Citation Nr: 1142049 Decision Date: 11/14/11 Archive Date: 11/30/11 DOCKET NO. 05-30 189 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Phoenix, Arizona THE ISSUES 1. Entitlement to service connection for diverticulitis claimed as secondary to (service-connected) posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for irritable bowel syndrome (IBS), claimed as secondary to PTSD. 3. Entitlement to service connection for hiatal hernia, claimed as secondary to PTSD. 4. Entitlement to service connection for hypertension, claimed as secondary to PTSD. 5. Entitlement to service connection (to include secondary service connection) for transient ischemic attacks (TIAs). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant and his spouse ATTORNEY FOR THE BOARD K.S. Hughes, Counsel INTRODUCTION The appellant is a Veteran who served on active duty from August 1966 to August 1969. These matters are before the Board of Veterans' Appeals (Board) on appeal from a February 2004 rating decision of the Phoenix, Arizona Department of Veterans Affairs (VA) Regional Office (RO). Hearings before a Decision Review Officer (DRO) at the RO were held in February 2006 and November 2007 (the hearing had to be repeated due to technical difficulties during the initial hearing). Transcripts of the hearings are associated with the Veteran's claims file. In October 2010 the Board sought Veterans Health Administration (VHA) advisory medical opinions in these matters. FINDINGS OF FACT 1. Symptoms of the Veteran's diverticulitis are reasonably shown to have been aggravated by his service-connected PTSD, and his (now) service-connected IBS.. 2. The Veteran's IBS is reasonably shown to have been aggravated by his service-connected PTSD. 3. Symptoms of the Veteran's hiatal hernia are reasonably shown to have been aggravated by his service-connected PTSD, and his (now) service-connected IBS.. 4. 50 percent of the Veteran's hypertension disability is reasonably shown to have been caused by his service-connected PTSD. 5. The Veteran's TIAs were not manifested in, and are not related to, his service; were not manifested within the first post-service year; and are not shown to have been caused or aggravated by a service-connected disability, to include PTSD and hypertension. CONCLUSIONS OF LAW 1. Secondary service connection for diverticulitis is warranted. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. § 3.310(a) (2011). 2. Secondary service connection for IBS is warranted. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. § 3.310(a) (2011). 3. Secondary service connection for hiatal hernia is warranted. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. § 3.310(a) (2011). 4. Secondary service connection for 50 percent of the Veteran's hypertension disability is warranted. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. § 3.310(a) (2011). 5. Service connection for TIAs, to include as secondary to a service connected disability, is not warranted. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310(a) (2011). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). The VCAA applies to the instant claims. Regarding the claims of service connection for hypertension, diverticulitis, IBS, and hiatal hernia, inasmuch as the benefits sought are being granted, there is no reason to belabor the impact of the VCAA as to these issues; any notice defect or duty to assist omission is harmless. Regarding the claim of service connection for TIAs, the Veteran was advised of VA's duties to notify and assist in the development of his claim prior to its initial adjudication. An August 2003 letter (prior to the initial February 2004 rating decision) as well an April 2005 letter explained the evidence necessary to substantiate his claim, the evidence VA is responsible for providing, and the evidence he is responsible for providing. A March 2006 letter informed the Veteran of disability rating and effective date criteria. He has had ample opportunity to respond/supplement the record and has not alleged that notice in this case was less than adequate. The Veteran's service treatment records (STRs) are associated with his claims file and pertinent postservice treatment records have been secured. The RO arranged for an examination in August 2003 (with addendum in September 2003). In October 2010, the Board sought a VHA medical advisory opinions (by a gastroenterologist and a cardiologist). The opinions received are adequate for rating purposes, as they reflect familiarity with the record, and include a detailed explanation of rationale, with citation to medical literature. Barr v. Nicholson, 21 Vet. App. 303 (2007). The Veteran has not identified any pertinent evidence in this matter that remains outstanding. VA's duty to assist is met. Legal Criteria, Factual Background, and Analysis Initially, the Board notes that all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to this appeal, has been reviewed. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence as appropriate, and the analysis below will focus specifically on what the evidence shows, or fails to show, as to the claims. Service connection may be granted for disability due to disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303, 3.304. Service connection may also be granted for any disease initially diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). To substantiate a claim of service connection, there must be: (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. Hickson v. West, 12 Vet. App. 247, 253 (1999). Certain chronic diseases (to include brain hemorrhage) may be presumed to be service connected if they are manifested to a compensable degree within a specified period of time (one year for brain hemorrhage) after a Veteran's discharge from active duty. 38 U.S.C.A. §§ 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. Service connection may be established on a secondary basis for a disability that is proximately due to, the result of, or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310(a); see also Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). The threshold legal requirements for a successful secondary service connection claim are: (1) Evidence of a current disability for which secondary service connection is sought; (2) a disability which is service connected; and (3) competent evidence of a nexus between the two. The determination as to whether these requirements are met is based on an analysis of all the evidence of record and an evaluation of its credibility and probative value. 38 C.F.R. § 3.303(a); Baldwin v. West, 13 Vet. App. 1 (1999). When there is an approximate balance of positive and negative 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. When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). The Veteran's STRs are silent as to hypertension, TIAs, diverticulitis, IBS, and hiatal hernia. There is likewise no evidence that TIAs were manifested in the first year following the Veteran's discharge from active duty. The evidence of record shows findings of colonic diverticulosis as early as in March 1999, hiatal hernia as early as in April 1999, and hypertension as early as in June 2000. A May 2003 statement from N.D.S, M.D., the Veteran's private physician, provides the following in support of his claim: [The Veteran] suffers from post-traumatic stress disorder and depression. He has a number of comorbid medical illnesses, which can be related to and/or exacerbated by PTSD, most notably he has significant irritable bowel problems, which is quite likely a result of and induced by emotional stressors related to PTSD. In addition, he suffers from symptoms of reflux and a hiatal hernia, which are exacerbated during times of emotional stress, as well as hypertension, which is also worsened by emotional stress as well. In addition, he has suffered from lacunar infarcts in the past a well as some TIAs [transient ischemic attacks]. Of note, he has only had episodes of TIA during times when his PTSD has been more florid, and he has more notable flashbacks and nightmares. In an August 2003 statement, Dr. N.D.S opined that there is no direct way to prove the relationship between the Veteran's PTSD and several of his physical conditions. Nonetheless, in the several years he has seen the Veteran, he noticed that a number of his complaints were worse during times when he manifested increased depression and anxiety. It was noted that when the Veteran was "having increased numbers of flashbacks, dreams, etc., he does report significant increase in bloating, cramping and loose watery stools consistent with irritable bowel." In addition, the Veteran reported his blood pressure rose considerably during periods of extreme anxiety, stress and flashbacks. Dr. Stolzberg stated "all of this is perfectly reasonable and plausible as all three of these conditions do have a strong psychological component." A June 2000 Progress Note from Dr. Stolzberg notes that the Veteran's hypertension had worsened recently "[p]robably the combined effects of weight gain, smoking, etc." (thus, attributing the worsening symptoms to factors other than the service-connected PTSD). An August 2003 VA examination report includes the following findings/conclusions: (1) The etiology of the patient's high blood pressure is that of essential hypertension. There is no direct relationship between the patient's hypertension and his posttraumatic stress disorder, even though his posttraumatic stress disorder actually predates his high blood pressure condition. His posttraumatic stress disorder can sometimes exacerbate his hypertension in an episodic fashion, that which is self-limiting, and that which has not caused any residuals as a result of his high blood pressure. (2) Diverticulitis; this is not related nor is it exacerbated by the patient's posttraumatic stress disorder. (3) Irritable bowel syndrome; the patient does, indeed, present with a history diagnostic of irritable bowel syndrome, but this is not secondary to his already service connected posttraumatic stress disorder condition. On the other hand, the patient's episodic stressful situations associated with his posttraumatic stress disorder can contribute to the worsening of his irritable bowel syndrome symptoms only when the irritable bowel syndrome symptoms are present prior to the exacerbation of the posttraumatic stress disorder symptoms. (4) Hiatal hernia; known gastroesophageal reflux disease and hiatal hernia on the patient's recent esophagogastroduodenoscopy dated August 2001. The patient's hiatal hernia and gastroesophageal reflux symptoms are not related nor are they exacerbated by his posttraumatic stress disorder condition. (5) Stroke; at the present time, aside from the patient's already established extremity neuropathy of unclear etiology, there are no neurological sequela from this alleged stroke to have occurred back in 1983. Even though the patient's primary care physician writes a letter mentioning some lacunar infarcts and transient ischemic attacks, there is no specific evidence to substantiate these. Moreover, even if there was a history of a real cerebrovascular accident in the past, again there are no residuals at the present time from this, and there is no medical literature showing a direct relationship between strokes and posttraumatic stress disorder. As such, there is also no exacerbation of the patient's "stroke" as a result of his posttraumatic stress disorder. Regarding hypertension, a September 2003 addendum to the August 2003 VA examination report explains, "there were no specific baseline manifestations elicited from the above evaluation other than the mentioned renal insufficiency. His episodic PTSD exacerbations marked by anxiety symptoms can only episodically worsen his blood pressure control but not likely to consequently cause any end organ damage that can be objectively measured. At the February 2006 and November 2007 DRO hearings, the Veteran testified that he had medication for hypertension prescribed 15 to 16 years prior, had PTSD diagnosed 6 or 7 years prior, and he was told by physicians that his strokes were stress-related. He recalled that he had diverticulitis diagnosed with about 10 to 12 years prior and that his symptoms fluctuate between diverticulitis and IBS. He and his wife testified that his hiatal hernia is triggered by acid reflux, which is brought on by stress. Because of the apparent conflict in the medical opinions and because no opinion included rationale that addressed all factors considered by the other opinion-providers, the Board found that further medical guidance was necessary. In October 2010, the Board sought VHA medical expert opinions in these matters from a gastroenterologist and a cardiologist. The consulting gastroenterologist opined that, "yes," it is as likely as not that a current gastrointestinal disability (specifically, diverticulitis, irritable bowel syndrome, and/or hiatal hernia) was caused or aggravated (i.e., chronically worsened) by the Veteran's service-connected PTSD and provided the following explanation of rationale: It is well known that the symptoms of irritable bowel syndrome can be exacerbated by psychological stress such as those that might result from PTSD. It is not clear to me whether exacerbations of the Veteran's diverticulitis and hiatal hernia symptoms are related to these named processes or are alternate manifestations of the patients irritable bowel syndrome which commonly magnifies the pain of underlying disorders (like diverticulosis). I would say that, no, diverticulitis cannot be made worse by PTSD exept through purely speculative mechanisms. I would also say that, no, hiatal hernias do not get worse because of PTSD. However, it is quite possible that symptoms of irritable bowel syndrome (and the upper GI tract variant non-ulcer dyspepsia), attributed to the Veteran's diverticulitis and hiatal hernia, are as likely as not to be aggravated by PTSD. Regarding the question of aggravation of the Veterna's diverticulitis, IBS and/or hiatal hernia by his PTSD, the VHA gastroenterologist provided the following additional explanation: In my opinion, it is not likely that the patient's hiatal hernia, irritable bowel syndrome and diverticulitis/diverticulosis were caused by the patient's PTSD. Review of his record reveals a host of other contributing factors as well (sedentary occupation, tobacco use, surgical removal of gallbladder, chronic pain syndrome treated with narcotics, obesity, prior alcoholism, etc.). It is, however, at least as likely as not that the symptoms attributed to the conditions in question are all aggravated by the patient's PTSD. This conclusion is most strongly supported by the narrative statements of the patient and the several letters from his primary care physician (Dr. [N.D.S]) which seem to relate flares in the symptoms attributed to these several conditions to flashbacks or other phenomena associated with his PTSD. It has already been stated several times in the file that the patient's PTSD could not be related to the diagnosis of hiatal hernia and diverticulosis. I agree that the relationship between PTSD and hiatal hernia and/or diverticulosis is tenuous at best. However, IBS can produce symptoms referred to both the upper and lower GI tract. It is quite plausible that symptoms attributed to the patients underlying conditions of hiatal hernia (bloating, GERD etc) and diverticulosis (lower quadrant abdominal pain and tenderness) could be magnified by the patient's IBS and exacerbated by his PTSD flares. Unfortunately, it is not possible for me to speculate about the degree of disability that results from the aggravation of this patient's IBS, hiatal hernia and diverticulitis by his PTSD as no objective criteria were provided for thresholds that could be used to establish this patient's level of disability (e.g. 10, 20, 30% etc). The VHA [Board-certified] cardiovascular diseases expert opined that "[i]t is at least as likely as not that hypertension was aggravated by the Veteran's service-connected PTSD." The VHA cardiovascular expert discussed numerous medical studies of the relationship between PTSD and the development of cardiovascular disease and provided the following explanation: These studies strongly support a link between PTSD and hypertension. The appellant in question exhibits multiple cardiovascular risk factors including obesity, tobacco use and [sic] which may indeed suggest essential hypertension as the underlying etiology for his high blood pressure, as suggested in a 2003 VA examination finding. The chronologic assignment of formal diagnoses of PTSD and hypertension are not germane to this evaluation, particularly as it appears likely (albeit by inference) that PTSD was present substantially before the formal VA establishment of diagnosis in 2002 based on preceeding documentation. The studies outlined above define an association between PTSD and risk of hypertension, but do not constitute a credible causitive effect. However, they do argue strongly for an aggravating effect of PTSD in the risk for development and severity of hypertension in this individual. The degree of contribution is not possible to estimate with any real validity. Given the ranges of relative risk increase suggested by a host of studies, a 25-50% contribution is speculated. Regarding, TIAs, the VHA cardiovascular expert opined that "it is not as likely as not that any causal or aggravating relationship exists between service-connected PTSD and TIAs and provided the following explanation of rationale: While a link is suggested between overall cardiovascular risk and PTSD, studies have examined overall mortality and/or incidence of ischemic heart disease. No data of substance was found in a search of the literature to suggest impact on cerebral events or stroke, and none related to TIA. The patient's reports of transient neurologic symptoms are quite unusual, depite putative association with circumstances of flashbacks and anxiety events, and very short lived. TIAs are conventionally considered atherothrombotic events, unrelated to BP [blood pressure] elevations. Severe hypertension can produce encephalopathy and clouding of mentation, but requires sustained and severe elevation of blood pressure. The relatively moderate elevation of BP reported with these episodes would be expected a secondary stress response but cannot be invoked as a cause of TIA. The remote and truly cryptogenic stroke more than 20 years ago cannot be related to either hypertension or PTSD. It is neither shown by the record, nor alleged, that the Veteran's diverticulitis, IBS, hiatal hernia, hypertension, or TIAs are directly related to his active service; the instant claims are based strictly on a secondary service connection theory of entitlement. The Veteran contends that the disabilities are secondary to his service-connected PTSD. An April 2003 rating decision granted the Veteran service connection for PTSD, effective June 4, 2002 and the evidence of record shows medical diagnoses of diverticulitis, IBS, hiatal hernia, hypertension, and TIAs. The remaining criterion for establishing secondary service connection for the claimed disabilities is whether there is competent evidence that such disabilities were either caused or aggravated by the PTSD. Diverticulitis, IBS, Hiatal Hernia, and Hypertension As the opinions of Dr. N.D.S. (that the Veteran's IBS and hiatal hernia and his hypertension and TIAs are related to and/or exacerbated by his PTSD) and the August 2003 VA examiner's (in essence that hypertension, diverticulitis, IBS, hiatal hernia, and stroke are unrelated to, or exacerbated by, his PTSD are conflicting, and neither was accompanied by sufficient explanation of rationale, the Board requested VHA medical advisory opinions in the matters. The VHA gastrointestinal diseases expert opined, with adequate explanation of rationale, that the Veteran's IBS is, as likely as not, aggravated by his PTSD. The Board notes, and has no reason to question, the opinion-provider's expertise in the matter. Therefore, secondary service connection for IBS is warranted. The VHA gastrointestinal diseases expert further opined (also with adequate explanation of rationale, specifically identifying some of the symptoms implicated) that the Veteran's hiatal hernia and diverticulitis are, as likely as not, aggravated by his PTSD and his (now) service-connected IBS. Therefore, secondary service-connection for such disabilities is also warranted. The cardiovascular diseases expert identified the various risk factors for hypertension, cited to various studies, and opined, in essence, that the Veteran's PTSD is responsible for 25 to 50 percent of his hypertension disability. The expert is well-qualified, and the Board has no reason to question his expertise. Because his opinion is accompanied by a detailed explanation of rationale (and the opinions previously of record are not), the Board finds the opinion the most probative evidence in the matter, and persuasive. Resolving reasonable doubt in the Veteran's favor, the Board concludes that service connection for 50 percent of the veteran's hypertension disability is warranted. TIAs The Veteran has sought to substantiate his claim of service connection for TIAs by statements from his private physician, Dr. N.D.S., who indicates in essence that the TIAs occurred when PTSD were exacerbated (and that therefore the TIAs are secondary to PTSD). However, this opinion provides insufficient explanation of rationale. The fact that two disabilities have concurrent manifestations does not establish that one caused or aggravated the other. Therefore, while the opinion has some probative value (because the Dr. N.D.S. is a medical professional who has been treating the Veteran), it lacks sufficient probative value to be persuasive; it cannot be properly weighed against opinions to the contrary. Here, there is an opinion refuting that of Dr. N.D.S. Specifically, a VHA cardiovascular diseases expert opined, referring to medical studies on the topic, that there is no causal or aggravating relationship between PTSD or hypertension and TIAs. The VHA cardiologist explained "[n]o data of substance was found in a search of the literature to suggest impact on cerebral events or stroke, and none related to TIA." The VHA cardiologist further explained that "TIAs are conventionally considered atherothrombotic events, unrelated to BP elevations. Severe hypertension can produce encephalopathy and clouding of mentation, but requires sustained and severe elevation of blood pressure. The relatively moderate elevation of BP reported with these episodes would be expected a secondary stress response but cannot be invoked as a cause of TIA." This opinion contraindicates a nexus between TIAs and both PTSD and the Veteran's serviced-connected hypertension. Because the VHA cardiovascular diseases expert based his opinion on a review of the complete record, citing to supporting clinical data (that were not addressed by Dr. N.D.S.), his opinion is the more probative (and persuasive) evidence in this matter. The statements of the Veteran and his spouse relating his TIAs to his service-connected PTSD are not competent evidence. They are laypersons, and lack the training to opine regarding the etiology of TIAs, and specifically whether they are related to the Veteran's service-connected PTSD and/or hypertension. While they are capable of observing symptoms of a disability such as TIAs, whether such symptoms are brought on, or increased, by another disability, such as PTSD or hypertension, is ultimately a complex medical question beyond the realm of lay observation. see also Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). In light of the foregoing, the Board concludes that the preponderance of the evidence is against a finding that the Veteran's TIAs are related to his service, or were caused or aggravated by his service-connected PTSD or hypertension (it is neither claimed, nor suggested by the record that the Veteran's service-connected gastrointestinal disabilities caused or aggravated the TIAs). Accordingly, this claim must be denied. ORDER Service connection for diverticulitis is granted. Service connection for IBS is granted. Service connection for hiatal hernia is granted. Service connection for 50% of the Veteran's hypertension disability is granted. Service connection for TIAs is denied. ____________________________________________ George R. Senyk Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs