BVA9507363 DOCKET NO. 93-08 159 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Denver, Colorado THE ISSUE Entitlement to service connection for post-traumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD K. E. Harrison, Associate Counsel INTRODUCTION The veteran had active military service from April 1968 to December 1971. This matter came before the Board of Veteran's Appeals (Board) on appeal from a December 1992 rating decision by the RO which denied a claim for service connection for PTSD; a prior claim for service connection for PTSD had been denied in November 1987 but was not appealed. CONTENTIONS OF APPELLANT ON APPEAL The veteran contends that he has PTSD as the result of traumatic experiences in Vietnam. He claims that his military occupational speciality (MOS) of military police caused him a lot of stress and depression. He claims that, while serving at a base camp in Vietnam, he was under mortar attack on a couple of occasions. He also claims that he witnessed the death of a soldier. He further claims that the most stressful event in Vietnam was the outgoing artillery fire above his camp every night. 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 a preponderance of the evidence is against the claim for service connection for PTSD. FINDINGS OF FACT 1. The RO has obtained the evidence required for proper adjudication of the veteran's claim. 2. Duty performed by the veteran in Vietnam did not involve combat with the enemy. 3. A stressor for PTSD during military service has not been documented. 4. The veteran does not have PTSD which is related to military service. CONCLUSION OF LAW The veteran is not shown to have PTSD due to disease or injury which was incurred in or aggravated by active military service. 38 U.S.C.A §§ 1110, 5107(a) 7104 (West 1991); 38 C.F.R. §§ 3.303, 3.304(f), 4.126 (1993). REASONS AND BASES FOR FINDINGS AND CONCLUSION Background. The veteran served in Vietnam from March 1970 to March 1971. The veteran's MOS was that of a military police security guard. The veteran's original claim for service connection for PTSD was received in January 1987; it was denied by a rating decision of November 1987. Received in March 1987 were records from the Weld Mental Health Center, Inc., dated in June 1985. Diagnoses of dysthymic disorder and a compulsive personality disorder were recorded. It was reported that the veteran was treated for depression from July to December 1986. In March 1987, the veteran underwent an evaluation for PTSD by I. E. Parris, M.A., and R. C. Atwell, Psy.D. The examiner reported that: The effect the Vietnam experience had on him was to have experienced the loss of a friend, the constant artillery mortaring, and being in a very sensitive job which required him to closely guard and keep confidential, very sensitive information. He, therefore, has internalized his fears and responses to war, which are manifested in depression and frozen rage, which, under stress can become assaultive against others and himself. Because of symptoms which were not evident prior to his combat experience, the picture of depression, isolation, helplessness and rage, as well as other prominent and active symptoms tend to give credence to a diagnosis [of PTSD]. In the evaluation of March 1987, the veteran stated that his primary job in Vietnam was "[a]s part of the interior security team assigned to the company" and "were primarily guarding access in and out and preventing breaches of security." He also indicated that the "330th Radio Research Company was a highly sensitive electronic warfare effort" and that he "worked at normal security duties for a while, then worked in the unit mailroom and also at the unit S-2 (intelligence office) as a clerk-typist." The veteran also reported that the compound which was in "Pleiku" was "mortared" in the first couple of days after his arrival and that he "was scared to death but then [he] didn't care." His worst experience in Vietnam was seeing a rocket hit immediately behind his office in the building. He stated that a man was killed, a friend and he had to go in and take pictures of the scene before the removal of the body. He also related that his unit shared the base with an artillery unit which fired all night and it took him months to stop hearing those guns. In January 1992, the RO received a statement from the veteran entitled "My Stressors in Vietnam". In this statement the veteran stated that his MOS was 95B20, Military Police in the Army Security Agency. He stated the sedentary nature and isolation of the job caused him a lot of stress and depression. He gave a history of mortar attacks and of witnessing a soldier who was killed in a van by a single rocket going through the roof. He also claimed that the most stressful situation was the outgoing artillery fire over his camp every night. In a VA examination in May 1992, the examiner related a full social and industrial history, including information concerning past treatment received by the veteran. It was noted that the veteran's statements concerning his Vietnam experience were similar to those recorded in 1987 by Dr. Atwell. The veteran indicated that "the whole thing" bothered him and that he sometimes had "sad feelings" if he saw something that brought it back. He also reported that a museum display of pictures and a book of names of all the dead veterans made him feel "kind of empty and sad because they died for no reason" and that he felt he did not do his part and "needed a chance to get to fight back." He was angry about that and felt that one of the reasons he was isolated from people