Citation Nr: 1317529 Decision Date: 05/29/13 Archive Date: 06/06/13 DOCKET NO. 09-18 272 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to service connection for an acquired psychiatric disability, to include posttraumatic stress disorder (PTSD). REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD M. M. Celli, Associate Counsel INTRODUCTION The Veteran served on active duty from February 1990 to January 1994. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2007 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. FINDING OF FACT The probative, competent evidence of record does not demonstrate that an acquired psychiatric disability is related to active military service. CONCLUSION OF LAW An acquired psychiatric disability, to include PTSD, was not incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2012). The record shows that a December 2006 letter satisfied the duty to notify provisions. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The Veteran was notified of regulations pertinent to the establishment of an effective date and disability rating in the December 2006 letter. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The Board also finds that the duty to assist the Veteran has been satisfied in this case. The record includes service treatment records, VA examination reports, VA treatment records, and lay evidence. In July 2012, the Board remanded the Veteran's claim for additional development. In pertinent part, the Board instructed that the RO contact the Veteran to give him another opportunity to provide any additional specific information concerning his claimed stressor. Then, the RO was instructed to forward a copy of the Veteran's military personnel records, together with the stressor information obtained, to the Joint Services Records Research Center (JSRRC) for an attempt at stressor verification. The JSRRC was asked to provide any additional information available regarding the Veteran's stressor. Thereafter, the RO was to schedule the Veteran for a VA examination to determine the etiology of any acquired psychiatric disability, to include PTSD. Review of the claims file reflects that the RO sent the Veteran a detailed notice letter in July 2012 regarding the information necessary to verify his claimed stressor, and the evidence includes additional statements and records provided in response by the Veteran in August 2012. In addition, the Veteran underwent VA examination in October 2012 and an addendum opinion was provided by an additional VA clinical psychologist in March 2013. Here, the Board notes that the RO did not forward the Veteran's military personnel records and the newly-obtained stressor information to the JSRRC for an attempt at stressor verification. However, the record shows the March 2013 VA examiner considered credible the Veteran's lay statements regarding his in-service stressors when providing the addendum opinion and thoroughly explained why the reported stressors, considered verified, did not meet the stressor criterion for a diagnosis of PTSD. Therefore, the Board finds the Veteran was not prejudiced by the absence of an additional attempt at stressor verification attempt. In addition, the record shows the October 2012 VA examiner reviewed the Veteran's claims file and performed a clinical evaluation of the Veteran. Additionally, the March 2013 VA examiner reviewed the Veteran's claims file and provided a detailed rationale for the opinions, citing to the Veteran's relevant medical history, service treatment records, and lay statements, to include the additional evidence obtained in August 2012. Therefore, the Board finds that taken together, the October 2012 VA examination and March 2013 addendum opinion are sufficient and adequate for purposes of determining service connection. 38 C.F.R. § 3.159(c)(4); Barr v Nicholson, 21 Vet. App. 303 (2007). As such, the Board finds the RO substantially complied with the July 2012 remand. See Stegall v. West, 11 Vet. App. 268 (1998). There is no indication in the record that any additional evidence relevant to the issue decided herein is available and not part of the claims file. See Pelegrini, 18 Vet. App. 112 (2004). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of the case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537, 543 (2006); see also Dingess/Hartman, 19 Vet. App. at 486. All of the evidence in the Veteran's claims file has been thoroughly reviewed. Although an obligation to provide sufficient reasons and bases in support of an appellate decision exists, there is no need to discuss, in detail, all of the evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that the entire record must be reviewed, but each piece of evidence does not have to be discussed). The analysis in this decision focuses on the most salient and relevant evidence and on what the evidence shows or fails to show with respect to the matter decided. The Veteran should not assume that pieces of evidence, not explicitly discussed herein, have been overlooked. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (noting that the law requires only that reasons for rejecting evidence favorable to the claimant be addressed). The Veteran asserts that he has an acquired psychiatric disability as the result of traumatic events during active military service. Service connection may be established for a disability resulting from diseases or injuries which are clearly present in service or for a disease diagnosed after discharge from service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a), credible supporting evidence that the claimed in-service stressor actually occurred, and a link, established by medical evidence, between current symptomatology and an in-service stressor. Effective July 13, 2010, 38 C.F.R. § 3.304(f) was amended to eliminate the requirement for corroborating evidence of a claimed in-service stressor if it is related to a veteran's fear of hostile military or terrorist activity. 