BVA9507004 DOCKET NO. 92-07 222 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Manchester, New Hampshire THE ISSUE Entitlement to service connection for post-traumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Massachusetts Department of Veterans Service WITNESSES AT HEARINGS ON APPEAL Appellant and a social worker ATTORNEY FOR THE BOARD P. Greif, Associate Counsel INTRODUCTION The veteran had active military service from September 1971 to September 1973. This matter came before the Board of Veterans' Appeals (Board) on appeal from a March 1991 rating decision from the Boston, Massachusetts, Regional Office (RO) of the Department of Veterans Affairs (VA). In that rating decision the RO denied entitlement to service connection for PTSD. A RO hearing was held in September 1991. The Board remanded the appeal in April 1993. A second RO hearing was held in July 1994. CONTENTIONS OF APPELLANT ON APPEAL The veteran contends, in essence, that the RO committed error in not granting service connection for PTSD. He avers that the record reflects the presence of both the requisite stressor(s) and a confirmed diagnosis of PTSD. 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 preponderance of the evidence is against the veteran's claim for entitlement to service connection for PTSD. FINDINGS OF FACT 1. The RO has obtained all relevant evidence necessary for an equitable disposition of the veteran's appeal. 2. The veteran was not involved in combat with the enemy while in service. 3. The veteran does not have PTSD as a result of his active military service. CONCLUSION OF LAW PTSD was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 5107 (West 1991); 38 C.F.R. §§ 3.303, 3.304(f) (1994). REASONS AND BASES FOR FINDINGS AND CONCLUSION The veteran's claim is "well grounded" within the meaning of 38 U.S.C.A. § 5107(a) (West 1991). That is, he has presented a claim that is plausible. Treatment records contained in his claims folder include references to PTSD. The veteran's service medical records, service personnel record, and VA treatment records have been obtained. He has also had three VA psychiatric examinations and two RO hearings in connection with this claim. Some private treatment records are available, and the RO made unsuccessful attempts to obtain other records from the private practitioners who reportedly treated the veteran in 1990 and 1991. I note that the private social worker who treated him testified at his 1991 hearing. I conclude that all relevant facts have been properly developed and no further assistance is required to comply with the duty to assist mandated by 38 U.S.C.A. § 5107(a). Service connection may be established for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110 (West 1991); 38 C.F.R. § 3.303 (1994). Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (1994). In determining whether service connection is warranted for disease or disability, VA must determine whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107(b) (West 1991); Gilbert v. Derwinski, 1 Vet.App. 49 (1990). The essential feature of PTSD is the development of characteristic symptoms following a psychologically distressing event that is outside the range of usual human experience. Service connection for PTSD requires medical evidence establishing a clear diagnosis of the condition, credible supporting evidence that the claimed inservice stressor actually occurred, and a link, established by medical evidence, between current symptomatology and the claimed inservice stressor. 38 C.F.R. § 3.304(f) (1994). If the claimed stressor is related to combat, service department evidence that the veteran engaged in combat will be accepted, in the absence of evidence to the contrary, as conclusive evidence of the claimed stressor. Id. In the instant case, the veteran has consistently reported, beginning with his July 1990 claim for service connection for PTSD, that his claimed stressor consisted of loading bombs, rockets, etc., onto airplanes at an air force base in Thailand from April to July 1973. He described this "stressor" in detail in written statements dated in August and November 1990 and June 1994, his July 1991 appeal, and his two hearings. He also described it at his VA examinations, as recounted in the examination reports. The report of the October 1994 VA examination also contains reference to other incidents reported by the veteran: being attacked with a knife in Thailand and witnessing a fellow serviceman being "cut . . . in half" by a metal rope that had snapped. The veteran does not allege that he served in combat. His service in Thailand and his described duties are substantiated by his service personnel records, which do not show combat service. The evidence supporting the claim for PTSD consists primarily of the testimony of his treating social worker at his 1991 hearing and records of treatment that contain diagnoses and impressions of PTSD. The social worker recounted that she first saw the veteran in July 1990, when he was referred to her as an appropriate candidate for a PTSD program. She stated that she concurred in the diagnosis of PTSD, as did a psychiatrist to whom she referred the veteran. She reported symptoms of nightmares, exaggerated response, anger, depression, and isolation. The record contains copies of her records, beginning in late June 1990 and ending in late July 1990. The multiaxial diagnosis was PTSD, obsessive-compulsive disorder, and polysubstance abuse. The record also contains a June 1990 record from the North Essex Mental Health Center, the organization that referred the veteran to the social worker. It indicates that a social worker had assessed that the veteran was experiencing symptomatology consistent with PTSD. The report contains a reference to persistent dreams and flashbacks of service connected activities. The discharge summary of the veteran's hospitalization at a VA facility from August to September 1990 contains discharge psychiatric diagnoses of PTSD, obsessive compulsive disorder, and major depression versus dysthemia. It indicates that the veteran had sought treatment in the substance abuse program for cannabis dependence but was transferred for evaluation of severe depression and increasing obsessive compulsive symptoms. The report states that, upon discontinuance of marijuana, he had experienced considerable increase in symptoms of PTSD, i.e., nightmares, and refers to his activities loading bombs. VA outpatient treatment records from June 1990 through July 1993 also contain some references to PTSD. The service medical records do not indicate any complaints, symptoms or medical findings suggestive of a psychiatric disability, including PTSD. They contain two brief notations, one in July 1973 that indicates that the veteran wanted to get out of the military and contains the impression of maladjustment, and the other, in August 1973, that references occupational maladjustment and a mental hygiene clinic referral. The veteran referred to depression and nervousness at examination for discharge from service, at which time a notation