was because he did not like conflict or was afraid that he would "lash back." He was angry at the Government, the Army and his ex-wife. The examiner concluded that the veteran did not seem to have the kind of stressor that would warrant a diagnosis of post-traumatic stress disorder; and there was insufficient clinical evidence at this time to meet the full criteria to warrant a diagnosis of a post-traumatic stress disorder. The examiner added that the complaints were those of anyone who had been in a war zone who had unpleasant experiences and memories and felt that the veteran's history of abuse as a child with his inability to fight back at that time and his recurrent major depressive episodes were far more compelling in this veteran. Major depressive episodes, alcohol abuse and a personality disorder were diagnosed. The veteran submitted additional evidence consisting of diagnosis of PTSD and treatment for PTSD. In a January 1992 statement, Charles H. Wingfield, C.A.C. III, reported that the veteran was treated for PTSD and that the diagnosis of PTSD is based on recurrent dreams of Vietnam with instances of death and dying, total avoidance of firearms, and difficulty concentrating. In a September 1992 statement, I. R. Marx, M.D. reported that the veteran is in treatment at the Centennial Health Center for PTSD. Treatment records from Centennial Health Center covering the period of May 1991 to March 1992 was received at the RO on October 1992 and showed a diagnoses of PTSD. In December 1992, the RO requested that the veteran provide the name of the veteran who was killed, his MOS if possible, his unit and any other information that may help verify his stressor. The veteran wrote the RO and stated that the veteran who was killed was name "Zane" and that he had a top secret MOS and that he served with the 303rd. Radio Research Battalion. In a letter dated in August 1987, in response to a request from the RO, the Environmental Support Group (ESG) stated that: [A]fter extensive research, we are unable to locate unit records for the 330th Radio Research (RR) Company, or their higher headquarters, the 313 RR Battalion and the 509th RR Group. However, it may be possible for us to research records of another unit, preferably an infantry unit, that was also stationed at Nha Trang. If [the veteran] could provide us a name of an infantry unit or the military police unit with which he states he worked that was responsible for base security at Pleiku, it may be possible for us to continue our research. The ESG also stated that the Vietnam Veterans Memorial Directory of Names lists an individual named "Zane" who was killed in Vietnam but that his death was prior to the veteran's Vietnam tour. Analysis. The Board finds that the veteran's claim is well grounded within the meaning of 38 U.S.C.A. § 5107(a) (West 1991). That is, it is "a plausible claim, one which is meritorious on its own or capable of substantiation." Murphy v. Derwinski, 1 Vet.App. 78, 81 (1990). Submission of a well-grounded claim imposes on VA an obligation to assist in the development of the evidence to support such a claim. 38 U.S.C.A. § 5107(a) (West 1991). In this case, receipt of the veteran's original claim in November 1987 was followed by request for information to verify his stressors for PTSD. Upon receipt of the information, the RO submitted the information to the United States Army and Environmental Support Group (ESG) which conducted a search to verify his stressors. In December 1992, the RO once again requested the veteran to submit information verifying stressors causing PTSD, specifically, information about his infantry unit or the military police unit with which he was assigned. The veteran was given the opportunity to submit evidence supporting his claim which consisted of doctor's statements, hospital reports and outpatient treatment reports. No further avenues for development are apparent. The Board deems the actions taken on the claim to date sufficient to satisfy the statutory requirement. Although the veteran's representative has requested another remand for additional research to be conducted by the ESG, the Board considers such a request unwarranted since the veteran already has failed to furnish the additional information specified by the ESG. His replies to RO requests for clarification merely duplicated information previously offered. A remand without the specified information requested by ESG in its report of August 1987 would be futile in the Board's opinion. ESG has stated that in order to continue the search, the veteran needs to provide the name of an infantry unit or the military police unit with which he claimed he worked as security while in Pleiku. The law permits the granting of service connection for disability which results from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110 (wartime), 1131 (peacetime) (West 1991). An award of service connection for PTSD requires that a current diagnosis be established which conforms to the Diagnostic and Statistical Manual of Mental Disorders (3rd ed., rev. 1987) (DSM- III-R) of the American Psychiatric Association. 38 C.F.R. § 4.126 (1993). An essential prerequisite for a diagnosis of PTSD is that there have been a verifiable "stressor". DSM-III-R defines a stressor as a life-threatening circumstance or other event that is outside the range of usual human experience and that would be markedly distressing to almost anyone. Id. at 146. In assessing a stressor for PTSD, a distinction may properly be drawn between the stress of ordinary traumatic circumstances and the "ordinary" stress experienced by anyone in a war zone. Wood v. Derwinski, 1 Vet.App. 190 (1991). The Court has indicated that the Board is not obligated to accept a claimant's uncorroborated account of his Vietnam experiences. See Wood, supra. Furthermore, VA regulations require corroboration of stressors for PTSD if the veteran is not shown to have engaged in actual combat with the enemy. 