POSTTRAUMATIC STRESS DISORDER (PTSD)

Summary

The Veteran, who served on active duty from May 1993 to August 1998, is the subject of this appeal following his death in April 2016, with his surviving spouse substituted as Appellant. The Veteran sought service connection for an acquired psychiatric disability, specifically PTSD and depression, claiming it was caused by his service. The Veteran's service treatment records did not initially document a psychiatric condition. However, later VA treatment records from September 2015 noted diagnoses of PTSD and depression, with a clinician identifying a 1996 incident involving almost falling overboard in rough seas on the USS Lake Erie as a potential index trauma. Private treatment records from January 2016 diagnosed depression but did not note PTSD. The Board remanded the claim twice to corroborate the in-service stressor, but the agency of original jurisdiction determined the stressor was uncorroboratable as it was an "almost happened" event. Despite the unverified stressor, the Board found the evidence in approximate balance regarding the Veteran's acquired psychiatric disability and its relation to service, noting the presumptive PTSD diagnosis from the PCL-5 screening and the depression diagnosis. Applying the benefit of the doubt, service connection for an acquired psychiatric disability was granted.

Rationale

Evidence in approximate balance regarding acquired psychiatric disability and service connection; Benefit of the doubt applied to grant service connection; Presumptive PTSD diagnosis noted from PCL-5 screening

Full Decision Text

Citation Nr: 25005802
Decision Date: 04/29/25	Archive Date: 04/29/25

DOCKET NO. 19-22 628
DATE: April 29, 2025

ORDER

Entitlement to service connection for an acquired psychiatric disability, claimed as posttraumatic stress disorder (PTSD), is granted.

FINDING OF FACT

Resolving reasonable doubt in favor of the Veteran's, his acquired psychiatric disability was incurred in or caused by his active service. 

CONCLUSION OF LAW

The criteria for entitlement to service connection for an acquired psychiatric disability have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303.

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran served on active duty from May 1993 to August 1998. 

Unfortunately, the Veteran died in April 2016. The Veteran's surviving spouse has been properly substituted as the Appellant. 

This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2015 rating decision. In February 2021, the Appellant testified at a Board hearing before the undersigned Veterans Law Judge. A transcript of that hearing is of record.

The claim was most recently before the Board in May 2023, when it was remanded for additional development. The Board is satisfied that there has been substantial compliance with the May 2023 remand directives and the Board may proceed with adjudication. Stegall v. West, 11 Vet. App. 268 (1998).

Entitlement to service connection for an acquired psychiatric disability, to include depression.

The Appellant contends that the Veteran had an acquired psychiatric disability, claimed as PTSD, that was caused by his service. Specifically, the Appellant testified the Veteran was a severe alcoholic with a bad temper who spoke with a psychiatric specialist about his PTSD during a period of hospitalization for addiction. See February 2021 Hearing Transcript. 

Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004).

There are particular requirements for establishing service connection for PTSD in 38 C.F.R. § 3.304 (f), that are separate from those for establishing service connection generally. Arzio v. Shinseki, 602 F.3d 1343 (Fed. Cir. 2010). Service connection for PTSD requires: (1) medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125 (a), i.e., a diagnosis conforming to specified diagnostic criteria (currently the DSM-5, previously the DSM-IV); (2) credible supporting evidence that the claimed in-service stressor actually occurred; and (3) medical evidence of a link, or causal nexus, between current symptomatology and the claimed in-service stressor. 38 C.F.R. § 3.304 (f).

In an August 2012 VA Form 21-526EZ, Fully Developed Claim, the Veteran requested service connection for "PTSD/Depression." The Veteran's service treatment records (STRs) do not include a diagnosis of a psychiatric condition, or treatment thereof. In September 2015, VA ask that the Veteran submit information regarding the specific details of the stressful incident(s) in service that resulted in PTSD. VA provided the Veteran with a PTSD questionnaire. The Veteran did not complete the questionnaire prior to his death in April 2016. 

