Citation Nr: 0002389 Decision Date: 01/31/00 Archive Date: 02/02/00 DOCKET NO. 97-26 506A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Los Angeles, California THE ISSUE Entitlement to service connection for post-traumatic stress disorder. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARINGS ON APPEAL Appellant ATTORNEY FOR THE BOARD R. A. Caffery, Counsel INTRODUCTION The veteran had a period of active honorable service from May 1971 to March 1973. He had another period of service from February 1974 to September 1975 that was terminated by a discharge under other than honorable conditions. This is an appeal from an April 1997 rating action by the Department of Veterans Affairs (VA) Regional Office Los Angeles, California, which denied entitlement to service connection for post-traumatic stress disorder. In July 1997 the veteran testified at a hearing at the regional office before a regional office hearing officer. In July 1999 he testified at a hearing before a member of the Board of Veterans' Appeals (Board) sitting at the regional office. The case is now before the Board for appellate consideration. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of the veteran's appeal has been obtained by the regional office. 2. A psychiatric disability, including post-traumatic stress disorder, was not demonstrated during the veteran's active military service. 3. Psychiatric disabilities, variously diagnosed, were initially demonstrated many years after the veteran's discharge from service. 4. The evidence does not establish that the veteran currently has post-traumatic stress disorder or any other acquired psychiatric disorder which can be associated with his military service or any verified incident in service. CONCLUSION OF LAW The veteran does not have a psychiatric disability, including post-traumatic stress disorder, that was incurred in or aggravated during service. A psychosis, if present, may not be presumed to have been incurred in service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5107 (West 1991); 38 C.F.R. §§ 3.307, 3.309 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Board notes that it has found the veteran's claim to be "well grounded" within the meaning of 38 U.S.C.A. § 5107(a); effective on and after September 1, 1989. That is, the Board finds that he has presented a claim which is plausible. The Board is also satisfied that all relevant facts have been properly developed. I. Background The veteran's service medical records do not reflect any complaints or findings regarding a psychiatric disability. The veteran's service records reflect that he served in the Republic of Vietnam from May 1972 to February 1973. His military occupational specialty was that of a military policeman. His decorations include the Vietnam Service Medal and Vietnam Campaign Medal. He was a member of the 146th Signal Company. The veteran's initial claim for service connection for post- traumatic stress disorder was submitted in June 1992. He was asked by the regional office to provide information regarding stressors during service. He was also scheduled for a VA psychiatric examination. Because he did not provide the requested information regarding stressors and did not report for the examination his claim was classified as denied or abandoned. 38 C.F.R. § 3.158. In February 1996 the veteran advised the regional office that he was currently incarcerated in a State prison. In November 1996 he reopened his claim for service connection for post- traumatic stress disorder. The regional office later received medical records from the State prison reflecting that the veteran was seen in April 1995 with complaints of nightmares and mood swings. He complained of nightmares since his return from Vietnam. It was noted that he had used various drugs. Various findings were recorded on mental status examination. Diagnoses were made of polysubstance abuse, substance-induced mood disorder and personality disorders. When he was seen in July 1995 it was indicated that paranoid schizophrenia should be ruled out. Possible post-traumatic stress disorder was also indicated. The veteran was afforded a VA psychiatric examination in January 1997. He had recently completed 22 months in prison and had not been employed since 1986 when he terminated his employment due to multiple problems including addiction. He had been in and out of jail from 1975 until recently for drug-related offenses. He claimed that he had been sober since July 1993. He had had multiple psychiatric hospitalizations and participated in post-traumatic stress disorder groups. A summary of the veteran's VA psychiatric hospitalization in October and November 1996 noted that the veteran had come to the VA through a homeless program referral. The discharge diagnoses from the hospital included schizo-affective disorder in remission, severe narcotics dependence and post-traumatic stress disorder. On mental status examination the veteran was oriented in all three spheres. He stated that he had frequent visions of a friend who had died in his arms in Vietnam and he relived that experience. He related that he had been in Vietnam from 1972 until 1973 and had been a military policeman and guarded a perimeter. He helped with radar installation and guarded aircraft. He had fired a weapon in a combat situation and had been under enemy fire. He had been exposed to dead and wounded men on a daily basis. He claimed that he had frequently been in jeopardy of injury or death. When a service acquaintance was killed in a bunker while he was a short distance away he went and held him and tried to console him. The acquaintance died in his arms. He described frightening situations in which ammunition dumps were blown up. He reported daily rocket attacks over a two-month period. The veteran's symptoms included persistently reexperiencing events, persistent avoidance of associated stimuli and persistent symptoms of increased arousal. A psychological profile was of questionable validity although the alternative hypothetical explanations for the high score included severe psychopathology. Diagnoses were made of chronic post- traumatic stress disorder, schizo-affective disorder in some remission with medication, alcohol and cocaine dependence in full remission since 1993 and antisocial personality by history. The regional office later received a report of the veteran's VA hospitalization of October and November 1996. He had been released from prison on parole the day prior to seeking admission and had sought admission initially because he was homeless and had no income and was afraid of resuming heavy drug abuse. He complained of Vietnam combat flashbacks and nightmares. He reported a long-standing history of clear manic and psychotic episodes as well as clear episodes of depression. He had been diagnosed as suffering from schizophrenia for many years and had gone through many alcohol and drug treatment programs. He had a history of violence and had been in jail on many occasions. The discharge diagnoses included bipolar disorder with psychosis, in remission, drug dependency, in remission, post-traumatic stress disorder and antisocial personality disorder. In March 1997 the veteran provided a statement regarding stressors which occurred during service. While serving with the 146th Signal Company in Pleiku, South Vietnam, beginning in June 1972 he had had stressful and life-threatening experiences. In July 1972 his unit had been involved in a firefight with enemy forces. The enemy had been successful in blowing up a nearby ammunition depot. He related that combat action with enemy forces was a common every-day occurrences as was small arms fire and rocket and mortar attacks. He witnessed the wounding of a fellow soldier and gave him moral support until medical personnel had been able to medivac him out of the country. During September and October 1972 his duties were to provide perimeter security at a radar site. The site had been on the top of a remote mountain and was an extremely stressful and life-threatening assignment for him. While stationed on top of the mountain he frequently experienced enemy small arms fire and rocket and mortar attacks. The veteran further related that during a cease-fire agreement in 1972 he was stationed at Da Nang Air Force Base and the whole area was experiencing rocket and mortar attacks. During January 1973 they experienced a large number of attacks. During the course of the hearing on appeal conducted in July 1997, the veteran related that Saigon had been fairly quiet, but after his transfer to Pleiku in the Central Highlands, he had experienced combat with fire from snipers and they had to be aware of booby traps and land mines. They also had mortar attacks. An acquaintance of the veteran had been killed in a bunker a short distance away from the veteran. The regional office later received a report of the veteran's VA hospitalization in December 1996 when diagnoses were made including diabetic keto-acidosis secondary to diabetes mellitus, history of bipolar disorder and history of positive hepatitis-C. A VA patient discharge information form dated in July 1997 reflects diagnoses including post-traumatic stress disorder. In July 1997 the U.S. Army and Joint Services Environmental Support Group (now the U.S. Armed Services Center for Research of Unit Records) provided documents including a unit history of the 146th Signal Company covering the period from March 1965 to April 1972. They were unable to document the destruction of any ammunition dumps during the veteran's tour in the Pleiku area. They were also unable to document the acquaintance listed by the veteran being killed in action during the time frame of the veteran's tour in Vietnam. U.S. Army casualty files indicated that an individual with the same name had been killed in action by rocket and mortar fire, but that happened in July 1969. During the July 1999 hearing before the Board, the veteran related that he had checked the Vietnam Wall and the name of his acquaintance was not on the wall. He had always assumed, because of the nature of the acquaintance's injuries that he had died. He had seen many casualties with chest wounds who were bleeding profusely and he had assumed that they had died because they were never seen again. His acquaintance had had chest wounds and had been bleeding. The veteran stated that while taking supplies to various units they would always be attacked. They had always sustained some casualties on those patrols. He still reminisced about events that occurred in Vietnam. II. Analysis Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by wartime service. 38 U.S.C.A. § 1110. Where a veteran served ninety (90) days or more during a period of war and a psychosis becomes manifest to a degree of 10 percent within one year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. 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). Service connection for post-traumatic stress disorder 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. Where the veteran did not serve in combat or the stressor is not related to combat, the veteran's 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 stressor. 38 C.F.R. § 3.304; West v. Brown, 7 Vet. App. 70 (1994). In this case, the veteran's military occupational specialty was that of a military policeman but his service records do not substantiate that he served in combat. His active service military personnel records file does not reflect the award of any combat decorations. His active service personnel records do indicate that he received the Vietnam Service Medal and Vietnam Campaign Medal among other decorations; however, the criteria for those medals do not include being engaged in combat. Thus, the veteran's uncorroborated statements regarding claimed stressors during service, of themselves, cannot be accepted as establishing the presence of such stressors in service. In particular, the wounding or death of the service acquaintance as reported by the veteran has not been verified. The record reflects that when the veteran was afforded the VA psychiatric examination in January 1997 the diagnoses included post-traumatic stress disorder; however, that diagnosis was based on the stressors reported by the veteran which, as indicated previously, have not been substantiated. Further, other psychiatric conditions including a psychosis and personality disorder were diagnosed when the veteran was hospitalized by the VA from October to November 1996. Post- traumatic stress disorder was also included as a diagnosis; however, that diagnosis was made based on the veteran's reports of flashbacks and nightmares of Vietnam combat experiences which have not been verified. In the Board's judgment, the evidence of record is insufficient to establish that the veteran currently has post-traumatic stress disorder or that the other diagnosed psychiatric conditions either became manifest in service or were otherwise a result of any incident of service or, in the case of a psychosis, became manifest to the required degree within one year following the veteran's separation from service. Accordingly, it follows that entitlement to service connection for a psychiatric disability, including post- traumatic stress disorder, is not in order. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309 (1999). The Board has carefully reviewed the entire record in this case; however, the Board does not find the evidence to be so evenly balanced that there is doubt as to any material issue regarding the matter on appeal. 38 U.S.C.A. § 5107. ORDER Entitlement to service connection for post-traumatic stress disorder is not established. The appeal is denied. ROBERT D. PHILIPP Member, Board of Veterans' Appeals