Citation Nr: 0007268 Decision Date: 03/17/00 Archive Date: 03/23/00 DOCKET NO. 95-05 730A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUE Entitlement to service connection for post-traumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Milo H. Hawley, Counsel INTRODUCTION The veteran had active honorable service from October 1967 to October 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 1994 decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio. The veteran also had active service from January 1970 to February 1971. A June 1971 administrative decision determined that the veteran's discharge from this period of service was under dishonorable conditions and the veteran was not entitled to VA benefits as a result thereof. A February 1996 RO decision denied the veteran's claim for a permanent and total disability rating for pension purposes. In October 1998 the veteran submitted a net worth and employment statement that the Board construes as a claim for nonservice-connected pension. The issue of entitlement to a permanent and total disability rating for pension purposes is referred to the RO for its consideration. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of the veteran's appeal has been obtained. 2. The veteran does not currently have PTSD that is related to his active service. CONCLUSION OF LAW PTSD was not incurred during the veteran's active service. 38 U.S.C.A. §§ 1110, 1154(b), 5107 (West 1991); 38 C.F.R. § 3.304(f) (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSION The veteran has claimed entitlement to service connection for PTSD. As a preliminary matter, the Board finds that his claim is "well grounded" within the meaning of 38 U.S.C.A. § 5107(a). A well-grounded service connection claim 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 inservice stressor, which in a PTSD case is the equivalent of inservice incurrence or aggravation; and [3] medical evidence of a nexus between service and the current PTSD disability." Cohen v. Brown, 10 Vet. App. 128, 137 (1997). The record reflects that a November 1993 VA medical record, relating to the veteran's treatment plan, reflects diagnoses including PTSD related to the veteran's Vietnam service in military intelligence and perimeter security. The veteran has reported that he was involved in perimeter security while in Vietnam during his first period of active service and that he was also involved in military intelligence. His reports are presumed credible for purposes of this decision. Therefore, the Board concludes that there is competent medical evidence that the veteran has been diagnosed with PTSD and there is competent medical evidence that relates his PTSD to events he has reported occurred while he was in Vietnam. The Board is satisfied that all relevant facts have been properly and sufficiently developed. Treatment records have been obtained and the veteran has been afforded multiple VA examinations. In a May 1999 statement the veteran indicated that he desired to withdraw his request for all personal hearings. In view of the above, the Board finds that no further action by VA is required to comply with the duty to assist under 38 U.S.C.A. § 5107(a). The report of a January 1982 VA neuropsychiatric examination reflects diagnoses including aggressive, dependent personality. A diagnosis of PTSD was not offered. Because the report does not indicate that the examiner had access to the veteran's record, this evidence will be accorded medium probative weight. An August 1993 VA medical record relating to a treatment program the veteran was participating in reflects that the veteran reported a long and convoluted history of neglect and child abuse, including witnessing his mother's murder as well as witnessing brutality in Vietnam. It reflects that the veteran experienced startle response, nightmares, and hypervigilance and indicates a diagnosis of PTSD due to childhood and Vietnam. A November 1993 VA treatment record reflects diagnoses including PTSD relating to Vietnam service in military intelligence and perimeter security and childhood trauma. The August and November 1993 treatment records will be accorded medium probative weight because while they reflect ongoing treatment of the veteran, they do not indicate that they were based on a review of the veteran's complete records. VA treatment records, dated in 1995, including a hospital discharge summary relating to a period of hospitalization in November and December, do not reflect any diagnosis of PTSD. These records will be afforded medium probative weight because they do not reflect that all of the veteran's records were considered. The reports of March 1998 VA psychiatric and psychological evaluations reflect that the veteran's claims file was reviewed extensively. Further, the veteran was afforded psychological testing. The psychiatric examiner, after extensive review and evaluation, concluded that the veteran did not have PTSD because he did not endorse an adequate number of symptoms as outlined in the Diagnostic and Statistical Manual (DSM-IV) for the diagnosis of PTSD. The psychological evaluation concluded that the veteran had an element of PTSD that existed prior to his service and was due to his childhood experiences, but was not due to any experience during active service and was not aggravated during any experience in active service. The final conclusion by the psychological evaluator was that psychological testing did not support a diagnosis of PTSD related to the veteran's experience in Vietnam. The March 1998 evaluations by the psychiatrist and psychologist will be accorded large probative weight because they reflect extensive review of the entire history relating to the veteran's care as well as service and because they were based upon psychological testing as well as extensive and complete evaluation of his history and current presentation. On the basis of the above analysis there is competent medical evidence that has been accorded medium probative weight that does not indicate any findings that the veteran had PTSD in 1982 or 1995, that he was initially diagnosed with PTSD in 1993 and his PTSD was related, at that time, to his service in Vietnam as well as his childhood experiences. There is competent medical evidence that has been accorded large probative weight that concludes either that the veteran does not currently experience PTSD, or that the PTSD that he experiences is related solely to his childhood experiences and was neither incurred in nor aggravated by his service in Vietnam. In light of the comparison of the various weights assigned to the competent medical evidence addressing whether or not the veteran has PTSD that is related to his service in Vietnam, a preponderance of the evidence is against a finding that the veteran currently has PTSD that is related to his service in Vietnam. In reaching this conclusion, the Board has presumed that the stressors reported by the veteran did occur, but since a preponderance of the evidence is against a finding that the veteran has PTSD that is related to the stressors, further development or verification with respect to the reported stressors is unnecessary as their occurrence has been presumed for purposes of this decision. ORDER Service connection for PTSD is denied. U. R. POWELL Member, Board of Veterans' Appeals