BVA9501884 DOCKET NO. 92-18 100 ) DATE ) ) On appeal from a decision by the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUE Entitlement to service connection for post-traumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Keith W. Allen, Associate Counsel INTRODUCTION The veteran served on active duty from November 1966 to September 1970. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a May 1992 decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee, which denied the veteran's claim for service connection for PTSD. The Board remanded the case in November 1993 for additional development, and the case was returned to the Board in September 1994. The RO has previously denied a permanent and total disability rating for non-service-connected pension purposes. The veteran's August 1994 statements, on VA Form 9, imply he may again be claiming pension benefits based on multiple medical problems. A question of possible entitlement to pension benefits is not before the Board at this time, and the matter is referred to the RO for appropriate action. CONTENTIONS OF APPELLANT ON APPEAL The veteran contends he has PTSD primarily as a result of stressful events he experienced while in combat in Vietnam. He and his representative assert that PTSD related to service has been adequately diagnosed. 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 service connection for PTSD. FINDING OF FACT There is no clear medical diagnosis of PTSD, and the evidence establishes that the veteran does not have this disorder. CONCLUSION OF LAW PTSD was not incurred in or aggravated by active service. 38 U.S.C.A. § 1110 (West 1991); 38 C.F.R. §§ 3.303, 3.304 (1993). REASONS AND BASES FOR FINDING AND CONCLUSION I. Factual Background The veteran served on active duty in the Marine Corps from November 1966 to September 1970. During his period of active service, he had a tour of duty in the Republic of Vietnam from July 1968 to July 1969. At a July 1968 general medical examination, shortly after arriving in Vietnam, the psychiatric system was clinically normal. On an accompanying medical history form, the veteran checked blocks to indicate a history of nervous trouble, frequent trouble sleeping, and nightmares. After returning from overseas, he requested to see a psychiatrist at sick call in October 1969. When examined, it was noted there was a questionable passive aggressive personality and there was no sign of mental or emotional illness. At his August 1970 separation examination, the psychiatric system was clinically normal. The veteran's service personnel records show various military infractions and related disciplinary actions. For example, from March to June 1968, prior to going to Vietnam, he had 104 days of lost time associated with being AWOL and confined; and from April to July 1970, after his Vietnam service, he had 97 days of lost time due to being AWOL. His service personnel records show that he was awarded various decorations, including the Combat Action Ribbon for his Vietnam service. His military occupational specialty was engineer equipment operator. There are numerous hospital, domiciliary, and outpatient medical records on file, dated in and after January 1991, showing extensive treatment that the veteran received for drug and alcohol abuse, human immunodeficiency virus (HIV), and hepatitis and other physical ailments. He was also treated during this time for depression associated with difficulty dealing with these disorders. On file is a May 1991 psychological evaluation from Holston Counseling Services. The veteran's symptoms focused on his HIV infection and fear of acquired immune deficiency syndrome (AIDS). A number of psychological test results were deemed invalid due to exaggeration of symptoms. Diagnoses were alcohol abuse, polysub- stance dependence, major depression, and a personality disorder. PTSD was not diagnosed. In August 1991, during an admission to a VA medical center, primarily involving treatment for substance abuse, probable PTSD was diagnosed. It was noted that the veteran had related a history of symptoms, suggestive of PTSD, such as nightmares, flashbacks, emotional isolation, and periods of extreme fear, triggered by recounts of his Vietnam experiences. He acknowledged that he had been consumed by his HIV status. He was encouraged to seek follow-up treatment for PTSD from the VA domiciliary psychiatric staff after his discharge from the hospital, and this was planned. The veteran claimed service connection for PTSD later in August 1991, reporting that he was currently enrolled in a PTSD program at a Vet Center. In subsequent statements, he identified several stressors which he claims he experienced while stationed in Vietnam during the war. They included witnessing the killing of soldiers and civilians and being subjected to numerous rocket and mortar attacks by the enemy. He said that, since service, he had a variety of PTSD-related symptoms. In October 1991, the veteran was evaluated by a VA psychologist for possible participation in a PTSD treatment program. After clinical evaluation, the examiner commented that the veteran presented with some markers of PTSD, such as nightmares, easily stimulated reminiscences, and reported hypervigilance. However, other symptoms had not been demonstrated, such as intrusive thoughts or intense flashbacks. The psychologist commented that the veteran could be considered to have a marginal case of PTSD. He said of greater clinical significance were the non-PTSD sequelae of war stress and substance abuse. The veteran's Vietnam service was considered by the examiner to have been a life-disrupting event, from which he had never recovered. It was commented that the veteran should continue with his existing treatment, but that the PTSD program had nothing more to offer his treatment plan. At a March 1992 VA psychiatric examination, the veteran reported that he had last worked in late 1990 and that he had been fired from many jobs because of his violent behavior and on-the-job drunkenness. He mentioned his combat experiences in Vietnam, a psychiatric examination that he had while still in service, and PTSD-type symptoms that he often experienced. Also noted was the effect that drug and alcohol abuse had had on his life, and his HIV positive status. It was noted that the veteran had already had a thorough special evaluation by a VA PTSD treatment team. This disorder was not included in the diagnoses made on the current examination. Those diagnoses included recurrent major depression; episodic alcohol dependence and abuse; history of polysubstance abuse, in remission; and a personality disorder. In April 1994 the veteran was given a VA compensation examination by two psychiatrists to determine if he had PTSD. The examiners reviewed the veteran's pre-service, service, and post-service history. It was noted the veteran was recently released from prison after serving a year for habitual traffic offenses and driving under the influence. Following examination, neither doctor diagnosed PTSD. One psychiatrist diagnosed