75 Fed. Reg. 39,843 (2011). The regulatory revision is applicable to a claim for service connection for PTSD that was received on or after July 13, 2010; received before July 13, 2010, but has not been decided by a regional office as of that date; appealed to the Board on or after July 13, 2010; appealed to the Board before July 13, 2010, but not decided by the Board as of that date; or pending before VA on or after July 13, 2010, because the Court of Appeals for Veterans Claims (Court) vacated a Board decision on the application and remanded it for adjudication. Id. The Board notes the Veteran's claim is affected by the amended regulation. The Veteran's service treatment records do not demonstrate complaints of, treatment for, or a diagnosis of an acquired psychiatric disability. In addition, the record does not show the Veteran had combat exposure during active duty. A March 1993 service treatment record shows an assessment of history of tachycardia periods possibly related to caffeine. The Veteran reported tightness in his chest and his heart beating fast for no reason. He stated that these symptoms began when he felt crowded or cooped up around a lot of people and also happened when he held his breath. Afterward, the Veteran reported feeling weak. It was noted that the Veteran drank caffeine regularly and had a long-term problem, with no history of chest pain or associated syncope. A December 2006 VA treatment record indicates a screening for PTSD was positive. A January 2007 VA treatment record shows diagnoses of major depressive disorder, recurrent, moderate, and rule out PTSD. The Veteran reported that he had a very stressful and dangerous job in service and remembered men being blown off the flight deck and others injured. He also stated that he was bothered by writing bad things on bombs. The Veteran reported nightmares, without remembering the details, and stated that he avoided talking about his service and watching the news about Iraq. An additional January 2007 VA treatment record indicates that when the VA physician attempted to clarify the nature of the Veteran's re-experiencing symptoms, he was somewhat vague in his description. The VA physician found the Veteran had generalized worry about bad things that might happen. The assessment was major depressive disorder, recurrent, moderate, and PTSD, chronic. VA treatment records show the Veteran participated in a PTSD educational group from February 2007 through May 2007. In a March 2007 written statement, the Veteran reported that his duties as a naval aircrewman aboard the USS America included maintaining bombs and missiles on the carrier flight deck. He contended that the flight deck was a very dangerous place, especially during night operations. The Veteran stated that he was in constant fear of being blown overboard by jet exhaust and lost at sea. He reported that a fellow airman, P., was critically injured on the flight deck when he ran into a missile and had to be airlifted off of the carrier. Thereafter, the Veteran reported he lost his nerve and became timid and scared of his job. He asserted that the incident had haunted him and affected his everyday life, with bad memories making him feel very sad and guilty. The Veteran reported being unable to sleep well and having difficulty with his marriage as the result of his inability to cope with the stress of everyday life. A June 2007 VA treatment record shows the Veteran was seen for re-evaluation and medication management with a diagnosis of PTSD, chronic. The Veteran reported having problems with insomnia but that his depression was not as bad. He stated the nightmares and flashbacks were less frequent and intense since attending the group therapy. He reported being guarded or suspicious and having conflicts with coworkers. The VA physician diagnosed PTSD, chronic. A March 2008 VA treatment record indicates the Veteran last underwent treatment for PTSD in June 2007. He reported that the PTSD group class was helpful, and he was able to cope with his symptoms at that time. A March 2012 VA treatment record shows a diagnostic impression of PTSD, and VA treatment records from May 2012 through August 2012 reflect diagnoses of depression. A September 2012 VA treatment record reveals diagnoses of depression, not otherwise specified; anxiety, not otherwise specified; alcohol dependence; cocaine abuse, in remission; rule out depression secondary to general medical condition; and rule out PTSD. The Veteran reported that he had been depressed since the early 1990's. He reported a history of being involved in Operation Desert Storm and witnessing traumatic events and injured people. The Veteran also reported a history of nightmares, flashbacks, being easily startled, and being isolative and distant in interpersonal relationships. In August 2012, the Veteran submitted additional information regarding specific in-service stressors. The Veteran reported that he witnessed two airmen assisting P. who appeared to have some sort of chest and head injury after colliding with a missile wing. He stated that he later found out P. was seriously injured and was flown off ship, and the Veteran reported that he did not see P. after he left the flight deck. The