38 C.F.R. § 3.304 (f) (1993). The service department records confirm that the veteran served in Vietnam from March 1970 to March 1971; there is no reference to combat duty per se. In fact, the veteran stated that he was never a part of the infantry or involved in combat. According to his enlisted qualification record DD Form 20 and DD Form 214, he served in a primary military occupational specialty (MOS) of "military police" (95B20). His decorations included the National Defense Medal, the Vietnam Service Medial with two overseas bars, the Republic of Vietnam Commendation Medal with 60 device and the Good Conduct Medal, none of which is issued for actual combat or for valor in combat. Therefore, the Board finds that the veteran did not engage in combat with the enemy. When it is determined that the veteran did not engage in combat with the enemy, lay testimony by itself will not be enough to establish the occurrence of the alleged stressor. Instead, the record must contain service records which corroborate the veteran's testimony as to the occurrence of the claimed stressors. 38 U.S.C.A. § 1154(b) (1991); 38 C.F.R. § 3.304(d), (f) (1993); Zarycki v. Brown, 6 Vet.App. 91 (1993); West v. Brown 7 Vet.App. 70 (1994). The veteran's claimed stressors include the stress of working in a sensitive position, witnessing a friends death in a rocket attack, outgoing artillery fire and mortar attacks. In the instant case, the ESG could not corroborate the veteran's statements regarding his claimed stressors. In fact, the information that the ESG reported was inconsistent with the veteran's report of witnessing the death of a fellow soldier by the name of "Zane." The ESG found that the Vietnam Veteran's Memorial Directory of Names list an individual named "Zane" who was killed in Vietnam, but added that his death was prior to the veteran's Vietnam tour of duty. The artillery fire and mortar attacks were never corroborated. Even if the veteran's assertions concerning the occurrence of stressful events are accepted at face value, the question of whether those events are sufficient stressors for PTSD is one which requires a medical opinion. The Board notes that the record contains two conflicting statements by medical professionals regarding the sufficiency of the alleged stressors in diagnosing PTSD. Based on its review of the entire record, the Board finds that the May 1992 VA examination report provides the only probative opinion in determining that the veteran actually had not experienced sufficient stressors to support a diagnosis of PTSD in this case. Both examinations accepted the occurrences of the alleged stressors as reported by the veteran. However, the VA physician had the benefit of basing his decision upon review of the complete claims file, including the other report of the examination, service records, and current clinical findings; whereas, the 1987 examination report based the sufficiency of the stressors largely on information as reported by the veteran. Thus, the evidence relied upon by the VA examiner was more complete and provided a credible basis for the opinion that the veteran did not seem to have the kind of stressor that would warrant the diagnosis of PTSD. Most importantly, the VA opinion, unlike the other report, directly addressed the sufficiency of the reported stressors in terms of the distinction between ordinary war zone stress as distinguished from an event that would be markedly distressing to almost anyone. Wood v. Derwinski, 1 Vet.App. 190 (1991). As indicated hereinabove, the incident involving the loss of a friend in the claimed rocket attack in Vietnam has not been objectively confirmed and cannot be considered by the Board as a stressor for the purpose of supporting the diagnosis of PTSD. In addition, the history as related by the veteran in 1987 did not focus on significant stress due to being "mortared." As indicated by the recent examination for VA, he was bothered by no specific incident of shelling, but seemed to feel "empty and sad" on occasion. Finally, the fact that the veteran might have had a "sensitive" job in Vietnam, in and of itself, would not be consistent with a stressor required for PTSD. This was made clear by the VA examiner in his opinion. Therefore, as reported by the VA examiner, the alleged stressors such as artillery or mortar attacks and being in a "sensitive" position as a military police did not expose the veteran to anything more than the ordinary stress of being in a war zone. Thus, a basis for the diagnosis of PTSD has not been demonstrated. In summary, the evidence of record does not support the diagnosis of PTSD as it is based on unsubstantiated reports of stressor or episodes involving insufficient stress as provided by the veteran. Accordingly, it is the opinion of the Board that the preponderance of the evidence is against the claim of service connection for PTSD and that the benefit of the doubt rule does not apply. The evidence in this regard is not in equipoise because evidence relating to the diagnosis of PTSD is not supported by the record. 38 U.S.C.A. §§ 5107(b) (West 1991). ORDER Service connection for PTSD is denied. STEPHEN L. WILKINS 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.