BVA9501873 DOCKET NO. 93-07 983 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Pittsburgh, Pennsylvania THE ISSUE Entitlement to service connection for post-traumatic stress disorder. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD Constance C. Hickey, Associate Counsel INTRODUCTION The veteran had active service from February 1969 to August 1970. This appeal to the Board of Veterans' Appeals (Board) arises from the October 1991 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) Pittsburgh, Pennsylvania, which denied service connection for post-traumatic stress disorder. On review of the record the Board notes that the veteran's representative has referred to comments by a private physician which characterize the veteran as totally disabled. The issues of entitlement to a total disability rating due to individual unemployability and to a permanent and total rating for pension purposes have neither been developed for appellate review nor are they "inextricably intertwined" with the issue properly before the Board. Accordingly these matters will not be addressed herein, but are referred to the RO for consideration and action as appropriate. CONTENTIONS OF APPELLANT ON APPEAL It is contended by and on behalf of the veteran that he is entitled to service connection for post-traumatic stress disorder (PTSD). The veteran asserts that he was subjected to many stressors while engaged in heavy combat in Vietnam and that he currently suffers from PTSD caused by stressful events he experienced in service. 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 folder. Based on our 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 of record warrants a grant of service connection for PTSD. FINDINGS OF FACT 1. The veteran was subject to stressors while engaged in combat in Vietnam. His service was recognized by numerous decorations including the Combat Action Ribbon. The veteran's combat experience included at least one incident in which he narrowly escaped serious injury and witnessed the deaths of numerous comrades. 2. The veteran has PTSD, as a result of stressors experienced in service. CONCLUSION OF LAW Post-traumatic stress disorder was incurred in service. 38 U.S.C.A. §§ 1110, 5107(b) (West 1991); 38 C.F.R. §§ 3.102, 3.303, 3.304 (1993). REASONS AND BASES FOR FINDINGS AND CONCLUSION At the outset, the Board finds that the veteran has met his burden of submitting evidence sufficient to justify a belief by a fair and impartial individual that his claim is well-grounded; that is, the claim is plausible. Additionally, there is no indication that there are unobtained records which are available and which would aid a decision in this case. Accordingly, we conclude that the record is complete and that there is no further duty to assist the veteran in developing the claim, as mandated by 38 U.S.C.A. § 5107(a). Factual Background The veteran's Form DD 214 indicates that he served as a rifleman in Vietnam. He received the National Defense Service Medal, the Vietnam Campaign Medal with device, the Combat Action Ribbon, the Vietnam Service Medal, and the Republic of Vietnam Cross of Gallantry with palm and frame. Service medical records are negative for complaints or symptoms of nervous or psychiatric disorders. The earliest record evidence of psychiatric difficulties is contained in the June 1973 clinical records of Dr. Julian Eligator, who noted his impression that the veteran's health problems were primarily emotional. Private medical records for July 1984 indicate that the veteran was seen for a general examination by Dr. David Fine who diagnosed chronic emotional stress with anxiety. The October 1984 VA examination report indicates that the veteran was seen for evaluation of a skin rash, but wanted to talk to the physician about his complaints of depression, forgetfulness and tiredness. The veteran stated that Dr. Fine had advised against his 1973 marriage, apparently because of the veteran's emotional problems. The veteran was noted to state that a psychotropic medication had been prescribed for him, although he did not know the name of the drug and no longer took it. Records indicate that the examining physician recommended that the veteran have psychotherapy. In February 1990 the veteran's private physician, Dr. Mark Morrissey, evaluated him for a state disability claim that was based on his Huntington's disease. The evaluation report states that in addition to neurological problems caused by Huntington's disease, the veteran also suffered from disabling PTSD, as manifested by sensory hallucinations, flashbacks of war, bad dreams, disturbed family life and low self -esteem since the war. VA outpatient records reflect that the veteran was referred to a PTSD program in February 1991. The referring social worker noted that the veteran had complained of intrusive nightmares and flashbacks of Vietnam which had been increasing since the beginning of the Gulf War. On VA compensation examination in June 1991, a panel of two VA psychiatric examiners noted that the veteran gave a history of combat duty. One reported incident involved an ambush in which the veteran narrowly escaped serious injury when a radio he was carrying was blown off his back. It was noted that he also told of witnessing the deaths of many soldiers during the ambush described and on other occasions. The examination report reflects the veteran's complaints of weekly nightmares, frequent intrusive thoughts of Vietnam and realistic flashbacks of combat situations. The veteran reportedly said that in order to reduce these symptoms he avoided various stimuli which reminded him of events in Vietnam and he avoided people in general. The examiners indicated that the veteran complained of ongoing feelings of sadness and chronic