Decision Date: 09/20/95 Archive Date: 09/19/95 DOCKET NO. 93-21 355 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUE Entitlement to service connection for post-traumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Patrick J. Costello, Associate Counsel INTRODUCTION The veteran had active military service from May 1970 to November 1971. This matter came before the Board of Veterans' Appeals (hereinafter the Board) on appeal from a May 1991 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO), in Roanoke, Virginia, that denied the veteran's claim for entitlement to service connection for PTSD. A hearing was held in December 1993, in Washington, D.C., before Bettina Callaway, who is a member of the Board section rendering the determination in this claim and was designated by the Chairman to conduct that hearing, pursuant to 38 U.S.C.A. § 7102(b) (West 1991). A transcript of the hearing was prepared, and the case was subsequently referred for appellate consideration. CONTENTIONS OF APPELLANT ON APPEAL The veteran claims that he has PTSD as a direct result of his service in Vietnam. He states that while he was stationed in Vietnam, he witnessed distressing events related to war, and that he has been distressed by these incidents since then. He maintains that the psychological problems he suffers from now are related to his service, and that he should receive just compensation from the VA. DECISION OF THE BOARD The Board, in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991), has reviewed and considered all of the evidence and material of record in the veteran's claims file. Based on its review of the relevant evidence in this matter, and for the following reasons and bases, it is the decision of the Board that the evidence supports the veteran's claim for entitlement to service connection for PTSD. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of the veteran's appeal has been obtained by the agency of original jurisdiction. 2. The veteran had active military service in Vietnam where he earned the Purple Heart for wounds received in action against the enemy. 3. Two independent psychiatrists have diagnosed the veteran has now suffering from PTSD. They have both related his PTSD with events he experienced while in Vietnam. CONCLUSION OF LAW PTSD was incurred as a result of the veteran's active service. 38 U.S.C.A. §§ 1110, 5107 (West 1991); 38 C.F.R. §§ 3.303(d), 3.304(f) (1994). REASONS AND BASES FOR FINDINGS AND CONCLUSION When a claim for service connection comes to the Board, we must first determine whether the claim is well-grounded. A well-grounded claim requires more than mere allegations; it must be plausible and with merit. 38 U.S.C.A. § 5107 (West 1991); Tirpak v. Derwinski, 2 Vet.App. 609 (1992); Murphy v. Derwinski, 1 Vet.App. 78 (1990). In this regard, the veteran's claim file shows that he served in Vietnam, engaged the enemy, and now has a diagnosis of PTSD. It is plausible that the veteran's PTSD is etiologically related to his military service. Therefore, we find that the veteran has presented a well-grounded claim. Additionally, the facts relevant to this appeal have been properly developed and the obligation of the Department of Veterans Affairs (VA) to assist the veteran in the development of his claim has been satisfied. Id. Under 38 U.S.C.A. § 1110, 1131 (West 1991), compensation will be provided if it is shown that the veteran suffers from a disease or injury incurred in or aggravated by service. In addition, service-connection may be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (1994). In order to establish service connection for PTSD, there must be objective medical evidence showing a diagnosis of, or symptomatology consistent with, the condition, and an evidentiary link between the claimed inservice stressor and the current PTSD symptomatology. For the purposes of establishing service connection, a stressor is an event experienced by the veteran during active service that is outside the range of normal human experience and that would be markedly disturbing to almost anyone. Examples of such events are experiencing an immediate threat to one's life, or witnessing another person being seriously injured or killed. It is the distressing event, rather than the mere presence in a "combat zone" that may constitute a valid stressor for the purposes of supporting a diagnosis of PTSD. See Zarycki v. Brown, 6 Vet.App. 91, 99 (1993); Wood v. Derwinski, 1 Vet.App. 190, 193 (1991). Additionally, VA Manual M21-1 outlines the specific procedures required for the VA to follow in evaluating claims for service connection based on PTSD. Essentially, this regulation requires evidence that the veteran served in the area in which the stressful event was alleged to have occurred and evidence to support the description of the event. If the claimed stressor is related to combat, in the absence of information to the contrary, receipt of the Purple Heart, Combat Infantryman Badge, Bronze Star, or other similar citations is considered supportive evidence of participation in a stressful