Citation Nr: 0000605 Decision Date: 01/07/00 Archive Date: 01/11/00 DOCKET NO. 94-02 981 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Seattle, Washington THE ISSUE Entitlement to service connection for post-traumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Washington Department of Veterans Affairs ATTORNEY FOR THE BOARD James A. Pritchett, Associate Counsel INTRODUCTION The veteran had active service from November 1961 to November 1967 and served in Vietnam from September 1966 to August 1967. This matter came before the Board of Veterans' Appeals (Board), on appeal from rating decisions by the Seattle, Washington, Department of Veterans Affairs (VA) Regional Office (RO). In August 1995 the RO found that the veteran had not submitted new and material evidence to reopen his claim. In January 1996 the case was remanded for further evidentiary development. The remand stated that the Board would accept the veteran's evidence of witnessing the wounding of a soldier as evidence of a combat-related stressor. In August 1998 the case was remanded for RO consideration of evidence that had been submitted directly to the Board without a waiver from the veteran. Upon remand an August 1999 supplemental statement of the case styled the action as one of service connection for PTSD and conducted a review of the case on the merits. Therefore, the Board will conduct its review on the basis that the RO has reopened the case and denied it on the merits. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of the veteran's claim for service connection has been obtained by the RO. 2. The veteran does not have PTSD. CONCLUSION OF LAW PTSD was not incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 5107(a) (West 1991); 38 C.F.R. §§ 3.303, 3.304 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSION Factual Background The veteran's service medical records, including the report of the examination for entrance dated in November 1961 and the report of the examination for separation, dated in November 1967 are negative for complaints, symptoms or findings regarding a psychiatric disorder. His DA Form 20 shows that he was stationed in Vietnam from September 1966 to August 1967, and his military occupational specialty was a radio repairman. The DA Form 20 and his DD Form 214 are negative for awards of the Purple Heart or any medals for valor. He received an honorable discharge for hardship in November 1967. From November 1977 to September 1980, the veteran was hospitalized at various private psychiatric facilities, including the Spokane Community Mental Health Center (Spokane), Sacred Heart Medical Center (Sacred Heart), and the Eastern State Hospital (Eastern State). The diagnosis was schizophrenia. The veteran was again hospitalized at Eastern State in June 1982 and July 1984 for a bipolar disorder and episodic alcohol abuse. Paranoid schizophrenia was diagnosed when he was confined at the Mid-Columbia Psychiatric Hospital in May 1983. A June 1983 psychological evaluation from the Richland Center included diagnoses of alcohol dependence and dependent personality disorder. In a July 1984 letter, the veteran stated that one stressor he encountered in Vietnam was seeing was a member of his unit, Co. D, 704th Maintenance Battalion, wounded north of Pleiku. Following a VA psychiatric examination in November 1984, the examiner stated that the veteran's primary problem was a manic depressive illness, especially manic episodes and that it had been complicated by alcohol abuse. Although the veteran was exposed to catastrophic stressors during the war, the examiner did not feel that he had trouble with intrusive recollections or nightmares or that he avoided people particularly because of the war; rather, he avoided them because of his manic depressive illness. He did not have particular overriding problems with guilt or startle reaction or with avoiding activities connected with the war. Therefore, since the overriding problem was the manic depressive illness, the veteran did not qualify for PTSD. The diagnoses were manic bipolar disorder, chronic alcohol abuse and rule out schizoaffective disorder A March 1986 statement from the Community Mental Health Center noted that the veteran had been in treatment since January 1985 and that his present status included an Axis I diagnosis of bipolar disorder. The report of a VA special Agent Orange examination dated in March 1985 was negative for a diagnosis of PTSD. A letter dated in May 1986 from the veteran detailed his Vietnam experience, to include claimed stressors. A March 1987 discharge summary from Eastern State included the provisional diagnoses of bipolar disorder, manic with mood congruent, psychotic features; rule out PTSD, chronic; mixed substance abuse, episodic. A November 1987 medical discharge summary from MountainView Hospital (Mountain View) diagnosed chronic alcoholism and manic depressive mental disorder, under treatment. Following a March 1989 psychiatric evaluation by John P. Moulton, M.D., states that the veteran's mood was neutral to minimally depressed. The report includes an extensive history, apparently as related by the veteran. There is no evidence that Dr. Moulton referred to any treatment records for the evaluation. The report states that the veteran had been found to be disabled by the VA and is negative for evidence of psychiatric testing. The diagnostic impressions were mixed substance abuse in apparent remission, post- traumatic stress disorder and bipolar affective disorder in partial remission on medication. A discharge summary dated in November 1989 from Sacred Heart included a diagnosis of manic depressive disorder. In June 1992, the veteran was admitted to Sacred Heart on an acute and emergent basis after endangering others. The diagnoses were depressed bipolar disorder and PTSD. The summary is negative for evidence of the basis for the PTSD diagnosis. A letter dated in September 1992 from the veteran's former wife states that he was manic depressive and that he had post traumatic stress syndrome. She felt that the veteran would not have had any mental problems if he had not gone to Vietnam. During a psychiatric evaluation conducted at Spokane in December 1992, the veteran claimed flash backs and nightmares about Vietnam in the past but added that they had decreased to the point that they no longer bothered him. The diagnosis was bipolar disorder, manic. A letter dated in August 1994 from the United States Army and Joint Services Environmental Support Group (now the U.S. Armed Services Center for Research of Unit Records) confirmed that a SP4 Kren of Co. D, 704th Maintenance Battalion, was wounded while securing the perimeter of a tea plantation in Pleiku Province, Republic of Vietnam in June 1967. A VA social work survey dated in September 1994 stated that the veteran slept with a gun and that during the Gulf War he fell asleep during the news and woke up at Eastern State. His flash backs and nightmares did not occur when he was on Lithium. When he was manic, his delusions were mostly flash backs to experiences in Vietnam. His flash backs and nightmares could be triggered by news reports. During a September 1994 VA psychological evaluation, the veteran complained that sometimes he became manic. He did not mention the intense horror at the events that he described. Nor did he describe helplessness about feelings of fear. He did not complain of difficulty with concentration. He did not complain of hypervigilance except when in his manic state. He complained of having had nightmares of 'gook' faces telling him to 'get out' in Vietnamese. He stated that he hardly had those nightmares anymore. He did avoid thinking about Vietnam, but had no trouble with a wide range of his feelings. He expected to live a long life. He reported no change in hobbies. He had no specific startle response. He reported amnesia only for the times in which he felt he was in a manic state. He did not feel clearly detached from others. He was only irritable when he did not feel well. A long history of substance abuse was noted. Objectively, the veteran was in a mildly hypermanic, but not clearly manic state during the examination because his ideas were reasonably well organized. His long and short-term memories were adequate. His interpretation of proverbs was rather concrete. He displayed adequate low level ability to think abstractly. His mood and affect were mildly hypermanic. He exhibited no flight of ideas or grandiose thoughts. He did not evidence any current thought disorder. Following psychological testing, the examiner stated that the veteran did not meet the American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders IV, criteria for PTSD even during that time. The diagnoses included bipolar disorder, hypermanic with depressive features and alcohol dependence. The Global Assessment of Functioning Scale (GAF) was 40 currently and for the past year. In November 1994 the veteran was examined by R. Proedrou, Ph.D. who indicated that the veteran had symptoms compatible with a diagnosis of bipolar disorder. Treatment notes and monthly review sheets from Spokane dated from May 1994 to January 1996 , and from the Eliza Coffee Memorial Hospital in June 1996 included the diagnoses of alcohol addiction, and bipolar disorder. A VA discharge summary dated in July 1996 states that the veteran was admitted pursuant to a commitment. He was discharged that month with diagnoses of manic bipolar disorder and medication noncompliance. Following a September 1997 VA PTSD examination, including psychological testing, it was opined that the veteran had some symptoms of PTSD but did not fulfill the full criteria for a diagnosis of PTSD. A diagnosis of bipolar disorder, mixed, not otherwise specified was also made. A June 1999 VA PTSD examination report by two psychiatrists notes the stressors