Citation Nr: 0003744 Decision Date: 02/14/00 Archive Date: 02/15/00 DOCKET NO. 95-09 344 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Paul, Minnesota THE ISSUE Entitlement to service connection for post-traumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Minnesota Department of Veterans Affairs ATTORNEY FOR THE BOARD Wm. Kenan Torrans, Associate Counsel INTRODUCTION The veteran served on active duty from February 1969 to December 1970. This matter arises from a June 1994 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Paul, Minnesota, which denied the benefit sought. The veteran filed a timely appeal, and the case has been referred to the Board of Veterans' Appeals (Board) for resolution. FINDING OF FACT The veteran has been diagnosed with PTSD, and has presented medical evidence of a nexus or link between his diagnosed PTSD and events reported by the veteran to have occurred during his active military service. CONCLUSION OF LAW The veteran's claim for service connection for PTSD is well grounded. 38 U.S.C.A. § 5107(a) (West 1991). REASONS AND BASES FOR FINDING AND CONCLUSION The veteran has claimed entitlement to service connection for PTSD. In reviewing a claim for service connection, the initial question is whether the claim is well grounded. In this regard, the veteran must satisfy three elements. First, there must be evidence of an incurrence or aggravation of an injury in service. Second, there must be evidence (i.e. medical) of a current disability. Third, there must be evidence of a nexus between the in-service injury or disease and the current disability, as shown through the medical evidence. See Epps v. Gober, 126 F.3d 1464 (1997). Lay or medical evidence, as appropriate, may be used to substantiate the service incurrence. See Caluza v. Brown, 6 Vet. App. 498, 506 (1995); Layno v. Brown, 6 Vet. App. 465, 469 (1994). A well-grounded claim for service connection for PTSD has been submitted when there is "[1] medical evidence of a current [PTSD] disability; [2] lay evidence (presumed to be credible for these purposes) of an in-service stressor, which in a case involving PTSD is the equivalent of in-service incurrence or aggravation; and [3] medical evidence of a nexus between service and the current PTSD disability." See Cohen v. Brown, 10 Vet. App. 128 (1997) (citations omitted). The record shows that the veteran served as a cook and as a cook's helper in the 25th Aviation Company (Corps) from approximately March 1970 through December 1970 in the Republic of Vietnam. He claims to have served in an area known as Long Binh. He was issued the National Defense Service Medal and the Vietnam Service and Campaign Medals upon completion of his tour of duty in Vietnam. The veteran maintains that during his tour of duty as a cook in the 25th Aviation Company (25th Av. Co.), his base camp was subject to periodic incoming mortar and rocket attacks. He has asserted that on one occasion he was knocked from his cot as a result of the concussion of an exploding incoming round. In addition, the veteran has stated that his base camp was infiltrated by enemy troops disguised as South Vietnamese (ARVN) soldiers, and that these enemy troops were either killed or captured. The veteran stated that while he was not involved in this incident, it frightened him a great deal. Further, the veteran maintains that he had become close to a number of helicopter crewmen who were killed or wounded in action. While he has thus far been unable or unwilling to provide dates or names of individuals involved in these alleged events, he claims that such events have resulted in his currently diagnosed PTSD. A review of the veteran's service medical and service personnel records fails to disclose any treatment for combat wounds or for any psychiatric disorders. The record shows that he first sought treatment at a VA Medical Center (VAMC) for PTSD in August 1989. The admitting physician at that time noted the veteran's complaints, and concluded with a diagnosis of "adjustment disorder." Nonetheless, a VA licensed clinical social worker (LCSW) concluded with his own diagnosis of PTSD, based on the veteran's self-reported history and the LCSW's assessment of the veteran's symptoms. The record shows that the veteran received treatment for this diagnosed PTSD from the same LCSW from August 1989 through February 1998. Throughout this period, the LCSW continued to diagnose the veteran with PTSD, which he indicated was based upon the veteran's alleged traumatic experiences in Vietnam. One clinical treatment note, dated in July 1994, suggests that the LCSW based his assessment on his impression that the veteran served in combat with a helicopter gunship unit. There is no indication of record that the LCSW ever attempted to verify the veteran's claimed stressors. In any event, a December 1994 inpatient discharge summary signed by a physician contains a diagnosis of PTSD. There is no indication in the treatment record as to what clinical evidence the