episode. Other types of supportive evidence, such as plane crash, ship sinking, explosion, rape or assault, duty on a burn ward or in a graves registration unit may be accepted. POW status is conclusive evidence of an in-service stressor. Relative to PTSD, if the evidence shows that the veteran was engaged in combat with the enemy and the claimed stressor was related to combat, no further development for evidence of a stressor is necessary. If the claimed stressor is not related to combat with the enemy, a history of a stressor as related by the veteran is, in itself, insufficient. Service records must support the assertion that the veteran was subjected to a stressor of sufficient gravity to evoke the symptoms in almost anyone. Thus, the existence of a recognizable stressor or accumulation of stressors must be supported. It is important that the stressor be described as to its nature, severity, and date of occurrence. Manual M21-1, Part VI, para. 7.46(e),(f) (Dec. 21, 1992). The veteran served in the Republic of Vietnam for approximately one year, participated in thirteen campaigns against the enemy, and sustained a shell fragment wound to his left leg. He received the Purple Heart for wounds received in action, and he was awarded the National Defense Service Medal, Vietnam Service Medal, and the Republic of Vietnam Campaign Medal. His recounting of stressful incidents in service is somewhat vague. He notes that he participated in many combat missions during his Vietnam service, and that he lost of many friends. He was most greatly affected, however, by his guilt that he had to leave his "comrades when wounded". Letter from A. Byrne, C.O.V.E.R. Counsellor, October 23, 1991. Through the letter of Mr. Byrne, we have learned of the veteran's participation in many combat missions while in Vietnam. Although these in-service stressors have not been verified, we find that his receipt of the Purple Heart provides supportive evidence of participation in stressful situations, inasmuch as this citation is awarded for wounds received in actions against the enemy. We would further note that the veteran's service personnel record substantiates his claim that he was involved in campaigns with the enemy since the record notes the veteran's involvement in thirteen campaigns while in Vietnam. We would further add that where it is determined that the veteran was engaged in combat with the enemy and the claimed stressors are related to such combat, his lay testimony regarding the claimed stressors must be accepted as conclusive as to their actual occurrence. See Zarycki, 6 Vet.App. at 98; VA Manual M21-1, Part VI, para. 7.46(e), (f) (Dec. 21, 1992). We therefore find sufficient basis to conclude that the veteran experienced valid stressors during his tour of duty in Vietnam. An award of service connection for PTSD also requires, however, that the veteran exhibit current symptomatology consistent with the disorder that links his stressors in service to a diagnosis of PTSD. 38 C.F.R. § 3.304(f) (1994). In support of the veteran's claim that he now suffers from PTSD, he has submitted two letters from psychiatrists and a statement from a veteran's counsellor. The first letter, from Dr. S. A. Reiter, states that for an unknown period of time, he treated the veteran for PTSD. Letter from Dr. S. A. Reiter, February 26, 1991. Dr. Reiter wrote that he had diagnosed the veteran as suffering from both PTSD and alcohol abuse because of the veteran's military experiences. The second psychiatric opinion comes from Dr. J. J. David, Clinical Associate Professor, of the University of Virginia Health Sciences Center. Letter from Dr. J. J. David, April 13, 1992. Dr. David diagnosed the veteran as having PTSD and he explained his diagnosis in the following manner: . . . Mr. G. was cooperative and articulate despite manifest anxiety. Other sources of information included his file from your Agency (COVER), copies of some records from the Veterans Administration, copies of military records, associated correspondence, and the like. These various sources of information in my opinion formed an adequate database for forming a diagnostic opinion. I hold this opinion with a high degree of medical certainty. It is my opinion as a psychiatrist that Mr. G. suffers from Post-Traumatic Stress Disorder (PTSD) (DSM-III-R 309.89). It is my opinion that his PTSD is the direct result of his experiences in the military while serving in the Republic of Vietnam. His PTSD has been complicated by a significant history of secondary alcohol abuse and dependence, presently in remission. The diagnosis of PTSD and its relation to his experience in Vietnam is well supported by the fact that on my examination he met or exceeded the necessary diagnostic criteria in each of the four symptom clusters associated with this diagnosis. I do not believe that a competent and open-minded independent psychiatric examiner would dispute my conclusions. At your request I will be happy to prepare an expanded report of my findings or if necessary to develop sworn testimony asserting these findings on