Citation NR: 9616425 Decision Date: 06/10/96 Archive Date: 06/24/96 DOCKET NO. 94-28 517 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Wilmington, Delaware THE ISSUE Entitlement to service connection for post traumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Paralyzed Veterans of America, Inc. WITNESSES AT HEARING ON APPEAL Appellant, his wife, and his sister ATTORNEY FOR THE BOARD Dan Schechter, Associate Counsel INTRODUCTION The veteran had active service from December 1966 to November 1968. This appeal arises from a February 1994 rating decision of the Wilmington, Delaware, Regional Office (RO). The veteran, his wife, and his sister appeared and testified in July 1994 at a personal hearing at the RO. CONTENTIONS OF APPELLANT ON APPEAL The veteran and his representative contend that the RO erred by failing to grant service connection for PTSD which resulted from his wartime experiences in Vietnam. The veteran maintains that he was exposed to multiple stressors in Vietnam to include mortar attacks to his base, one of which penetrated his barracks; daily travel under sniper fire; sniper fire at the veteran while moving from building to building at his base; guard duty without ammunition to defend himself; and the death of a childhood friend in Vietnam. Due to his experiences in Vietnam, the veteran states that he began to develop a high state of nervousness; loss of sleep and inability to sleep eventually requiring medication; nightmares; loss of ability to concentrate at work and reduced work productivity; loss of energy and loss of interest in activities; and suicidal thoughts. DECISION OF THE BOARD The Board, in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991 & Supp. 1995), has reviewed and considered all of the evidence and material of record in the veteran's claim 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 preponderance of the evidence favors the veteran’s claim for service connection for PTSD. FINDINGS OF FACT 1. The veteran has a clear diagnosis of PTSD, medically linked to stressful events he experienced while stationed in Vietnam. 2. Credible supporting evidence establishes that the claimed stressors actually occurred. CONCLUSION OF LAW The veteran’s PTSD was incurred as a result of wartime service. 38 U.S.C.A. §§ 1110, 5107 (West 1991); 38 C.F.R. §§ 3.303, 3.304 (1995). REASONS AND BASES FOR FINDINGS AND CONCLUSION 1. Factual Background The veteran’s service medical records do not reflect treatment for a nervous condition, including PTSD, while he was on active duty. He had a tour of duty in Vietnam. The veteran does not claim and the records do show that the veteran was engaged in combat duty; the veteran has no medals or awards showing combat duty. The veteran was discharged from service in November 1968, shortly after returning from Vietnam. In March 1993 the veteran claimed service connection for PTSD. During the course of the appeal, he identified numerous events and experiences that he considers to have been particularly stressful to him while he was on active duty in Vietnam, including mortar attacks to his base and his barracks, one of which penetrated his barracks; witnessing the wounded of those attacks; standing on guard duty without ammunition, being subject to sniper fire; learning of the death of a childhood friend killed while also in Vietnam; and receiving and sending stateside messages of deaths, woundings, and missing persons. For the majority of his tour in Vietnam, from June of 1967 through June of 1968, the veteran was assigned to a Signal Battalion at Phu Lam as a communication center specialist. In his May 1993 statement in support of his claim, the veteran described his experiences at Phu Lam. The veteran stated that when he first arrived there, the base was relatively calm and the fighting was miles away through December of 1967. The veteran stated, however, that rocket and mortar fire could be heard from attacks at Tan Son Nhut Air Force Base a few miles away, and the sky over his base was always alight with flares looking for Viet Cong. He also stated there was the possibility of sniper attack when he was forced to leave Phu Lam on sand bag detail, and this increased his sense of tension. The veteran stated that the stress greatly heightened with the Tet offensive, beginning with the Chinese New Year in January 1968, which brought fighting to Phu Lam. He stated that his present nightmares came from that time, when his base first came under mortar attack. The veteran described scrambling for the bunkers with the sound of incoming mortars all around. The veteran also stated that in March of 1968 he learned that a friend that he had gone to school with since the second grade, with whom he had corresponded in the service since his friend’s arrival in Vietnam in September 1967, had been killed on patrol, greatly increasing the veteran’s tension as he approached the end of his own tour. The veteran has provided several labeled photographs to support his account of his experience in Vietnam. These purportedly show the perimeter of Phu Lam and its proximity to Cholon; flares lighting the perimeter of his base to see if VC were approaching after a mortar attack in January 1968; barracks damage from a mortar attack following the February 8, 1968, Tet offensive; a hole in the veteran’s own barracks’s roof from an incident when the veteran claims he had to run from the barracks to escape the mortar shell and could hear the shrapnel hitting the other wall of the barracks; mortar damage to the base’s orderly room; mortar damage to the base’s communications center; mortar damage to the roof of the base PX; a base bunker hit by a mortar, where the veteran stated he sheltered from the mortar attacks; armored personnel carriers transporting troops to reinforce Phu Lam; a VC arms depot blown-up just outside Phu Lam; a transport convoy to pick-up troops from the “Kingsport Hotel” during his last days in Vietnam, with streets empty because of snipers; and an Air Force helicopter firing mini guns over Phu Lam, just before the veteran left for Bien Hoa at the end of his rotation. The veteran provides an article in the Viet Nam Reporter detailing fighting in January 1968 in the Saigon-Colon region. The veteran also provides a Viet Nam Reporter article, with a photograph, featuring himself and a service comrade, as fellow Delaware soldiers serving in Phu Lam. That article goes on to describe some mortar attacks on Phu Lam. A local Delaware newspaper photograph shows the veteran and provides a brief caption noting his return from active duty in Phu Lam, and mentions that Phu Lam had been the scene