anxiety, as well as difficulty in controlling his anger, disruptive irritability, and marital problems. He also reportedly acknowledged some violent behavior. The report of his mental status examination indicates that the veteran was alert and oriented. The examiners noted excessive motor activity, and tremors prominently visible in the neck and face, giving an overall impression of tension. His speech was described as clear and understandable although slightly disarticulated. It was noted that the veteran's thought form showed derailment and tangentiality, and it was occasionally difficult to redirect him to pertinent topics. His thought content was reportedly dominated by consideration of problems with his wife and their arguing. The report noted that the veteran admitted to auditory hallucinations. His insight was described as fair. The VA examiners diagnosed PTSD, organic personality disorder, organic hallucinosis, ethanol abuse in partial remission, and Huntington's disease, manifested by movement problems and declining memory. The examiners stated in their report that Huntington's disease is frequently complicated by psychotic symptoms, disinhibition and cognitive impairment, which seemed to be present in the veteran. In addition, the panel noted the difficulty in distinguishing the organic effects of Huntington's disease from the features of PTSD with respect to irritability and uncontrolled anger. The examiners concluded that the veteran appeared to suffer substantial impairment from both disorders. Entitlement to Service Connection for Post-Traumatic Stress Disorder Service connection connotes many factors, but basically it means that the facts, as shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service in the Armed Forces or, if preexisting such service, was aggravated therein. 38 U.S.C.A. § 1110. Such a determination requires a finding of current disability which is related to an injury or disease incurred in service. Watson v. Brown, 4 Vet.App. 309, 310 (1993); Rabideau v. Derwinski, 2 Vet.App. 141, 143 (1992). Each disabling condition as shown by a veteran's service records, or for which he seeks service connection, must be considered on the basis of the places, types and circumstances of his service as shown by service records, the official history of each organization in which he served, his medical records and all pertinent medical and lay evidence. 38 U.S.C.A. § 1154. Additionally, regulations provide that 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). Service connection for PTSD, therefore, requires evidence of a current diagnosis of PTSD resulting from traumatic or stressful experiences during service. For VA purposes mental disorders such as PTSD must be diagnosed in accordance with the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM III). 38 C.F.R. §§ 4.125, 4.126. The Board finds that the June 1991 diagnosis of PTSD by a panel of two VA psychiatrists, which accords with the earlier finding by the veteran's private physician, is supported by evidence of the PTSD criteria set forth in DSM III, as described below. At the outset, a PTSD diagnosis requires the existence of a recognizable stressor that would evoke significant symptoms of distress in almost anyone. In the instant case the veteran reported that he experienced numerous stressful events during heavy combat in Vietnam, including at least one incident in which he narrowly escaped injury and witnessed the deaths of numerous close comrades. Moreover, the veteran's combat citation, the Combat Action Ribbon, is accepted, in the absence of evidence to the contrary, as conclusive evidence of a claimed inservice stressor. 38 C.F.R. § 3.304(f). Secondly, DSM III criteria for PTSD require that there be reexperiencing of the trauma, such as the recurrent dreams or intrusive thoughts of Vietnam reported by the veteran or his flashbacks of combat situations. A third category of criteria involves evidence of general numbing of responsiveness or the avoidance of stimuli associated with the initiating stressful event. The Board notes that these criteria are reflected by the veteran's pervasive sadness, his avoidance of stimuli associated with traumatic events in Vietnam and his avoidance of other people in general. The final category of PTSD criteria calls for persistent symptoms of increased arousal which were not present before the traumatic events. According to DSM III this criteria is satisfied by facts which are present in the instant case such as the sleep disturbance experienced by the veteran, his avoidance of activities which stimulate memory of the stressful events, and his irritability and outbursts of anger. The Board is mindful of the panel's acknowledgment that it is difficult to distinguish the effects of Huntington's disease and PTSD as manifested by irritability and inability to control anger. Nevertheless, the panel of examiners, who were fully aware of the diagnosis of Huntington's disease and noted the presence of psychotic symptoms, disinhibition and cognitive impairment attributable to Huntington's disease, clearly stated their conclusion that the veteran suffered impairment from both PTSD and Huntington's disease. When, after consideration of all evidence and material of record, there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of a veteran's claim, the benefit of the doubt must be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. The Board finds that the evidence concerning service connection for PTSD is at least in relative equipoise. Accordingly, the issue is resolved in favor of the veteran. The Board concludes that service connection is warranted for PTSD . ORDER Service connection for PTSD is granted. N. R. ROBIN 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.