treating physician used to base this diagnosis. The treating physician noted that the veteran was to continue treatment with the LCSW. The Board observes that the veteran was afforded two VA rating examinations in May 1994 and in September 1998, which were conducted by psychiatrists. On both occasions, the examining physicians concluded that the veteran did not meet the criteria for a diagnosis of PTSD. The report of the May 1994 rating examination includes the examining physician's observation that PTSD symptoms were distinguished by their absence. He concluded with a diagnosis that "PTSD is not found currently, and I am not entirely certain that the experiences that he (the veteran) recounts qualify as meeting the appropriate criteria. the veteran does have a history of major depression, with a suicide attempt in 1993. He probably also has had some generalized anxiety in the past" (emphasis added). The report of the September 1998 rating examination concluded with similar results and diagnoses. During the course of the interview, the examining physician noted that the veteran was unable to provide dates of occurrences of his claimed stressors, and was unable to provide or recall the names of the individuals whose deaths allegedly resulted in so much personal trauma. The examiner noted the veteran's long history of psychiatric problems, domestic violence, and other difficulties, and concluded with Axis I diagnoses of recurrent major depression, and PTSD not found (emphasis added). The Board further observes that VA inpatient treatment records, dated in January and February 1996, contain "provisional" diagnoses of PTSD, but do not contain final diagnoses of this disorder. His Axis I diagnoses included "adjustment reaction with mixed disturbance of emotions and conduct, marital discord, and PTSD, provisional." The veteran's LCSW noted in an "assessment", dated in February 1997, that the veteran was very dysfunctional at that time, and was divorced and unemployed. The LCSW stated that the veteran had been able to produce some records substantiating his claimed stressors relating to his claim for service connection for PTSD. The Board has reviewed this evidence, and concludes that the veteran has presented evidence of a well-grounded claim for service connection for PTSD. The Board recognizes that the reports of the two VA rating examinations, conducted for the express purpose of determining whether or not the veteran had PTSD related to service, contained the examiner's express opinions that he did not, in fact, have PTSD. Nonetheless, inasmuch as the veteran's medical records contain diagnoses of PTSD, at least one of which was apparently rendered by a licensed medical doctor, the Board finds that all elements for a finding of well groundedness have been met. Further development of evidence is required before a final disposition of the issue on appeal. The additional development will be addressed in the REMAND portion of this decision. ORDER The veteran's claim for service connection for PTSD is well grounded, and to this extent only, the appeal is granted. REMAND Given that the veteran has presented evidence of a well- grounded claim for service connection, the Board observes that the VA has a further obligation to assist him in the development of evidence to support his claim. See 38 U.S.C.A. § 5103 (West 1991); McKnight v. Gober, 131 F.3d 1483 (Fed. Cir. 1997); Epps, 126 F.3d 1464. The veteran has presented medical records showing diagnoses of PTSD. As noted, while there may be some issue as to whether these diagnoses are based on accurate or valid accounts of his stressor history, the veteran has, nonetheless presented medical evidence establishing the required nexus between PTSD and his active service. See Cohen, 10 Vet. App. at 128. The record shows that the veteran served with the 25th Aviation Company as a cook or a cook's helper from approximately March 1970 to December 1970. He has indicated that he served in the Long Binh area in the Republic of Vietnam during this period. Specifically, the veteran has listed the following as his claimed stressors: 1) During his service in Vietnam, his base camp was subject to enemy mortar and rocket attack, and on one occasion, he claims that he was knocked from his bunk due to the concussion from an incoming round. 2) According to the veteran, he was frightened by an alleged incident in which enemy soldiers, presumably Viet Cong disguised as friendly ARVN troops infiltrated his company area, and were either killed or captured in the ensuing combat. 