Citation Nr: 0001460 Decision Date: 01/18/00 Archive Date: 01/27/00 DOCKET NO. 98-17 955 ) 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 ATTORNEY FOR THE BOARD L. Helinski, Associate Counsel INTRODUCTION The veteran had active military service from February 1979 to February 1982, and from May 1982 to November 1991. This matter comes before the Board of Veterans' Appeals (BVA or Board) on appeal from a November 1997 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio, which denied the benefit sought on appeal. The veteran also appealed the RO's August 1997 decision denying service connection for numbness of both hands, headaches, fatigue, short term memory loss, a chronic condition manifested by chest pains, gastroesophageal reflux disorder, a skin disorder, a chronic condition manifested by joint pain, and numbness of the legs. These issues were addressed in the Statement of the Case issued in June 1998. However, the veteran's Substantive Appeal was not received until October 1998, which perfected his appeal of the PTSD issue in a timely manner but was not timely as to the remaining nine issues. 38 C.F.R. §§ 20.200, 20.202 (1999). The veteran was so informed in a Supplemental Statement of the Case issued in January 1999, and he has not appealed the RO's decision that he did not file a timely Substantive Appeal to perfect the appeal of service connection for the multiple physical disabilities in question. Accordingly, the only issue in appellate status is service connection for PTSD. FINDING OF FACT The veteran did not engage in combat with the enemy but there is medical evidence of record that contains a diagnosis of PTSD, which has been medically related to the veteran's report of in-service, unverified stressors. CONCLUSION OF LAW The claim for service connection for PTSD is well grounded. 38 U.S.C.A. § 5107 (West 1991). REASONS AND BASES FOR FINDING AND CONCLUSION The Board finds that the veteran's claim is "well grounded" within the meaning of 38 U.S.C.A. § 5107(a). See Epps v. Gober, 126 F. 3d 1464, 1468 (1997); 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 implausible when his contentions and the evidence of record are viewed in a light most favorable to that claim. In this regard, the Board notes that a claim for PTSD is well grounded 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 PTSD case is the equivalent of in-service 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) (citations omitted). In the present case, the veteran contends that he currently has PTSD due to stressful experiences during his military service in the Persian Gulf, including a chemical threat, mortar attack, and a fall from a vehicle. The service personnel records show that he served in Southwest Asia during the Persian Gulf War. There is no indication that he received any medals or citations evincing combat. Medical evidence of record reflects that a January 1997 VA outpatient treatment record reflects a tentative diagnosis of PTSD. A March 1997 VA outpatient treatment record reflects a diagnosis of PTSD/anxiety or depressed mood. In a September 1997 VA outpatient treatment record, the veteran reported having nightmares and flashbacks of his service in Desert Storm. The diagnosis was PTSD and depression. In a January 1998 outpatient treatment record, the veteran was assessed with PTSD and depression. The veteran reported experiencing flashbacks of war. Service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a) [i.e., under the criteria of DSM-IV]; a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. If the evidence establishes that the veteran engaged in combat with the enemy and the claimed stressor is related to that combat, 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. 38 C.F.R. § 3.304(f) (revised June 18, 1999, effective March 7, 1997, 64 Fed. Reg. 32807 (1999)). The Board notes that as the veteran did not engage in combat, his statements are inadequate to prove the occurrence of a stressor in service; such a stressor must be established by official service records or other credible supporting evidence. 38 C.F.R. § 3.304(f); Cohen v. Brown, 10 Vet. App. 128 (1997); Doran v. Brown, 6 Vet. App. 283 (1994). The veteran claims that he has PTSD as the result of stressful incidents during his service in the Persian Gulf War. While the medical evidence is conflicting as the nature of the veteran's psychiatric disorder or disorders, there is medical evidence of PTSD. As such, the Board finds that the claim for service connection for PTSD is well grounded, within the meaning of 38 U.S.C.A. § 5107 and Cohen v. Brown, supra, and to that extent, the appeal is allowed. ORDER The claim for entitlement to service connection for PTSD is well grounded, and to that extent only the appeal is allowed. REMAND As the veteran's claim for service connection for PTSD is well grounded, the Board must ensure that the duty to assist is satisfied. In that regard, the Board notes that notwithstanding the PTSD diagnoses of record, those diagnoses were made in the absence of verified stressors of record. Consequently, none of the diagnoses of PTSD are based on verified stressors. The Board notes that in October 1997, the veteran submitted to the RO his responses to a PTSD questionnaire, regarding his claimed stressors. Additionally, the veteran attached a statement in which he describes stressful incidents during his service in the Persian Gulf. Despite the veteran's contentions and the PTSD diagnoses of record, it does not appear that the RO made any attempts to verify the veteran's claimed stressors. The Board finds that the RO should contact the United States Armed Services Center for Research of Unit Records (USASCRUR), to ascertain from that entity