POSTTRAUMATIC STRESS DISORDER (PTSD)

Summary

The Veteran, an Army Veteran who served from March 1969 to October 1971, including service in Vietnam, appeals the denial of service connection for PTSD. The Veteran also had a period of service from January 1975 to September 1975. The Board reviewed evidence of record up to a February 2021 rating decision, noting that any evidence submitted after a November 2025 hearing or more than 90 days after was not considered. The Veteran initially claimed PTSD, but the Board considered all diagnosed acquired psychiatric conditions per Clemons v. Shinseki. The Veteran's prior attorney was revoked, and a new representative was appointed, but the Board proceeded as the decision was a full grant. The Board found the Veteran's fear of hostile military activity during Vietnam service to be a conceded stressor. Conflicting medical evidence existed: VA records from 2017 suggested PTSD, while recent records noted depression and anxiety without a chronic psychiatric diagnosis. A November 2020 VA examination did not meet PTSD criteria but diagnosed an unspecified trauma and stressor related disorder, finding it related to Vietnam service. A private opinion from an LSW in October 2025 diagnosed PTSD, depression, and anxiety related to service, but the Board questioned the LSW's qualification to diagnose PTSD. However, the Board found the VA examiner's opinion, which diagnosed an unspecified trauma and stressor related disorder and linked it to service, to be highly probative. Resolving doubt in the Veteran's favor, the Board granted service connection for an unspecified trauma and stressor related disorder.

Rationale

Conceded Vietnam stressor; VA examiner diagnosed unspecified trauma and stressor related disorder; VA examiner found disorder related to Vietnam service; Benefit of doubt resolved in Veteran's favor

Full Decision Text

Citation Nr: A26017425
Decision Date: 02/26/26	Archive Date: 02/26/26

DOCKET NO. 210415-153220
DATE: February 26, 2026

ORDER

Entitlement to service connection for unspecified trauma and stressor related disorder is granted.

FINDING OF FACT

Resolving reasonable doubt in his favor, the Veteran has been diagnosed with an unspecified trauma and stressor related disorder due to his in-service stressor of fear of hostile military or terrorist activity during his service in Vietnam.

CONCLUSION OF LAW

The criteria for service connection for an unspecified trauma and stressor related disorder are met.  38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 4.125.

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran served on active duty from March 1969 to October 1971, including service in Vietnam; and reportedly also served from January 1975 to September 1975.

This matter comes on appeal from a February 2021 rating decision, which denied service connection for posttraumatic stress disorder (PTSD).  In the April 2021 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Hearing docket.  A Board hearing was held on November 5, 2025 before the undersigned.  Therefore, the Board may only consider the evidence of record at the time of the February 2021 agency of original jurisdiction (AOJ) decision on appeal, as well as any evidence submitted by the Veteran or his representative at the hearing or within 90 days following the hearing.  38 C.F.R. § 20.302(a).  If evidence was submitted either (1) during the period after the AOJ issued the decision on appeal and prior to the Board hearing, or (2) more than 90 days following the hearing, the Board did not consider it in its decision.  38 C.F.R. §§ 20.300, 20.302(a), 20.801. 

If the Veteran would like VA to consider any evidence that was submitted that the Board could not consider, the Veteran may file a Supplemental Claim (VA Form 20-0995) and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claim, considering the new evidence in addition to the evidence previously considered.  Id.  Specific instructions for filing a Supplemental Claim are included with this decision.

At the outset, the Board notes the Veteran previously contended that he suffers from PTSD, which was the only diagnosis and disorder noted in the rating decision and VA Form 10182.  In light of Clemons, however, the Board has considered all of the Veteran's diagnosed acquired psychiatric conditions in relation to his service connection claim.  Clemons v. Shinseki, 23 Vet. App. 1, 4-5 (2009) (recognizing that the Secretary "has no duty to read the mind of the claimant" but should "construe a claim based on the reasonable expectations of the non-expert, self-represented claimant and the evidence developed in processing that claim).

Prior to the Board hearing, the Veteran revoked representation by his previous private attorney.  Subsequently, he appointed his current representative.  The Board acknowledges that his current representative has not been given the opportunity to submit evidence or argument on behalf of the Veteran.  However, as the decision herein is a full grant of the benefit sought on appeal, the Board finds that there is no prejudice to the Veteran in proceeding with this decision.  

Entitlement to service connection for PTSD.

The Veteran has asserted that his PTSD and other psychiatric disorders are due to his service in Vietnam.

For purposes of this analysis, the Board notes that service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a) (i.e., in accordance with DSM-V; 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.  38 C.F.R. § 3.304(f).

Further, if a stressor claimed by a Veteran is related to the Veteran's fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of PTSD and that the Veteran's symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the
 C.F.R. § 4.125(a) (i.e., in accordance with DSM-V; 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.  38 C.F.R. § 3.304(f).

