Citation Nr: 0000685 Decision Date: 01/10/00 Archive Date: 01/19/00 DOCKET NO. 98-13 964 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in White River Junction, Vermont THE ISSUE Entitlement to service connection for post-traumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Vietnam Veterans of America WITNESS AT HEARING ON APPEAL The veteran ATTORNEY FOR THE BOARD A. C. Mackenzie, Associate Counsel INTRODUCTION The veteran is reported to have had honorable military service from September 1966 to June 1970 and from September 1970 to August 1972. His DA Form 20 confirms service in the Republic of Vietnam from May 8, 1968 to June 17, 1970 and from September 23, 1970 to September 22, 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 1998 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in White River Junction, Vermont. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of this appeal has been obtained by the RO. 2. The veteran was not in combat and does not have a diagnosis of PTSD based upon a verified stressor from service. CONCLUSION OF LAW The criteria for entitlement to service connection for PTSD have not been met. 38 U.S.C.A. §§ 1110, 1154, 5107 (West 1991); 38 C.F.R. §§ 3.303, 3.304 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSION Initially, the Board finds that the veteran's claim for service connection for PTSD is well grounded within the meaning of 38 U.S.C.A. § 5107(a) (West 1991). See Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). That is, the Board finds that the veteran has presented a claim which is not inherently implausible when his contentions and the evidence of record are viewed in the light most favorable to his claim. The Board is also satisfied that all relevant facts have been properly developed and that no further assistance to the veteran is required to comply with the VA's duty to assist him with the development of facts pertinent to his claim, as mandated by 38 U.S.C.A. § 5107(a). Generally, in order to establish service connection for a particular disorder, the evidence of record must demonstrate that a disease or injury resulting in a current disability was incurred in or aggravated by active military service. 38 U.S.C.A. § 1110 (West 1991); 38 C.F.R. § 3.303 (1999). However, VA regulations reflect that symptoms attributable to PTSD are often not manifested in service. Accordingly, service connection for PTSD requires a current medical diagnosis of PTSD (presumed to include the adequacy of the PTSD symptomatology and the sufficiency of a claimed in- service stressor), credible supporting evidence that the claimed in-service stressor(s) actually occurred, and medical evidence of a causal nexus between current symptomatology and the specific claimed in-service stressor(s). See 38 C.F.R. § 3.304(f) (1999); Cohen v. Brown, 10 Vet. App. 128, 138 (1997) (citing Moreau v. Brown, 9 Vet. App. 389, 394-95 (1996)). The evidence necessary to establish the occurrence of a stressor during service to support a claim for PTSD will vary depending on whether the veteran was "engaged in combat with the enemy." See Hayes v. Brown, 5 Vet. App. 60, 66 (1993). If the evidence establishes that the veteran was engaged in combat with the enemy or was a prisoner of war (POW), and the claimed stressor is related to combat or POW experiences (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. Where, however, the VA determines that the veteran did not engage in combat with the enemy and was not a POW, or the claimed stressor is not related to combat or POW experiences, the veteran's lay statements, by themselves, will not be enough to establish the occurrence of the alleged stressor. Instead, the record must contain service records or other credible evidence which corroborates the stressor. 38 U.S.C.A. § 1154(b) (West 1991); 38 C.F.R. § 3.304(d), (f) (1999); Gaines v. West, 11 Vet. App. 353, 357-58 (1998). Such corroborating evidence cannot consist solely of after- the-fact medical nexus evidence. See Moreau v. Brown, 9 Vet. App. 389, 396 (1996). The Board has first considered the question of whether the veteran has a medical diagnosis of PTSD. In this case, during service, the veteran was seen for "[e]motional and attitudinal problems which might compromise his judgment and reliability" in January 1972. However, his periodic examination reports, including the report of his June 1972 separation examination, reflect no psychiatric diagnoses. Subsequent to service, the first evidence of a psychiatric disorder is the report of a January 1997 examination conducted by Richard Michaud, M.D., at the request of the VA. This report reflects that the veteran reported a severe sleeping problem, "bad dreams," uncontrollable daydreams, irritability, jumpiness, loss of self-esteem, guilt feelings, loneliness, and apprehensiveness about family gatherings. The veteran indicated his dates of service in Vietnam, but the examination report contains no descriptions of specific in-service events. A mental status examination revealed the veteran to be initially tense and uncomfortable. His speech was coherent, logical, and rational, without either psychomotor retardation or acceleration. The content of his thoughts revealed anxiety, with low self-esteem and mixed feelings about his life, his work, and his role as a father and as a partner for his wife. The examiner noted that the veteran's general mood was depressed, with such somatic symptoms as chronic headaches and sleep disturbances, and that he was "rationalizing his discomfort" so as not to appear "emotional" and "crazy" to others. No signs of a hallucinatory process were elicited, and the examiner noted no actual clinical symptoms of major depression. The examiner concluded that the veteran suffered from chronic PTSD of an "important" degree. In an addendum dated in June 1997, Dr. Michaud noted that the veteran reported that he underwent several "dramatic experiences" during service. When questioned, the veteran described the dropping of a bomb on a bunker in Vietnam, with the subsequent deaths of the soldiers inside. However, the examiner also noted that the veteran was reluctant to describe his experiences in greater detail because of his preoccupation with his feelings, shame, and sense of revolt. The claims file also includes an July 1998 statement from Frederick W. Lundell, MDCM, CSPQ, FRCP(C), FAPA, who had also treated the veteran. In this letter, Dr. Lundell did not cite to specific in-service experiences of the veteran, although he noted that the veteran's "story of three tours in Vietnam would make a classic novel, rather autobiography." He noted that the Axis I diagnosis was "unequivocally" chronic PTSD. A Global Assessment of Functioning (GAF) score of 50 was assigned, and Dr. Lundell noted that the veteran's social and family adjustment was minimal and that his symptoms had interfered with his employability. In the present case, in view of the evidence described above, the Board finds that the veteran has submitted evidence of a medical diagnosis of PTSD. Nonetheless, the veteran's diagnosis of PTSD must be based upon either participation in combat with the enemy or a verified in-service stressor for service connection to be warranted, as noted above. Medical nexus evidence is insufficient, in and of itself, to predicate the grant of service connection for PTSD. See Moreau v. Brown, 9 Vet. App. at 396. Thus, the question becomes whether the veteran either engaged in combat with the enemy during service or experienced a verified in-service stressor upon which the diagnosis of PTSD is predicated. With regard to the question of whether the veteran served in combat with the enemy, the Board has considered his military commendations. In this regard, the Board observes that the veteran's military records indicate that he was awarded the National Defense Service Medal; the Vietnam Campaign Medal, with a "60" device; four Overseas Stripes; the Army Commendation Medal; the Republic of Vietnam Service Medal; and an SPS Rifle commendation. The Board also notes that the veteran's DD Form 214 indicates that his military occupational specialty was in armor intelligence, and his DA Form 20 also indicates principal duties as a water supply specialist, a water purification specialist, and a squad leader. However, these records do not reflect that the veteran received such combat-related citations as the Purple Heart or the Combat Infantryman Badge, and there is no further evidence suggesting participation in combat with the enemy, such as treatment for combat-related injuries during service. In short, the veteran's claims file includes no evidence, other than his lay assertions, to verify his claimed stressor events from service. As such, the Board has considered whether the veteran's diagnosis of PTSD is based upon a verified stressor or stressors. In statements received by the RO in July 1996 and April 1997, the veteran reported six separate stressors. He described an incident on May 11 or 12 of 1968, when an unidentified man was killed in a rocket attack. The second stressor reportedly occurred in late May or early June in 1969 at Long Binh and involved a mortar attack in the vicinity of where the veteran was stationed; he noted that the area looked like "a moon scope." The veteran further reported that, on October 30, 1969 at Long Binh, he accidentally hit an old man while driving a jeep. With regard to the fourth incident, the veteran indicated that, between October 7 and October 14 of 1970, he witnessed a Vietnamese man nearly beaten to death by the local regional force commander at Cam Lo. Also, reportedly on October 13 or 14 of 1970 and at Cam Lo, the veteran accidentally discharged his gun while disarming it and shot himself in the left leg. The final incident allegedly occurred on December 26 or December 27 of 1970, when the veteran was reportedly hit by a truck loaded with civilian workers and driven by a civilian. Additionally, in a statement received in August 1997, the veteran described an attack on a bunker near Quang Tri during the second half of October 1970. He noted that this attack was "the first and last time that I came under intense mortar and rocket attack." The Board also observes that, during his July 1999 VA videoconference hearing, the veteran placed particular emphasis on the October 1969 vehicular incident, which, according to the veteran, might have actually occurred in September 1969, and the May 1968 rocket attack. The veteran testified that there was no record made of the vehicle incident and he did not know the name of the man killed in the rocket attack. The veteran testified that he had difficulty remembering dates. He also testified that while he witnessed events he was not actually in a combat unit. As the veteran reported specific details of his alleged stressors, the RO requested pertinent materials for the veteran's units, Company A of the 7th Engineering Battalion and the 82nd Engineering Company, from the United States Armed Services Center for Research of Unit Records (Unit Records Center). The only mention of the veteran in these reports concerns treatment for a minor right leg wound from cleaning a pistol on October 28, 1970. However, these records also show that Long Binh Post was subjected to fire on May 11, 1968, with one man killed in action, and to a rocket landing on May 12, 1968, with no resultant deaths. Also, on May 12, 1969, Long Binh Post received approximately 22 rounds of 107 mm. rocket fire, with one soldier killed and 16 others wounded. In reviewing the materials received from the Unit Records Center, the Board notes that these records confirm attacks on Long Binh on May 11 and May 12 of 1968 and that the veteran's reported stressor from late May/early June of 1969 appears to be consistent with the May 12, 1969 attack on Long Binh Post described in the military records. The Board observes, however, that these records do not confirm that the veteran was in the vicinity of these attacks at the times of their occurrences. The Board also notes the confirmation of an accidental, self-inflicted leg injury in October 1970, although the veteran reported a left leg injury and the records indicate a right leg injury. Nevertheless, even assuming, without conceding, that the materials received from the Unit Records Center sufficiently verify these particular stressors, the veteran's examiners have not based their diagnoses of chronic PTSD on those specific stressors. Rather, the only specific in-service event noted in any of the veteran's examination reports is an undated bunker explosion with multiple deaths, as noted in the June 1997 addendum from Dr. Michaud. These reports contain no references whatsoever to the specific events noted in the materials from the Unit Records Center. Overall, based upon a review of the entire claims file, the Board finds that the evidence of record shows that the veteran has been diagnosed with PTSD. However, the evidence of record, including the veteran's testimony, does not reflect participation in combat with the enemy, and there is no evidence showing that the veteran's current medical diagnosis of PTSD is based upon a verified stressor from service. In that regard, it is also noted that the veteran testified at his personal hearing that he could not remember dates and was not able to provide additional details warranting further efforts to verify his claimed stressors. As such, the Board finds that the preponderance of the evidence is against his claim for service connection for PTSD. In reaching this determination, the Board has considered the doctrine of reasonable doubt, as set forth in 38 U.S.C.A. § 5107(b) (West 1991). However, as the preponderance of the evidence is against the veteran's claim, this doctrine is not for application. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). ORDER The claim of entitlement to service connection for PTSD is denied. STEVEN L. COHN Member, Board of Veterans' Appeals