was made that this was associated with personal problems and had no complications or sequelae. No psychiatric abnormalities were noted on examination. The service medical records do not necessarily exclude the possibility of PTSD resulting from service. The evidence against the claim for service connection for PTSD includes the reports of VA psychiatric examinations conducted in January 1991 and February and October 1994, none of which contain a diagnosis of PTSD, as well as the VA treatment records. The report of a January 1991 VA psychiatric examination contains diagnoses of dysthymia, chronic, delayed, severe with obsessive compulsive features, and moderate substance dependence. The report indicates that the veteran complained of nightmares, depression and extreme sweating, and recounted his duties loading bombs, rockets, etc., onto airplanes in Thailand. The examiner reported that throughout the interview the veteran was fighting back tears. She noted that he was somewhat irritated, and ill at ease, but that there was no evidence of delusions, hallucinations, or psychotic determinence. She noted that the veteran had been abusing alcohol since the 1970's, that he currently smoked marijuana, and that he had experimented with heroin, cocaine, and downers. The examiner reported that the veteran's sensorium was clear, that he was correctly oriented as to time, place, and person, and that his memory was intact. She noted that his attention, comprehension, and concentration were diminished due to severe preoccupation with depressive feelings. His insight was reported as superficial and judgment as fair. This same physician examined the veteran again in February 1994 and diagnosed chronic dysthymia, delayed, severe with obsessive compulsive features, and polysubstance abuse. The examination report indicates that the veteran complained of sleep disturbance, including dreams about fires, people being killed, and loading airplanes with bombs, and suicidal ideation. The examiner reported that the veteran had obsessive, compulsive traits, but no delusions, hallucinations, or psychotic determinants. She noted that his sensorium was clear and that his recent and remote memory were satisfactory. The examiner reported that the veteran's attention and concentration span were poor, that his insight into his illness was marginal, and that his judgment was compromised by psychopathology. The veteran was accorded another VA psychiatric examination by a Board of two examiners, each of whom evaluated him separately, in October 1994. The examination report indicates that the veteran reported that he had PTSD. He claimed that his "stressors" included loading bombs to be used in Cambodia and being on night shift and not being able to sleep during the day. He reported that he had to be careful not to be sucked into the intake of the engine and described other dangers associated with this duty. He described the loading and unloading of explosives as a terrifying life-threatening stressor. He reported that he was never shelled directly but he could frequently hear explosions in the distance. He also reported that all the noise at the runway was a stressor. He reported that other stressors were being attacked by a Thai person with a knife in downtown and frequent accidents at the runway. The examiner reported that the veteran's most prominent symptoms appeared to be his chronic dysphoria. He complained of survival guilt, dreams of people accusing him of bombing and murdering Cambodians, startle response to loud noises, aggravated temper, sense of feeling inferior, poor concentration, but no flashbacks per se. On mental status evaluation the examiner reported that the veteran had some psychomotor slowing when he talked, made intermittent eye contact, and was somewhat hostile in demeanor. The veteran denied homicidality or suicidality and showed no evidence of thought disorder. The examiner noted that the veteran's insight into his own life was poor and that his social judgment seemed to be somewhat limited. The final diagnosis was dysthymia with some obsessive features and some PTSD features. The VA outpatient treatment records from June 1990 through October 1993 contain scattered references to PTSD, however, they primarily contain references to substance abuse, alcohol abuse, obsessive-compulsive behavior, and depression. They indicate that the veteran sought treatment in June 1990, complaining of feeling depressed and suicidal. Obsessive compulsive behavior and PTSD symptoms were also referenced at that time. Treatment records in July 1990 indicate that the social worker who testified at his 1991 hearing referred him to VA for substance abuse groups. Subsequent notations show his participation in groups for both alcohol and drug abuse and refer to depression and obsessive compulsive behavior. In weighing the evidence of record in this case, I gave much weight to the findings of the VA examiners who specifically addressed the question of whether the veteran had PTSD. The VA psychiatric examination of October 1994 contains a diagnosis of dysthymia with some features of PTSD. However, the examiners did not proffer a firm diagnosis of PTSD. The other VA psychiatric examination reports contain diagnoses of dysthymia with obsessive compulsive features, and polysubstance abuse or substance dependence. These examination reports indicate that the veteran does not have PTSD. Even though the VA treatment records contain references to PTSD, and a diagnosis of PTSD was entered into the discharge summary of his VA hospitalization in 1990, the compensation examination reports are essentially supported by the VA treatment records, which essentially show treatment for the psychiatric diagnoses listed in the compensation examination reports. Even if I were to concede that the veteran has PTSD, the record does not contain a verifiable inservice stressor that is so psychologically distressing that it can be considered outside the range of usual human experience. None of the VA psychiatric examiners described the veteran's military duties in Thailand as such a stressor. As noted above, 38 C.F.R. § 3.304(f) (1994) provides that service connection for PTSD requires medical evidence establishing a clear diagnosis and credible supporting evidence that the claimed inservice stressor actually occurred and a link established by medical evidence between current symptoms and the inservice stressor. The references to PTSD in the treatment records have not been linked medically to inservice stressors. In fact, some of the treatment records referring to PTSD also contain references to Vietnam. The veteran's service records do not substantiate such service. After considering all of the evidence of record, I conclude that the preponderance of the evidence demonstrates that the veteran does not have PTSD attributable to his period of active service. Accordingly, service connection for PTSD is not warranted. ORDER Entitlement to service connection for PTSD is denied. MARY GALLAGHER 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.