POSTTRAUMATIC STRESS DISORDER (PTSD)

T. BERRY · 2026 · Case ID: A26034773

DENIED

Summary

The Veteran, who served from July 2008 to July 2012, appeals the denial of service connection for Posttraumatic Stress Disorder (PTSD). The Veteran had previously been granted service connection for schizophrenia spectrum and other psychotic disorder at a 100 percent rating. The Board reviewed the evidence, including three VA examinations conducted in August, September, and January of 2020-2021. Each VA examiner concluded that the Veteran did not meet the full diagnostic criteria for PTSD under the DSM-5, specifically noting deficiencies in Criterion D (mood/cognition) and Criterion E (hyperarousal). The Veteran's own statements and treatment records were considered, including a 2015 diagnosis of chronic PTSD by history, which was based on self-report for treatment purposes and not considered sufficient to establish a current DSM-5 diagnosis. The Board also considered the Veteran's report of being prescribed sertraline (Zoloft) during service, but found it was more likely than not for the existing schizophrenia spectrum disorder, not PTSD. The Board found the VA examinations adequate and probative, concluding that the preponderance of the evidence weighed against a current PTSD diagnosis. Therefore, the Board denied service connection for PTSD.

Rationale

No current DSM-5 diagnosis of PTSD established by medical evidence.; VA examiners found Veteran did not meet full diagnostic criteria for PTSD.; Evidence did not establish a link between current symptoms and in-service stressor.

Special Benefit

NO SPECIAL BENEFIT

Docket No.

210227-142607

Full Decision Text

Citation Nr: A26034773
Decision Date: 04/15/26 Archive Date: 04/15/26

DOCKET NO. 210227-142607
DATE: April 15, 2026

ORDER

Entitlement to service connection for posttraumatic stress disorder (PTSD) is denied.

FINDINGS OF FACT

The Veteran does not have a current diagnosis of PTSD conforming to the applicable Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) established by medical evidence.

CONCLUSIONS OF LAW

The criteria for entitlement to service connection for PTSD are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304(f), 4.125.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran had active service from July 2008 to July 2012.

This matter comes to the Board of Veterans' Appeals (Board) on appeal of a January 2021 decision by a Department of Veterans Affairs (VA) Regional Office (RO/AOJ). In February 2021, the Veteran filed a VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement (NOD)). The Veteran elected the Board Hearing docket.

The Veteran did not appear for a Board Hearing scheduled for February 27, 2025. As a result of the Veteran not filing a motion to reschedule a new hearing within 15 days (i.e., March 14, 2025), the Board may only consider the evidence of record at the time of the January 28, 2021 supplemental claim decision on appeal as well as any evidence submitted by the Veteran within 90 days following the scheduled February 27, 2025 hearing for which the Veteran did not appear (i.e., May 28, 2025). 38 C.F.R. §§ 20.302(b), 20.704(d). If evidence was submitted either (1) during the period after the supplemental claim decision and prior to the scheduled hearing, or (2) more than 90 days following the hearing scheduled for February 27, 2025, the Board did not consider it in its decision. 38 C.F.R. §§ 20.202(c)(1), 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. 38 C.F.R. § 3.2501. Specific instructions for filing a Supplemental Claim are included with this decision.

Entitlement to Service Connection for PTSD

The Veteran claims entitlement to service connection for PTSD only. See February 2021 VA Form 10182; November 2020 VA Form 20-0995.

Service connection for schizophrenia spectrum and psychotic disorder was granted and a 100 percent initial rating assigned in a November 2020 Rating Decision. The January 2021 Rating Decision on appeal continued that award of service connection for schizophrenia spectrum and psychotic disorder and the initial rating. The January 2021 Rating Decision also noted that the evidence did not show a PTSD diagnosis meeting all diagnostic criteria. The February 2021 VA Form 10182 specifically stated that the Veteran was seeking PTSD and did not indicate disagreement with either the effective date or initial ratings for the service connected schizophrenia spectrum and psychotic disorder. As such, the Board has characterized the issue on appeal as entitlement to service connection for PTSD pursuant to Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009).

Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a link between the claimed in-service disease or injury and the present disability. Romanowsky v. Shinseki, 26 Vet. App. 289, 293 (2013).