3) The veteran claims that he had friends (currently unnamed) among attached helicopter units who were either killed or wounded. Thus far, the veteran has failed to provide any further specific information regarding these alleged stressors. The veteran appears to have acknowledged that he was not in combat, which is confirmed by the available service personnel records. As the veteran has what can be characterized as clear diagnoses of PTSD which are related to his period of active service, verification of the occurrence of the claimed stressors from the United States Center for Research of Unit Records (USASCRUR) is required. See 38 C.F.R. § 3.304(f) (1999); Zarycki v. Brown, 6 Vet. App. 91, 93 (1993). In addition, in the event that the alleged stressors are verified, competent medical evidence is required to link PTSD to the verified in-service stressor(s). The examiners are requested to comment on the validity of previous diagnoses of PTSD in light of the evidence of record and the veteran's symptomatology. It is therefore, the opinion of the Board, that in the event the veteran's claimed stressors can be verified, that the RO should refer the veteran's claims file to a panel of two VA board certified psychiatrists, to review the claims file, and all the medical evidence associated with it, in order to make those determinations. Therefore, this case is REMANDED for the following action. 1. The RO should contact the veteran and attempt to obtain a more detailed account of his claimed stressors, such as names of alleged friends killed or wounded in action, and dates on which the alleged traumatic events occurred. In this regard, in a medical assessment dated in February 1997, the veteran's treating LCSW stated that the veteran had produced records supporting his purported stressors. The RO should attempt to obtain these records and associate them with the claims file. The RO should then attempt to verify the occurrence of the purported stressors, and to the extent possible, the facts and circumstances surrounding the deaths of any individuals the veteran is able to identify through the United States Center for Research of Unit Records (USASCRUR), 7798 Cissna Road, Suite 101, Springfield, Virginia 22150-3197. In addition, the RO is requested to attempt to determine, to the extent possible, the locations where any named individuals were killed in relation to the veteran's documented area(s) of operation at those specific times. In this regard, the veteran's statements (or the RO's summary of the pertinent information contained therein), copies of the veteran's service personnel records, and a copy of his record of service (DD- 214) should be forwarded to USASCRUR. 2. If and only if, after completing the above actions, the record contains evidence of a verified stressor, including a stressor during combat, the veteran should be examined by a panel of two VA board certified psychiatrists, to determine the nature and extent of any current psychiatric disorder. If there are different psychiatric disorders, the panel should reconcile the diagnoses and should specify which symptoms are associated with each disorder. If certain symptomatology cannot be disassociated from one disorder or another, it should be specified. The entire claims folder, and a copy of this REMAND must be made available to and reviewed by the examiners prior to the examinations. The examiners are informed that any diagnosis reached should conform to the psychiatric nomenclature and diagnostic criteria contained in DSM-IV. If the veteran is found to have PTSD, the examiners are requested to identify the diagnostic criteria supporting the diagnosis. Any necessary special studies or tests, including psychological testing, should be accomplished. The examiners should express an opinion as to the etiology of any psychiatric disorder diagnosed, and the likely onset of any psychiatric disorders found. Should PTSD be found, the examiners should report the circumstances of the veteran's independently verified stressors, and determine whether it is at least as likely as not that the diagnosed PTSD is related to service. Only those stressors which have been independently verified may be used as a basis for establishing PTSD as related to service. A complete rationale for all opinions and conclusions expressed should be given. 3. If applicable, after the examinations have been completed, the RO should review the examination reports to ensure that they comply with the directives of this REMAND. Any examination report failing to comply with the directives of this REMAND should be returned for any necessary action. 4. The RO should then adjudicate the veteran's claim for service connection for PTSD. If the benefit sought is not granted, the veteran and his representative should then be afforded an opportunity to respond before the case is returned to the Board for further action. The purpose of this REMAND is to obtain additional information and development, and to ensure that all due process requirements have been met. The Board does not intimate any opinion as to the merits of the case, either favorable or unfavorable, at this time. The veteran is free to submit any additional evidence he desires to have considered in connection with his current appeal. See Kutscherousky v. West, 12 Vet. App. 369 (1999). No action is required of the veteran until he is notified. MILO H. HAWLEY Acting Member, Board of Veterans' Appeals