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