Service connection for PTSD, in particular, requires (1) medical evidence diagnosing PTSD conforming with the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), American Psychiatric Association (2013); (2) a link, established by medical evidence, between current symptoms and an in-service stressor, and (3) credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304
) in-service incurrence or aggravation of a disease or injury; and (3) a link between the claimed in-service disease or injury and the present disability. Romanowsky v. Shinseki, 26 Vet. App. 289, 293 (2013).

If a PTSD claim is based on in-service personal assault, evidence from sources other than service records may corroborate the stressor. Examples of such evidence include, but are not limited to: records from law enforcement authorities, rape crisis centers, mental health counseling centers, hospitals, or physicians; pregnancy tests or tests for sexually transmitted diseases; and statements from family members, roommates, fellow service members, or clergy. Evidence of behavior changes following the claimed assault is one type of relevant evidence that may be found in these sources. Examples of behavior changes that may constitute credible evidence of the stressor include, but are not limited to: a request for a transfer to another military duty assignment; deterioration in work performance; substance abuse; episodes of depression, panic attacks, or anxiety without an identifiable cause; or unexplained economic or social behavior changes. VA will not deny a PTSD claim that is based on in-service personal assault without first advising the claimant that evidence from sources other than service records or evidence of behavior changes may constitute credible supporting evidence of the stressor and allowing opportunity to furnish this type of evidence or advise VA of potential sources of such evidence. 38 C.F.R. § 3.304(f)(5).

In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge).

In rendering this decision, the Board has reviewed all evidence of record whether discussed in detail. See Newhouse v. Nicholson, 497 F.3d 1298, 1302 (Fed. Cir. 2007) (holding the Board must only discuss the evidence which is relevant to the issues on appeal). A Veteran is entitled to the benefit of the doubt when the evidence is in approximate balance or "nearly equal," and does not require that the evidence be in exact equipoise. Evidence is in approximate balance when the evidence in favor of and opposing the veteran's claim is found to be almost exactly or nearly equal. Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021).

Acquired psychiatric disorders are rated under the General Rating Formula for Mental Disorders at 38 C.F.R. § 4.130, which compensates Veterans for the functional impairment caused by all service-connected psychiatric disorders as opposed to individual diagnoses. A separate rating for the same overlapping impairment would constitute impermissible pyramiding of disability ratings and may not be assigned. 38 C.F.R. § 4.14. However, separate ratings for multiple psychiatric disabilities are warranted when they do not have overlapping symptomatology. Amberman v. Shinseki, 570 F.3d 1377 (Fed. Cir. 2009).

The Veteran underwent VA examinations for PTSD in August 2020, September 2020, and January 2021. Each examining VA psychologist determined that the Veteran did not meet full diagnostic criteria under the DSM-5 for current diagnosis of PTSD. Specifically, the Veteran's descriptions of her own symptoms during structured clinical interview did not meet Criterion D (negative mood/cognition) or Criterion E (hyperarousal).

The Board finds the examinations adequate and probative with regard to the presence or absence of a current diagnosis of PTSD. The examiners considered and discussed the Veteran's description and treatment for symptoms during service and currently, her reported and medical histories, and past examinations and psychiatric hospitalizations for diagnoses other than PTSD. Specifically, in August 2020, the Veteran's self-reported assessment score was well below the recommended threshold for diagnostic consideration of PTSD. In September 2020, the Veteran vehemently denied current symptoms such as could meet Criterion C. Upon VA examination in January 2021, the Veteran reported that her mood was "fine." The August 2020, September 2020, and January 2021 VA examiners provided thorough and detailed reasoning clearly connecting all current symptoms and impairment to an acquired psychiatric disorder other
or absence of a current diagnosis of PTSD. The examiners considered and discussed the Veteran's description and treatment for symptoms during service and currently, her reported and medical histories, and past examinations and psychiatric hospitalizations for diagnoses other than PTSD. Specifically, in August 2020, the Veteran's self-reported assessment score was well below the recommended threshold for diagnostic consideration of PTSD. In September 2020, the Veteran vehemently denied current symptoms such as could meet Criterion C. Upon VA examination in January 2021, the Veteran reported that her mood was "fine." The August 2020, September 2020, and January 2021 VA examiners provided thorough and detailed reasoning clearly connecting all current symptoms and impairment to an acquired psychiatric disorder other than PTSD, all reaching the same conclusion-that the Veteran did not meet full criteria for DSM-5 diagnosis of PTSD currently. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4); Miller v. Wilkie, 32 Vet. App. 249, 254 (2020); Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008).

