Citation Nr: 22018175 Decision Date: 03/28/22 Archive Date: 03/28/22 DOCKET NO. 17-08 169 DATE: March 28, 2022 ORDER Entitlement to service connection for posttraumatic stress disorder (PTSD) is granted. FINDING OF FACT The approximate balance of the evidence shows that the appellant at least as likely as not has PTSD related to a corroborated in-service stressor. CONCLUSION OF LAW The criteria for service connection for PTSD are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304(f). REASONS AND BASES FOR FINDING AND CONCLUSION The appellant served on active duty in the United States Air Force from September 2001 to February 2008. This case comes before the Board of Veterans' Appeals (Board) on appeal from an October 2015 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) which, in pertinent part, denied the claim for service connection because the appellant's claimed stressor was not verified and she had not been previously diagnosed with PTSD. This decision was appealed in a notice of disagreement (NOD) received by VA in May 2016. A Statement of the Case (SOC) was issued by VA in February 2017. VA received the appellant's Substantive Appeal (Form 9) requesting a hearing before the Board in February 2017, perfecting the appeal. The appellant appeared before the undersigned Veterans Law Judge for a hearing on this issue in November 2021. A transcript of that hearing has been added to the record on appeal. 1. Entitlement to service connection for PTSD is granted. The appellant contends that she has posttraumatic stress disorder that is directly related to an in-service personal assault. She asserts that, during the process of separating from and divorcing her first husband, he threatened her with a firearm and later pushed her to the ground, leading to an injury to her back. She contends this occurred in the Spring of 2004 and that she has experienced psychiatric symptoms related to this incident since. Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty from active military, naval, or air service. 38 U.S.C. §§ 1110, 1131. 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' the so-called nexus' requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (citing Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that which is pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a); 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. 38 C.F.R. § 3.304(f). 38 C.F.R. § 4.125(a) requires that mental health diagnoses conform to the Diagnostic Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). 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. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. The appellant's service treatment records contain notes from May to July 2004, which indicate she was receiving treatment with the "Family Maltreatment Case Management Team" at 2 MDOS Family Advocacy Office: Barksdale Air Force Base, Louisiana. These counselling records, while incomplete, note that a physical intrafamilial altercation had occurred. These records indicate that the incident status was "substantiated," by the counselling center. Affording the appellant the benefit of the doubt, the Board find that this is credible supporting evidence that the claimed stressor occurred. Considering this, the Board finds that the reported in-service stressor is credibly corroborated by the record, and as such, meets the criteria for service connection for PTSD. 38 C.F.R. § 3.304(f). The appellant underwent a private psychological examination in April 2021 with Dr. B.W., Ph.D., Licensed Psychologist. After a complete psychological examination of the appellant, the examiner determined that the appellant had a diagnosis of PTSD which was as likely as not related to various in-service stressors, to include the appellant's reported in-service personal assault. The examining clinician noted that significant diagnostic testing supported the diagnosis and that observations of the appellant's behavior during the examination indicated that they were related to the stressor. The examiner observed that the appellant's reactions and mannerisms during the interview appeared genuine. The Board notes this examination was conducted by a licensed mental health professional and included extensive diagnostic testing. The reasoning and rationale provided in support of the opinion was extensive and well-reasoned. As such, the Board affords the opinion significant probative weight. See Nieves - Rodriguez v. Peake, 22 Vet. App. 295 (U.S. 2008) (explaining that most of the probative value of a medical opinion comes from its reasoning). A VA medical opinion diagnosed the appellant with adjustment disorder but attributed that to currently occurring stressors, to include the appellant's then current divorce proceedings. The evaluating clinician noted though that the appellant reported difficulty remembering past events due to her current stress, so the examiner did not consider the prior incidents in attributing a cause to the adjustment disorder. (Continued on the next page) Considering all the evidence of record, the Board finds that there is an approximate balance of the evidence both in favor of and against the appellant having a diagnosis of PTSD which is related to an incident during her period of active service. As there is an approximate balance of the evidence, and it is not persuasively against the claim, the Board grants the appellant the benefit of the doubt and finds that she is currently diagnosed with PTSD which is as likely as not due to her claimed in-service personal assault. Therefore, the Board can conclude that the criteria for service connection for PTSD are met for this claim. 38 C.F.R. §§ 3.102, 3.303(f). K. Conner Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Kleponis, 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.