Further, if a stressor claimed by a Veteran is related to the Veteran's fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of PTSD and that the Veteran's symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of the Veteran's service, the Veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor.

For diagnoses other than PTSD, entitlement to benefits may be found through direct service connection by establishing: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service," also known as the nexus element.  Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004).

The AOJ made the favorable finding that a fear-based stressor has been conceded based on the Veteran's service in Vietnam.  This finding is binding on the Board.  As such, the question is whether the Veteran has been diagnosed with a psychiatric disorder, including PTSD, based on his conceded inservice stressor.  

Based on the evidence of record and when resolving the benefit of the doubt in favor of the Veteran, the Board concludes that the Veteran has been diagnosed with PTSD due to his service in Vietnam.  38 U.S.C. §§ 1110, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a).

In this regard, the Board is faced with conflicting medical evidence as to whether the Veteran has a psychiatric disorder related to such stressor.  VA clinical records from 2017 appear to indicate that the Veteran was diagnosed with PTSD.  However, recent clinical records while noting depression and anxiety at times do not appear to show a chronic psychiatric diagnosis.  

The Veteran was afforded a VA examination in November 2020, wherein the examiner found that the Veteran did not meet the diagnostic criteria for PTSD. Nevertheless, the Veteran was diagnosed with unspecified trauma and stressor related disorder.  The examiner opined that descriptions by Veteran including information provided in records indicate that his issues are associated with his Vietnam combat experience.  

In contrast, the Veteran submitted an October 2025 private opinion within the evidentiary window, which stated that the Veteran has been diagnosed with PTSD.  The opinion, submitted by a licensed social worker (LSW) and the Veteran's therapist, provided that the Veteran is their patient and has been under their care.  The examiner continued that they are very familiar with the Veteran's history and opined that the Veteran suffers from depression, anxiety, and severe PTSD specifically related to his military service in the Army during the war.   

As noted by the Court of Appeals for Veterans Claims, "[a] clear (that is, unequivocal) PTSD diagnosis by a mental-health professional must be presumed (unless evidence shows to the contrary) to have been made in accordance with the applicable DSM criteria as to both the adequacy of the symptomatology and the sufficiency of the stressor." Cohen v. Brown, 10 Vet. App. 128, 140 (1997). The evidence does not presently indicate, though, that the private LSW is a mental health professional qualified to provide such a diagnosis. While social workers are generally competent to provide mental health treatment, such as therapy services, they do not possess the requisite education, training, or experience to provide medical, including mental health, diagnoses. See 38 C.F.R. § 3.159(a)(1) (explaining that competent medical evidence is "evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions"). The opinion does not indicate that the diagnosis was made by a separate provider, who would be considered a qualified mental health professional in this instance.

The Board recognizes its duty to assist in obtaining clarification of an examination report that reasonably appears to contain information necessary to decide a claim. See Savage v. Shinseki, 24 Vet. App. 259, 270 (2011). However here, the Board is granting service connection for an unspecified trauma and
 medical, including mental health, diagnoses. See 38 C.F.R. § 3.159(a)(1) (explaining that competent medical evidence is "evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions"). The opinion does not indicate that the diagnosis was made by a separate provider, who would be considered a qualified mental health professional in this instance.

The Board recognizes its duty to assist in obtaining clarification of an examination report that reasonably appears to contain information necessary to decide a claim. See Savage v. Shinseki, 24 Vet. App. 259, 270 (2011). However here, the Board is granting service connection for an unspecified trauma and stressor related disorder, which encompasses his other reported diagnoses, and importantly, all the symptoms and resulting impairment. Thus, there is no benefit to the Veteran in remanding for a clarifying opinion. See e.g., Amberman v. Shinseki, 570 F.3d 1377, 1381 (Fed. Cir. 2009); Dollison v. Wilkie, 750 F. App'x 986, 989 (Fed. Cir. 2018) (Veteran failed to establish standing to appeal a Board decision that denied benefits for PTSD and granted benefits for MDD because he had not established that diagnoses had different manifestations).

The VA examiner was familiar with the Veteran's service in Vietnam, diagnosed an unspecified trauma and stressor related disorder due to his presenting symptomatology, and found this diagnosed psychiatric disorder was related to his service in Vietnam.  The examiner's opinion was based on a review of the record, including an extensive evaluation, and provided enough rationale for the Board to understand the conclusion.  Therefore, the Board finds it highly probative.  Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008).

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?

Accordingly, the evidence persuasively weighs in favor of finding he has been diagnosed with an unspecified trauma and stressor related disorder due to his service in Vietnam.  Accordingly, service connection for an unspecified trauma and stressor related disorder is granted.

 

 

J.M. ESTES

Acting Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	J.N. Moats, Counsel 

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.