Consideration was given to the Veteran's statements as well as other medical evidence of record. Such is insufficient to establish a current diagnosis of PTSD.

The Veteran submitted a statement describing sertraline (Zoloft) as having been prescribed for PTSD during service. See July 2020 VA Form 21-0781. Service treatment records (STRs) show the Veteran was referred for intensive outpatient mental health treatment and prescribed sertraline, in March 2009 and April 2009, respectively. On a separation report of medical history, the Veteran reported nervousness and having received counseling for being under a lot of stress. The evaluating clinician stated that the Veteran was nervous when standing in front of crowds. The Veteran denied having been evaluated for a mental disorder and depression.

The Veteran identified April 2015 records as supporting her current claim for PTSD. VA outpatient records show that the Veteran reported PTSD after a referral from marriage counseling in April 2015. The psychologist stated the criteria for PTSD were met and listed a diagnosis of chronic PTSD by history. However, this diagnosis was based on self-report and rendered for purposes of establishing treatment only. A history of diagnosis in 2015, or during service, does not establish a current DSM-5 diagnosis of PTSD.

The Veteran identified October 2020 VA treatment records as establishing that her service-connected acquired psychiatric diagnosis of unspecified schizophrenia spectrum and other psychotic disorder is incorrect. VA psychology records dated in October 2020 show the Veteran described a diagnosis of psychosis by a treating provider as having prompted her to transfer care to a new VA Medical Center (VAMC). Noting that the Veteran had submitted a claim for PTSD, the evaluating psychologist documented the Veteran's stated goal for treatment as "to get a diagnosis and sue the psychiatrist who gave a psychosis and catatonia diagnosis in the previous VA," and then, to get treatment for PTSD. When a diagnosis of PTSD was not rendered, beginning in November 2020, the Veteran requested record of that initial visit be amended to state that she instead had a current diagnosis of PTSD. The Veteran was unsuccessful in having mental health providers amend treatment records to reflect the current diagnosis of PTSD necessary to substantiate her claim, however.

The Board finds that the medical evidence of record does not establish a current diagnosis of PTSD conforming to DSM-5 criteria. VA examiners accepted military sexual trauma as a stressor sufficient to support a diagnosis of PTSD, but determined that the Veteran's symptoms and impairment currently could not be attributed to any acquired psychiatric disorder in accordance with DSM-5 criteria for PTSD. Additionally, in October 2020, a VA examiner explained that sertraline (Zoloft) is an antidepressant medication that was more likely than not prescribed during service as treatment for symptoms of the Veteran's already service-connected unspecified schizophrenia spectrum and other psychotic disorder.

The Board has considered the Veteran's contentions regarding accuracy of current psychiatric diagnosis and finds such does not constitute competent medical evidence that could establish a current DSM-5 diagnosis of PTSD. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); 38 C.F.R. § 3.304(f).

As noted, the persuasive weight of the competent medical evidence establishes that the Veteran does not currently meet the full DSM-5 criteria for PTSD. The first element of service connection for PTSD, specifically, is therefore not met.

For the reasons and bases discussed, the Board finds that the evidence for the claim versus the evidence against the claim is not in "approximate" balance (i.e., nearly equal). Instead, the most probative and, therefore, most
evidence that could establish a current DSM-5 diagnosis of PTSD. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); 38 C.F.R. § 3.304(f).

For the reasons and bases discussed, the Board finds that the evidence for the claim versus the evidence against the claim is not in "approximate" balance (i.e., nearly equal). Instead, the most probative and, therefore, most persuasive medical evidence is against a finding of current diagnosis of PTSD conforming to DSM-5 criteria, and thus the claim for service connection for PTSD. See Lynch, 21 F.4th at 781-82; see also Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001). With regard to current diagnosis of PTSD, there is no reasonable doubt to resolve. See 38 U.S.C. §§ 1154(b), 5107(b). The claim for entitlement to service connection for PTSD is denied.

T. Berry

Acting Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board W. Dwyer

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.

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