polysubstance abuse and chronic dysthymia with occasional major depression; it was also noted he had stressors from substance abuse and HIV/AIDS-related complex. The other psychiatrist diagnosed recurrent major depression, a history of alcohol and polysubstance abuse, and a personality disorder; HIV positive status was also noted. Later in April 1994, the veteran was given a psychological evaluation by Holston Psychological Services. The report, which is signed by a psychological intern and a clinical psychologist, indicates that the veteran was being evaluated as a condition of parole, and that he was paroled in February 1994 after serving one year of a four year sentence related to habitual drunk driving and possession of marijuana. The veteran gave a history which included alcohol and drug abuse, being HIV positive, and having to take care of his disabled parents. He also reported depression, nightmares, and other difficulties associated with his tour of duty in Vietnam. Psychological testing suggested clinical depression. Diagnostic impressions included PTSD, dysthymia, alcohol dependence, cocaine dependence in remission, and a personality disorder. It was commented, in part, that the veteran had been suffering from PTSD and depression for quite some time, and he seemed to be clinically depressed and had significant stress related to his HIV illness, frequent PTSD symptoms, and the added responsibilities of having to take care of his parents. It was reported in a May 1994 statement from Angelina Walsh, B.S., of Project H.O.P.E., that she had never met the veteran but had reviewed June 1991 treatment records at the facility which revealed that PTSD (as well as polysubstance dependence and a personality disorder) had been diagnosed. There are lay statements on file, dated in 1991 and 1994, from friends and relatives of the veteran. These are to the effect that the veteran was well adjusted before service, and developed psychiatric problems as the result of his Vietnam war experiences. In July 1994, the two psychiatrists who performed the April 1994 VA compensation examination reviewed the veteran's records, and both doctors stated that the veteran did not have PTSD. II. Legal Analysis The veteran's claim is well-grounded within the meaning of 38 U.S.C.A. § 5107(a). That is, he has presented a claim which is not inherently implausible. All relevant facts have been properly developed and, therefore, the VA's statutory duty to assist him in developing evidence pertinent to his claim has been satisfied. Id. Service connection may be granted for a disability resulting from a disease or injury that was incurred in or aggravated by service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Service connection for PTSD requires medical evidence establishing a clear diagnosis of the condition, credible supporting evidence that the claimed in-service stressor actually occurred, and a link, established by medical evidence, between current symptomatology and the claimed in-service stressor. If a claimed stressor is related to combat, service department evidence that the veteran engaged in combat or that he was awarded the Purple Heart, Combat Infantryman Badge or similar combat citation will be accepted, in the absence of evidence to the contrary, as conclusive evidence of the claimed service stressor. 38 C.F.R. § 3.304(f). As a result of his service in Vietnam, the veteran was awarded the Combat Action Ribbon, which indicates combat service; he claims stressors related to combat; and, pursuant to 38 C.F.R. § 3.304(f), a valid service stressor which might lead to PTSD is accepted. However, more than an injury (or stressor) during service is required for service connection; a related disability must be currently shown. See Rabideau v. Derwinski, 2 Vet.App. 141 (1992). In this regard, 38 C.F.R. § 3.304(f) expressly requires a clear diagnosis of PTSD in order for service connection to be established. It is on this legal requirement that this case turns. The Board specifically remanded the case to develop the evidence on this matter. The Board notes that statements by the veteran and his friends and relatives, asserting a diagnosis of PTSD, are of no evidentiary value on this point since, as laymen, they have no competence to make a medical diagnosis. Espiritu v. Derwinski, 2 Vet.App. 492 (1992). There is, however, at least some medical evidence of a diagnosis of PTSD. PTSD was reportedly one of multiple diagnoses which were made when the veteran was treated by Project H.O.P.E. in June 1991, although the basis of that diagnosis is not clearly shown (the record diagnosis was reported in May 1994 by a therapist who had never met the veteran). During an August 1991 VA hospitalization, primarily for treatment of substance abuse, "probable" PTSD was among the diagnoses; and an October 1991 VA psychological evaluation assessed the veteran as having a "marginal" case of PTSD. An April 1994 psychological evaluation, as a condition of recent parole from prison, performed by a psychological intern and a clinical psychologist at Holston Psychological Services, led to several diagnostic impressions, including PTSD; but the strength of this evidence is diminished as it appears to be based on incomplete records and a reliance on the veteran's own stated history of having PTSD, rather than on objective medical findings. See Reonal v. Brown, 5 Vet.App. 458 (1992). Evidence against a clear diagnosis of PTSD includes numerous medical treatment records since 1991 which contain diagnoses of various psychiatric disorders and substance abuse, but no diagnosis of PTSD. Similarly, a March 1992 VA compen-sation examination diagnosed psychiatric and behavioral disorders other than PTSD. The Board finds the most persuasive evidence in this case, as to the presence or absence of a PTSD diagnosis, to be the April 1994 VA psychiatric examination by two psychiatrists, and their further review in July 1994 after evidence favorable to the veteran was added to the record. The two psychiatrists clearly found the veteran did not have PTSD. The Board finds this assessment to be particularly probative as it was based on thorough examinations by specialized physicians (psychiatrists) who reviewed the veteran's historical records. See Green v. Derwinski, 1 Vet.App. 121 (1991). Such evidence against a diagnosis of PTSD outweighs that which favors the diagnosis. See Burger v. Brown, 5 Vet.App. 340 (1993). In the judgment of the Board, the evidence preponderates against a diagnosis of PTSD, and an essential element for service connection for that disorder is lacking. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine does not apply, and service connection must be denied. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet.App. 49 (1990). If, in the future, the veteran obtains a clear medical diagnosis of PTSD, he may apply to reopen his claim based on new and material evidence. 38 U.S.C.A. § 5108. ORDER Service connection for PTSD is denied. L. W. TOBIN 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.