Citation Nr: 1317679 Decision Date: 05/30/13 Archive Date: 06/06/13 DOCKET NO. 12-00 056 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Indianapolis, Indiana THE ISSUES 1. Entitlement to service connection for diabetes mellitus type II. 2. Entitlement to service connection for a psychiatric disability other than posttraumatic stress disorder (PTSD), to include bipolar disorder, depression and an anxiety disorder. REPRESENTATION Veteran represented by: The American Legion WITNESSES AT HEARING ON APPEAL Veteran, his father, mother and a friend ATTORNEY FOR THE BOARD L. J. N. Driever INTRODUCTION The Veteran served on active duty from October 2004 to January 2006. He also served in the National Guard from August 1994 to December 1994 (active duty for training) and from October 2005 to May 2006. These claims come before the Board of Veterans' Appeals (Board) on appeal of a February 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Indianapolis, Indiana. The Veteran, J. S., L.S. and S.M. testified in support of these claims during a video conference hearing before the undersigned Acting Veterans Law Judge (AVLJ) in September 2012. In November 2012, the Board remanded these claims to the RO for additional action. At the time, the claims on appeal included entitlement to service connection for a cognitive disorder, PTSD, traumatic brain injury and vision disorder. In a rating decision dated March 2013, however, the Board granted these claims. There are therefore no longer before the Board for appellate review. The Virtual VA paperless claims processing system (Virtual VA) includes no other pertinent documents for consideration in support of these claims. This appeal is advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. A medical examiner noted that the Veteran had type II diabetes on his entrance examination. 2. The Veteran's preexisting diabetes mellitus type II did not worsen in severity in service beyond its natural progression. 3. The Veteran has variously diagnosed psychiatric disabilities other than PTSD, the symptoms of which are related to the Veteran's active service, but already considered part of his service-connected PTSD and residuals of a traumatic brain injury (TBI). CONCLUSIONS OF LAW 1. Diabetes mellitus type II was not incurred in or aggravated by active service and may not be presumed to have been so incurred. 38 U.S.C.A. §§ 101, 1101, 1110, 1111, 1112, 1113, 1153 (West 2002); 38 C.F.R. §§ 3.6, 3.303, 3.304, 3.306, 3.307, 3.309 (2012). 2. Psychiatric disabilities other than PTSD, variously diagnosed, were incurred in service and are part of, rather than separate from, the Veteran's PTSD and residuals of a TBI. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duties to Notify and Assist Upon receipt and prior to consideration of most applications for VA benefits, VA is tasked with satisfying certain procedural requirements outlined in the Veterans Claims Assistance Act of 2000 (VCAA) and its implementing regulations. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). The United States Court of Appeals for Veterans Claims (Court) has mandated that VA ensure strict compliance with the provisions of the VCAA. Quartuccio v. Principi, 16 Vet. App. 183 (2002). A. Notice The VCAA and its implementing regulations provide that VA is to notify a claimant and his representative, if any, of the information and medical or lay evidence not previously provided to the Secretary that is necessary to substantiate a claim. As part of the notice, VA is to specifically inform the claimant and his representative, if any, of which portion of the evidence the claimant is to provide and which portion of the evidence VA will attempt to obtain on the claimant's behalf. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). These notice requirements apply to all five elements of a service connection claim, including: (1) veteran status; (2) existence of disability; (3) a connection between service and disability; (4) degree of disability; and (5) effective date of disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 484 (2006), aff'd sub nom. Hartman v. Nicholson, 483 F.3d 1311 (2007). Ideally, the RO should provide the claimant VCAA notice before initially deciding his claim unfavorably. Pelegrini v. Principi, 18 Vet. App. 112 (2004) (Pelegrini II). If, however, for whatever reason the RO does not, or provides the notice in a timely manner but it is inadequate or incomplete, the RO can effectively cure this error by providing any necessary VCAA notice and then readjudicating the claim in a statement of the case (SOC) or supplemental SOC (SSOC). In such a case, the intended purpose of the notice is not frustrated, rather preserved, and the claimant is given ample opportunity to participate effectively in the adjudication of the claim. See Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007) (Mayfield IV); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). The U. S. Supreme Court has made clear that VCAA notice errors, even when shown to have occurred, are not presumptively prejudicial, instead, must be judged on a case-by-case basis. As the pleading party attacking the agency's decision, the Veteran has the burden of proof of not only establishing error but also, above and beyond that, of showing how it is unduly prejudicial, meaning outcome determinative of his claim, i.e., more than harmless. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009). The RO in this case sent the Veteran VCAA notice letters pertaining to his claims in November 2009, December 2009 and November 2012, the latter after initially deciding those claims. That letter is therefore untimely. The RO cured this timing defect later, however, by readjudicating the Veteran's claims in a supplemental statement of the case issued in March 2013. These letters satisfy the content requirements of the VCAA. Therein, the RO informed the Veteran of the evidence needed to substantiate his claims, identified the type of evidence that would best do so, notified him of VA's duty to assist and indicated that it was reviewing his claims pursuant to this duty. The RO provided the Veteran all necessary information on disability ratings and effective dates. The RO identified the evidence the RO had requested and/or received in support of the Veteran's claims and the evidence it was responsible for securing. The RO noted that it would make reasonable efforts to assist the Veteran in obtaining all outstanding evidence provided he identified its sources, but that it was the Veteran's responsibility to ensure VA's receipt of all pertinent evidence. The Veteran received further notice in September 2012, during his hearing, when the undersigned AVLJ questioned him regarding whether his diabetes mellitus and psychiatric disability existed prior to service and what types of stressful events he experienced during service. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that, pursuant to 38 C.F.R. § 3.103(c)(2), the VLJ who chairs a hearing must satisfy two duties, including : (1) fully explaining the issue; and (2) suggesting the submission of evidence that may have been overlooked. Here, the AVLJ elicited testimony from the Veteran, family members and a friend on the onset of the diabetes mellitus and psychiatric disability. By so doing, the AVLJ implicitly described the nature of service connection claims, including those based on aggravation. The AVLJ did not suggest the submission of any outstanding evidence, thereby violating Bryant. Nonetheless, a remand for further notification is not necessary. Rather, given subsequent action the Board took, any notification error is harmless and non-prejudicial to the Veteran and does not affect the essential fairness of this adjudication. Conway v. Principi, 353 F.3d 1369, 1374 (Fed. Cir. 2004); Bernard v. Brown, 4 Vet. App. 384, 394 (1993). Following the hearing, in a Remand dated November 2012, the AVLJ identified outstanding treatment records that needed to be obtained in support of the Veteran's claims. The AVLJ also described the nature of these claims by indicating that evidence was needed to establish whether the Veteran has a psychiatric disorder other than PTSD that is due to active service and whether his diabetes mellitus, detected on enlistment, permanently worsened beyond its natural progression during active service. The Veteran therefore received all essential notice and, as such, had a meaningful opportunity to participate in the development of these claims. Neither the Veteran nor his representative asserts that VA failed to comply with VCAA's notice provisions or the requirements set forth in Bryant. B. Assistance VA is also to assist a claimant in obtaining evidence necessary to substantiate a claim, but such assistance is not required if there is no reasonable possibility that it would aid in substantiating the claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). The RO attempted to obtain all evidence the Veteran identified as being potentially pertinent to his claims, including service and post-service VA treatment records. In addition, the RO afforded the Veteran a hearing, during which he testified as to the onset of his psychiatric disabilities and diabetes mellitus, and multiple VA examinations, during which examiners addressed the etiology of these disabilities. The Veteran does not now contend that the hearing or VA examinations were inadequate or that further opinion is needed. II. Analysis The Veteran seeks grants of service connection for diabetes mellitus and a psychiatric disability other than PTSD. According to his initial application for compensation and a written statement received in June 2009, both of these disabilities initially manifested in December 2005. According to subsequently submitted written statements, his diabetes existed prior to service, but was diet controlled, not necessitating medication until shortly after discharge. The Veteran asserts that, given this fact, he should be granted service connection for this condition on an aggravation basis. He also asserts that he has psychiatric disabilities other than PTSD, including bipolar disorder, which are related to the stress and anxiety caused by his combat service and, as such, should be service connected on a direct basis. During his hearing, the Veteran clarified that he was prediabetic prior to service, ate unhealthy MREs continuously during service, began seeing higher blood glucose readings following discharge, and was diagnosed with diabetes in 2008. The Veteran disputes the adequacy of his first VA mental health examination, conducted in January 2010, on the basis that the VA examiner focused on events that occurred during his childhood, rather than on events that occurred during his combat period. He questions how a VA examiner who met with him for less than a hour can formulate a psychological diagnosis that refutes diagnoses rendered during years of continuous VA treatment, therapy and counseling. Acknowledging the Veteran's assertions and considering them in conjunction with all other pertinent documents of record, the Board finds that the evidence supports a grant of the claim for service connection for a psychiatric disability other than PTSD, as part of the PTSD, but that the preponderance of the evidence is against a grant of service connection for diabetes mellitus on a direct, presumptive or aggravation basis. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active military, naval or air service. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303(a) (2012). Active service includes: active duty; any period of active duty for training (ACDUTRA), during which an individual became disabled or died from injury or disease incurred in or aggravated in the line of duty; and any period of inactive duty training (INACDUTRA), during which an individual became disabled or died from injury or disease incurred in or aggravated in the line of duty or from an acute myocardial infarction, a cardiac arrest, or a cerebrovascular accident that occurred during such training. 38 U.S.C.A. §§ 101(21), (24), 106 (West 2002); 38 C.F.R. § 3.6(a), (d) (2012). To prevail on the issue of service connection, there must be competent evidence of: (1) a current disability; (2) in-service occurrence or aggravation of a disease or injury; and (3) a nexus between the in-service injury or disease and the current disability. Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Once evidence is determined to be competent, its credibility must be evaluated. Layno v. Brown, 6 Vet. App. 465, 469 (1994) (distinguishing between competency, a legal concept focusing on whether testimony may be heard and considered, and credibility, a factual determination focusing on the probative value of the evidence); see also Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994) (in rendering a decision on appeal the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant). Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises or authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). A layperson is generally incapable of opining on matters requiring medical knowledge. Routen v. Brown, 10 Vet. App. 183, 186 (1997), aff'd sub nom. Routen v. West, 142 F.3d 1434 (Fed. Cir. 1998), cert. denied, 119 S. Ct. 404 (1998). In certain instances, however, a lay statement may be deemed competent and adequate to support a claim for service connection by substantiating the occurrence of lay-observable events or a disability or symptoms of disability subject to lay observation. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence); Barr v. Nicholson, 21 Vet. App. 303 (2007) (layperson is competent to report disease with unique and readily identifiable features such as varicose veins); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept. 14, 2009). If a chronic disease is shown in service, subsequent manifestations of the same disease, however remote, are to be service connected, unless clearly attributable to intercurrent causes. For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or diagnosis including the word "chronic." 38 C.F.R. § 3.303(b). When certain chronic diseases are at issue, such as diabetes mellitus and psychoses, or any other disease enumerated at 38 C.F.R. § 3.309(a), see Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013), a claimant may establish entitlement to service connection based on a demonstration of continuity of symptomatology. Evidence of continuity of symptomatology is required only where the condition noted during service is not, in fact, shown to be chronic or when the diagnosis of chronicity may be legitimately questioned. 38 C.F.R. § 3.303(b). Continuity of symptomatology may be demonstrated by submitting evidence showing: (1) that a condition was "noted" during service; (2) post-service continuity of the same symptomatology; and (3) a nexus between the present disability and the post-service symptomatology. Savage v. Brown, 10 Vet. App. 488, 495-97; see also Hickson v. West, 12 Vet. App. 247, 253 (1999) (lay evidence of in-service incurrence sufficient in some circumstances for purposes of establishing service connection). Service connection may 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) (2012). Service connection may also be granted when a claimed disability is found to be proximately due to or the result of a service-connected disability, or when any increase in severity (aggravation) of a nonservice-connected disease or injury is found to be proximately due to or the result of a service-connected disability, not to the natural progress of the nonservice-connected disease or injury. VA will not concede service connection in such a case unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the non-service connected disease or injury. 38 C.F.R. § 3.310(a) (2012); see also Allen v. Brown, 7 Vet. App. 439, 448 (1995). A claim for service connection on a secondary basis requires medical evidence that connects the asserted secondary disorder to the service-connected disability. Velez v. West, 11 Vet. App. 148, 158 (1998). More specifically, to establish entitlement to service connection on a secondary basis, the claimant must submit: (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical evidence establishing a nexus (i.e., link) between the service-connected disability and the current disability. Wallin v. West, 11 Vet. App. 509, 512 (1998). Service connection may be presumed for certain medical conditions such as diabetes mellitus and psychoses if it is shown that a veteran served continuously for 90 days or more during a period of war or during peacetime after December 31, 1946, the condition manifested to a degree of 10 percent within one year from the date of discharge, and there is no evidence of record establishing otherwise. 38 U.S.C.A. §§ 1101, 1112(a), 1113 (West 2002); 38 C.F.R. §§ 3.307, 3.309(a) (2012). In the case of any veteran who has engaged in combat with the enemy in active service during a period of war, satisfactory lay or other evidence that an injury or disease was incurred or aggravated in combat will be accepted as sufficient proof of service connection if the evidence is consistent with the circumstances, conditions or hardships of such service, even though there is no official record of such incurrence or aggravation. 38 U.S.C.A. § 1154(b) (West 2002). "Satisfactory evidence" is credible evidence. Collette v. Brown, 82 F.3d 389, 392 (1996). Such evidence may be rebutted by clear and convincing evidence to the contrary. 38 U.S.C.A. § 1154(b). The provisions of 38 U.S.C.A. § 1154(b) do not establish a presumption of service connection in combat cases but rather ease the combat veteran's burden of demonstrating the occurrence of some in-service incident to which a current disability may be connected. Clyburn v. West, 12 Vet. App. 296, 303 (1999); Caluza v. Brown, 7 Vet. App. 498, 507 (1995). A. Diabetes Mellitus 1. Preexistence A veteran who served during a period of war is presumed to have been in sound condition when examined, accepted and enrolled in service, except for defects noted at the time of entrance, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C.A. § 1110 (West 2002). According to 38 C.F.R. § 3.304(b) (2012), the term "noted" denotes only such conditions that are recorded in examination reports. A history of pre-service existence of conditions recorded at the time of examination does not constitute a notation of such conditions but will be considered together with all other material evidence in determinations as to inception. 38 C.F.R. § 3.304(b)(1); Crowe v. Brown, 7 Vet. App. 238 (1994). If a preexisting disability is noted upon entry into service, the veteran may not bring a claim for service connection for that disability on a direct basis, but may bring that claim on an aggravation basis. In such a case, the provisions of 38 C.F.R. § 1153 apply and the veteran has the burden of establishing such aggravation. See Jensen v. Brown, 19 F.3d 1413, 1417 (Fed. Cir. 1994). To rebut the presumption of soundness, VA must show by clear and unmistakable evidence both that the disease or injury existed prior to service and that the disease or injury was not aggravated by service. See VAOPGCPREC 3-2003 (July 16, 2003); see also Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004) (holding that VA, rather than the claimant, bears the burden of proving that a disability preexisted service and was not aggravated therein); 70 Fed. Reg. 23,027, 23,029 (May 4, 2005) (applies to claims pending on or filed after May 4, 2005). The Veteran in this case had active service from October 2004 to January 2006. On examination conducted in February 2003, prior to active duty for the purpose of retention in the Army National Guard, the Veteran had a blood glucose level of 136. He reported a history of diet-controlled diabetes and the examiner noted that condition since 2001. On initial medical review conducted in July 2004 for the purpose of entering active duty, the Veteran again reported that he had diet-controlled type II diabetes. The service department noted that this medical history required further evaluation by a Medical Evaluation Board and that, temporarily, the Veteran was unfit for active duty. The Veteran underwent this evaluation in November 2004, at which time a physician found that, because the Veteran did not need medication for diabetes, he was fit for active duty. The Veteran contends that these findings establish that he was prediabetic on entrance into the service, but no medical professional characterized him as such at that time. Rather, two medical examiners noted type II diabetes, albeit diet controlled, including one on the initial examination report. The Veteran is therefore not presumed to have been in sound condition with regard to his pancreas when examined, accepted and enrolled in service. 2. Aggravation A preexisting disease will be considered to have been aggravated by military service when there is an increase in disability during such service, unless there is a specific finding that the increase is due to the natural progress of the disease. 38 U.S.C.A. § 1153 (West 2002); 38 C.F.R. § 3.306(a) (2012). Temporary or intermittent flare-ups of a preexisting injury or disease are not sufficient to be considered aggravation unless the underlying condition, as contrasted to symptoms, is worsened. Jensen v. Brown, 4 Vet. App. 304, 306-07 (1993); Hunt v. Derwinski, 1 Vet. App. 292 (1991). Clear and unmistakable evidence is required to rebut the presumption of aggravation when the pre-service disability underwent an increase in severity during service. 38 C.F.R. § 3.306(b) (2012). A claimant is not required to show that the disease or injury increased in severity during service before VA's duty under this rebuttal standard attaches. Cotant v. Principi, 17 Vet. App. 116 (2003). According to the Veteran and his service treatment records, during service, the Veteran's diabetes did not worsen. The Veteran expressed no diabetes-related complaints and did not require medication for diabetes. In November 2005 during a VA post-deployment health assessment, the Veteran reported that, during his deployment, his health stayed the same or got better. Following discharge, physicians prescribed medication for the Veteran's diabetes, which the Veteran is still taking. Since then, a VA examiner has discussed the etiology of the diabetes. In a report of VA examination conducted in December 2012, the examiner opined that the Veteran's preexisting diabetes, which was diet and exercise controlled during service, was less likely than not aggravated in service. He based this opinion on findings that the diabetes did not change during service, was diet controlled and stable from 2001 to 2008, and necessitated the same medication since a physician initiated it in 2008. The Veteran has not submitted a medical opinion refuting that of the VA examiner. His assertions of aggravation secondary to his consumption of MREs thus represent the only other evidence that speaks to the matter of in-service aggravation and those assertions are not competent. Although the Veteran is competent to describe certain symptoms of his diabetes as they are capable of lay observation, he does not have the necessary medical training or expertise to offer an opinion as to whether that medical condition permanently worsened during active service. Jandreau v. Nicholson, 492 F.3d at 1377. In the absence of competent and credible evidence indicating that the Veteran's preexisting type II diabetes increased in severity during active service, the Board concludes that the disability was not aggravated by active service. In the absence of evidence indicating that the diabetes initially manifested during or is otherwise related to service or manifested to a compensable degree within the year following discharge, the Board also concludes that the disability was not incurred in service and may not be presumed to have been so incurred. A claimant is responsible for presenting evidence in support of his claim for benefits under laws administered by VA. VA is responsible for considering all such evidence, lay and medical. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA is to give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107 (West 2002); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). In this case, the evidence is not in relative equipoise. The benefit-of-the-doubt rule is therefore not applicable. B. Psychiatric Disability other than PTSD Medical documents dated during the course of this appeal, including VA treatment records dated since 2008 and reports of VA examinations conducted in January 2010 and December 2012, confirm that the Veteran currently has psychiatric disabilities other than PTSD, which physicians have diagnosed as a mood disorder, not otherwise specified, bipolar disorder I, mixed, dysthymic disorder, depression, not otherwise specified, and major depressive disorder. The question is whether these disabilities are related to the Veteran's active service or proximately due to his service-connected PTSD. During the Veteran's service on active duty from October 2004 to January 2006, he worked as a combat engineer in Iraq, an occupational specialty that exposed him to combat, and experienced multiple stressors, including being in close proximity to an improvised explosive device (IED) when it exploded. He was awarded, in part, a Combat Action Ribbon for such service. According to his service treatment records, during active duty, he did not report any mental health complaints and no medical professional diagnosed a psychiatric disability. Rather, in February 2008, approximately a year and a half after discharge, he underwent an initial psychiatric evaluation and, since then, medical professionals have treated the Veteran with the previously noted psychiatric disabilities, PTSD, a cognitive disorder and attention deficit disorder (ADD), all noted to be related to service, the symptoms of which overlap. Based on his combat service, he is now service-connected for PTSD, residuals of a TBI and associated headaches with photophobia. The 50 percent rating assigned the Veteran's PTSD contemplates mood and motivation disturbances, anxiety, sleep impairment, depression and the social and occupational effects thereof. The 10 percent rating assigned the Veteran's TBI residuals contemplates the ADD and the cognitive deficits affecting the Veteran's memory and concentration. It is possible for a claimant to have separate and distinct manifestations from the same injury, which permit rating the manifestations under several diagnostic codes (DCs). The critical element in permitting the assignment of several ratings under various DCs is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition(s). Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Pyramiding, which is the evaluation of the same disability or the same manifestation of a disability under different DCs, is to be avoided. 38 C.F.R. § 4.14 (2012). In this case, manifestations of the Veteran's various psychiatric disabilities are not separate and distinct from those of his PTSD and other service-connected disabilities and are therefore not separately ratable under different DCs. Rather, during VA outpatient treatment visits and VA examinations, medical professionals attributed the same symptoms not only to the Veteran's PTSD, a cognitive disorder and ADD, but also to the other psychiatric disabilities noted above. And since then, in rating the severity of the Veteran's PTSD and residuals of a TBI, the RO considered the effect of all such symptoms. The Board thus finds that the Veteran has variously diagnosed psychiatric disabilities other than PTSD, including a mood disorder, not otherwise specified, bipolar disorder I, mixed, dysthymic disorder, depression, not otherwise specified, and major depressive, the symptoms of which are related to his active service, but already considered part of his service-connected PTSD and residuals of a TBI. In light of this finding, the Board concludes that such disabilities were incurred in service and are part of, rather than separate from or proximately due to, the Veteran's PTSD and residuals of a TBI. ORDER Service connection for diabetes mellitus type II is denied. Service connection for psychiatric disabilities other than PTSD, as part of, not separate from, the service-connected PTSD, is granted. ____________________________________________ KELLI A. KORDICH Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs