Citation Nr: 0812345 Decision Date: 04/14/08 Archive Date: 05/01/08 DOCKET NO. 05-16 919 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Lincoln, Nebraska THE ISSUES 1. Entitlement to service connection for post-traumatic stress disorder (PTSD). 2. Entitlement to service connection for hypertension, claimed as secondary to PTSD. 3. Entitlement to service connection for a gastrointestinal disability, to include gastroesophageal reflux disease and/or irritable bowel syndrome-claimed as secondary to PTSD. 4. Entitlement to service connection for a heart disability, claimed as secondary to PTSD. REPRESENTATION Appellant represented by: Richard J. Mahlin, Attorney ATTORNEY FOR THE BOARD Mary C. Suffoletta, Counsel INTRODUCTION The veteran served on active duty from December 1966 to December 1970. These matters initially came to the Board of Veterans' Appeals (Board) on appeal from a September 2004 rating decision that denied service connection for PTSD, hypertension, gastroesophageal reflux disease, and irritable bowel syndrome. The veteran timely appealed. These matters also came to the Board on appeal from an August 2005 rating decision that denied service connection for a heart disability. In April 2007, the Board remanded the matters for additional development. FINDINGS OF FACT 1. There is no competent evidence establishing that the veteran currently has PTSD. 2. Hypertension was first demonstrated many years after service and is not related to a disease or injury during active service, and is not due to or aggravated by a service- connected disability. 3. Gastroesophageal reflux disease was first demonstrated many years after service; and a gastrointestinal disability, to include gastroesophageal reflux disease and irritable bowel syndrome, is not related to a disease or injury during active service, and is not due to or aggravated by a service- connected disability. 4. A heart disability is not related to a disease or injury during active service, and is not due to or aggravated by a service-connected disability. CONCLUSIONS OF LAW 1. PTSD was not incurred or aggravated in service. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.303, 3.304(f) (2007). 2. A cardiovascular disease, including heart disease and hypertension, was not incurred or aggravated in service, may not be presumed to have been incurred therein and is not proximately due to or the result of a service-connected disability. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2007). 3. A gastrointestinal disability, to include gastroesophageal reflux disease and irritable bowel syndrome, was not incurred or aggravated in service, an ulcer may not be presumed to have been incurred therein and gastrointestinal disability is not proximately due to or the result of a service-connected disability. 38 U.S.C.A. §§ 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2007). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2007). In Pelegrini v. Principi, 18 Vet. App. 112 (2004), the United States Court of Appeals for Veterans Claims (Court) held that proper VCAA notice should notify the veteran of: (1) the evidence that is needed to substantiate the claim(s); (2) the evidence, if any, to be obtained by VA; (3) the evidence, if any, to be provided by the claimant; and (4) a request by VA that the claimant provide any evidence in the claimant's possession that pertains to the claim(s). Through May 2004 and June 2005 letters, the RO notified the veteran of elements of service connection, and the evidence needed to establish each element. These documents served to provide notice of the information and evidence needed to substantiate the claims. VA's letters notified the veteran of what evidence he was responsible for obtaining, and what evidence VA would undertake to obtain. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). VA informed him that it would make reasonable efforts to help him get evidence necessary to support his claims, particularly, medical records, if he gave VA enough information about such records so that VA could request them from the person or agency that had them. The letters asked him if he had any additional evidence to submit, and thereby put him on notice to submit information or evidence in his possession. The veteran was not provided with notice of the type of evidence necessary to establish a disability rating or to assign an effective date for each disability on appeal. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993) (where the Board addresses a question that has not been addressed by the agency of original jurisdiction, the Board must consider whether the veteran has been prejudiced thereby). The Board finds no prejudice to the veteran in proceeding with a denial of service connection for each claim on appeal, as concluded below, because any question as to the appropriate disability rating and effective date to be assigned is rendered moot. He had previously received all required notice regarding service connection. The claims denied obviously do not entail the setting of a new disability rating or an effective date. Accordingly, the veteran is not harmed by any defect with regard to these elements of the notice. There is no indication that any additional action is needed to comply with the duty to assist the veteran. The RO or AMC has obtained copies of the service medical records and outpatient treatment records, and has arranged for VA examinations in connection with the claims on appeal, reports of which are of record. The veteran has not identified, and the record does not otherwise indicate, any existing pertinent evidence that has not been obtained. Given these facts, it appears that all available records have been obtained. There is no further assistance that would be reasonably likely to assist the veteran in substantiating the claims. 38 U.S.C.A. § 5103A(a)(2). II. Analysis Service connection is awarded for disability that is the result of a disease or injury in active service. 38 U.S.C.A. §§ 1110, 1131. Service connection requires competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004), citing Hansen v. Principi, 16 Vet. App. 110, 111 (2002); see also Caluza v. Brown, 7 Vet. App. 498 (1995). Service connection may be presumed, for certain chronic diseases-such as hypertension, organic heart disease, psychoses, and peptic ulcers (gastric or duodenal)-which develop to a compensable degree within one year after discharge from service, even though there is no evidence of such diseases during the period of service. This presumption is rebuttable by probative evidence to the contrary. 38 U.S.C.A. §§ 1110, 1112, 1113 (West 2002); 38 C.F.R. 3.307, 3.309 (2007). Every veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time. 38 U.S.C.A. § 1111. Service medical records of the veteran's entry report no defects, and the Board presumes the veteran to have been in sound condition at the time of entry. Parker v. Derwinski, 1 Vet. App. 522 (1991). Service connection is available on a secondary basis for disability that is proximately due to a service-connected disease or injury, and when, generally, a service connected disability aggravates a non-service-connected disability. 38 C.F.R. § 3.310(a). A secondary service connection claim requires competent medical evidence linking the claimed disability to a service- connected disability. Wallin v. West, 11 Vet. App. 509, 512 (1998); Velez v. West, 10 Vet. App. 432 (1997); see Jones (Wayne) v. Brown, 7 Vet. App. 134, 136-37 (1994) (lay testimony that one condition was caused by a service- connected condition was insufficient to well ground a claim). A. PTSD Service connection for PTSD requires a current medical diagnosis of PTSD in accordance with 38 C.F.R. § 4.125 (the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (4th ed.) (1994) (DSM-IV)); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible evidence that the claimed in-service stressor actually occurred. See 38 C.F.R. 3.304(f). Service medical records contain no diagnosis of any psychiatric disorder. The veteran was treated for in-service symptoms of anxiety. VA progress notes, dated in September 1994, reflect assessments of depression and anxiety. Records received from the Social Security Administration show that the veteran has been considered disabled since August 10, 1998; his disabilities include back disorders and essential hypertension. The report of an August 2004 VA examination reveals an Axis I diagnosis of generalized anxiety disorder. The examiner specifically noted that the veteran's symptomatology did not meet the criteria for a diagnosis of PTSD. In August 2007, a VA examiner noted that the veteran reported a number of symptoms consistent with PTSD, but that the details he provided did not support a diagnosis of PTSD. His symptoms and the medical records were consistent with a diagnosis of generalized anxiety disorder. While there is corroborative evidence of the claimed in- service stressor, service connection for PTSD still cannot be granted. A grant of service connection requires a current diagnosis of PTSD, as well as medical evidence of a nexus between current symptomatology and the specific claimed in- service stressor. What is missing in this case is competent evidence of a current diagnosis of PTSD. Neither the veteran nor his attorney has presented or alluded to the existence of any medical opinion that would, in fact, establish a diagnosis of PTSD, despite being asked to present or identify such evidence. Although the veteran has claimed that he has PTSD, he is a lay person, and lacks the requisite medical knowledge to make a competent diagnosis. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). Accordingly, notwithstanding the veteran's assertions, there is no competent evidence that he currently has PTSD. Because there is competent medical evidence diagnosing a generalized anxiety disorder, further examination is not required to satisfy the duty to assist. Congress has specifically limited entitlement to service connection for disease or injury to cases where such incidents have resulted in a disability. See 38 U.S.C.A. §§ 1110, 1131. Hence, in the absence of proof of the currently claimed disability, there can be no valid claim for service connection. See Gilpin v. West, 155 F. 3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); 38 C.F.R. § 3.304(f). Because there is no competent evidence of a current diagnosis of PTSD, the preponderance of the evidence is against the claim. The benefit-of-the-doubt doctrine is not for application, and the claim must be denied. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). B. Hypertension, a Gastrointestinal Disability, and a Heart Disability The veteran's main contention is that service connection is warranted on the basis that his hypertension, his gastrointestinal disability, and his claimed heart disability are caused or aggravated by his service-connected psychiatric disability. In this case, service connection has been established for a generalized anxiety disorder, effective April 1, 2004. Service medical records contain neither manifestations nor complaints, nor findings of hypertension or heart disease, or of gastroesophageal reflux disease or irritable bowel syndrome. The veteran was treated in March 1969 and February 1970 for diarrhea, and in August 1969 for an upset stomach. VA outpatient treatment records, dated in September 1994, include assessments of hypertension and gastroesophageal reflux disease. As noted above, records received in July 2007 from the Social Security Administration reflect a secondary diagnosis of essential hypertension. Records show that, in December 2007, a VA physician rendered a medical opinion that the veteran's claimed disabilities (hypertension, gastroesophageal reflux disease and/or irritable bowel syndrome, and heart disease) were less likely as not-i.e., less than 50/50 probability, due to, or a result of, or permanently aggravated by the service-connected generalized anxiety disorder. The VA physician reviewed the veteran's claims file and reviewed medical literature, noting that essential hypertension had no clear-cut etiology and that it was a primary condition and not secondary or due to any other factor. Nor had essential hypertension been related to anxiety or neurosis. The VA physician referenced medical literature (cite omitted), indicating that while stress can transiently elevate blood pressure, this was a normal physiologic response; and that temporary elevation did not cause the underlying condition of hypertension, nor permanently aggravate essential hypertension in a predictable or measurable manner. The VA physician concluded that there appeared to be no cause and effect relationship between generalized anxiety disorder and the development of hypertension or of cardiovascular disease. The Board also notes that the VA physician was unable to identify any cardiac condition-such as coronary artery disease, pericarditis, valvular heart disease, or congestive heart failure. Lastly, the VA physician identified a clinical assessment of gastroesophageal reflux disease in 2003, but no specific diagnosis of irritable bowel syndrome. The VA physician noted that medical literature was silent regarding evidence that generalized anxiety disorder could serve as a causative or etiologic agent for the development of gastroesophageal reflux disease. While stress can cause transient increase in stomach hyperacidity, the VA physician found no evidence that the veteran's gastroesophageal reflux disease was due to, or permanently aggravated by, his anxiety disorder. The VA physician noted that the veteran's medical records did not note any somatization or physiologic symptoms, or other gastrointestinal symptoms as a persistent, predictable component of his anxiety. The VA physician opined that it was most likely that any gastrointestinal conditions would have occurred, progressed, and responded to treatment as they have, independent of the veteran's diagnosed generalized anxiety disorder. Here, the competent evidence weighs against a finding that any cardiovascular disease and/or gastrointestinal disability is/are proximately due to or the result of a generalized anxiety disorder, or that pertinent disability was aggravated by a generalized anxiety disorder. Nor is there competent medical evidence showing manifestations of hypertension or peptic ulcers (gastric or duodenal) to a degree of 10 percent within one year from the date of termination of active service. Paulson v. Brown, 7 Vet. App. 466 (1995); Espiritu v. Derwinski, 2 Vet. App. 492 (1992). While the veteran may have had a long history of hypertension or gastroesophageal reflux disease, the record does not document any hypertension or peptic ulcer within one year of service. Hence, the weight of the evidence is against each of the claims, and against the grant of service connection. Inasmuch as the preponderance of the evidence is against each of the claims for service connection, reasonable doubt does not arise and the claims are denied. 38 U.S.C.A. § 5107(b). (CONTINUED ON NEXT PAGE) ORDER Service connection for PTSD is denied. Service connection for hypertension, to include as secondary to service-connected generalized anxiety disorder, is denied. Service connection for a gastrointestinal disability, to include gastroesophageal reflux disease and irritable bowel syndrome, and as secondary to service-connected generalized anxiety disorder, is denied. Service connection for a heart disability, to include as secondary to service-connected generalized anxiety disorder, is denied. ____________________________________________ THOMAS J. DANNAHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs