Missouri Approves Medical Marijuana – PTSD included among treatable disabilities

Medical Marijuana legalized in Missouri for PTSD. Time to start parting my hair in the middle and wearing those doper dark glasses. I don’t think we will actually see anything till 2020 maybe late 2019. All kidding aside there are several disabilities that a doctor can recommend it for including the following:
What conditions qualify?

Missouri Medical Marijuana Frequently Asked Questions

  • Cancer;
  • Epilepsy;
  • Glaucoma;
  • Intractable migraines unresponsive to other treatment;
  • A chronic medical condition that causes severe, persistent pain or persistent muscle spasms, including but not limited to those associated with multiple sclerosis, seizures, Parkinson’s disease, and Tourette’s syndrome;
  • Debilitating psychiatric disorders, including, but not limited to, post-traumatic stress disorder, if diagnosed by a state licensed psychiatrist;
  • A chronic medical condition that is normally treated with a prescription medication that could lead to physical or psychological dependence, when a physician determines that medical use of marijuana could be effective in treating that condition and would serve as a safer alternative to the prescription medication;
  • Any terminal illness; or
  • In the professional judgment of a physician, any other chronic, debilitating or other medical condition, including, but not limited to, hepatitis C, amyotrophic lateral sclerosis, inflammatory bowel disease, Crohn’s disease, Huntington’s disease, autism, neuropathies, sickle cell anemia, agitation of Alzheimer’s disease, cachexia and wasting syndrome.

Veterans Suicide – An American Legion White Paper

Suicide prevention is a top priority of The American Legion.
Deeply concerned about the number of military veterans who take their own lives at rates higher than that of the general population, the nation’s largest organization of wartime veterans established a Suicide Prevention Program under the supervision of its TBI/PTSD standing committee, which reports to the national Veterans Affairs & Rehabilitation Commission.
The TBI/PTSD Committee reviews methods, programs and strategies that can be used to treat traumatic brain injuries (TBI) and post-traumatic stress disorder (PTSD). In order to reduce veteran suicide, this committee seeks to influence legislation and operational policies that can improve treatment and reduce suicide among veterans, regardless of their service eras.
This white paper report examines recent trends in veteran suicide and their potential causes and recommends steps to address this public health crisis.

Since 2001, the U.S. military has been actively engaged in combat operations on multiple continents in the Global War on Terror.More than 3 million Americans have served in Iraq or Afghanistan through the first 17 years of the war. Traumatic brain injury (TBI) and post-traumatic stress disorder (PTSD) have become known as the “signature wounds” of the war, and in recent years, countless studies, articles and reports have documented an inordinately high suicide rate among those who have come home from the war, those of previous war eras and among active-duty personnel.

The American Legion is deeply concerned by the high suicide rate among service- members and veterans, which has increased substantially since 2001.1 The suicide rate among 18-24-year-old male Iraq and Afghanistan veterans is particularly troubling, having risen nearly fivefold to an all-time high of 124 per 100,000, 10 times the national average. A spike has also occurred in the suicide rate of 18-29-year-old female veterans, doubling from 5.7 per 100,000 to 11 per 100,000.2 These increases are startling when compared to rates of other demographics of veterans, whose suicide rates have stayed constant during the same time period.

Read the full report below:
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4 Powerful Ways to Improve Our VA Claims – From Veterans Court decisions

With 10 years of representing Veterans before VA Regional Offices all around the country and the BVA, I have a firm belief that Veterans can improve their VA Claims by following 8 Steps to Improve their VA Claim A recent non-precedential opinion of the Veterans Court seemed to follow those Steps in  pointing out the flaws in a BVA decision.
Guest Post from Veterans Law Blog
A recent non-precedential opinion of the Veterans Court seemed to follow those Steps in  pointing out the flaws in a BVA decision.
I’m going to teach you how the Veterans Court taught us the value of 4 of those Steps in a Vietnam Veteran’s PTSD increase claim:

General Facts of the Thomas Case.

The Veteran – who served in Vietnam from April 1969 – November 1970 – challenged the VA’s decision to grant an Impairment Rating of 10% for his  PTSD.  The Veteran thought he was entitled to a higher rating, above 50%.
The Veteran included — among other things — the following evidence in his claim:
  1. A statement from his wife that he “sat up all night waiting on the enemy”.
  2. VA Medical exam documenting suicidal and homicidal thoughts, hearing noises that sounded like booms
  3. A VA Medical exam that diagnosed the Veteran as “malingering”
  4. A private medical opinion that diagnosed PTSD, and documented poor short-term memory, poor coping skills, and an inability to handle changes in stressful situations
  5. A VA Medical Exam that documented intrusive daily thoughts of Vietnam, twice weekly nightmares, difficulty sleeping, problems concentrating, and detachment from others.
  6. VA Exams that documented hearing non-existent gunfire, isolation, jail time for fighting with his wife, and more.  The Veteran for example, did not know the 1st US President, concluded that 5+4 equalled 20, and thought the colors of the US flag were red and white.
  7. A private medical exam with a GAF Score of 49, and a statement that the Veteran was “adequately reliable” in the information he provided, given his level of functioning due to the mental health condition.
  8. A VA exam which “Un-diagnosed” malingering.
  9. A lot more favorable — and unfavorable — medical evidence, from private and VA practitioners.
The BVA, in 2012 (3 years after the most recent denial of the claim in 2009), concluded that the Veteran was not credible, and (this point may be arguable) that anybody who relied on the Veteran was not credible, and gave a “thumbs-up” to the VA on its denial of the increased impairment rating for Post Traumatic Stress (PTS, or PTSD).
In 2014, the Veterans’ Court vacated and remanded the BVA Decision.
The Veterans’ Court was concerned with the BVA decision: a common theme running through the decision is how the BVA assessed the evidence — not the weighing of it (the Veteran’s Court cannot weigh evidence).
Instead, the Court thought that the BVA did not properly assess legal issues related to the evidence-something that is wholly within the bailiwick of the Veteran’s Court.
And that is where the Court’s lesson begins.
[Editorial Note: The Court’s decision was not intended as a lesson — it was an opinion based on the law and facts of the case.  Reference to the “lesson” in the Court’s decision is based on my assessment of how other Veterans can LEARN from this case, and improve their OWN VA Claim or Appeal, hopefully, before it ever gets to the BVA.]

Lesson 1: Get your C&P Exam Results IMMEDIATELY after the exam (Step 2: Get your Claims File NOW!)

If you wait to  see your C-File until you are at the BVA – or worse, before the Veterans Court – you will have very little time to get evidence in the record to counter very negative evidence like a diagnosis of malingering.
I recommend that Veterans request their C-File from the VA shortly after the VA C&P Exam.  If you already have your C-File, then request the 3 documents that comprise the C&P Exam: the VBA Request for an exam (formerly, the VA Form 2507), the Examiner’s notes, and the Opinion itself.
This eBook has instructions how to get not only your C-File, but also all 3 documents that comprise the VA C&P Exams in a way that the VA MUST comply with:

Lesson 2: You must use “5 Star Evidence”.  (Step 5: Use 5 Star Evidence)

The 1st Star is Competence.   Competence is largely about WHO can offer certain evidence.
The 2nd Star is Credibility. Credibility is about the WEIGHT that the BVA should assign to individual “pieces” of evidence.
In this case, the BVA appears to have — without explanation-decided that any evidence (except the VA Medical evidence) that relied on the Veteran’s statements lacked CREDIBILITY.
What saved this Veteran was 2 things: first, he had a LOT of COMPETENT medical and lay evidence from a lot of sources that recorded their first-hand observations — not just echoing what the Veteran said.
Because that evidence was in the file, the BVA’s error started when it gave less weight to competent evidence that it thought lacked credibility, without explanation.
Lesson? If lay evidence is the bullet, and medical evidence is the rifle, when you are trying to service connect and/or properly rate a mental health condition you will need a LOT of bullets.
In this eBook, I have 2 worksheets that will help you identify as much Lay Evidence of Symptoms and Limitations as you can, as well as a template for a Sworn Declaration that may save you the costs of Notary Fees while demonstrating the credibility of your lay evidence:

Lesson 3: Fight the Right Battle on the Right Battlefield (Step 6: Choose Your Battlefield)

The Veterans Court reviews LEGAL issues.
The Veterans Court cannot weigh evidence (unless the BVA weighing was clearly erroneous — and those decisions are rare).
Since the BVA Weighs evidence, you need to be spending that 2.5 year period between decision and BVA Hearing getting as much lay and medical evidence into your file as you can.
Submit the evidence in a way that makes it easier for the BVA Judge to see why you have the better facts than it would be for the BVA Judge to deny your claim.
If you get a bad C&P exam calling you a mooching faker with PTSD, go out and get a private exam/opinion.  Ask that examiner diagnose your condition, review all of the evidence in your C-File (and say that he/she did that review), ANDoffer an opinion as to the adequacy — or inadequacy of the VA Exam/Opinion.
You can learn about the stages of the VA Claims Process – and what happens at each stage — in this eBook:

Lesson 4:  A Diagnosis of Malingering is an Atomic Bomb in Your VA Claim. (Step 7: Get Help)

Malingering is a “medical condition” in and of itself.
Though there are strict criteria for diagnosing it which are not often followed, and criteria that need to be distinguished from other conditions or symptoms of other conditions (such as complex avoidance  strategies or hyperbolic cries for help), it is a dangerous diagnosis to carry through the VA Claims Process.
It cannot be left unanswered, in my opinion.
I have a real problem with the word ‘malingering’.
First, I have only seen ONE soldier ‘malinger’ in the last 20 years.  Its just not that common in the Veterans’ community — this is a group of people who have “fulfill your mission despite your personal pain”pounded into them from Day One of Boot Camp.
Here’s the story of the 1 Malinger-er that I knew.  The soldier smashed his fingers with a fire extinguisher to get out of a Field Training Exercise. Joke was on him, in the end. He got busted a rank AND had to go on the exercise anyway — working as the Colonel’s radio operator due to his busted fingers.
This particular Colonel was a notorious pain-in-the-a** to work for.  In fact, it was rumored that he had a Layer of Hell named after him.  One of these days I’ll have to tell you about his escapades.
Second, one Veteran recently told me of a VA Doctor who said that 60% of Veterans are malingerers, and that his cure for the backlog was to dismiss all PTSD claimants as “malingerers”.
That’s some scary stuff to hear from a medical professional.
Aren’t they supposed to treat — not judge?
And how do you know if your PTSD condition is in the 40% or the 60%? Seriously, that’s a scary comment from a VA Doctor.
Any time you see the word “malinger” in your case — or any word that suggests malingering — the best thing for you to do is get in touch with an attorney ASAP.  That is going to need to be fixed, or its going to haunt your claim — as it did Mr. Thomas’s – for years.

The Thomas Case

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BVA No 09-48865 Entitlement to service connection for an acquired psychiatric disorder, to include schizophrenia, depression, and post-traumatic stress disorder (PTSD).

BVA NO. 09-48 865 Citation Nr: 1717500 Decision Date: 05/19/17 Archive Date: 06/05/17
On appeal from the Department of Veterans Affairs Regional Office in Phoenix, Arizona

THE ISSUE

Entitlement to service connection for an acquired psychiatric disorder, to include schizophrenia, depression, and post-traumatic stress disorder (PTSD).
REPRESENTATION
Veteran represented by: Disabled American Veterans
WITNESS AT HEARINGS ON APPEAL
The Veteran
ATTORNEY FOR THE BOARD
Kate Sosna, Associate Counsel

INTRODUCTION

The Veteran had active duty service from October 1972 to April 1977, as well as subsequent periods of active duty for training (ACDUTRA) and inactive duty for training (INACDUTRA) with the Wisconsin Army National Guard from January 1985 to January 1986.
This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a September 2008 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Phoenix, Arizona.
The Veteran testified at an RO hearing in October 2009 and a Board hearing at the local RO before the undersigned Veterans Law Judge in May 2012. Transcripts from these hearings have been associated with the record.
The case was remanded by the Board for additional development in January 2013 and July 2014.
In November 2015, the Board denied entitlement to service connection for an acquired psychiatric disorder. The Veteran appealed the Board’s November 2015 denial of service connection for an acquired psychiatric disorder to the United States Court of Appeals for Veterans Claims (Court), which, in June 2016, on the basis of a May 2016 Joint Motion for Partial Remand (JMPR), vacated the Board’s decision and remanded the matter to the Board for further action. Thereafter, in October 2016, the Board remanded the claim again for additional development pursuant to the JMPR.
A review of the record reveals that additional documents were added to the file after the issuance of the February 2017 supplemental statement of the case. However, in a February 2017 submission, the Veteran’s representative waived the right to have any additional evidence submitted by the Veteran considered by the RO. 38 C.F.R. § 20.1304(c) (2016). Therefore, the Board may properly consider such newly received evidence.
This appeal was processed using the Virtual VA (VVA) and Virtual Benefits Management System (VBMS) paperless claims processing systems.

FINDINGS OF FACT

1. The Veteran does not have PTSD as a result of a verified in-service stressor.
2. An acquired psychiatric disorder other than PTSD is not shown to be causally or etiologically related to any disease, injury, or incident during service, and a psychosis did not manifest within one year of the Veteran’s discharge from active service.

CONCLUSION OF LAW

The criteria for establishing service connection for an acquired psychiatric disorder, to include PTSD, have not been met. 38 U.S.C.A. §§ 101(24), 1101, 1110, 1112, 1131, 1137, 5107 (West 2014); 38 C.F.R. §§ 3.1(d), 3.6(a), 3.102, 3.303, 3.304, 3.307, 3.309 (2016).

REASONS AND BASES FOR FINDINGS AND CONCLUSION

I. Due Process Considerations

The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2016).
In the instant case, VA’s general duty to notify was satisfied by a March 2008 letter sent prior to the issuance of the rating decision on appeal. Thereafter, a March 2013 letter and attachment provided the Veteran with the notice required for claims for service connection for PTSD (to include, as requested in the January 2013 remand, claims for service connection for PTSD based on personal assault), and a PTSD stressor questionnaire for the Veteran’s completion was attached to this letter. While this letter was not provided prior to initial adjudication, the deficiency in the timing of this notice was remedied by readjudication in subsequent supplemental statements of the case in December 2013, December 2014, and February 2017. See 38 U.S.C.A. §§ 5102, 5103, 5103A; 38 C.F.R. § 3.159; see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006); Mayfield v. Nicholson, 444 F. 3d 1328, 1333-34 (Fed. Cir. 2006); Prickett v. Nicholson, 20 Vet. App. 370 (2006).
The VCAA also requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate his claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c), (d). This “duty to assist” contemplates that VA will help a claimant obtain records relevant to his claim, whether or not the records are in Federal custody, and that VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4).
In the instant case, the Board finds that all relevant facts have been properly developed and that all evidence necessary for equitable resolution of the issues decided herein has been obtained. The Veteran’s service treatment records (STRs), service personnel records, and post-service VA and private treatment records have been obtained and considered. He has not identified any additional, outstanding records that have not been requested or obtained.
Additionally, the Veteran was afforded a VA examination in December 2013 and addendum opinions were provided in September 2014 and January 2017 addressing the claim decided herein. The conclusions reached following these examinations and in the addendum opinions are, in their totality, based on an interview with the Veteran, a review of the record, and a full psychiatric examination. Moreover, the clinicians offered clear conclusions with supporting data as well as reasoned medical explanations connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (“[A]medical opinion…must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions”). Accordingly, the Board finds that VA’s duty to assist with respect to obtaining a VA examination and opinion regarding the issue decided herein has been met.
The Veteran also offered testimony before a Decision Review Officer (DRO) of the RO in October 2009 and the undersigned Veterans Law Judge at a Board hearing in May 2012. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) requires that the DRO or Veterans Law Judge who chairs a hearing to fulfill two duties: (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked.
During the October 2009 DRO hearing and the May 2012 Board hearing, the DRO and the undersigned Veterans Law Judge noted the issue on appeal. Also, information was solicited regarding the Veteran’s in-service experiences he alleges resulted in his psychiatric disorder, the type and onset of symptoms, and his contention that his military service caused his psychiatric disorder. Therefore, not only were the issues “explained…in terms of the scope of the claim for benefits,” but “the outstanding issues material to substantiating the claim,” were also fully explained. See Bryant, 23 Vet. App. at 497. As the hearing discussions raised the possibility that there were outstanding treatment records available through the Veteran’s National Guard unit, the Board remanded the case to obtain such records. Additionally, the testimony suggested the need for a VA examination addressing the claim for service connection adjudicated herein, and as indicated above, such was conducted in December 2013, and addendum opinions were obtained in September 2014 and January 2017. Under these circumstances, nothing gives rise to the possibility that evidence had been overlooked with regard to the Veteran’s claim decided herein. As such, the Board finds that, consistent with Bryant, the DRO and the undersigned Veterans Law Judge complied with the duties set forth in 38 C.F.R. 3.103(c)(2) and that the Board may proceed to adjudicate the claim based on the current record.
Furthermore, the Board finds there has been substantial compliance with the Board’s January 2013, July 2014, and October 2016 remand directives and no further action in this regard is necessary. See D’Aries v. Peake, 22 Vet. App. 97 (2008) (holding that only substantial, and not strict, compliance with the terms of a Board remand is required pursuant to Stegall v. West, 11 Vet. App. 268, 271 (1998)). In January 2013, the Board directed the Agency of Original Jurisdiction (AOJ) to afford the Veteran notice of the types of evidence that may be considered in a personal assault claim under 38 C.F.R. § 3.304(f) and request that he provide a detailed description of the incidents of personal assault. Such was accomplished by way of the aforementioned March 2013 VCAA letter. The January 2013 remand also directed the AOJ to obtain the Veteran’s service personnel records, which was accomplished in May 2013, as well as records regarding the Veteran’s period of service with the Wisconsin Army National Guard, which were received in May 2013 as well as in August 2014, after the July 2014 remand requesting additional records. The January 2013 remand also directed that the Veteran be provided an opportunity to identify any outstanding records and obtain updated VA treatment records, which was accomplished in the March 2013 VCAA letter and VA treatment records dated through December 2013 were subsequently obtained. Notably, while VA treatment records have not been associated with the record since that time, the Veteran has not reported and the record does not suggest that any outstanding, relevant treatment records exist. Finally, the January 2013 remand directed that the Veteran be afforded a VA examination in order to determine the current nature and etiology of his claimed disorders, which was accomplished in December 2013.
Additionally, and as requested in the July 2014 remand, an August 2014 letter from the AOJ asked the Veteran to provide more specific dates with respect to the injuries he claimed occurred during his time with the Wisconsin Army National Guard, and to provide any ACDUTRA or INACDUTRA orders. However, he did not reply to such letter. Therefore, development to obtain any additional National Guard records is not indicated. Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). Moreover, the Veteran did not complete the PTSD stressor questionnaire provided to him in March 2013, and given the nature of the stressors as described below, which are inherently unlikely to be verified (even if they were sufficient to result in a valid diagnosis of PTSD), the Board finds that additional development with regard to stressor verification is also not indicated. Id. Finally, as directed by the July 2014 remand, an addendum opinion was obtained in September 2014.
Most recently, in October 2016, the Board remanded the appeal for procurement of a medical opinion as to whether there is evidence of behavioral changes to indicate that any incidents of personal assault occurred, to specifically include the Veteran’s claimed stressor of being the victim of a mugging while he was in service. The requested addendum was provided in January 2017 and, as discussed above and further discussed below, the Board finds that the opinion is adequate to decide the claim.
Therefore, the Board finds that the AOJ has substantially complied with the January 2013, July 2014, and October 2016 remand directives such that no further action is necessary in this regard with respect to the claim adjudicated below. See D’Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet, App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board’s remand instructions were substantially complied with), aff’d, Dyment v. Principi, 287 F.3d 1377 (2002).
In light of the foregoing, the Board finds that VA’s duties to notify and assist have been satisfied. Thus, appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993).

II. Analysis

A Veteran is a person who served in the active military, naval, or air service and who was discharged or released under conditions “other than dishonorable.”
38 C.F.R. § 3.1(d). The term “active military, naval, or air service” includes:
(1) active duty; (2) any period of ACDUTRA during which the individual concerned was disabled or died from a disease or injury incurred or aggravated in the line of duty; and (3) any period of INACDUTRA during which the individual concerned was disabled or died from an injury incurred or aggravated in the line of duty. 38 U.S.C.A. § 101(24); 38 C.F.R. § 3.6(a).
Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R.
§ 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d).
Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. Id.; see also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff’d, 78 F.3d 604 (Fed. Cir. 1996) [(table)].
Where a Veteran served for at least 90 days during a period of war or after December 31, 1946, and manifests certain chronic diseases, to include psychoses, to a degree of 10 percent within one year from the date of termination of such service, such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during the period of service.
38 U.S.C.A. §§ 1101, 1112, 1137; 38 C.F.R. §§ 3.307, 3.309. According to 38 C.F.R. § 3.384, as applicable in the instant case, the term ‘psychosis’ includes a brief psychotic disorder; delusional disorder; psychotic disorder due to general medical condition; other specified schizophrenia spectrum and other psychotic disorder; schizoaffective disorder; schizophrenia; schizophreniform disorder; and substance/medication-induced psychotic disorder.
Alternatively, service connection may be established under 38 C.F.R. § 3.303(b) by (a) evidence of (i) the existence of a chronic disease in service or during an applicable presumption period under 38 C.F.R. § 3.307 and (ii) present manifestations of the same chronic disease, or (b) when a chronic disease is not present during service, evidence of continuity of symptomatology. The United States Court of Appeals for the Federal Circuit clarified that the law providing for awards of service connection on the basis of continuity of symptomatology is limited to “chronic” diseases such as psychoses listed under 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013).
In addition to the general principles governing service connection, to establish entitlement to service connection for PTSD the evidence must satisfy three basic elements. There must be: 1) medical evidence diagnosing PTSD; 2) a link, established by medical evidence, between current symptoms of PTSD and an in-service stressor; and 3) credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f). A diagnosis of PTSD must be established in accordance with 38 C.F.R. § 4.125(a). In this regard, the Board notes that for cases certified to the Board prior to August 4, 2014, as is the case here, the diagnosis of PTSD must be in accordance with the DSM-IV.
With regard to the second PTSD element as set forth in 38 C.F.R. § 3.304(f), evidence of an in-service stressor, the evidence necessary to establish that the claimed stressor actually varies depending on whether it can be determined that the Veteran “engaged in combat with the enemy.” See 38 U.S.C.A. § 1154(b); 38 C.F.R. 3.304(d).
If it is determined through military citation or other supportive evidence that a Veteran engaged in combat with the enemy, and the claimed stressors are related to combat, the Veteran’s lay testimony regarding the reported stressors must be accepted as conclusive evidence as to their actual occurrence and no further development or corroborative evidence will be necessary. See 38 C.F.R. § 3.304(f).
Additionally, effective July 13, 2010, VA has amended its adjudication regulations governing service connection for PTSD by liberalizing, in certain circumstances, the evidentiary standard for establishing the required in-service stressor.
Personality disorders are not “diseases” for which service connection can be granted, and as a “matter of law” are not compensable disabilities. 38 C.F.R.
§ 3.303(c); Beno v. Principi, 3 Vet. App. 439, 441 (1992). However, disability resulting from a mental disorder superimposed upon a personality disorder may be service-connected. 38 C.F.R. § 4.127.
Similarly, for claims filed after October 31, 1990, service connection may not be granted for substance abuse on the basis of service incurrence or aggravation. 38 U.S.C.A. §§ 105, 1110; 38 C.F.R. § 3.301 (a); VAOPGCPREC 2-98. However, the law does not preclude a Veteran from receiving compensation for an alcohol or drug abuse disability acquired as secondary to, or as a symptom of, a service-connected disability. Allen v. Principi, 237 F.3d 1368 Fed. Cir. 2001).
When there is an approximate balance in the evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990).
The Veteran contends that he has an acquired psychiatric disorder as a result of his military service.
Review of the Veteran’s service personnel records do not reflect that he served in combat. As such, his unsupported assertions of service stressors are not sufficient to establish the occurrence of such events. Rather, his alleged service stressors 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 regulatory requirement for “credible supporting evidence” means that “the Veteran’s testimony, by itself, cannot, as a matter of law, establish the occurrence of a non-combat stressor.” Dizoglio v. Brown, 9 Vet. App. 163 (1996).
However, VA recognizes that, because a personal assault is a personal and sensitive issue, many incidents are not officially reported, which in turn creates a proof problem in establishing they did. It is not unusual for there to be an absence of service records documenting the events the Veteran has alleged. Therefore, evidence from sources other than service records may corroborate an account of a stressor incident that is predicated on a personal assault. See, e.g., Patton v. West, 12 Vet. App. 272, 277 (1999). 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. 38 C.F.R. § 3.304(f)(5).
Evidence of behavior changes following the claimed assault is one type of relevant evidence that may be found in the mentioned 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 may submit any evidence that it received to an appropriate mental health professional for an opinion as to whether it indicates that a personal assault occurred. Id.
The STRs, to include the February 1977 discharge examination, do not reflect a psychiatric disability. The Veteran did report having “nervous trouble” on a medical history completed in conjunction with separation from service. A service hospital report for treatment for hepatitis showed that the Veteran reported a history of nervous condition prior to service. He had seen a psychiatrist, but no diagnosis was given.
The Veteran was discharged because he had been found to be dependent on alcohol or other drugs. In April 1977, he was treated at the VA for drug abuse, and an October 1977 VA examination showed a diagnosis of drug abuse, opiate type, in remission, by history. No other psychiatric diagnosis was given, although the Veteran reported previously being diagnosed with schizophrenia.
In July 1981, the Veteran was admitted to the VA following a suicide attempt. The diagnosis was mixed personality disorder with borderline, histrionic and explosive components. Again, in September 1987, the Veteran was admitted to the VA for a suicide attempt. The diagnosis was depression with suicidal ideation. During this period, clinical records also showed a diagnosis of PTSD and acute adjustment disorder. He was again admitted for drug abuse in May 1989. A VA treatment record in September 1993 showed that the Veteran was admitted for treatment for adjustment disorder with depressed mood. Follow up treatment records showed treatment for depression as well as PTSD. He was afforded a VA examination for pension purposes in September 1997. The examiner diagnosed major depressive disorder, but did not provide any sort of etiological opinion.
Additional VA and Vet Center records continued to document ongoing psychiatric treatment, to include in a PTSD group. In his hearing testimony, the Veteran asserted that he received psychiatric treatment while stationed at Fort Hood. He also reported that he was mugged while in service. The Veteran further alleged that he was “slapped around” by his drill sergeant and indicated that he experienced an incident where he dropped a grenade that caused him stress as well as more problems with his drill sergeant. He further claimed that he used drugs in service to self-medicate and that his symptoms have continued since service.
The January 2013 remand requested a VA psychiatric examination in which the examiner was to specifically indicate whether the Veteran met the diagnostic criteria for PTSD. In making this determination, the examiner was directed by the Board to offer an opinion as to whether there was evidence of behavioral changes to indicate that any incidents of personal assault occurred during service and, if so, whether any currently diagnosed PTSD was causally related to such incidents. For each currently diagnosed acquired psychiatric disorder other than PTSD, the examiner was to offer an opinion as to whether such was as least as likely as not related to the Veteran’s military service.
The requested VA psychiatric examination was completed in December 2013, and the conclusion, documented on the reports from this examination to have included a review of the claims file, was that the Veteran did not meet DSM criteria for a diagnosis of PTSD or other acquired psychiatric disability, and that the only current diagnosis was a personality disorder; namely, “Personality Disorder NOS with antisocial, narcissistic, schizotypal, and schizoid traits.” The examiner indicated that the Veteran’s personality was longstanding, beginning in his late adolescence, and was manifested as a “pervasive and persistent pattern of behaviors and cognitions that deviate from the cultural norm.” The Veteran’s stressors reported at that time were recorded as: an incident in which a drill sergeant embarrassed him in formation for marching in the wrong direction by slapping him on the side of his head, and another incident in which a drill sergeant yelled at him and embarrassed him when he dropped a hand grenade during training; the Veteran apparently did not report the alleged mugging incident. The examiner noted that neither of the reported stressors was adequate to support a diagnosis of PTSD and that neither stressor was related to a personal assault.