Veteran was unable to remember the exact date of P.'s accident. The Veteran also reported that he had a close friend who died while serving on the USS America, C. G. The Veteran stated that discussing these things brought back unwanted thoughts about C. G.'s death and P.'s accident. The Veteran contended that after those two events, he began to feel timid and afraid of being killed or injured on the flight deck. When he reported those symptoms to a doctor, the doctor misdiagnosed the Veteran and said his symptoms were from drinking coffee. The Veteran contended that this was untrue as he was not a heavy coffee drinker. He also recalled hearing the ship's intercom system more than once announce that a man was overboard; however, he could not recall the outcome of those situations or whether the sailors were recovered. The Veteran reported that going to sick call for mental health issues was looked down upon, which discouraged him from seeking more help in service. He stated that he continued to suffer from disturbing memories of C. G.'s death and nightmares about P.'s accident. The Veteran stated that when he returned home from service, his depression and anxiety worsened; he developed marital problems, was hypervigilant, irritable, easily startled, and had poor concentration. The Veteran reported that he became more fearful of crowds and activities that reminded him of service; his moods were mostly depressed and he felt numb and detached, which affected his relationships with everyone. The Veteran stated that he had been unable to maintain steady employment since service due to his mental health issues. The Veteran also submitted a written statement from his buddy, K. S., who reported that he was stationed aboard the USS America with the Veteran. He noted that he and the Veteran were assigned to the flight deck shop and that their responsibilities included signing out ordnance to the squadron personnel, maintaining ready service lockers, and bringing ordnance up an elevator. K. S. also stated that he and the Veteran were responsible for running the elevator down to medical for anyone that might have been injured on the flight deck so that they could receive treatment. He reported they also assisted the air wing ordnance personnel in providing a safe area on the flight deck to disarm various forward firing ordnance. K. S. reported that around June 1993, a fellow ordnance man, P., was disarming a missile and ran into a very sharp missile wing, which split his head open. K. S. stated P. needed immediate medical attention, and therefore he and the Veteran went to operate the elevator. As P. was brought over on a stretcher, they observed the extent of his injury. K. S. repeated the Veteran's assertions that the flight deck was a very dangerous place where you had to be aware at all times, and he stated that he and the Veteran had to be removed from the flight deck after the incident as P. was a very good friend. K. S. also reported that in August 1993, he and the Veteran were in their home port and veterans of the flight deck shop. In September 1993, he decided to travel with a new guy who was a friend of the two, C. G. On the trip, he stated that he and C. G. ended up with pneumonia and severe dehydration. K. S. stated that upon their return to their home port, C. G. became sick and passed away two days after he and the Veteran helped him to medical. K.S. reported that he and the Veteran were unable to attend the funeral but did feel the effects afterward of the loss of their friend. In October 2012, the Veteran underwent VA examination in connection with his claim. The VA examiner reviewed the Veteran's claims file and performed a psychological evaluation of the Veteran. The VA examiner found the Veteran did not have a diagnosis of PTSD that conformed to the Diagnostic and Statistical Manual of Mental Disorders, Fourth edition (DSM-IV), American Psychiatric Association (1994). Further, the VA examiner determined that the Veteran did not have any mental disorder that conformed to DSM-IV criteria. The VA examiner noted that the Veteran was spontaneously tearful during the interview and tried to make a case that he had PTSD because of exposure to normal aircraft carrier flight deck duty. The VA examiner found the Veteran's contentions were not plausible and that the Veteran was not able to detail PTSD symptoms. The Veteran described that he was distant from his wife because he could not adjust to civilian life. The Veteran was enrolled in college pursuing an Associate's degree and last worked full-time approximately five years prior. The Veteran described symptoms of anxiety and a negative attitude toward working and marriage. However, the VA examiner saw no link between any mental complaints and the Veteran's military service. As such, the VA examiner found the Veteran's claim of PTSD lacked credibility and plausibility. The VA examiner noted the Veteran's reported stressor of a dangerous flight deck assignment for two and a half years but found it did not meet Criterion A to support a diagnosis of PTSD and was not related to the Veteran's fear of hostile military or terrorist activity. The VA examiner found the Veteran's intelligence was within the superior range based on Vocabulary SS 17 on the Wechsler Adult Intelligence Scale III. Despite his high intellect, however, the Veteran produced an exaggerated, invalid Minnesota Multiphasic Personality Inventory (MMPI). Therefore, in light of the clinical findings and the Veteran's lack of credibility, the VA examiner opined that the Veteran did not have PTSD or any mental disorder caused by military service. A different VA examiner provided an addendum opinion in March 2013 with respect to the Veteran's claim. After a review of the Veteran's claims file, the VA examiner opined that the claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The VA examiner found there was no evidence to support a clinical diagnosis of PTSD according to DSM-IV-TR criteria. The VA examiner stated that the Veteran's reported stressor did not meet Criteria A, as merely experiencing unpleasant events, such as working under stressful or dangerous conditions, irrespective of how subjectively upsetting they may be, does not qualify one for a diagnosis of PTSD. Furthermore, the Veteran had produced an invalid and exaggerated MMPI profile on objective testing in October 2012. The VA examiner found this invalid and exaggerated MMPI profile provided objective evidence that the Veteran did not have a clinical diagnosis of an Axis I mood disorder because of over-exaggeration, feigning, or possibly malingering of mood disorder symptoms in an effort to be seen in an unfavorable light for evaluation and monetary purposes. The VA examiner further opined that the Veteran's diagnoses of alcohol dependence, cocaine abuse, and substance-induced mood disorder with depressive features were not caused by or related to his military service, and it was at least as likely as not that any mood disorder symptoms previously reported were secondary to the Veteran's substance use/abuse/dependence issues. The VA examiner reported that the rationale for the opinion was based on an extensive review of the Veteran's claims file, to include his service records, mental health records, DSM-IV-TR diagnostic criteria, the October 2012 VA examination, and the training and experience of the examiner herself. As noted above, the March 2013 VA examiner diagnosed alcohol dependence, cocaine abuse, and substance-induced mood disorder with depressive features. The VA examiner found that the best mood disorder diagnosis for the Veteran's reported symptoms during the period of 2006 through 2012 would be a substance-induced mood disorder with depressive features, given the extent of his alcohol dependence and cocaine abuse, rather than major depression, depressive disorder, not otherwise specified, or PTSD. The VA examiner opined that it was at least as likely as not that the Veteran was incorrectly diagnosed by his outpatient mental health providers because the Veteran was not forthcoming about his problems with addiction to alcohol and cocaine during his therapeutic meetings with them. According to the VA examiner, the diagnosis of substance-induced mood disorder was most appropriately used when the prominent and persistent disturbance in mood that predominated the clinical picture was characterized by depressed mood, diminished interest or pleasure in almost all activities, and irritable mood, with evidence from history and examinations that the symptoms developed during or within a month of substance intoxication/withdrawal. Further, the VA examiner noted that at the Veteran's last medication management visit in January 2013, it was reported that his mood was euthymic and his affect congruent, which implied a normal, non-depressed, reasonably positive mood. The VA examiner found the fact that the Veteran's medications helped with his symptoms supported the contention that his mood disorder was substance-induced because as the Veteran maintained sobriety, his mood continued to improve with the use of psychotropic medications, which it had not done in the past while he was still abusing alcohol and cocaine. Furthermore, the March 2013 VA examiner found that the previous diagnoses were all based on the Veteran's subjective reports of symptoms with no collection of objective data until psychological testing was completed in October 2012. In this respect, the VA examiner found the Veteran was not forthcoming with his mental health providers regarding his alcohol and cocaine use/abuse/dependence so that a more appropriate clinical diagnosis could be rendered. The VA examiner stated that extensive review of the mental health records did not reveal sufficient evidence of symptoms reported by the Veteran that would be supportive of the clinical diagnoses. The VA examiner agreed with the October 2012 VA examiner's contention that the Veteran's claim lacked credibility and plausibility and also agreed that the Veteran did not have PTSD or any mental disorder caused by military service. The VA examiner commented on the specific mental disorders previously diagnosed and highlighted the inconsistencies in the Veteran's reported symptomatology and the lack of objective data. The VA examiner also acknowledged the Veteran's reported stressor of witnessing his friends injured on the flight deck but noted that the stressor was not related to combat and did not meet Criteria A for a diagnosis of PTSD. Further, VA mental health progress notes did not provide any specific evidence of a stressful event in service necessary to support the clinical diagnosis of PTSD. In fact, one of the mental health notes showed the Veteran was vague when asked for specific stressors. Here, the Board finds the probative, competent evidence of record does not demonstrate that the Veteran has an acquired psychiatric disability as the result of active military service. First, the Board acknowledges that multiple VA treatment records indicate various diagnoses of acquired psychiatric disabilities, to include PTSD, major depressive disorder, and anxiety, during the pendency of the appeal. However, the Board affords this evidence less probative value than the October 2012 and March 2013 VA examination and opinions. Here, it is not clear whether the VA physicians providing the previous diagnoses reviewed the Veteran's claims file, to include his service treatment records. Conversely, the evidence demonstrates that the October 2012 and March 2013 VA examiners reviewed the Veteran's claims file in detail prior to providing the opinions. In addition, the March 2013 VA examiner cited to specific records as bases for the opinions provided. The Board acknowledges that when contemplating a medical opinion, the relevant inquiry is whether "the examiner providing the report or opinion is fully cognizant of the claimant's past medical history." Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). Here, it appears that the VA physicians were basing their diagnoses on the medical history and symptoms as reported by the Veteran. In this respect, the Veteran is competent to testify to events and symptoms that he actually experienced or witnessed. See Layno v. Brown, 6 Vet. App. 465, 469-70 (1994) (holding that a lay witness is competent to testify to that which the witness has actually observed and is within the realm of his personal knowledge). However, while the Veteran's statements have been deemed competent evidence, the Board must also determine whether such evidence is credible. Id. Upon review, the Board finds the Veteran's service treatment records do not corroborate the information provided by the Veteran and K. S. In particular, although K. S. stated P. was injured in June 1993, the Veteran asserted that the March 1993 service treatment record showed he went to sick call following the incident. Additionally, per the October 2012 and March 2013 VA examiners, the Veteran's reported stressors, if presumed credible, still did not satisfy the criteria for a diagnosis of PTSD and also did not involve fear of hostile military or terrorist activity as provided for in 38 C.F.R. § 3.304(f). In addition, the October 2012 VA examiner specifically found that the Veteran's claim of PTSD lacked credibility and plausibility and that despite the Veteran's high intellect, he had produced an exaggerated, invalid MMPI. As pointed out by the March 2013 VA examiner, the claims file reflects various inconsistencies with respect to the Veteran's reported medical history and symptomatology. See Caluza v. Brown, 7 Vet. App. 498, 511 (1995) (noting that credibility may be impeached by a showing of inconsistent statements or consistency with other evidence), aff'd, 78 F.3d 604 (Fed. Cir. 1996). The VA examiner opined that it was at least as likely as not that the Veteran was incorrectly diagnosed by his outpatient mental health providers because the Veteran was not forthcoming about his problems with addiction to alcohol and cocaine during his therapeutic meetings with them. As a result, the Board finds the Veteran's lay testimony not credible, and therefore, the previous diagnoses of acquired psychiatric disabilities that were based solely upon the Veteran's own reports carry less probative weight than the opinions provided by the October 2012 and March 2013 VA examiners. Additionally, the Board notes that the October 2012 and March 2013 VA opinions that the Veteran did not have a diagnosis of PTSD in accordance with the DSM-IV are not contradicted by any other medical opinions of record. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991) (VA may only consider independent medical evidence to support its findings and is not permitted to base decisions on its own unsubstantiated medical conclusions). Here, the October 2012 and March 2013 VA examiners reviewed the Veteran's claims file in detail and cited to specific records when providing the opinions. Moreover, the March 2013 VA examiner provided a thorough, detailed rationale for the opinions, specifically addressing the history of mental disorder diagnoses of record and the Veteran's reported stressors and symptomatology. As a result, the Board affords the October 2012 VA examination and the March 2013 VA addendum opinion significant probative value with respect to the issue on appeal. Furthermore, although the Veteran asserts that he has PTSD, it is well established that a layperson without medical training is not qualified to render a medical diagnosis of an acquired psychiatric disability. See 38 C.F.R. § 3.159(a)(1); see Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); see also Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). The question of whether the Veteran currently has an acquired psychiatric disability related to active military service does not lie within the range of common experience or common knowledge. It is not shown that the Veteran is otherwise qualified through specialized education, training, or experience to offer a medical opinion as to a diagnosis or etiology of an acquired psychiatric disability. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). Based on the foregoing, the Board finds that the preponderance of the evidence is against a grant of service connection for an acquired psychiatric disability, to include PTSD. In reaching the above conclusion, the Board has considered the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable, and service connection must be denied. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). ORDER Entitlement to service connection for an acquired psychiatric disability, to include PTSD, is denied. ____________________________________________ ROBERT C. SCHARNBERGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs