Citation Nr: A25035804 Decision Date: 04/18/25 Archive Date: 04/18/25 DOCKET NO. 191010-38608 DATE: April 18, 2025 ORDER Entitlement to service connection for an acquired psychiatric disorder, diagnosed as posttraumatic stress disorder (PTSD) is granted. FINDING OF FACT It is at least as likely as not the Veteran has been diagnosed with PTSD and it is at least as likely as not that his PTSD was caused by his active service. CONCLUSION OF LAW The criteria for service connection for an acquired psychiatric disorder, diagnosed as PTSD, have been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from August 1999 to August 2002 and from September 2003 to April 2004. This appeal comes to the Board of Veterans' Appeal (Board) under the Appeals Modernization Act (AMA) review system. Specifically, the Veteran filed an April 2019 VA Form 20-0995 Supplemental Claim seeking readjudication of entitlement to service connection for PTSD which was previously denied in a May 2018 Department of Veterans Affairs (VA) Agency of Original Jurisdiction (AOJ) rating decision. In July 2019, the AOJ issued a new rating decision which continued the denial of entitlement to service connection. The Veteran's October 2019 VA Form 10182, Decision Review Request: Board Appeal (AMA Notice of Disagreement) sought Board review of the July 2019 (notification in August 2019) rating decision. He selected the Hearing docket and a Board hearing was held on November 21, 2023. In April 2023, the Board granted entitlement to service connection for an acquired psychiatric disorder, diagnosed as unspecified depressive disorder and unspecified anxiety disorder and denied entitlement to service connection for PTSD. The Veteran appealed the denial of entitlement to PTSD to the United States Court of Appeals for Veterans Claims (CAVC). In October 2024, the CAVC approved a Joint Motion for Partial Remand (JMPR) and vacated the denial. The claim has been remanded to the Board for continued adjudication as directed in the JMPR. Entitlement to service connection for posttraumatic stress (PTSD) disorder Service connection for PTSD generally 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. See Cohen v. Brown, 10 Vet. App. 128, 139-43 (1997); 38 C.F.R. § 3.304(f). The provisions of 38 C.F.R. § 4.125 (a) require that a diagnosis of a mental disorder conform to the American Psychiatric Associations DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, 5th Edition (DSM-5). Mental health professionals "are presumed to know the DSM requirements applicable to their practice and to have taken them into account in providing" a psychiatric diagnosis. See Cohen, supra. If a claimed stressor is related to the fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a PTSD diagnosis and that the claimant's symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of the claimant's service, the claimant's lay testimony alone may establish the occurrence of the claimed in-service stressor. 38 C.F.R. § 3.304(f)(3). For purposes of 38 C.F.R. § 3.304(f)(3), "fear of hostile military or terrorist activity" means the claimant experienced, witnessed, or was confronted with an event or circumstances that involved actual or threatened death or serious injury, or a threat to the physical integrity of the claimant or others, such as from an actual or potential improvised explosive device, vehicle-imbedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon friendly military aircraft, and the claimant's response to the event or circumstances involved a psychological or psycho-physiological state of fear, helplessness, or horror. Id. When there is an approximate balance of positive and negative evidence regarding any material issue, reasonable doubt will be resolved in favor of the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. The Veteran's January 2018 claim and April 2019 supplemental claim sought service connection for PTSD. This claim included a claim for any acquired psychiatric disorder diagnosed. Clemons v. Shinseki, 23 Vet. App. 1 (2009) (The scope of a disability claim includes any disability that may reasonably be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record.) Here, the Veteran's form DD 214 confirms his service Kosovo and the July 2019 rating decision included the favorable finding that a stressor based on this service was conceded. An April 2018 VA PTSD examiner identified the Veteran's psychiatric symptoms and diagnosed the Veteran with unspecified depressive disorder with anxious distress. She found the Veteran did not meet the complete diagnostic criteria for PTSD. She noted the Veteran's report that he had deployed to Kosovo for six months and served in an area where "severe things went on." She also noted that he learned that some of his friends were injured while they were deployed. The examiner stated the stressor was sufficient to support a diagnosis of PTSD and it was based on the Veteran's fear of hostile military or terrorist activity. She opined the Veteran's psychiatric disorder was at least as likely as not caused by his "deployment to Kosovo to include learning of injuries to fellow soldiers." In June 2019, the VA examiner continued to find the Veteran did not meet the full diagnostic criteria for PTSD. The Veteran submitted a March 2019 letter and treatment records from Dr. T. D., MD, a private psychiatrist. Dr. T. D. confirmed a diagnosis of PTSD. As a mental health professional, Dr. T. D. is presumed to have made her diagnosis in accordance with the requirements of the DSM. Thus, the evidence as to whether PTSD has been diagnosed is in approximate balance. The Board resolves reasonable doubt in favor of the Veteran and finds it is at least as likely as not that he has been diagnosed with PTSD. The Board further finds, the April 2018 VA examination report supports findings that the conceded stressor is based on hostile military or terrorist activity; the conceded stressor is sufficient to support a PTSD diagnosis; and the Veteran's psychiatric symptoms are causally linked to the stressor. Entitlement to service connection for an acquired psychiatric disability, to include PTSD, is granted. 38 C.F.R. §§ 3.304(f), 4.125(a); See Wise v. Shinseki, 26 Vet. App. 517, 531 (2014) ("By requiring only an 'approximate balance of positive and negative evidence' the Nation, "in recognition of our debt to our veterans,' has 'taken upon itself the risk of error' in awarding . . . benefits."). M. HYLAND Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Jeanne Celtnieks 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.