As noted in the July 2014 remand, the December 2013 examiner did not address whether the personality disorder diagnosed at this examination was subject to a superimposed disease or injury that resulted in additional disability. Additionally, while the 2013 examiner determined that the Veteran’s alleged stressors were insufficient to support a diagnosis of PTSD and that the Veteran had no other psychiatric disorder other than a personality disorder, she did not reconcile these determinations with the evidence of record showing diagnoses and treatment for a variety of disorders, such as major depressive disorder, reflected on records contemporaneous to the VA examination, including December 2013 VA treatment records. As such, in July 2014 the Board remanded the appeal and requested an addendum opinion from the December 2013 VA examiner. The examiner was asked to identify all of the Veteran’s acquired psychiatric disorders that met the DSM criteria and offer an opinion as whether (1) the Veteran’s personality disorder was subject to a superimposed disease or injury during service that resulted in additional disability; and (2) reconcile the determination at the December 2013 VA examination that the Veteran did not have a psychiatric disorder other than a personality disorder with the substantial evidence of record showing diagnoses and treatment for a variety of acquired psychiatric disorders, to include major depressive disorder, contemporaneous to the VA examination, i.e., in December 2013 VA treatment records.
The requested addendum opinion, by the mental health professional who conducted the December 2013 VA examination, was completed in September 2014. She found with respect to Question 1 posed in the July 2014 remand that there was “no supporting documentation that would indicate a nexus for his…personality disorder, which has progressed normally, with[out] any service related event or diagnosis.”
As for Question 2 posed in the in the July 2014 remand, the clinician responded as follows:
At the time of the December 2013 exam[,] the patient had been carrying only the following [diagnoses]: depression by history, alcohol dependence by history, [and] polysubstance abuse by history[.] [The Veteran was] discharged from therapy by both his psychiatrist 9/2/12 and his psychologist 5/10/13. He returned to care Nov 8, 2013 but continued to carry [diagnoses] only [of] depression by history, and r/o anxiety disorder or PTSD. On Nov 22, his psychologist diagnosed him with Major Depression, however the symptoms which were described at this time were not sufficient to support such diagnosis. After a review of the patient’s records in their entirety including efile, and remand, and the C&P exam and interview of Dec 2013, it is the opinion of this examiner that the patient meets DSM[-]5 criteria for the following diagnoses: Personality Disorder NOS with borderline, antisocial, narcissistic, schizotypal and schizoid traits….
The patient over an 18 year period has been variously diagnosed with Major Depression, adjustment disorder, polysubstance dependence, cocaine dependence, anxiety disorder nos, alcohol dependence, depression nos, r/o [] schizophrenia, PTSD, and since 8/12/11 by psychiatrist H[] and psychologist D[] with “depression by history, polysubstance abuse by history, and alcohol abuse by history.” A diagnosis which contains the phrase “by history” does not imply that the patient meets criteria for that diagnosis at the time of the note, otherwise it would simply be noted as “Depression,” rather it indicates either that the patient has a history that contains that diagnosis and/or that the patient has some symptoms of that diagnosis but does not fulfill sufficient diagnostic criteria to support the diagnosis. In the case of [the Veteran], this has consistently been the case.
The patient over the years has consistently exhibited or reported the symptoms which support the DSM[-]IV and DSM[-]5 diagnosis of Personality Disorder NOS as described above with the most frequent symptoms reported being irritability and rumination about incidents during which he felt he was not sufficiently appreciated or respected. His mood component has always been reactive and generally related to issues of abandonment or rejection, and again the symptoms [the Veteran] reports consistently are irritability or anger over his treatment by others. There is nothing which connects the patient’s personality disorder to his military experience. Although he has some DSM[-]IV symptoms of PTSD[,] there is nothing in his reported military stressors which would support this diagnosis, which fact has been noted by several providers most recently Dr. H[]. He was given a diagnosis of MDD on 11/22/13[,] however the provider’s assessment did not document symptoms which would support this diagnosis and indeed the assessment in this note does not vary from previous notes which indicated that he met only criteria for depression by history. Additionally[,] his note of 12/18/13 lists his mood as “happy go lucky” by his own report. Given his history, his affective symptoms are clearly accounted for most effectively by the DSM[-]IV and DSM[-]5 diagnosis [of] Personality NOS as described above.
In light of the above, it is the opinion of this examiner that the patient meets most clearly the criteria for a diagnosis of Personality Disorder NOS which has progressed normally without evidence of exacerbation or aggravation and that he has met this criteria for many years and that it is less likely than not that his Personality Disorder NOS was caused by or the result of by any event in his military service.
In the June 2016 JMPR, the parties found that, as the 2013 and 2014 opinions did not address whether “any incidents of personal assault occurred[,]’ and “whether any currently diagnosed PTSD [was] related to such incident[,]” the VA examiner did not address the Veteran’s claimed stressor of being the victim of a mugging while he was in service. Thus, in October 2016 the Board remanded the appeal to obtain an addendum medical opinion to specifically address the Veteran’s claimed stressor of being the victim of a mugging while he was in service.
Accordingly, in January 2017, the VA examiner who performed the 2013 examination and provided the 2013 and 2014 opinions provided another addendum opinion to specifically address the whether the Veteran meets the DSM-IV criteria for PTSD based on a personal assault. Following a comprehensive review of the record, the examiner found that there is no evidence of an eligible or credible stressor that occurred in the military and, therefore, the Veteran cannot meet the DSM-IV or DSM-5 criteria for PTSD, and he did not meet the DSM-5 criteria for any diagnosis with a clear nexus to his military service.
Regarding the Veteran’s claim for PTSD, the examiner reviewed all of the Veteran’s claimed stressors, starting with his most recently alleged stressor and working backwards. First, she noted the alleged stressor of a suicide attempt during service. The examiner observed that there was no record of this event nor any mental health issue (besides substance abuse) in the Veteran’s STRs or for some time after service. Here, the Board observes that the examiner erroneously noted 1987 as the Veteran’s first suicide attempt but the records indicate an attempted in 1981; however as neither date was during the Veteran’s service, the Board finds this error is without consequence. Returning to the alleged in-service attempt, the examiner further noted that not only were there not records of such in the Veteran’s STRs, but that his post-service reports regarding the attempt were inconsistent in that the Veteran alternatively reported that he made the attempt by slashing his wrists, overdosing, and/or hanging.
Turning to the second alleged stressor, the Veteran reported being involved in a “serious” bus accident and hospitalized thereafter. However, the examiner noted that the Veteran’s STRs do not support his assertion that the accident was traumatic or serious in nature. In fact, the Board observes that the STRs do not reflect an accident occurred; rather such show that the bus stopped suddenly to avoid an accident. Specifically, the March 1975 record states that the Veteran was “involved in [an] accident while on [a] Greyhound bus…talking to another passenger behind him when the bus made [a] sudden stop[,] avoiding accident[.]” Moreover, as acknowledge by the examiner, the Veteran was not hospitalized after the accident. He was seen in sick call and advised to apply heat to his back which he injured when the bus suddenly stopped.
The third alleged stressor of being slapped “upside” the head by a drill instructor was address in the 2013 and 2014 opinions. The examiner again found that this stressor was insufficient to support a diagnosis of PTSD. Similarly, the fourth stressor of being humiliated in front of his peers when a drill instructor yelled at him for dropping a grenade was also addressed by the examiner previously and was found not to support a diagnosis of PTSD.
The fifth stressor involved the Veteran’s reports that a drill sergeant “jumped him and beat him up[.]” However, the examiner noted that there was no record of this in the Veteran’s STRs and that the report was not consistent with the Veteran’s reports during the 2013 examination with regard to his interactions with his drill instructor.
The sixth alleged stressor was being “stabbed by an ice pick” during service. Here, the examiner observed that an August 1975 STR (discussed below) notes the Veteran’s report that he was “playing around” with a friend when he was accidentally stuck with a hair pick. Thus, the examiner noted that being accidentally struck with a hair pick was not sufficient to support a diagnosis of PTSD and that the Veteran had provided inconsistent information regarding the incident.
The seventh alleged stressor relates to the alleged personal assault via mugging. In this regard, the Veteran reported someone was going to hit him over the head (apparently with a knife) but that he blocked the attack with his arm resulting in a serious laceration to his arm. The examiner observed that there was no evidence of this alleged attack in the Veteran’s STRs, despite the fact that “he used sick call frequently and in fact used it for several of his other reported traumas including the ‘bus accident’ and being ‘stabbed with an ice pick.'” The examiner further noted that there was no military police report regarding this alleged attack.
The eighth stressor was an alleged attack with a straight razor during a card game. Like the alleged mugging, the examiner observed that there was no documentation of treatment related to this incident and that there was no police report related to it.
The ninth and final stressor relates to the Veteran’s reports that he was a combat veteran who began using drugs in Vietnam and that “in situations when he has felt like others were attacking him or humiliating him[,]” he spoke in Vietnamese. However, the examiner found that the Veteran was never in Vietnam and his DD 214 does not show that he had any overseas service.
In addition to reviewing the Veteran’s reported stressors, the examiner also considered whether the Veteran may have exhibited certain behaviors in the military indicating he had been personally assaulted but was reluctant to discuss it. Specifically, she observed that he had numerous legal issues in service including an incident of misconduct (1973), civilian confinement in jail (1973), disobeying orders (1975), sleeping on duty (1976), being absent without leave (AWOL) (1976), being continuously late for formations (1976), being AWOL (1977), and a 1976 recommendation that the Veteran be dishonorably discharged to his shirking of his duties and lying.
After reviewing the alleged stressors and the Veteran’s military record, the examiner opined that it was less likely than not that the Veteran was mugged during service as:

1. It was [the Veteran’s] habit to use sick call frequently including for wounds or injuries received outside the line of duty and there is no evidence of this wound in his STRs, nor was it reported to the police/MPs.

2. There is actual documented evidence in the [Veteran]’s efile that many of [his] claimed stressors either did not occur or did not occur in the traumatic manner he has later stated.

3. During 2016 the patient did not report his mugging as being his trauma but instead specifically report[ed] his trauma was interaction with [a] drill [sergeant]…, suicide attempt while in the military…, and being in a serious bus accident and hospitalized….

[4]. The only markers (frequent disciplinary actions…) of psychological issues for this patient are entirely consistent with his known severe drug abuse diagnosis which was the focus of treatment for 5 months prior to being discharged due to rehab[ilitation] failure.”

Here, the Board also observes that there is no record of the Veteran being a victim of a mugging in his STRs. However, in March 2017, after the January 2017 addendum opinion was provided, the Veteran submitted a statement from his ex-wife and from a comrade, both of whom reported remembering the Veteran reporting to them that he had been attacked and stabbed. They reported taking him to the hospital for treatment of his alleged stab wound. Here, the Board notes that, while the Veteran, his ex-wife, and his comrade are competent to report what they witnessed, the reports regarding the mugging lack credibility in light of the evidence of record.
In this regard, the Veteran’s STRs contain records related to three left arm injuries. The first incident occurred in August 1975, and while the Veteran subsequently reported to treatment providers that he was injured by an ice pick (see above), treatment records indicate that there was a puncture wound to the left wrist that occurred “while playing around with a buddy who accidentally struck [the Veteran] with a hair comb…called a pick.” The second injury, which also occurred in August 1975, was reported as a laceration to the left forearm “while washing dishes[,]” which required stitches. Notably, the Veteran claimed at his October 2009 DRO hearing that, while he did not report the alleged mugging to any psychiatric treatment providers during service, he did report the mugging to the medical professionals who stitched his arm following the attack. Again, the records indicate that the left arm stitches the Veteran received were related to an injury incurred while washing dishes. In fact, when the Veteran sought service connection for the residual scar of his left forearm in 1994, he made no reference to a mugging, he subsequently reported in September 2002 that he received an “accidental knife wound,” and in October 2009 that he was stabbed by a fellow soldier, not an unknown assailant. The third left arm injury occurred in April 1976 when the Veteran “allegedly incurred [a left palm injury] when [he was] cleaning [a] .22 caliber pistol that fired into [his] left palm” while he was off duty. In addition to the fact that the records do not support the Veteran’s assertions of the in-service mugging, the record also indicates that the Veteran has other characteristics that call his veracity into question including the fact that he was a well-documented drug abuser during his service, he was cited for stealing property of other veterans during service, and attempted “to shirk his duties and trie[d] to lie his way out of it” during service.
Given the foregoing, the Board finds that the Veteran’s descriptions of his in-service mugging are inconsistent and not supported by the contemporaneous record, and, therefore, lack credibility. In weighing credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self-interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff’d 78 F.3d 604 (Fed. Cir. 1996). In the instant case, the Veteran has not provided specific details surrounding such alleged stressors so as to allow verification, to include dates or names of the persons involved. Furthermore, there is no record in the Veteran’s STRs or personnel records that he ever experienced a mugging incident during his service, despite his reports to the DRO that he told the medical professionals about his mugging. In fact, the records document the Veteran’s left arm injury occurred while washing dishes, and clearly attribute his alleged injuries to other incidents, not a mugging. Finally, the Board acknowledges the Veteran’s comrade and his ex-wife’s reports that the Veteran told them he had been mugged and that they took him to the hospital for treatment of his injuries. However, neither person claims to have witnessed the mugging and their lay observations are based on the Veteran’s reports, which have been found to lack credibility. Therefore, in light of the fact that the Veteran’s statements regarding the alleged mugging are inconsistent with the available evidence, and were not reported until he had a self-interested reason for doing so, the Board finds that the Veteran’s statements describing his alleged in-service mugging to be not credible and they are afforded no probative weight. Similarly, the other lay statements of record that are based on the Veteran’s non-credible testimony are also afforded no probative weight.
Notably, in conjunction with the 2017 addendum opinion, the examiner again revisited whether the Veteran had any non-PTSD psychiatric diagnoses related to service. She acknowledged that the Veteran’s in-service diagnosis was related to substance abuse and that post-service diagnoses continued to be substance abuse. Moreover, his reports of using illicit substances to treat depression was not made until significantly after service, indicating no nexus to the Veteran’s military service. In this regard, the examiner observed that the Veteran’s post-service depression diagnoses were reactive in nature and were documented in his records as variously related to relationship issues, drug issues, legal issues, work stress, behavioral issues, anger issues, and the residuals of these. In fact, the criteria for an actual diagnosis, when met, was of an adjustment disorder with depression and anxiety, and the examiner noted that the Veteran experienced remission and/or improvement of these symptoms based on environmental factors. Thus, she found his post-service mental health disability was most consistent with an adjustment disorder, but that he did not exhibit symptomatology consistent with such a diagnosis during the appeal period.
Rather, the only diagnosis manifested during the appeal period was an unspecified personality disorder/personality disorder as was fully discussed in the 2013 and 2014 examination reports. Importantly, the parties to the JMPR found no fault in the Board’s discussion of any issue except as to whether the Veteran exhibited a PTSD diagnosis based on the alleged in-service mugging stressor. Carter v. Shinseki, 26 Vet. App. 534, 542-43 (2014), (vacated on other grounds sub nom. Carter v. McDonald, 794 F.3d 1342 (Fed. Cir. 2015) (“[W]hen an attorney agrees to a [JMR] based on specific issues and raises no additional issues on remand, the Board is required to focus on the arguments specifically advanced by the attorney in the motion, see Forcier [v. Nicholson, 19 Vet. App. 414,] 426 [(2006)], and those terms will serve as a factor for consideration as to whether or to what extent other issues raised by the record need to be addressed.”)
The above September 2014 and January 2017 addendum opinions are not directly contradicted by any other competent evidence, and the Board finds the comprehensive opinions, which clearly reflect detailed consideration of the entire record, to be definitive as to the matter of whether the Veteran has an acquired psychiatric disorder that is the result of service or a disability of in-service origin resulting from a mental disorder superimposed upon a personality disorder. See Nieves-Rodriguez, supra; Stefl, supra. In addition, given the lack of any evidence of a psychosis within one year of service, presumptive service connection on the basis of chronic disease, to include based on continuity of symptomatology, is not warranted. 38 U.S.C.A. §§ 1101, 1112, 1137; 38 C.F.R. §§ 3.307, 3.309; Walker, supra.
In making this determination, the Board has considered the Veteran’s assertions with regard to why he feels his psychiatric problems are the result of his experience during service. However, a determination as to whether the Veteran has an acquired psychiatric disorder that is related to service or a mental disorder superimposed on a personality disorder requires the expertise of a mental health professional as such a determination may only be made after a clinical analysis that a lay person does not that have the requisite training or knowledge to undertake. As such, the matter of whether the Veteran has an acquired psychiatric disorder that is the result of service, or a disability of in service origin resulting from a mental disorder superimposed upon a personality disorder, are complex questions that may not be competently addressed by lay evidence, and the Veteran’s own opinion in this regard is nonprobative evidence. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis); Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Therefore, the most probative evidence of record does not support the Veteran’s contentions and, rather, his statements are substantially outweighed by the conclusions set forth in the September 2014 and January 2017 opinions. Additionally, as fully discussed above, the Board finds that his statements regarding the alleged in-service mugging, the only element of the claim with which the parties to the JMPR found fault, are not credible.
In light of the above and in conclusion, the Board finds that service connection for an acquired psychiatric disorder is not warranted. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the probative evidence is against the Veteran’s claim of entitlement to service connection for an acquired psychiatric disorder. As such, that doctrine is not applicable, and this claim must be denied. 38 U.S.C.A.
§ 5107; 38 C.F.R. § 3.102; Gilbert, supra.

ORDER

Service connection for an acquired psychiatric disorder, to include schizophrenia, depression, and PTSD, is denied.
____________________________________________
A. JAEGER
Veterans Law Judge, Board of Veterans’ Appeals
Department of Veterans Affairs

VA Clears The Air On Doctors Talking To Veterans About Marijuana Use

Do you trust the VA to discuss medical marijuana? Many veterans don’t, VA docs can’t prescribe, they can, it says, discuss how it might interact with other medications or how it might effect pain management or PTSD symptoms.
VA providers are still NOT permitted to refer veterans to state-approved medical marijuana programs, since the drug is illegal under federal law, with no accepted medical use.
So do you trust VA?
https://www.npr.org/sections/health-shots/2018/01/09/576577596/va-clears-the-air-on-doctors-talking-to-veterans-about-marijuana-use
Related
https://www.politico.com/magazine/story/2017/12/16/jeff-sessions-marijuana-216109

Will PTSD NEXUS letter, from VA Psychologist help my NOD-I already submitted a Nexus?

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 Question. Will submitting a NEXUS letter  for PTSD, from my VA Psychologist help my NOD if I have already submitted a Nexus from my Private Psychologist for PTSD?

PTSD RELATED TO FEAR OF HOSTILE MILITARY OR TERRORIST ACTIVITY

A veteran who is diagnosed with PTSD that is related to fear of hostile military or terrorist activity does not need to provide stressor corroboration evidence as long as a VA psychologist or psychiatrist has diagnosed the PTSD and says that the stressor is related to the veteran’s fear of hostile military or terrorist activity. If a veteran’s stressor is adequate to support a diagnosis of PTSD, that stressor is consistent with the circumstances of the veteran’s service, and there is no clear and convincing evidence to the contrary, the veteran’s own statements may be used to establish the occurrence of the claimed stressor.
PTSD FactsWhat is fear of hostile military or terrorist activity? The veteran must have experienced, witnessed, or been confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the vet or others, such as from an actual or potential improvised explosive device; vehicle-embedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon friendly military aircraft, and the veteran’s response to the event or circumstance must have involved a psychological or psycho-physiological state of fear, helplessness, or horror.
This lower burden of proof applies to all veterans, regardless of where they experience the fear of hostile military or terrorist activity, but it does not include sexual assault or hostile criminal actions of US military personnel directed against other US military personnel. It also only applies to claims received on or pending after July 13, 2010. If a veteran has a previously denied PTSD claim, in order to reopen the claim under this lower burden of proof standard, he or she would need a lay statement of his or her fear of hostile military or terrorist activity and service records that show service in an area involving exposure to hostile military or terrorist activity.
It is important to note that while this lower burden of proof requires a diagnosis by a VA psychologist or psychiatrist, a diagnosis by a non-VA practitioner and a veteran’s statement describing an in-service stressor relating to a fear of hostile military or terrorist activity should be enough to trigger the VA’s duty to assist by scheduling a VA PTSD exam.
Go to step 3.
NOTE: If a veteran is attempting to get service connection for PTSD under this lower burden of proof standard, but the VA psychologist or psychiatrist’s opinion states that the doctor does not believe that the veteran’s PTSD is related to a fear of hostile military or terrorist activity, the veteran should attempt to gather corroborating evidence of the stressor, which another doctor can use as a basis for a medical nexus opinion under step 3.

Did the claimed stressor occur during combat?

PTSD FOR COMBAT VETERANS

Similar to veterans who were diagnosed with PTSD during service, there is a lower burden of proof for combat veterans when it comes to stressor corroboration evidence. Essentially, the VA admits that when a veteran is engaged in combat, his or her primary focus is going to be carrying out the mission, not taking notes on any and all injuries. If a veteran’s stressor is related to combat, that stressor is consistent with the circumstances of the veteran’s service, and there is no clear and convincing evidence to the contrary, the veteran’s own statements may be used to establish the occurrence of the claimed stressor.
PTSD Facts Vietnam WarThe VA Adjudications Procedures Manual M21-1MR (available on the VA website) defines combat as “personal participation in events constituting an actual fight or encounter with a military foe or hostile unit or instrumentality. It includes presence during such events either as a combatant, or service member performing duty in support of combatants, such as providing medical care to the wounded.” Even a brief participation in combat triggers the lower burden of proof. But, depending on the circumstances, it is important to note that the veteran may have an additional hurdle in proving that he or she was in combat.
For some veterans, this is a simple task due to their military service records or military occupational specialty (MOS) and where or when they served. But for other veterans, it may not be obvious at first glance that they served in combat. For these veterans, the VA will look to not only military service records and MOS, but also certain military decorations, buddy statements, letters home to family or friends, copies of newspapers or regimental or divisional newsletters, photographs, or any other credible supporting evidence that can help to establish whether the veteran was in combat or not. If a veteran contends that he was in combat action that cannot be confirmed by his or her MOS or military service records, the VA must make a finding as to the credibility of his or her statement and provide reasons for its finding of whether the veteran engaged in combat, keeping in mind the benefit of the doubt rule.
At this stage, if a veteran states that he served in combat and identifies a stressor that is not impossible to believe, and has a current diagnosis of PTSD (see step 1), then the VA must take steps to develop evidence. The VA will look for evidence of both combat service and additional evidence that the combat stressor actually took place. It is usually a good idea for the veteran to request these records as well. Relevant service records may be found at the National Personnel Records Center, the US Army and Joint Services Records Research Center, the Marine Corps Archives and Special Collections, and the National Archives.
Once it is established that the veteran served in combat, the VA must also accept lay evidence as proof that the alleged stressor happened during combat even in the absence of official records or supporting clinical evidence. Even if the veteran does not have any other evidence that the stressor occurred other than his or her own statement, as long as there is not clear and convincing evidence to the contrary, the VA is obligated to apply the benefit of the doubt rule and accept the veteran’s own statement as proof that the stressor occurred. Go to step 3.

Is the stressor related to an in-service personal assault or trauma, including Military Sexual Trauma (MST)?

SPECIAL RULES FOR IN-SERVICE PERSONAL ASSAULT OR TRAUMA AS STRESSOR

If a veteran suffers from PTSD as a result of an in-service personal assault or trauma such as rape, physical assault, domestic battering, robbery, mugging, stalking, or harassment, the stressor can be corroborated through alternative evidence if military records do not document that a personal assault occurred. The VA has a special obligation to assist in these cases (commonly referred to as Military Sexual Trauma or MST) and must inform the veteran that evidence other than that found in service records may be submitted. PTSD Facts MSTAlternative sources for evidence may be things such as records from law enforcement, rape crisis centers, mental health counseling centers, hospitals, or physicians; pregnancy or STD tests; statements from family members, roommates, fellow service members, or clergy; a personal diary or journal; or evidence of behavior changes such as a request to transfer, deterioration in work performance, substance abuse, depression, panic attacks, or anxiety. Unfortunately, these cases are frequently denied, partly due to the fact that VA has difficulty compensating for disabilities that are less obvious than a physical disability, and because due to the nature of MST cases it is rare for there to be a formal report or complaint in the record. The VA often must rely on the alternative evidence listed above, and typically fails to give that evidence the weight that is required. PTSD claims in general are difficult to win, but MST claims are even tougher.
According to a June 2014 report from the Government Accountability Office, since 2008, there have been 29,000 veterans who have sought disability benefits for problems related to MST. PTSD is the most common disability claimed as a result of MST at 94 percent of claims, with major depressive disorder and anxiety disorder being the second and third most common. The overall approval rating for PTSD related to MST is up from 28 percent in 2010 to roughly 50 percent in 2013, but this is still lower than the 55 percent approval rating for other forms of PTSD (Note: According to a report by the ACLU and Service Women’s Action Network, between 2008 and 2012, the award of MST-related PTSD claims was lower than the rate of other PTSD claims by between 16.5 and 29.6 percent each year). Also of note is the wide disparity among regional offices: in some ROs as few as 14 percent of claims were approved, while other ROs approved as many as 88 percent of claims. The GAO report found that regional offices are having ongoing difficulty applying broadened MST standards and may differ wildly in their interpretations of the evidence in the claim file.
Another hurdle identified in the GAO report is the variation in the thoroughness of C&P examinations for MST claims. In fact, during the only formal training for VA examiners who are conducting MST exams, less than 5% of the one-hour certification course for PTSD examiners is devoted to MST. This goes to show that there is still a lot of work and training that needs to be done on the VA side in regards to MST claims, which can be discouraging for many veterans. But just remember that while MST claims take time, they are not impossible to win. The key is to get the VA to look at the stressor evidence in the right context in order to show, for example, a behavior change that corroborates the occurrence of the stressor. See Part Seven for a list of resources for survivors of MST.
Go to step 3.

IF NONE OF THE ABOVE APPLIES, STRESSOR CORROBORATION IS NEEDED

If a veteran’s claim for PTSD does not fit into one of the above categories, there must be evidence that corroborates the occurrence of the stressor, meaning credible supporting evidence that the claimed in-service stressor occurred. The supporting evidence must include more than the veteran’s own testimony. Unless there is no reasonable possibility that assistance by the VA would aid in substantiating the claim, the VA must assist the veteran in developing evidence that supports the existence of a stressor.
2.2 PTSD Facts Non-OEF or OIF vetsFor the veteran’s service records to corroborate the stressor, they do not need to include every detail of the event. If there is independent evidence of the occurrence of a stressful event and that evidence shows the veteran’s personal exposure to the event, that could be sufficient corroborative evidence. In addition, credible supporting evidence can come from lay sources such as buddy statements.
An example of a situation in which a veteran would need stressor corroboration evidence is if he or she was in a bad car accident during service, the car accident was not related to combat, and the veteran was not diagnosed with PTSD until after leaving service. In this situation, the veteran would need to be able to corroborate that the car accident happened. This may be through a police report, hospital records, statements of the other individuals involved in the accident, or other supporting evidence. Another situation in which corroboration evidence would be required is if a veteran was involved in an accident during a non-combat situation, such as an explosion or fire. Again, hospital records, notations in service records, and statements of other persons who witnessed the explosion would be helpful corroboration evidence.
It is important to note that if a veteran’s account of an event is contradicted by official records, the VA can reject the veteran’s account, but as long as the veteran produces evidence to back up his or her story, the benefit of the doubt rule still applies.
Go to step 3.
The final step of establishing service connection for PTSD is proving a causal nexus between the current symptomatology and the claimed in-service stressor. This step requires an opinion by a medical expert. The evidence must show that the stressor was at least a contributory basis for the current symptoms. As long as there is a clear relationship between the stressor encountered in service and the current diagnosis of PTSD, a veteran whose service medical records show no evidence of a mental disorder can be entitled to service connection for PTSD, even if the PTSD develops many years after service.
Note that this step can be more complicated if a veteran has more than one stressor. For example, say a veteran was in a car accident in service in which his best friend was killed, and there are service records and hospital records backing up this stressor.  The second stressor was when the vet was in his bunk and some fellow soldiers came in the room and threw a grenade at him.  The grenade was a dummy, but the veteran did not know that, and he still has nightmares about it.  There is no independent verification of this stressor.  For the veteran to receive service connected compensation for his PTSD, the doctor would have to relate his PTSD specifically to the car accident in service because that is the only stressor with independent verification, and the second stressor does not qualify under one of the lower burden of proof situations mentioned in step 2. And remember, the VA will always send the veteran to a Compensation and Pension exam to determine if the veteran is entitled service connected disability benefits for his PTSD.
Continue to Part Three to learn more about Compensation & Pension exams for PTSD.

Introduction – PTSD Guide

Post traumatic stress disorder, or PTSD, is a very common mental health condition brought on by witnessing or experiencing a traumatic or terrifying event. The Mayo Clinic estimates that more than three million Americans are diagnosed with PTSD every year.


Here’s a good write up of the process flow for PTSD Claims from Hill and Ponton

Part 2 – PTSD Service Connection Flowchart

There are three elements needed to establish service connection for PTSD in order to receive VA benefits. First, you must have a current diagnosis of PTSD

Bruxism secondary to PTSD


I know this thread is a little old now, but I was looking for someone who has filed for and been awarded service connection for bruxism. I do not have a diagnosis (yet), but have had bruxism for years. I have multiple broken teeth and some missing from where I have destroyed them from the grinding. I don’t only grind my teeth during sleep, but often times I do it during the day, as well. I was just awarded SC for PTSD earlier this year and would like to file a claim for bruxism as secondary to the PTSD. There’s little doubt in my mind that they’re related.
Anyway, my real question is, how the heck do you file a claim for bruxism? I have seen people refer to their Bruxism C&P exams and even being awarded SC for bruxism, but I can’t find anything in the VA rating info for bruxism. When I go onto eBenefits to file a claim, there is not category for bruxism, either. So, how do you file a claim for something they don’t have listed? Read the full post here
More on Bruxism from HadIt.com Veterans

Secondary Conditions To PTSD Title 38 – Hadit.com For Veterans Who’ve Had it With The VA

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Secondary Conditions in VA Disability Claims – Hadit.com For Veterans Who’ve Had it With The VA

When was he DX’d with SA (? OSA CSA or MSA?)? He was Denied Direct SC, you didn’t file as Secondary to his CAD DX? He applied for non s/c OSA and was denied. Different decision.

History of PTSD in Veterans: Civil War to DSM-5 by Matthew J. Friedman, MD, PhD Senior Advisor and former Executive Director, National Center for PTSD

[no_toc]Exposure to traumatic experiences has always been a part of the human condition. Attacks by saber tooth tigers or twenty-first century terrorists have likely led to similar psychological responses in survivors of such violence. Literary accounts offer the first descriptions of what we now call posttraumatic stress disorder (PTSD). For example, authors including Homer (The Iliad), William Shakespeare (Henry IV), and Charles Dickens (A Tale of Two Cities) wrote about traumatic experiences and the symptoms that followed such events.

The PTSD diagnosis has filled an important gap in psychiatry in that its cause was the result of an event the individual suffered, rather than a personal weakness. PTSD became a diagnosis with influence from a number of social movements, such as Veteran, feminist, and Holocaust survivor advocacy groups. Research about Veterans returning from combat was a critical piece to the creation of the diagnosis. War takes a physical and emotional toll on Servicemembers, families, and their communities. So, the history of what is now known as PTSD often references combat history.

Early attempts at a medical diagnosis

Accounts of psychological symptoms following military trauma date back to ancienttimes. The American Civil War (1861-1865) and the Franco-Prussian War (1870-1871) mark the start of formal medical attempts to address the problems of military Veterans exposed to combat. European descriptions of the psychological impact of railroad accidents also added to early understanding of trauma-related conditions.
 

Nostalgia, Soldier’s Heart, and Railway Spine

Prior to U.S. military efforts, Austrian physician Josef Leopold (1761) wrote about “nostalgia” among soldiers. Among those who were exposed to military trauma, some reported missing home, feeling sad, sleep problems, and anxiety. This description of PTSD-like symptoms was a model of psychological injury that existed into the Civil War.
 
A second model of this condition suggested a physical injury as the cause of symptoms. “Soldier’s heart” or “irritable heart” was marked by a rapid pulse, anxiety, and trouble breathing. U.S. doctor Jacob Mendez Da Costa studied Civil War soldiers with these “cardiac” symptoms and described it as overstimulation of the heart’s nervous system, or “Da Costa’s Syndrome.” Soldiers were often returned to battle after receiving drugs to control symptoms.
The thought that physical injury led to PTSD-like symptoms was supported by European reports of “railway spine.” As rail travel became more common, so did railway accidents. Injured passengers who died had autopsies that suggested injury to the central nervous system. Of note, Charles Dickens was involved in a rail accident in 1865 and wrote about symptoms of sleeplessness and anxiety as a result of the trauma.

Shell Shock

In 1919, President Wilson proclaimed November 11th as the first observance of Armistice Day, the day World War I ended. At that time, some symptoms of present-day PTSD were known as “shell shock” because they were seen as a reaction to the explosion of artillery shells. Symptoms included panic and sleep problems, among others. Shell shock was first thought to be the result of hidden damage to the brain caused by the impact of the big guns. Thinking changed when more soldiers who had not been near explosions had similar symptoms. “War neuroses” was also a name given to the condition during this time.
During World War I, treatment was varied. Soldiers often received only a few days’ rest before returning to the war zone. For those with severe or chronic symptoms, treatments focused on daily activity to increase functioning, in hopes of returning them to productive civilian lives. In European hospitals, “hydrotherapy” (water) or “electrotherapy” (shock) were used along with hypnosis.

Battle Fatigue or Combat Stress Reaction (CSR)

In World War II, the shell shock diagnosis was replaced by Combat Stress Reaction (CSR), also known as “battle fatigue.” With long surges common in World War II, soldiers became battle weary and exhausted. Some American military leaders, such as Lieutenant Gen. George S. Patton, did not believe “battle fatigue” was real. A good account of CSR can be found in Stephen Crane’s Red Badge of Courage, which describes the acute reaction of a new Union Army recruit when faced with the first barrage of Confederate artillery.
Up to half of World War II military discharges were said to be the result of combat exhaustion. CSR was treated using “PIE” (Proximity, Immediacy, Expectancy) principles. PIE required treating casualties without delay and making sure sufferers expected complete recovery so that they could return to combat after rest. The benefits of military unit relationships and support became a focus of both preventing stress and promoting recovery.

Development of the PTSD diagnosis

In 1952, the American Psychiatric Association (APA) produced the first Diagnostic and Statistical Manual of Mental Disorders (DSM-I), which included “gross stress reaction.” This diagnosis was proposed for people who were relatively normal, but had symptoms from traumatic events such as disaster or combat. A problem was that this diagnosis assumed that reactions to trauma would resolve relatively quickly. If symptoms were still present after six months, another diagnosis had to be made.
Despite growing evidence that trauma exposure was associated with psychiatric problems, this diagnosis was eliminated in the second edition of DSM (1968). DSM-II included “adjustment reaction to adult life” which was clearly insufficient to capture a PTSD-like condition. This diagnosis was limited to three examples of trauma: unwanted pregnancy with suicidal thoughts, fear linked to military combat, and Ganser syndrome (marked by incorrect answers to questions) in prisoners who face a death sentence.
In 1980, APA added PTSD to DSM-III, which stemmed from research involving returning Vietnam War Veterans, Holocaust survivors, sexual trauma victims, and others. Links between the trauma of war and post-military civilian life were established.
The DSM-III criteria for PTSD were revised in DSM-III-R (1987), DSM-IV (1994), DSM-IV-TR (2000), and DSM-5 (2013) to reflect continuing research. One important finding, which was not clear at first, is that PTSD is relatively common. Recent data shows about 4 of every 100 American men (or 4%) and 10 out every 100 American women (or 10%) will be diagnosed with PTSD in their lifetime.
An important change in DSM-5, is that PTSD is no longer an Anxiety Disorder. PTSD is sometimes associated with other mood states (for example, depression) and with angry or reckless behavior rather than anxiety. So, PTSD is now in a new category, Trauma- and Stressor-Related Disorders. PTSD includes four different types of symptoms: reliving the traumatic event (also called re-experiencing or intrusion); avoiding situations that are reminders of the event; negative changes in beliefs and feelings; and feeling keyed up (also called hyperarousal or over-reactive to situations). Most people experience some of these symptoms after a traumatic event, so PTSD is not diagnosed unless all four types of symptoms last for at least a month and cause significant distress or problems with day-to-day functioning.

Today and tomorrow

Today VA operates more than 200 specialized programs for the treatment of PTSD. In Fiscal Year (FY) 2013, more than a half million Veterans diagnosed with PTSD received treatment at VA medical centers and clinics.
VA is committed to provide the most effective, evidence-based care for PTSD. It has created programs to ensure VA clinicians receive training in state-of-the-art treatments for PTSD. At of the end of FY 2013, VA had trained more than 5000 of its clinicians to use Cognitive Processing Therapy (CPT) or Prolonged Exposure (PE), which are cited by the Institute of Medicine Committee on Treatment of PTSD as proven to be effective treatments for PTSD.
VA’s National Center for PTSD was created in 1989 by an act of Congress, and celebrated its 25th anniversary on August 29, 2014. We continue to be at the forefront of progress in the scientific understanding and treatment of PTSD. In addition to improving upon existing treatments, we are researching effective new treatments. We are also developing new educational products such as our What is PTSD?whiteboard video. For more information on the National Center for PTSD, please visit our About Us section of the website.

Sources

National Center for PTSD May 2017
Portions of this fact sheet originally appeared in a Veterans Day observance post on VA’s blog, VAntage Point (November 7, 2013). For more information about the history of the PTSD diagnosis, see PTSD History and Overview in the Professional Section of our website.

Can Service Dogs Help Veterans with PTSD? The VA Is Skeptical

A growing number of veterans are acquiring service dogs to help cope with PTSD. But the VA won’t pay for them and says their effectiveness hasn’t been…
Sourced through Scoop.it from: wunc.org
“Keyser is among hundreds of U.S. veterans who are working with service dogs to help relieve symptoms of Post Traumatic Stress Disorder. At the Ronkonkoma, N.Y. veterans home where Keyser lives, Artemis hangs close to him, watching him carefully with her amber-colored eyes.
When the pair leave home, Artemis gets behind Keyser and blocks him from people who might startle him.
“If the service dog helps me stay in public places around people, that means I can get the help I need,” said Keyser, who said he was too anxious to attend treatment sessions until Artemis began going with him.”

PTSD Veterans Compensation Benefits Claims

[no_toc]

There are three main elements you need to understand in how to prove PTSD to VA:

  1. Diagnosis

  2. In-service stressor

  3. Medical “nexus” or link between your PTSD and the in service stressor.

VA Compensation for PTSD and Other Mental Disorders – Hill & Ponton, P.A. – Hadit.com For Veterans Who’ve Had it With The VA

Source: Hill and Ponton Does it matter whether the VA finds that a veteran is service-connected for PTSD, as opposed to some other psychiatric disorder? For purposes of compensation, no, it does not.


https://hadit.com/proving-non-combat-stressor-va-ptsd-disability-claim/

DSM-5 Criteria for PTSD – Hadit.com For Veterans Who’ve Had it With The VA

no_toc] In 2013, the American Psychiatric Association revised the PTSD diagnostic criteria in the fifth edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM-5) (1). The diagnostic criteria are specified below.