Citation Nr: 22017193 Decision Date: 03/24/22 Archive Date: 03/24/22 DOCKET NO. 17-11 402 DATE: March 24, 2022 ORDER Service connection for adjustment disorder with mixed anxiety and chronic depressed mood is granted. FINDING OF FACT Resolving doubt in favor of the Veteran, his adjustment disorder with mixed anxiety and chronic depressed mood is at least as likely as not caused by his active service. CONCLUSION OF LAW The criteria for service connection adjustment disorder with mixed anxiety and chronic depressed mood are met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2021). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active duty in the United States Army from September 1968 to August 1971, including service in the Republic of Vietnam. This matter comes before the Board of Veterans' Appeals (Board) from a December 2014 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran submitted a Notice of Disagreement (NOD) in December 2015 and a Statement of the Case (SOC) was issued in January 2017. The Veteran perfected an appeal by submitting a timely VA Form 9 in February 2017. The issue was previously before the Board. In July 2021, the Board remanded the appeal to the RO for additional development. In August 2021, the Veteran was afforded a VA examination for his claim of service connection for acquired psychiatric disorder. Thus, the Board finds that the RO substantially complied with the remand directives and no further action is necessary in this regard. Stegall v. West, 11 Vet. App. 268 (1998). Service Connection Service connection may be granted for a disability resulting from personal injury suffered or disease contracted in the line of duty. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.304. Service connection may also be granted for a disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Establishing service connection generally requires (1) evidence of a current disability; (2) evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The standard of proof to be applied in decisions on claims for VA benefits is set forth in 38 U.S.C. § 5107(b). Under that provision, VA shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. Id.; see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Service connection for adjustment disorder with mixed anxiety and chronic depressed mood The Veteran contends that his acquired psychiatric disorder was caused by his active service in Vietnam. Service treatment records are silent for any mental health symptoms, diagnoses, or treatment. In a September 2006 VA outpatient mental health assessment, a clinician noted the Veteran's reports of thoughts about his experiences in Vietnam. He reported serving in a combat area and though not witnessing deaths, he recalled the sound of bullets hitting bodies. After assessing the Veteran at length, the clinician diagnosed adjustment disorder and alcohol dependence in full remission but not posttraumatic stress disorder (PTSD). He began a course of medication and therapy. Later, the attending clinician added depressed mood to the diagnosis. In a December 2014 VA contract mental health evaluation, the Veteran reported more specific combat events, but the examiner found that the Veteran did not have a mental health disorder. In July 2021, the Board found that the December 2014 VA examination was inadequate as the examiner did not address all the pertinent information in the record, including the Veteran's VA Medical Center treatment records that note the Veteran having an adjustment disorder with depressed mood. In August 2021, the Veteran was afforded a VA examination for his claim of service connection for acquired psychiatric disorder. The examiner opined that the Veteran did not meet the DSM-V criteria for posttraumatic stress disorder (PTSD) but opined that the Veteran's adjustment disorder with mixed anxiety and chronic depressed mood was at least as likely as not related to in-service stressors and combat engagement in Vietnam. In November 2021, the Veteran stated that he was in the Republic of Vietnam and deployed "somewhere in the area around Tuy Hoa" via helicopter in 1970. The Veteran added that he was "involved in several firefights and witnessed bodies being loaded" onto helicopters. In February 2022, the RO issued a Supplemental Statement of the Case (SSOC) denying the Veteran's claim. The RO, contrary to the November 2021 medical opinion, found that the Veteran's adjustment disorder with mixed anxiety and chronic depressed mood was not caused by service as "these conditions were not shown during military service." The RO did not, however, cite any evidence that contradicted the Veteran's statements or address the service records that showed duty as an artillery repair technician in Vietnam in hostile areas. After reviewing the evidence of record and resolving doubt in favor of the Veteran, the Board finds that the Veteran's adjustment disorder with mixed anxiety and chronic depressed mood was at least as likely as not related to in-service stressors and combat engagement in Vietnam. There is no evidence of record that discredit the Veteran's statements of engaging in firefights in the Republic of Vietnam and having witnessed bodies being loaded onto medical evacuation helicopters. Thus, resolving doubt in favor of the Veteran, the Board finds that the events described by the Veteran took place during his active service. Next, the Board finds that the August 2021 VA medical opinion is adequate as the diagnosis was made by a psychologist using DSM-V criteria and based on the events as described by the Veteran. There are no other adequate medical opinions of record contrary to the August 2021 VA medical opinion. In summary, resolving doubt in favor of the Veteran, the Board finds that the Veteran's service connection for adjustment disorder with mixed anxiety and chronic depressed mood is granted. See 38 U.S.C. § 5107. J.W. FRANCIS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board H.S. Yun, 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.