Mr. G.'s behalf. The final letter proffered by the veteran is that of Mr. A. Byrne. Letter from Mr. A. Byrne, October 23, 1991. Mr. Byrne was a counsellor for C.O.V.E.R. [Community Outreach Vietnam Era Returnees]. Mr. Byrne wrote that the veteran had been seen on a weekly basis over a period of five months, and during that time period, the veteran related many experiences of Vietnam from which he has nightmares, depression, and feelings of isolation. On the basis of Mr. Byrne's recurrent contact with the veteran, Mr. Byrne opined that the veteran was suffering from PTSD. Contrary to the three letters offered by the veteran are two VA Compensation and Pension Examinations conducted at the Martinsburg VA Medical Center. SF 513, Consultation Sheet, May 2, 1991; PTSD Exam, February 25, 1993. The examinations, accomplished by the same physician, both conclude that the veteran does not have PTSD. They do however find that the veteran is alcohol dependent. The Board would note that neither examination reported conducting psychological testing or reviewing the veteran's claim folder. In addition to the clinical reports offered by the veteran, he has also provided testimony before the Board. See Board Transcript, December 7, 1993. During his hearing, the veteran admitted that he had a problem with alcohol abuse since his return from Vietnam in 1971. He stated that he did not have social contact with other individuals outside his immediate family and that he had recurrent intrusive thoughts of his wartime experiences. As a concluding statement, the veteran's representative requested that the Board obtain additional medical documentation from the individuals who have reported that the veteran suffers from PTSD. Additionally, both the veteran and his representative have asked that the veteran be examined by a board of three psychiatrists to determine the nature of any psychiatric illness from which the veteran now suffers. The Secretary [of the VA] has a duty to assist a claimant who has submitted a well-grounded claim. 38 U.S.C.A. § 5107 (West 1991); Butts v. Brown, 5 Vet.App. 532 (1993); Murphy v. Derwinski, 1 Vet.App. 78 (1990); 38 C.F.R. § 3.159 (1993). "The 'duty to assist' is neither optional nor discretionary." Littke v. Derwinski, 1 Vet.App. 80 (1990). The Court has repeatedly held that the duty to assist includes providing a thorough and contemporaneous medical examinations, especially where it is necessary to determine the current level of a disability. Schroeder v. Brown, 6 Vet.App. 220 (1994). Moreover, the VA must support its medical conclusions on the basis of independent medical evidence in the record or through adequate quotation from recognized treatises; it may not rely on its own unsubstantiated medical judgment to reject expert medical evidence in the record, but may reject a claimant's medical evidence only on the basis of other such independent medical evidence. See Thurber v. Brown, 5 Vet.App. 119, 122 (1993); Hatlestad v. Derwinski, 3 Vet.App. 213, 217 (1992) (Hatlestad II); Colvin v. Derwinski, 1 Vet.App. 171, 175 (1991). "If the medical evidence of record is insufficient, or, in the opinion of the Board, of doubtful weight or credibility, the Board is always free to supplement the record by seeking an advisory opinion [or] ordering a medical examination". Colvin, supra; see Hatlestad II and Thurber, both supra; see also 38 U.S.C.A. § 7109 (West 1991); 38 C.F.R. § 20.901(a), (d) (1994). Although we could remand this claim to obtain additional psychiatric information, we believe that such a maneuver is unnecessary because the evidence now of record supports the veteran's claim. The record reflects that the veteran had military service in Vietnam and he experienced combat stressors. Now he possesses a diagnosis of PTSD related to his Vietnam military service. We conclude, therefore, that the evidence supports a finding that the veteran currently suffers from PTSD attributable to service. 38 U.S.C.A. §§ 1110, 5107 (West 1991); 38 C.F.R. § 3.303(d) (1994). ORDER Entitlement to service connection for PTSD is granted. BETTINA S. CALLAWAY Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, ___ (1994), permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a determination. This proceeding has been assigned to an individual member of the Board. NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West 1991), a decision of the Board of Veterans' Appeals granting less than the complete benefit, or benefits, sought on appeal is appealable to the United States Court of Veterans Appeals within 120 days from the date of mailing of notice of the decision, provided that a Notice of Disagreement concerning an issue which was before the Board was filed with the agency of original jurisdiction on or after November 18, 1988. Veterans' Judicial Review Act, Pub. L. No. 100-687, § 402 (1988). The date which appears on the face of this decision constitutes the date of mailing and the copy of this decision which you have received is your notice of the action taken on your appeal by the Board of Veterans' Appeals. - 2 -