was seen at the Barrak/Wenceslao Gengras. The Veteran stated that he felt depressed after the loss of his sister. In May 2009, the Veteran was seen at the Manchester Memorial Hospital Ambulatory Behavioral Health for relationship help. During the initial evaluation, the Veteran noted his stressors, to include, the breakup of his relationship, conflict with a significant other, the death of his sister, family conflict, and job stress. The Veteran stated that as a child, his mother verbally abused him. Additionally, as a child, he witnessed sexual abused and was the perpetrator of abuse. The Veteran's discharge diagnosis was adjustment disorder w/mixed disturbance of emotions/conduct, acute. His September 2013 PTSD and depression screens were negative. In October 2013, the Veteran was seen at the Hartford Vet Center (Vet Center). The Veteran grew up in the Virgin Islands. He reported having a good life with no history of abuse or neglect. The Veteran presented with anxiety with the stressful condition that were surrounding his life. He stated that memories of an in-service missile accident at sea triggered his stress. However, for a number of years, he coped and worked on his resiliency. In January 2014, the Veteran saw a re-adjustment counselor at the Vet Center. The Veteran was first seen at the center in July 2008 and was previously seen by Mr. L.W., MSSW and Mr. T.M., LCSW. Both clinicians noted that due to his combat experiences, the Veteran had significant readjustment difficulty. During his 2014 evaluation, the Veteran stated that he experienced difficulty coping with trauma related to his combat experience in which an American naval vessel accidentally fired a missile at a Turkish ship killing individuals. The Veteran felt that he was unable to cope with the anxiety of the experience. The symptoms that continued to impact the Veteran's life included difficulty concentrating, memory loss, and sensitivity to loud noises. The counselor identified PTSD symptoms which included feelings of guilt; increased irritability/anger; hypervigilance; frequent intrusive thoughts; avoidance of thoughts and feelings, people, and places that remind him of the military accident; difficulty feeling connected to family; and difficulty falling and staying asleep along with frequent vivid nightmares. In August 2014, the Veteran was afforded a VA examination to determine the nature and etiology of his acquired psychiatric disorder. He identified several stressors, to include, being aboard the U.S.S. Saratoga in 1992, engaging in war games, and witnessing the accidental firing of actual missile which hit a Turkish ship. The accident caused injury and death. He witnessed the injured being brought on board. Additionally, before he was aboard the Saratoga, it capsized and 21 sailors, including the Veteran's friend died. After service, and five to seven years prior to the VA examination, and, even more salient (based on his affect on the interview), the Veteran witnessed a man shot in the head at a Caribbean carnival in NYC. He stated, "I stay away from crowds" as a result of this stressor. He also reported verbal and emotional abuse by his mother throughout childhood, and when he was approximately seven to eight, a teenage female family friend sexually abused the Veteran. Finally, Manchester Memorial 2009 diagnosed the Veteran with adjustment disorder and the primary stressor was the loss of his sister in 2008. The Manchester record also references childhood sexual and verbal abuse. There is no mention or reference to military trauma in this record. The examiner diagnosed the Veteran with unspecified depressive disorder, anxiety, and chronic sleep impairment. The examiner stated that the Veteran's symptoms did not meet the diagnostic criteria for PTSD under DSM-5 criteria. The examiner opined that it is more likely than not that the Veteran's depressive condition is not caused by or related to military service. The examiner stated that the Veteran had limited stressor exposure in service and exposure to multiple other life stressors that are more likely than not the substantial cause of any stressor-related condition. His diagnosed depressive disorder is based on a credible described history of longstanding problems with mood, irritability, social withdrawal, rumination, and intermittent sleep disturbance. However, there is no evidence to support a causal connection between the Veteran's military experience and this depressive condition. On the contrary, his PTSD and depressive screenings were negative in the past, and the record identified other stressors reported by the Veteran in 2009 that were considered relevant to his condition, with no reference to military trauma. During his November 2018 Board hearing, the Veteran recounted many in-service stressors, to include, witnessing his friend falling overboard the ship and drowning. Additionally, a fellow shipmate was "playing around" when the crew was supposed to be training. The chief commanded the shipmate and the Veteran to stop playing around, threatened to, and then choked the Veteran. Also, while onboard the U.S.S. Saratoga during war games, a shipmate accidentally fired a real missile that blew up a Turkish ship. The Veteran witnessed the bodies being taken out of the ship. He also witnessed men walking off the ship limping and bloodied. However, because of his culture, he did not seek mental health treatment until 2005 or 2006. In November 2019, the Veteran was seen at the Newington, Mental Health Psychiatric Consult for his psychiatric disorder. The examiner stated that the Veteran had a long history of mood symptoms. He had significant PTSD related to multiple traumas starting in childhood, then augmented by multiple traumatic events while in the Navy, and witnessing a man getting shot post military. The examiner stated that the main issue included on and off depression and frustration and dissatisfaction of where he was in life. The examiner noted initial and ongoing trauma assessment, to include, childhood verbal and emotional abuse by his mother and, at the age of 7 or 8, multiple incidents of sexual abuse by a teenage female family friend. The examiner also noted that in 1992 aboard the U.S.S. Saratoga, the Veteran engaged in war games and an actual missile was accidentally fired, hitting a Turkish ship, and causing injury and death. The Veteran witnessed the injured being brought on board. Additionally, on the U.S.S. Forrestal, the Veteran witnessed a plane crashed in the sea and a man being overboard and drowned. Finally, around 2007 or 2009, the Veteran witnessed a man getting shot in the head. In December 2019, the Veteran's clinical social worker, A.S., BCD, LCSW, stated that the Veteran had been attending treatment at the Vet Center since October 2008. A.S. stated that the Veteran initially sought treatment due to increasing anxiety, but, over the years, he sought treatment and disclosed more symptoms of anxiety, depression, and PTSD. A.S. noted that the Veteran was diagnosed with PTSD as well as anxiety disorder. The Veteran disclosed that he was exposed to trauma while he served in the Navy. During this time, he spent a great deal of time aboard ships and out to sea on a variety of missions. While at sea, he witnessed events where his fellow comrades were killed or died. A.S. noted that it was unknown, however, that the Veteran suspected that one of the deaths was a successful suicide, and he struggled with the guilt and shame related to this death. He did not know his friend was not doing well and carried guilt on a regular basis for not asking him more and finding a way to help him more. A.S. stated that the Veteran recently began talking more about the trauma that he experienced while in service. It appeared that the Veteran was struggling with survivor's guilt as well as negative self-talk, hypervigilance, and struggled with interpersonal relationships. The Veteran was able to share his cultural beliefs and how they had been barriers to him seeking treatment. The Veteran reported that he had been coping with a great deal of shame and guilt, and this had been a huge reason that he had just started to address things more aggressively in treatment. A.S. stated that upon reviewing the Veteran's records, it was A.S.'s opinion that the Veteran was exposed to trauma during his military career and this was reflected in his symptoms. In November 2020, the Veteran submitted a statement from Dr. K. The Veteran began seeing Dr. K. in November 2019. Dr. K. confirmed the Veteran's PTSD and major depression diagnoses. Dr. K. stated that the Veteran's PTSD is complex and is related to emotional abuse in childhood, several traumatic events during his service, and after his discharge from service, he witnessed a man getting shot. The traumatic events the Veteran experienced during his service on the U.S.S. Saratoga included seeing a fellow veteran jumping off-board to his death, an incident that is associated with significant guilt and nightmares. He also saw numerous injuries related to a Turkish ship accidentally hit during war games. The examiner noted that there is a large body of clinical work indicating that individuals with childhood maltreatment are more sensitive to additional trauma later in life. Moreover, it is abundantly clear that the traumatic events the Veteran experienced during his service have exacerbated his PTSD symptoms most notably his intrusive thoughts, nightmares, guilt, mistrust of others, difficulties in crowded places, and increased anger and irritability. In summary, the Veteran meets full criteria for the diagnosis of complex PTSD that has been exacerbated by his military service and is associated with difficulties socializing and trusting others. In September 2021, VA noted that it had completed comprehensive research on the Veteran's April 1990 stressor, i.e., he witnessed a fellow sailor fall overboard and declared dead at sea. VA verified the stressor incident/event. In October 2021, the Veteran was afforded a VA examination to determine the nature and etiology of his acquired psychiatric disorder. The examiner confirmed the Veteran's unspecified depressive disorder. The examiner stated that the Veteran did not have more than one mental disorder diagnosed. The examiner stated that the Veteran met DSM-5 diagnostic criteria for unspecified depressive disorder. The examiner opined that the Veteran's unspecified depressive disorder is less likely than not (less than a 50 percent probability) incurred in or caused by the reported in-service stressor. The examiner also stated that there is no evidence to suggest that this diagnosis was aggravated beyond its natural progression by an in-service related event. The examiner found evidence of other pre-and post-military stressors that would account for the Veteran's mental health symptoms. The examiner noted that the Veteran had no history of mental health treatment or reported issues in the military. The October 2021 examiner agreed with the August 2014 VA examiner who also diagnosed the Veteran with unspecified depressive disorder. The 2021 examiner quoted the 2014 examiner. The 2014 examiner stated that the Veteran "...reports verbal and emotional abuse by his mother throughout childhood, and childhood sexual abuse multiple times by a teenage female family friend when the vet was approximately 7-8 yrs old...recent loss of sister to illness in 2008 as primary stressor..." Additionally, "...Vet with limited stressor exposure in service and exposure to multiple other life stressors that are more likely than not the substantial cause of any stressor-related condition...there is no evidence to support a causal connection between the vet's military experience and this depressive condition..." The 2014 examiner opined that "...it is more likely than not that the vet's depressive condition is not caused by or related to military service." In February 2022, the Veteran submitted a statement from Dr. K.. Dr. K. stated that the October 2021 examiner relied heavily on the 2014 examination and dismissed several traumatic incidents that the Veteran experienced as "insignificant." Dr. K. stated that this assessment is inconsistent with the medical records. Dr. K. noted, among other things, the Veteran's confirmed stressor and concluded that the Veteran met criteria A for PTSD. Dr. K. stated that the denial letter and compensation and pension evaluations noted that the Veteran had a difficult childhood and additional stressors and attributed his symptoms to these other traumatic events. Dr. K. stated that this conclusion is incorrect as there is a large body of work indicating that childhood adversity increases the risk and vulnerability for PTSD. In other words, his difficult childhood makes him more likely to develop PTSD with additional exposure to trauma. In concluding, Dr. K. stated that the Veteran met the full criteria for the diagnosis of complex PTSD that is directly linked to traumatic incidents he experienced during his service. The Board notes that while the VA examiners indicated that the Veteran does not have a PTSD diagnosis, the Veteran's regular treating examiners and the Veteran's VA treatment records indicate a PTSD diagnosis. As such, the Board concedes a diagnosis. Therefore, after reviewing the entire record and weighing the relevant medical opinions, the evidence for and the evidence against the Veteran's claim is at least in relative equipoise. After affording the Veteran the benefit of the doubt, the Board finds there is competent and credible medical and lay evidence of record connecting the Veteran's acquired psychiatric disorder to his service. Accordingly, the Board grants service connection for acquired psychiatric disorder to include PTSD, depression, and anxiety. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). MICHAEL LANE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Moore, T. 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.