September 2014 VA treatment records note the Veteran was administered the PCL-5; a 20-item self-report screening measure that assesses PTSD symptoms consistent with the DSM-5. During the screening, the Veteran identified a 1996 index trauma where he almost fell overboard in rough water while serving on the USS Lake Erie. The record notes a presumptive PTSD diagnosis per DSM diagnostic rules.

VA treatment records from September 2015 note diagnoses of PTSD and unspecified depressive disorder. An October 2015 VA mental health record indicated the Veteran had traumatic intrusive nightmares about holding onto a bridge extension that swung over rough seas while his boat was listing. Private treatment records from January 2016 did not note a PTSD diagnosis, but
6. 

September 2014 VA treatment records note the Veteran was administered the PCL-5; a 20-item self-report screening measure that assesses PTSD symptoms consistent with the DSM-5. During the screening, the Veteran identified a 1996 index trauma where he almost fell overboard in rough water while serving on the USS Lake Erie. The record notes a presumptive PTSD diagnosis per DSM diagnostic rules.

VA treatment records from September 2015 note diagnoses of PTSD and unspecified depressive disorder. An October 2015 VA mental health record indicated the Veteran had traumatic intrusive nightmares about holding onto a bridge extension that swung over rough seas while his boat was listing. Private treatment records from January 2016 did not note a PTSD diagnosis, but did endorse a diagnosis of depression. 

In the February 2021 Board hearing, the Appellant testified that the Veteran was a severe alcoholic with a bad temper. See February 2021 Hearing Transcript. The Appellant noted the Veteran never completed the VA questionnaire regarding his stressor, but asserted the Veteran met with a PTSD specialist during inpatient treatment in February 2016. However, the Veteran died shortly thereafter, in April 2016. 

In April 2022 and May 2023 decisions, the Board remanded the claim to attempt to corroborate the Veteran's in-service stressors, including almost falling off the USS Lake Erie into the water in 1996, as noted in the September 2015 VA treatment record. The agency of original jurisdiction (AOJ) was advised to document all attempts in the record and note if it was not possible to corroborate the stressor based on the available information. 

January 2024 email correspondence indicated stressor verification could not be completed, as the stressor is an "almost happened" and should not have been submitted for research. In an April 2024 Supplemental Statement of the Case (SSOC) the AOJ indicated that some stressors are clearly impossibly to verify and should not be referred to the Military Records Research Center (MRRC). Specifically, the AOJ noted they are unable to verify stressors for events that almost happened. 

Based on the foregoing, the Board finds the evidence is in approximate balance as to whether the Veteran had an acquired psychiatric disorder, to include PTSD and depression, that was caused by his military service. September 2014 VA treatment records noted the Veteran was administered the PCL-5, which resulted in a presumptive PTSD diagnosis per the DSM-5. The clinician identified a 1996 incident where the Veteran almost fell off ship in rough water while serving on the USS Lake Erie as the index trauma. Several VA treatment records note diagnoses of PTSD and depression. An October 2015 VA mental health record indicated the Veteran had traumatic intrusive nightmares about holding onto a bridge extension that swung over rough seas while his boat was listing. 

The Board acknowledges that the in-service stressor of the 1996 incident cannot be verified. However, an in-service stressor that is verified by credible supporting evidence is only required in a claim for PTSD. 38 C.F.R. § 3.304 (f). The Veteran's claim had previously been recharacterized as a claim for entitlement to service connection for an acquired psychiatric disability, and the record supports an additional psychiatric diagnosis of depression. Though a VA medical opinion has not been rendered regarding the etiology of the Veteran's acquired psychiatric disability, the Board finds no need to remand this matter, as the Veteran is deceased, and no additional evidence is available for review. 

The Board finds the evidence is in approximate balance as to whether the Veteran's acquired psychiatric disability was related to service. Accordingly, and resolving all reasonable doubt in favor of the Veteran, entitlement to service connection for an acquired psychiatric disability is granted. 38 U.S.C. § 510; 38 C.F.R. § 3.102; Lynch v. McDonough, 21 F.4th 776, 782 (Fed. Cir. 2021). 

 

M.E. Larkin

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	R. Buchanan, Attorney Advisor

The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.