of heavy fighting in the prior two weeks. The veteran provided for the record a signed statement from his wife, describing the progress of the disorder, including its increase in severity with the Gulf War in 1991. The veteran provided for the record a signed statement of his sister attesting to written accounts sent her by her brother telling of the increased activity of the VC around Phu Lam, and telling of her brother’s increased nervousness upon his return from Vietnam, which she said continued thereafter. The record also contains the signed statement of an individual who served in Vietnam at the same base with the veteran. This statement verifies the heightened military activity around Phu Lam during and after the Tet offensive including a mortar attack at Phu Lam the night of February 8, 1968, lasting about fifteen minutes and resulting in several wounded at the base but none dead. He also verifies that the signal corps was very short staffed after that pull-out, requiring 23 straight days of twelve-hour shifts. The statement further indicates that the north side barracks in the base, where he stated the veteran was quartered, were often harassed by sniper fire from the village of Phu Lam even before the Tet offensive. The veteran’s first diagnosis of mental disorder reportedly occurred in the summer of 1990, when he began seeing a psychologist for severe depression. The veteran received in- patient and out-patient treatment at The Institute of Pennsylvania Hospital, a psychiatric hospital, in 1992 and 1993, where the February 1993 report from the Evaluation Unit of The Institute summarized results of his psychiatric evaluation, with a symptom profile that met criteria for panic disorder without agoraphobia, PTSD, and a single episode of major depression. A behavioral therapy consultation in February 1993 noted the following observable difficulties: subjugation of own needs, intrusive memories and flashbacks (with criteria met for PTSD by DSM-III-R); depressive and anxious symptomatology (including dissociative episodes) characteristically occurring on the job; coping strategies of avoidance, denial, and “keeping busy” (including avoidance of environmental stimuli that would remind him of Vietnam); and a strained state of exaggerated vigilance. A VA psychiatric examination in June 1993 yielded a diagnosis of PTSD, moderate, characterized by a memory of the war, his experiences in Vietnam, nightmares, intrusive recollection of those events, depression, irritability, withdrawal from people, and a numbing of affect. II. Legal Analysis The veteran’s claim is well-grounded within the meaning of 38 U.S.C.A. § 5107(a). That is, he has presented a claim which is not inherently implausible. All relevant facts have been properly developed and, therefore, the VA’s statutory duty to assist him in developing evidence pertinent to his claim has been satisfied. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Service connection for PTSD requires medical evidence establishing a clear diagnosis of the condition, credible supporting evidence that the claimed in-service stressor actually occurred, and a link, established by medical evidence, between current symptomatology and the claimed in-service stressor. If a veteran did not engage in combat with the enemy, his own testimony by itself is not sufficient to establish the incurrence of a stressor; rather, there must be service records or other credible supporting evidence to corroborate his testimony. Zarycki v. Brown, 6 Vet.App. 91 (1993); Doran v. Brown, 6 Vet.App. 283 (1994). VA and non-VA psychiatric examinations establish a clear diagnosis of PTSD and link this psychiatric disorder to events that occurred while the veteran was stationed in Vietnam. The issue left to be decided is the presence of a recognizable stressor. Adjudication of a claim for service connection for PTSD requires evaluation of the supporting evidence in light of the places, types, and circumstances of service, as evidenced by service records, the official history of each organization in which the veteran served, the veteran’s military records, and all pertinent medical and lay evidence. 38 U.S.C.A. § 1154(b). Service connection for PTSD is a factual determination which must be made based upon the evidence in each individual case. Smith v. Derwinski, 2 Vet.App. 137, 140 (1992), reviewing the legislative history of 38 U.S.C.A. § 1154. The veteran has not been awarded any citations or decorations denoting combat-related service, and the veteran does not claim to have engaged in combat during his period of service. The veteran’s service file, as contained within the record, also provides no evidence of combat. However, the veteran’s claims of stressor situations are supported by sufficient corroboration to establish that the stressors occurred and were experienced by the veteran. The veteran’s statements that he was stationed at Phu Lam between June 1967 and June 1968, that his base was subject to mortar attack on more than one occasion on and after the Tet offensive, and that the base was subject to sniper fire from the nearby village of Phu Lam, may all readily be verified by the Joint Service Environmental Group, but there is sufficient evidence of record to support these findings to make such verification unnecessary. The supporting statements of a service comrade, and the newspaper articles verifying the statements of both the veteran and that service comrade are sufficient corroboration of the veteran’s tour of duty at the base at Phu Lam and his experiences of sniper fire and mortar attack while there. The veteran’s photographs provide further evidence of his personal exposure to these stressors which, of themselves, are of sufficient gravity to evoke symptoms in almost anyone. The photographs provide evidence of physical damage from the mortar attacks, just as the statements of the veteran’s service comrade corroborate the injuries that resulted. Though the veteran did not engage in combat in Vietnam, the record provides ample evidence of stressors linked to his PTSD. Because medical evidence establishing a clear diagnosis of the disorder, and a link, established by medical evidence, between current symptomatology and the claimed in- service stressors are both also present, service connection is warranted. ORDER Service connection for PTSD is granted. J. E. DAY Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, 741 (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 & Supp. 1995), 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, 102 Stat. 4105, 4122 (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 -