whether any corroborating information can be obtained regarding the stressors described by the veteran. In this regard, to the extent that is possible, the USASCRUR should be asked to comment on the veteran's duties in the Persian Gulf, given the information that is provided. All pertinent service personnel records and a summary of the veteran's description of his claimed stressors and duties during the periods of time in question must be forwarded to USASCRUR. The Board further notes that as there is no PTSD diagnosis of record that is based on corroborated stressors, once the RO completes all attempts to verify the veteran's claimed stressors, the veteran should be scheduled for another VA examination, to determine whether he currently has PTSD, due to a verified stressor(s). See Cohen, 10 Vet. App. at 140; West v. Brown, 7 Vet. App. 70, 77 (1994); Swann v. Brown, 5 Vet. App. 229, 233 (1993). Any current PTSD diagnosis must comply with the Fourth Edition of the Diagnostic and Statistical Manual of Mental Disorders, 1994 (DSM-IV), see 38 C.F.R. § 4.130 (1999), which reflects a subjective stressor standard. See Cohen, 10 Vet. App. at 139-144. In view of the foregoing, this case is REMANDED to the RO for the following: 1. The RO should review the veteran's claims file, including his service medical records and service personnel records, medical records, and any other statements from the veteran of record, and prepare a summary of all of the veteran's claimed stressors. This summary, a copy of the veteran's DD Form 214, and all associated service documents should be sent to the to the USASCRUR, with a request to provide any additional information that might corroborate the veteran's alleged stressors. The USASCRUR should also be requested to furnish the unit history for the unit the veteran was assigned to while in the Persian Gulf. The USASCRUR's review is requested to include a search for any incident reports pertaining to the events detailed by the veteran in his statements. Any information obtained should be associated with the claims folder. 2. Following the receipt of the USASCRUR's report, and the completion of any additional development warranted or suggested by that office, including notifying the veteran of the USASCRUR's response, the RO should prepare a report detailing the nature of any combat action, or in-service stressful event, verified by USASCRUR. This report is then to be added to the claims folder. 3. If the RO obtains verification of any of the veteran's claimed stressors, the RO should schedule the veteran for a VA psychiatric examination in order to determine the nature and extent of any current psychiatric disorders, including PTSD. The veteran is advised that failure to report for a scheduled VA examination may have adverse consequences, including the possible denial of his claim. Connolly v. Derwinski, 1 Vet. App. 566 (1991). The examiner must consider the Fourth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), which recommends the use of a multi-axial diagnosis and sets forth the criteria for diagnosing psychiatric disorders. All indicated studies, tests and evaluations deemed necessary should be performed, and these should include psychological testing, including PTSD sub scales. The RO must provide to the examiner the summary of verified stressors described above, and the examiner must be instructed that only these events may be considered for the purpose of determining whether exposure to an in-service stressor has resulted in the current psychiatric symptoms. If a diagnosis of PTSD is deemed appropriate, the examiner should explain how the diagnostic criteria of the DSM-IV are met, to include identification of the specific verified stressor(s) underlying the diagnosis, and comment upon the link between the current symptomatology and one or more of the in-service stressors found to be established by the RO. The report of the examination should include complete rationales for all opinions expressed. The claims file must be made available to the examiner. 4. Following the completion of the foregoing, the RO should review the claims file to ensure that all of the foregoing development has been completed in full. In particular, the RO should review the VA psychiatric examination report to verify that any diagnosis of PTSD was based on the verified history provided by the USASCRUR and/or the RO. If the examiner relied upon a history which is not verified, that examination report must be returned as inadequate for rating purposes. The Board emphasizes that the Court has held that a diagnosis of PTSD, related to service, based on an examination which relied upon an unverified history is inadequate. Cohen v. Brown, 10 Vet. App. 128, 140 (1997); West v. Brown, 7. Vet. App. 70, 77 (1994). 5. After completion of all actions outlined in this REMAND, the RO should readjudicate the veteran's claim for service connection for PTSD, in light of all pertinent evidence and all applicable laws, regulations, and case law (including Cohen v. Brown, supra). If the determination remains adverse to the veteran, he and his representative should be furnished with a supplemental statement of the case and be given the appropriate opportunity to respond before the case is returned to the Board. The purpose of this REMAND is to accomplish additional development, and to afford the veteran due process of law. The Board intimates no opinion, either favorable or unfavorable, as to the ultimate outcome of this case. The veteran is free to submit any additional evidence he desires to have considered in connection with his current appeal. No action is required of the veteran until he is notified by the RO. R. F. WILLIAMS Member, Board of Veterans' Appeals