claimed by the veteran. It also notes that the veteran complained of sleep loss after talking about Vietnam, of nightmares of Vietnam, of guilt, nervousness during discussions of Vietnam, and nervousness in crowds. He did have several friends, did trust other people, could express emotions and affection and wanted to live as long as his father (an eighty-year-old). The examiners concluded by stating that the veteran had some symptoms of PTSD, but did not meet the full criteria for a PTSD diagnosis. Analysis The appellant's claim is well grounded, that is, it is not inherently implausible. The facts relevant to the issue on appeal have been properly developed and the statutory duty of the VA to assist the appellant in the development of his claim has been satisfied. 38 U.S.C.A. § 5107(a) (West 1991). Service connection for post-traumatic stress disorder requires medical evidence diagnosing the condition in accordance with Sec. 4.125(a) of this chapter; 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. If the evidence establishes that the veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. If the evidence establishes that the veteran was a prisoner-of-war under the provisions of Sec. 3.1(y) of this part and the claimed stressor is related to that prisoner-of-war experience, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. 38 C.F.R. § 3.304(f) (1999) A PTSD claim is well grounded where the veteran has "submitted medical evidence of a current disability; lay evidence (presumed to be credible for these purposes) of an in-service stressor, which in a PTSD case is the equivalent of in-service incurrence or aggravation; and medical evidence of a nexus between service and the current PTSD disability". Cohen (Douglas) v. Brown, 10 Vet.App. 128, 136-37 (1997) The Court also noted that, if there is an unequivocal diagnosis of PTSD by mental heath professionals, it presumes that the diagnosis was made in accordance with the applicable DSM criteria as to both adequacy of symptomatology and sufficiency of the stressor (or stressors)." Id. If there is a question as to whether the report or examination is in accord with applicable DSM criteria, the report must be returned for a further clarification as needed. Id. In the present case, the Board has accepted the existence of an in-service stressor. The question is therefore whether there is a current diagnosis of PTSD. Although the March 1989 examination by Dr. Moulton and the June 1992 discharge summary from Sacred Heart contain diagnoses of PTSD, there is no evidence in the record of the basis used for either diagnosis. Both appear to have used histories related by the veteran. In contrast, the veteran has undergone several VA examinations and psychiatric testing, to include psychological testing. The most recent VA board of two psychiatrists specifically found that the veteran did not meet the criteria for a diagnosis of PTSD, even though he had some symptoms of it. The Board finds that the March 1989 report from Dr. Moulton and the June 1992 discharge summary from Sacred Heart, when considered along with other evidence of record, do not persuasively establish a basis for a diagnosis of PTSD. The Board notes that February 1979 and March 1987 discharge summaries from Sacred Heart did not include definitive diagnoses of PTSD. The March 1987 discharge summary merely included "rule out PTSD" in its diagnoses. It is emphasized that the diagnoses of PTSD appear to have been premised on histories reported by the appellant without any evidence of psychiatric testing. The VA has examined the veteran thoroughly on several occasions and has performed psychiatric testing, none of which has resulted in a diagnosis of PTSD. Numerous private psychiatric reports are negative for a diagnosis of PTSD. The Board finds that the repeated diagnoses of psychiatric conditions other than PTSD are more persuasive than those of Dr. Moulton and the Sacred Heart discharge summary of June 1992. In light of the foregoing, the Board concludes that the preponderance of the evidence is against the veteran's claim for service connection for PTSD. 38 U.S.C.A. §§ 1110, 5107(a); 38 C.F.R. §§ 3.303, 3.304. The Board notes that its January 1996 remand conceded the presence of a stressor and rejected the RO's interpretation that the stressor had to be outside normal human experience. The Board has therefore applied the standards regarding PTSD under both the old and new versions of the Diagnostic and Statistical Manual of Mental Disorders, see Karnas v. Derwinski, 1 Vet.App. 308 (1991) and given the benefit of the more favorable version to the veteran. However, even though the existence of a stressor has been conceded, the fact remains that there is no persuasive unequivocal diagnosis of PTSD and therefore the service connection claim must fail. ORDER Entitlement to service connection for PTSD is denied. RENÉE M. PELLETIER Member, Board of Veterans' Appeals